Bob Luttman, Robert Luttman & Associates
(Briefly) Revisiting VMS Design Issues
Gateway Documentation - Normal Days
Gateway Documentation - Insert Days
Pushing Variance Data Up The Ladder
Dig Deeper
Finding Root Causes: Digging Deeper Into Variance Data
Now that we have identified the key process problems we will start talking about finding their causes. This is an introduction to process thinking, which continues in more depth next week. Along with other process thinking tools.
The focus at this time is what to look for, what additional data do you need? Let's take a real example: arrhythmia in cardiac surgery patients.
Here your clinical knowledge comes into play. What would you want to know first? Perhaps the type or arrhythmia, patient ages, comorbidities, complications, extubated time?
The basic root cause analysis technique is the "5 Why?'s" Ask why the arrhythmia and identify the main reason, then ask why that happens, then why again, and again, and again. Five times you ask why something happens. Within that series of questions the answer should emerge. if not keep asking why.
The analysis may also branch as you ask the questions. In fact it is likely that different arrhythmia types occur, each with its own causality. The pareto principle (20% of cause account for 80% of the problem) will identify the most important arrhythmias.
The key takeaway here is that the Gateway system has identified the problem patients and answered the first why. Now you no which patients to pull charts for and what to look for. The rest is drilling into the critical and detail variances recorded on the pathway documentation.
And you have answered the So What question.
