J U N E 2 0 1 6 O R E X C E L L E N C E . C O M 3 5
to fix the current problem at hand but, in reality, that problem is only a tiny symp-
tom of a much larger, complex concern. If you try to fix only the issue directly in
front of you without zooming out to see what other systems are involved or affect-
ed, you'll end up with a bunch of Band-Aids on a giant, broken process.
• Diving deep. There is certainly a textbook methodology to proper root cause
analysis that includes determining the frequency, severity and outcome of the
problem. You have to consider whether the event was isolated or part of a trend,
how likely it is that the event could happen again, the harm severity — minor or
major injury or potential for injury — and the worst-case scenario. You have to
have a solid understanding of the processes involved in order to perform an effec-
tive analysis and avoid a quick-fix solution.
• Communication is key. Just when you think you have communicated
enough with your staff, communicate some more. Make the communication
meaningful — it's not enough to send a memo or hang reminders throughout the
facility. You need to really engage your staff in the conversation and make sure
you're listening to their feedback.
• Making change happen. Monitor the lessons and solutions that have been
implemented. This is a step that many administrators forget to follow up on. Go
back and see if minor adjustments are needed to ensure that there will not be a
recurrence.
OSM
