Introduction to Process Problem Solving - Section 1 -
Introductions • Facilitator • Participants • Safety
Define and resolve problems using Process Problem Solving: • Standards • Root cause analysis • Problem red flags • Corrective actions
Defining a Problem • Problems: • Are abnormalities that vary from the desired or expected condition. • Are OPPORTUNITIES. • Are a normal part business (i.e. management, HR, patient care).
PPS Defined • A structured method to determine the quickest, most cost effective way to ensure the root cause of a problem is: • Identified • Addressed • Permanently eliminated
Why Use PPS Methodology ? • It provides an effective, repeatable process to: • Maintain current capability, status and capacity • Improve capability, capacity, and reliability • Prevent problem recurrence ? ? ?
PPS Objectives • Recognize abnormal conditions • Determine the REAL problem • Identify potential causes • Locate the point of cause (POC) • Identify the root cause • Generate solutions • Implement corrective actions • Standardize processes and revise documentation
Problems… • Are REAL WORLD • May be caused by complex interactions of multiple variables • CANNOT be seen as mysterious and unsolvable • Have tangible and physical clues • Should be explained in terms of Standards and Measures
Current Situation What is an Abnormality? Standard
A specific, known expectation of – Standard (WSBH) Standards What Should Be Happening
Control Points - Measures What’s Actually Happening Current Situation (WAH)
Problem Red Flags - Section 2 -
Review injury data Examine safety gear Check if standards are being followed SAFETY Problem Red Flags
Problem Red Flags QUALITY • Review abnormality data and customer complaints • Check process/products at startup and breaks • Examine completed process or product • Re-examine standards
Problem Red Flags • Check the number of abnormalities • Have a system to indicate when and where a problem occurs • Note changes in productivity rates • Regroup tasks for even distribution • Review scrap reports QUANTITY
Problem Red Flags COST • Examine excessive labor costs • Review expenditures
Problem Red Flag Human Relations • Review absenteeism • Track job rotation • Assess and track training and development • Track employee suggestion program
Problem Red Flags OTHER • Track Maintenance • Talk with preceding and following position personnel
Identification Tools - Section 3 -
Problem Identification Tools • Standard • Visual controls • Reports • Variation in measurable • Flow diagrams • Check sheets • Statistical Process Control • Pareto diagram
Problem Solving Report Functions • Set a standard for a common format • Display the originator’s thinking • Prompts thorough problem solving process • Give a “snapshot” overview • Record the schedule • Maintain the history
Problem Solving Report (Cont’d) I. Theme What Are You Trying To Change Or Accomplish Example: High Acuity patient sent to RME
Problem Solving Report (Cont’d) II. Problem Situation 4 to 8 Capsule Statements Of the what was actually happening Example: 3 High Acuity patients sent to RME on 7/18
Problem Solving Report (Cont’d) III. Goal A description of What Should Be Happening Example: Zero high acuity patients sent to RME
Problem Solving Report (Cont’d) IV. Cause Analysis The 5-Why Chain of Cause/Effect Relationships
Problem Solving Report (Cont’d) V. Countermeasures List the steps taken to Eliminate the problem and Permanently prevent recurrence
Problem Solving Report (Cont’d) VI.Timing Plan Critical Steps, Dates, Responsibility Example: Training For Staff 7/1/07 ME What Resp. Date
Process Problem Solving Systems - Section 4 -
Cause Analysis Initial Problem Perception (Large, Vague, Multiple Problems) Clarify the Problem Problem Defined Most Likely Cause Direct Cause Cause Cause Cause Basic Cause / Effect Investigation Five Why’s? Investigation to Root Cause Why? Why? Why? Why? Root Cause Why? Corrective Action Share Best Practices
Application Questions ? • What do you think is the problem? • What is actually happening? • Can you see the point of cause? • What is the root cause? • What action(s) should you take to address the problem? • How will you confirm results?
Process Problem Solving Steps - Section 5 -
Step 1 Define Problem and Gather Data What do you think is the problem?
What is the problem What is actually happening What should be happening How did you find the problem How is the problem affecting you Identify the Problem
Defining the Problem Define the problem in a clear way so that others can grasp the situation.
Initial Problem Perception • Some things to avoid when first identifying a problem: • Identifying and jumping to a perceived cause or solution • Making decisions without actually seeing the problem • Using quick fix solutions
Determine Problem Theme • Themes should be: • Clear and concise statements • Attract readers attention • Consistent with the goals and targets
Step 2 Grasping and Clarifying the Situation What is actually happening?
Clarify the Situation • Clarify the problem by: • Studying What’s Actually Happening • Studying What Should Be Happening • Breaking problem down into individual problems, if necessary WSBH WAH
State the Problem • Highlight important ways the current situation is different from the desired situation • Define: • Standard (WSBH) • Current situation relating to standard • Difference between WAH and WSBH • Extent of problem
Locate the Point of Cause Step 3 Can you see the point of cause?
Locating Point of Cause • Two major steps: • Track back to see the POC first hand • Narrowing to Locate POC
An staff member identifies platelets, but he cannot see where this is happening (he cannot see the POINT of CAUSE). To find the POINT of CAUSE he needs to Track Back along the workflow past the POINT of CAUSE until the sign-off sheet showed last cooler count. Example Team member first picked up problem here Track back
Narrowing • Narrowing is the process of letting data take you to the Point of Cause by breaking it down until you know where to go look in order to see the problem.
Activities at the Point of Cause • Determine WAH versus WSBH • What do you see ? – list observations • Identify most likely direct cause of the problem
Step 4 Establish Cause/Effect Relationships What is the root cause?
Three Major Investigational Steps • Identify and confirm the direct cause of the abnormal occurrence • Continue asking “Why?” to build a chain of cause and effect relationships to the root cause • Stop at the cause that must be addressed to prevent recurrence
Discuss Actions to Test Direct Cause • Identify and confirm the direct cause of the abnormal occurrence.