Root Cause Analysis Detailed Checklist (for Conducting a Maxi-LCA)

This checklist provides a lot of detail for those who want follow the process "by the book."

Evidence-Gathering Phase (Respond)

• Initial Response

  • Principal Investigator should request 5 Items.

  • Principal Investigator should obtain 3 evidence-gathering leaders -- one for each of the 3 Ps (People, Physical, and Paper evidence).

  • Principal Investigator should assemble as many people as possible (from the affected area) to brainstorm 3 lists of evidence to gather -- one for each of the 3 Ps.

• Evidence-Gathering and Summarization

  • Sub-team leaders should gather the evidence on their lists, independent of one-another.

  • Sub-team leaders should "pretend" that their evidence is the only evidence, summarizing their findings in writing (and sketches) by stating "if our evidence were the only available evidence, we would have to conclude the following:"

    • Physical Causes (a paragraph describing the physics of the incident, past tense and specific).

    • Human Causes (a bulleted list stating "who did what wrong" to trigger the above physical causes, past tense and specific).

    • Latent Causes (a bulleted list answering "what does this evidence suggest about the way they are that might have lead to this incident", present tense and generic).

  • When each sub-team is ready, the Principal Investigator should summon a meeting of all 3 sub-team leaders so that each can present its evidence to one another.  After reviewing and discussing the all the evidence, re-define the following (now based on all the evidence):

    • Physical Causes (a paragraph describing the physics of the incident, past tense and specific).

    • Human Causes (a bulleted list stating "who did what wrong" to trigger the above physical causes, past tense and specific).

    • Latent Causes (a bulleted list answering "what does this evidence suggest about the way they are that might have lead to this incident", present tense and generic).

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  Identify the Stakeholders (Organize)

• Identification of Stakeholders

  • Based on the above preliminary conclusions, the Principal Investigator and evidence-gathering sub-team leaders should identify stakeholders.  Stakeholders are anyone whose:

  • Behavior has to change

  • Has to spend money

  • Is either accusing someone, or

  • Is being accused

  • Including all inferred in either the Human or Latent Causes

• Stakeholder Preparation Meeting (plan for approximately 30 minutes)

  • The Principal Investigator should gather the stakeholders together to prepare them for the Stakeholder Meeting.

  • Show the Stakeholder Preparation Slides.  They will generate discussion.  Any discussion would be good.

  • This meeting should be considered a "gatekeeper" meeting.  If the stakeholders agree to "The Golden Rule of an LCA," and the other slides then the Stakeholder Meeting should be conducted.  If they do not agree, do not conduct the meeting.  Put the onus on them.

Discover the Causes (Order)

• Stakeholder Discovery Meeting #1:  Evidence-Review Meeting (2 to 4 hours, depending on the amount of evidence)

  • Principal Investigator should assemble the stakeholders and evidence-gathering sub-team leaders.

  • Each of the lead evidence gathers should be given 20 minutes to show the essence of their evidence.  Try to focus on the evidence that suggests the Physical and Human Causes.  Evidence that suggests Latent Causes should be presented during the Stakeholder Meeting #3 (Define Latent Causes)

  •  Principal Investigator, after each form of evidence, should ask the stakeholders what they heard or saw.  This will generate dialogue.  Dialogue is good.

  • After all 3 forms of evidence are presented, insist on an overnight break to allow stakeholders to absorb the evidence.

• Stakeholder Discovery Meeting #2:  Physical and Human Causes (2 to 4 hours, depending on the amount of evidence)

  • After all 3 forms of evidence have been presented, and after the overnight break, the Principal Investigator should divide the stakeholders into at least 2 groups.  Either put all the strong personalities into one group, or divide the strong personalities between groups.  Use your judgment.

  • Explain the concept of Physical Cause, then ask each group to define it on flip charts -- based on the evidence that they heard.

  • Explain the concept of Human Cause, then ask each group to define it on flip charts -- based on the evidence that they heard.  It is imperative for them to define who did what wrong (no names).  This is what will either make or break the process.

• Stakeholder Discovery Meeting #3:  Latent Causes (about 2 hours per Human Cause)

  • The Principal Investigator should plan on at least 2 hours per Human Cause.  Since Human Causes often have similar Latent Causes, it is typical to dwell on 2 or 3 Human Causes as a result of a Maxi or Midi-LCA -- instead of analyzing all of the Human Causes.

  • The Principal Investigator should "seed" this meeting by having each of the evidence-gathering leaders present latency evidence.  Limit the presentation of this evidence to 30 minutes.  Allow time for discussion.

  • Use the Situation-Filter-Outcome Aid (the discussion generator) for each of the Human Causes.  Concentrate on one Human Cause at a time.

  • Remember:

    • Understanding the situation is critical to understanding the thoughts.  The person that was confronted with the situation should be the one to define it.  If you cannot get the person who was actually there to be involved in this process, get someone with a similar background.  Whatever, make sure you get the group to accept the situation as true.

    • Next, you must try to understand the thoughts (as-is versus as-desired) that were in the people's mind that lead to each Human Cause.  You cannot assume these thoughts.  The people who were thinking the thoughts (or their close associates) must divulge them.

    • Finally, you must help the other stakeholders answer the 2 key latency questions:

      • 1.  What is it about the way WE ARE that contributed to this incident?  The question should be answered by the whole group of stakeholders, open-discussion style.  Their answers must be prefaced by the word "we."   Only list the answers (on flip charts) that everyone agrees upon.  Do NOT suggest, or tell them "the answer."  They must come up with their own answers.

      • 2.   What is it about the way YOU ARE are that contributed to this incident?  Each person is required to ask this question of themselves.  Ask people to initially write their answers on index cards, then have them read them aloud -- one at a time.  Their answers must be prefaced with the word "I."

    • Always end the stakeholder meetings with some kind of forced venting.  Ask each person to write down something what the "liked," and what they "wished might have been different."  Finally ask them to rate the usefulness of the meetings on a scale of 0 to 5 -- 5 high.

Resolution Phase (continuation of Order)

It is important to remember that Action Items are typically defined for only the Physical Causes of the Maxi or Midi event being investigated.  Action Items are usually NOT defined for Latent Causes.  Instead, significant Latent Causes are to be addressed twice per year after reviewing Maxi, Midi, and Mini-LCA findings during that time.

• Definition of Action Items (plan for approximately 30 minutes)

  • This meeting should occur after the other stakeholders meetings to intentionally separate identification of causes from identification of action items.

  • The Principal Investigator should review the Physical Causes developed by the stakeholders, asking whether or not anyone has any doubts about their conclusions.

  • Assuming no doubts, divide the stakeholders into at least 2 groups, either dividing or combining the strong personalities.  Use your judgment.

  • Ask each group to suggest what to do about each of the Physical Causes.  Suggestions must be SMART:

    • Specific

    • Measurable

    • Actionable

    • Reasonable

    • Time-Bound