Root Cause Analysis Archives

08Mar 2018 by Steve Musica 95 Comments

The Power of A3 Process Improvement

The Lean East team helps organizations learn how to use Lean thinking and tools to remove waste from their processes. We prefer to employ a “learn by doing” approach where we train and coach these methods while engaged in organizational improvement projects. If organizations already have an established improvement process we will work within that process and seek to improve it. But if the organization does not have a robust process in place (and most do not) then we recommend using the Lean East A3 Process Improvement tool. Lean thinking Let’s define a few terms first. Lean refers to a philosophy and management strategy focused on customer value and respect for people. Lean is not about layoffs or running the organization on a shoestring. Lean is continually improving the…

05Oct 2017 by Steve Musica No Comments

Immunity to Change

Lesson

Immunity to Change: How to Overcome it and Unlock the Potential in Yourself and Your Organization is a 2009 book written by Robert Kegan and Lisa Laskow Lahey. It has updated examples of their experience using their immunity to change concepts first introduced in their 2001 book, How the Way We Talk Can Change the Way We Work. This book was recently recommended by another experienced improvement consultant. Since I was unfamiliar with the book and change process, I decided to learn the process and share key points with my friends and colleagues. I typically work with teams and organizations, not individuals, and have not used the immunity to change process myself. It does provide a path to understanding root cause, so I see reasons why it could work well…

23Feb 2016 by Steve Musica No Comments

Problem Solving to Root Cause

Summary

While facilitating an improvement project for a hospital's surgical department recently, our team was presented with a clear opportunity for improvement. Recent data logged during a long day of procedures included three separate surgical cases where the patient's discharge paperwork was incorrect. These three errors were all caught by the surgeon before the patient was discharged, but other patients had reported receiving and following the wrong post-op procedures. The team decided that this issue was a priority to address and the Nursing Director took a leadership role in bringing together the team involved in preparing the pre-op paperwork to review the problem and propose solutions. The team was able to work together to quickly make some significant improvements while learning some core concepts of problem solving. Some of the tools…