Variation in performance would often produce unexpected and undesired adverse outcomes, including the occurrence or risk of a sentinel event. A root cause can be defined as one of the most fundamental reasons of failure, or a situation in which performance does not meet expectations. The word cause in the context of root cause analysis should not imply or assign responsibility or a factor to blame for a problem. Instead, the cause should focus on a positive and preventive approach and refer to the potential relationship between the responsible factors that result in a sentinel event. Root cause analysis usually performed retrospectively, and it evaluates the reasons for the bad outcomes or for sentinel events that have already occurred.
The root causes lie at level 1 which inevitably influence the effectiveness of all the risk control systems and workplace precautions that exist at levels 2 and 3. The most useful definition identified to date is the definition used by Paradies and Busch (1988), that is: The most basic cause that can be reasonably identified And that management has control to fix This definition will be used for this review. It contains three key elements: Basic Cause: Specific reasons as to why an incident occurred that enable recommendations to be made which will prevent recurrence of the events leading up to the incident. Reasonably Identified: Incident investigation must be completed in a reasonable time frame. Root causes analysis, to be effective, must help investigators to get the most out of the time allotted for investigation.
The Six Sigma methodology decreases variations in business processes. Six Sigma can be executed in any business, paying little respect to what we do or how little we are. Six Sigma is about problem-solving, and problems are all over the place. It doesn't make a difference what sort or size of business this leap forward methodology is connected to. Six Sigma uncovers the layers of procedure variables and defects that we have to comprehend and control to kill the squandered time, exertion, and materials that add to our expenses yet don't include esteem for our clients.
Step two, detailed collection of information, information collected must come from various origins depending on the actual incident including staffs who witnessed the incident. Step three of the root cause analysis recognises the reasons that may have emerged in the sentinel event. It includes reviewing the order of events that became the issue, the factors that caused the issue to escalate, and considers as many recognised reasons as possible. At step four of the root cause analysis, advices and applications are included in the data garnered by using the root cause analysis to rule out future problems. Applying the four steps to my case, firstly, I will recognise the issue which is patient’s fall risk.
However, learning from the project resources, I was able to know how to formulate a POV statement. Now that I learned the issue, and confirmed that there is for sure a communication problem, the next step is to find a solution. My understanding is that it is going to be tricky to find a solution that allows only people who want to know the whereabouts of the tech and finance staff members. This is maybe because the idea of email is stuck in my head, but I have to move past that and think more creatively. Thanks to the design thinking process, I believe that I will get to a more suitable solution of the existing problem.
Some people tend to think in a linear fashion, that is, A causes B which causes C. Systems thinking recommends that we introduce circular feedback, that is, what if C can cause A? What if a combination of B and C can cause A? Analytical thinking on the other hand, suggests that we split the whole into parts to understand how the whole works. Dr. Russell Ackoff, an American organizational theorist, points out that this is how we were taught in school. Complex subjects were broken down into themes to aid understanding.
The possible causes should be documented and ranked in scale of not likely (1) to inevitable (10). The seventh step is identifying the current design controls and decide the probability of detection. Then, identify the highest risks based on Risk Priority Numbers (RPN). The last step is recommending action taken to remove the highest
DMAIC or Define, Measure, Analyse, Improve and Control is used for existing processes. DMADV which stands for Define, Measure, Analyse, Design and Verify is used for new processes (Harris, A., (2013). Six Sigma offers six strategic advantages to an organization once implemented. First, customer satisfaction is improved due to the purchasing experience and employee attitude which develops customer loyalty and return business. Second, a well-organized company and increased employee productivity results from helping employees understand how to manage their time effectively.
The first disadvantage is based on the need of training which is needed to train the staff in order to use the tool because it is complex for which it needs more training as compared to other tools. There is a complete cycle of (DMAIC) which has to be followed each time there is a problem which however makes the process even more challenging and time consuming. Another issue and limitation is based on the following of these steps because if the intended person even misses one step in the process then it will be creating much problem and confusion in the minds of the workers and could also create much problem for the employees. This eventually results in the wastage of time as well as human and material resources. Therefore there is much more need of time and training to be used by the organizations in order to train them for the changes which are prevailing in the SS (Six Sigma) methodology, eventually making the process