The problem with ‘5 whys’

Card, Alan J.

doi:10.1136/bmjqs-2016-005849

Cited by 70 publications

(55 citation statements)

References 61 publications

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“…Such analysis led to the passing of the PETS Act in 2006 that requires government entities to "account for the needs of individuals with household pets and service animals before, during, and following a major disaster or emergency." The 5 Whys method can be strengthened by engaging in various iterations of the questioning process to overcome any simplistic, linear thinking (i.e., there is only one root cause) (Card 2017). It is important to include diverse participants and particularly people across the value chain (e.g., theorists, developers, users), because root cause exploration is limited by the knowledge base of those involved (Murugaiah et al 2010).…”

Section: Identify the Root Causes Of A Problemmentioning

confidence: 99%

Ten rules to increase the societal value of earth observations

Virapongse

Pearlman²,

Pearlman³

et al. 2020

Earth Sci Inform

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Earth Observation (EO) data play an important role in our society today, but there is still tremendous opportunity to improve how these data are used to affect change. In this paper, we provide guidance to help data providers and intermediaries within the EO value chain (from data to applications) increase the societal value of the EO data, information, and data products that they work with. We first describe the EO value chain as a conceptual framework for how data are translated and applied for societal benefit. We then introduce three approaches that are often used to assess and improve the EO value chain. Finally, we present "10 rules" that can be implemented to increase the societal benefits of Earth science information. The 10 rules emphasize meeting user needs, problem-solving within interdisciplinary teams, and long-term sustainable solutions. Some rules focus on a specific segment of the value chain or phase in the problem-solving process, while others are relevant to the value chain or process as a whole. Each rule includes at least one case study example to illustrate the key points. The rules are loosely organized according to project management principles with the initial rules focusing on defining problems, planning for data use, creating effective teams, and examining a diverse selection of solutions. The next set of rules are best applied throughout a project, and include such concepts as evaluation, interoperability, trust, adoption, and documentation. Finally, the last rule addresses the challenge of determining when to close a project.

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Section: Identify the Root Causes Of A Problemmentioning

confidence: 99%

Ten rules to increase the societal value of earth observations

Virapongse

Pearlman²,

Pearlman³

et al. 2020

Earth Sci Inform

View full text Add to dashboard Cite

show abstract

“…Though easy to use, both techniques have their drawbacks and RCA panel members have to use these techniques with caution. [31,32] Other incident investigation and human factors tools and techniques including fault tree analysis, cognitive walkthrough, task analysis, heuristic evaluation techniques and interview question bank, are very useful to facilitate investigation on the evaluation of workflow, equipment and user interface and support data analysis and should be considered in the investigation process. [12, [33][34][35][36][37][38] Currently, the HA RCA report template does not provide any of the above tools for the RCA panel to make reference.…”

Section: Discussionmentioning

confidence: 99%

Our First Review in 12 Years: An Evaluation of Effectiveness of Root Cause Analysis in Hong Kong Public Hospitals

Kwok

Mah

Pang

2020

Preprint

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Background: To evaluate the effectiveness of root cause analysis (RCA) and propose possible ways to enhance its effectiveness in Hong Kong public hospitals.Methods: A retrospective cross-sectional study was performed across 43 public hospitals and institutes in Hong Kong, reviewing RCA reports of all Sentinel Events and Serious Untoward Events within a two-year period. The incident nature, types of root causes and strengths of recommendations were analysed. The RCA recommendations were categorised as 'strong', 'medium' or 'weak' strengths utilizing the US's Veteran Affairs National Center for Patient Safety action hierarchy.Results: A total of 214 reports from October 2016 to September 2018 were reviewed. These reports generated 504 root causes, averaging 2.4 per RCA report, and comprising 282 (49%) system, 233 (46%) staff behavioural and 22 (4%) patient factors. There were 658 recommendations identified in the RCA reports with an average of 3.1 per RCA. Of these, 18 (2%) recommendations were rated strong, 116 (15%) medium and 626 (82%) weak. Most recommendations were related to 'training and education' (466, 61%), 'additional study/review' (104, 14%) and 'review/enhancement of policy/guideline' (39, 5%). Conclusions: This study provided insights about the effectiveness of RCA across all public hospitals inHong Kong. The results showed a high proportion of root causes were attributed to staff behavioural factors and most of the recommendations were weak. The reasons include the lack of training, tools and expertise, appropriateness of panel composition, and complicated processes in carrying out large scale improvements. The Review Team suggested conducting regular RCA training, adopting easy-touse tools, enhancing panel composition with human factors expertise, promoting an organization-wide safety culture to staff and aggregating analysis of incidents as possible improvement actions. Strengths And Limitations Of This StudyThis study is the first study evaluating the effectiveness of RCA in Hong Kong public hospitals.This study used a robust methodology to analyse the root causes and recommendations of RCA reports.This study highlighted the key factors contributing to the distribution of strengths of recommendations.The study only reviewed the strengths of recommendations but not the work progresses and feasibilities.

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“…Though easy to use, both techniques have their drawbacks and RCA panel members have to use these techniques with caution. [32,33] Other incident investigation and human factors tools and techniques including fault tree analysis, cognitive walkthrough, task analysis, heuristic evaluation techniques and interview question bank, are very useful to facilitate investigation on the evaluation of workflow, equipment and user interface and support data analysis and should be considered in the investigation process. [12, [34][35][36][37][38][39] Currently, the HA RCA report template does not provide any of the above tools for the RCA panel to make reference.…”

Section: Discussionmentioning

confidence: 99%

Our First Review: An Evaluation of Effectiveness of Root Cause Analysis Recommendations in Hong Kong Public Hospitals

Kwok

Mah

Pang

2020

Preprint

View full text Add to dashboard Cite

Background: To evaluate the effectiveness of root cause analysis (RCA) recommendations and propose possible ways to enhance its quality in Hong Kong public hospitals.Methods: A retrospective cross-sectional study was performed across 43 public hospitals and institutes in Hong Kong, reviewing RCA reports of all Sentinel Events and Serious Untoward Events within a two-year period. The incident nature, types of root causes and strengths of recommendations were analysed. The RCA recommendations were categorised as ‘strong’, ‘medium’ or ‘weak’ strengths utilizing the US’s Veteran Affairs National Center for Patient Safety action hierarchy.Results: A total of 214 reports from October 2016 to September 2018 were reviewed. These reports generated 504 root causes, averaging 2.4 per RCA report, and comprising 282 (49%) system, 233 (46%) staff behavioural and 22 (4%) patient factors. There were 658 recommendations identified in the RCA reports with an average of 3.1 per RCA. Of these, 18 (2%) recommendations were rated strong, 116 (15%) medium and 626 (82%) weak. Most recommendations were related to ‘training and education’ (466, 61%), ‘additional study/review’ (104, 14%) and ‘review/enhancement of policy/guideline’ (39, 5%).Conclusions: This study provided insights about the effectiveness of RCA recommendations across all public hospitals in Hong Kong. The results showed a high proportion of root causes were attributed to staff behavioural factors and most of the recommendations were weak. The reasons include the lack of training, tools and expertise, appropriateness of panel composition, and complicated processes in carrying out large scale improvements. The Review Team suggested conducting regular RCA training, adopting easy-to-use tools, enhancing panel composition with human factors expertise, promoting an organization-wide safety culture to staff and aggregating analysis of incidents as possible improvement actions.

show abstract

The problem with ‘5 whys’

Cited by 70 publications

References 61 publications

Ten rules to increase the societal value of earth observations

Ten rules to increase the societal value of earth observations

Our First Review in 12 Years: An Evaluation of Effectiveness of Root Cause Analysis in Hong Kong Public Hospitals

Our First Review: An Evaluation of Effectiveness of Root Cause Analysis Recommendations in Hong Kong Public Hospitals

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