Analysis and Root Causes Why the problem is

Analysis and Root Causes Why the problem is occurring

Learning Objectives 1. Review the purpose of the analysis section 2. Demonstrate tools and templates to help you identify root causes 3. And support catchball

Analysis: Goal: • To develop deep understanding of a problem and why it is occurring • To break down the gap into smaller “contributors” or causes

Analysis: Goal: • To develop deep understanding of a problem and why it is occurring • To break down the gap into smaller “contributors” or causes Recommended Tools: • Process Maps What is the process? • Value Stream Maps • Swim Lanes • Run Charts or Bar Charts data? • Stratification of Data down data? • Pareto Charts What is the historical How have you broken What are the top contributors? Additional useful tools: • Cause Effect Diagram (Fishbone) What causes have you

Process or Flow Maps • Visualization of current Benefits: - Visualizes deep, shared work or flow understanding of actual work (the Gemba) - Reveals problems and opportunities, data Tips: - Map reality, not assumptions - Don’t do it alone - May include in Current Conditions

How-to: Process Map Steps I. Identify a Process Start or End • Define start and end • Decide level of detail: Simple or detailed II. Information Gathering & Mapping: Process Step • Walk through the major steps • Place the boxes in the correct sequence • Add directional arrows and decision diamonds Decision N III. Review & Analysis: • Review the process again, add stakeholders • Identify gaps, problem areas, waste • Identify data points and opportunities Improvement Idea! Y

Swim Lane 12/31/2021 Zuckerberg San Francisco General Hospital and Trauma Center 8

Run Chart Histogram/Bar • Bar chart Chart • Visualizes performance, stratified by • Line chart over time • Visualizes performance (sometimes goal, baseline, expected variation) relevant groups, periods FY 15 -16 ED LOS Falls – Time of Med-Surg Discharged Patients 5/21/16 - 7/13/16 ED LOS - Discharged Patients (Minutes) 300 8300 250 7 (Minutes) 7 250 6 200 5 150 4 4150 3 1 1 6 4 - 4 2 - 2 0 - 9 : 5 23 -2 2 20 Target 22 - -2 0 18 -1 6 YTD Avg or Previous Year Total Baseline 16 Baseline (FY 14 -15) 1 0 14 Target 1 10 6 - MTD 2 0 8 0 2 50 8 - Jul Aug. Sep Oct Nov. Dec Jan Feb. Mar Apr. May. Jun 2 -1 4 0 1 100 12 50 2 3 -1 2 3 10 100 - May include Current Conditions

Weekly Data Collection/(Watermelon) Run Chart: __Delayed Discharges_____ Units: # of events or % 100% 90% 80% 70% Baseline 50% 60% 50% 40% Goal: <30% X 20% 10% X Sunday Data: 0/8 Monday Data: 2/10 Tuesday Data: 3/10 X X X Wednesday Data: 1/10 Thursday Data 1/10 X Friday Data 0/10 Saturday Data: 1/10 Week Summary: __11%____ Numerator: __8_____ Denominator: _70______ 12/31/2021 Zuckerberg San Francisco General Hospital and Trauma Center 11

Stratification • Dividing data into relevant groups [Example of Stratification] Units 30 20 25 20 20 15 10 10 5 5 5 Group B Group C Group D 2 5 5 1 1 0 Group A Jan Feb Mar Group E Common Groups • Provider type/individuals • Patient types • Care Settings • Date or time • Equipment needed • Materials used • Process steps

• Purpose: To identify top contributors • Ranked Bar chart • Line chart – Cumulative % Missed Sepsis Treatment Bundle Elements, by Frequency (optional) 14 120% 12 100% 10 93% 80% 81% 8 60% 69% 6 50% 4 40% 29% 2 0 ent ssm asse Re 100% 98% s Fluid ABX Lactate eck h c e R BCx Pres sors ate Lact 0% % of total missed elements # of missed elements Pareto Diagram

Pareto Data Collection Worksheet: __Sepsis Bundle Failures in February___ # of Events (Insert date/identifiers for each event) 13 12 2/24 11 2/14 10 2/13 9 2/11 2/21 8 2/9 2/20 2/14 7 2/8 2/19 2/13 6 2/5 2/18 2/11 5 2/4 2/17 2/29 2/10 4 2/15 2/28 2/8 3 2/4 2/13 2/28 2/6 2 2/3 2/12 2/25 2/17 1 2/2 2/10 2/24 2/15 2/23 - 2/1 Cause #1: Reasses s Cause #2: Fluids Cause #3: BCx Cause #4: Pressors Cause #5 Lactate Cause #6: Abx 2/4 Cause #6: Insert relevant causes 12/31/2021 Zuckerberg San Francisco General Hospital and Trauma Center 14

Fishbone/Ishikawa (Cause • A cause-effect diagram of a problem and Effect) causes • Encourages broader consideration of contributors • Powerful brainstorming tool, especially in • Caveats: groups • How have you asked 5 Whys? • Which are the top contributor s?

How-To: Fishbone Exercise I. Draw head, backbone, and 4 -5 primary spines • In the head, write the “effect, ” problem, or problem statement • Label end of each of 4 -5 primary spines with a category name • Common categories: 1) People, 2) Materials, 3) Equipment, 4) Environment, 5) Method; Others: Patient, Data • Other “category” types: Process steps, time points, error types, diseases, etc… II. Invite stakeholders to brainstorm subspines by category: • Contributing factors, causes, barriers or constraints in each category • May include Examples of causes III. Consider enhancements:

A) People • • • Why? Why #2? Why #3? Why #4? Why #5? B) Methods • Why? • Why #2? • Why #3? • Why #4? • Why #5? C) Environment • Why? • Why #2? • Why #3? • Why #4? • Why #5? Problem Statement D) Equipment • Why? • Why #2? • Why #3? • Why #4? • Why #5? E) Materials • Why? • Why #2? • Why #3? • Why #4? • Why #5? F) Other • Why? • Why #2? • Why #3? • Why #4? • Why #5?

Problem Definition Tree • Diagram of a problem, possible causes, and connected threads of thinking using 5 Whys Problem Why? Cause #1 Cause #2 Cause #3 Why? 1 Document potential root causes 2 Ask if any causes are more likely the root than another 3 “Drill down” by asking “why” on most likely root causes

Construction of a Good Analysis q Clarifies deep understanding of cause and effect links to your problem (5 Whys) q Explores reasonable range of possible causes q Reflects understanding of related work processes and agreement with stakeholders who own the work q Reflects measurement, stratification and ranking of top contributors where possible; Not jumping to conclusions q Causes are not “lack of countermeasures/solutions” 19

Thank You! What questions do you have?

A 3 Catchball • Intentional sharing of A 3 and inquiry where goal is to offer service to someone by developing their thinking • Can be done between 2 people or a group of people • Get as many “fingers” on your thinking as you can to constantly check and adjust, so when you get to the end you will not need to “sell” your thinking

Practicing Humble Inquiry w/ 4 Question Types from Edgar Schein 4 Types Example Pure, Humble Inquiry Questions • Questions for which you do not have an answer • Allows owner to tell his/her story • • Silence, non-verbal cues Tell me more… What are examples? What’s happening? Diagnostic Questions • Questions focus/redirect attention • Support problem solver to think through cause/effect, past/future actions, feelings/reactions • • • Why is this happening? What is the top contributor? What have you tried? What impact will X have? What concerns do you have? Prompting Questions – *CAUTION* (Confrontational Inquiry) • Your idea with a question mark • • • Why don’t we try [solution]? Did you talk to him about it? Did that make you frustrated? Special Case: Process Questions • Reflects on status of process and relationship How did this coaching session go? Ownership remains with owner Learning>Telling Ownership taken away from owner Telling>Learning

Analysis Toolbox • How-To Instructions • Templates and Tools • • Process Maps Instructions Watermelon chart Fishbone Instructions and Template Pareto data collection worksheet and instructions • Problem Definition Tree How-To 12/31/2021 Zuckerberg San Francisco General Hospital and Trauma Center 23

How-to: Process Map Steps I. Identify a Process Start or End • Define start and end • Decide level of detail: Simple or detailed II. Information Gathering & Mapping: Process Step • Walk through the major steps • Place the boxes in the correct sequence • Add directional arrows and decision diamonds Decision N III. Review & Analysis: • Review the process again, add stakeholders • Identify gaps, problem areas, waste • Identify data points and opportunities Improvement Idea! Y

Weekly Data Collection/(Watermelon) Run Chart: ______ Units: 100% # of events or 90% % 80% 70% Baseline Goal 60% 50% 40% 30% 20% 10% Sunday Data: Monday Data: Tuesday Data: Wednesday Data: Thursday Data Friday Data Saturday Data: Week Summary: _____ Numerator: _______ Denominator: _______ 12/31/2021 Zuckerberg San Francisco General Hospital and Trauma Center 25

Fishbone/Ishikawa (Cause • A cause-effect diagram of a problem and Effect) causes • Encourages broader consideration of contributors • Powerful brainstorming tool, especially in • Caveats: groups • How have you asked 5 Whys? • Which are the top contributor s?

How-To: Fishbone Exercise I. Draw head, backbone, and 4 -5 primary spines • In the head, write the “effect, ” problem, or problem statement • Label end of each of 4 -5 primary spines with a category name • Common categories: 1) People, 2) Materials, 3) Equipment, 4) Environment, 5) Method; Others: Patient, Data • Other “category” types: Process steps, time points, error types, diseases, etc… II. Invite stakeholders to brainstorm subspines by category: • Contributing factors, causes, barriers or constraints in each category • May include Examples of causes III. Consider enhancements:

A) People • • • Why? Why #2? Why #3? Why #4? Why #5? B) Methods • Why? • Why #2? • Why #3? • Why #4? • Why #5? C) Environment • Why? • Why #2? • Why #3? • Why #4? • Why #5? Problem Statement D) Equipment • Why? • Why #2? • Why #3? • Why #4? • Why #5? E) Materials • Why? • Why #2? • Why #3? • Why #4? • Why #5? F) Other • Why? • Why #2? • Why #3? • Why #4? • Why #5?

• Purpose: To identify top contributors • Ranked Bar chart • Line chart – Cumulative % Missed Sepsis Treatment Bundle Elements, by Frequency (optional) 14 120% 12 100% 10 93% 80% 81% 8 60% 69% 6 50% 4 40% 29% 2 0 ent ssm asse Re 100% 98% s Fluid ABX Lactate eck h c e R BCx Pres sors ate Lact 0% % of total missed elements # of missed elements Pareto Diagram

Pareto Data Collection Worksheet: __________ 13 # of Events (Insert date/identifiers for each event) 12 11 10 9 8 7 6 5 4 3 2 1 Cause #1: Cause #2: Cause #3: Cause #4: Cause #5: Cause #6 Cause #7: Insert relevant causes 12/31/2021 Zuckerberg San Francisco General Hospital and Trauma Center 37

How-To: Problem Definition • Diagram of a problem, possible causes, Tree and connected threads of thinking using 5 Whys Problem Why? Cause #1 Cause #2 Cause #3 Why? 1 Document potential root causes 2 Ask if any causes are more likely the root than another 3 “Drill down” by asking “why” on most likely root causes