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| free root cause analysis training: Root Cause Analysis, Second Edition Duke Okes, 2019-02-06 This best-seller can help anyone whose role is to try to find specific causes for failures. It provides detailed steps for solving problems, focusing more heavily on the analytical process involved in finding the actual causes of problems. It does this using figures, diagrams, and tools useful for helping to make our thinking visible. This increases our ability to see what is truly significant and to better identify errors in our thinking. In the sections on finding root causes, this second edition now includes: more examples on the use of multi-vari charts; how thought experiments can help guide data interpretation; how to enhance the value of the data collection process; cautions for analyzing data; and what to do if one cant find the causes. In its guidance on solution identification, biomimicry and TRIZ have been added as potential solution identification techniques. In addition, the appendices have been revised to include: an expanded breakdown of the 7 Ms, which includes more than 50 specific possible causes; forms for tracking causes and solutions, which can help maintain alignment of actions; techniques for how to enhance the interview process; and example responses to problem situations that the reader can analyze for appropriateness. |
| free root cause analysis training: The PROACT® Root Cause Analysis Kenneth C. Latino, Mark A. Latino, Robert J. Latino, 2020-09-10 Root Cause Analysis, or RCA, What is it? Everyone uses the term, but everyone does it differently. How can we have any uniformity in our approach, much less accurately compare our results, if we’re applying different definitions? At a high level, we will explain the difference between RCA and Shallow Cause Analysis, because that is the difference between allowing a failure to recur or dramatically reducing the risk of recurrence. In this book, we will get down to basics about RCA, the fundamentals of blocking and tackling, and explain the common steps of any investigative occupation. Common investigation steps include: Preserving evidence (data)/not allowing hearsay to fly as fact Organizing an appropriate team/minimizing potential bias Analyzing the events/reconstructing the incident based on actual evidence Communicating findings and recommendations/ensuring effective recommendations are actually developed and implemented Tracking bottom-line results/ensuring that identified, meaningful metrics were attained We explore, Why don’t things always go as planned? When our actual plans deviate from our intended plans, we usually experience some type of undesirable or unintended outcome. We analyze the anatomy of a failure (undesirable outcome) and provide a step-by-step guide to conducting a comprehensive RCA based on our 3+ decades of applying RCA as we have successfully practiced it in the field. This book is written as a how-to guide to effectively apply the PROACT® RCA methodology to any undesirable outcome, is directed at practitioners who have to do the real work, focuses on the core elements of any investigation, and provides a field-proven case as a model for effective application. This book is for anyone charged with having a thorough understanding of why something went wrong, such as those in EH&S, maintenance, reliability, quality, engineering, and operations to name just a few. |
| free root cause analysis training: Apollo Root Cause Analysis Dean L. Gano, 2008 The purpose of this book is to share what the author has learned about effective problem solving by exposing the ineffectiveness of conventional wisdom and presenting a principle-based alternative called Apollo Root Cause Analysis that is robust, yet familiar and easy to understand. This book will change the way readers understand the world without changing their minds. One of the most common responses the author has received from his students of Apollo Root Cause Analysis is they have always thought this way, but did not know how to express it. Other students have reported a phenomenon where this material fundamentally re-wires their thinking, leading to a deeply profound understanding of our world. At the heart of this book is a new way of communicating that is revolutionizing the way people all around the world think, communicate, and make decisions together. Imagine a next decision-making meeting where everyone is in agreement with the causes of the problem and the effectiveness of the proposed corrective actions with no conflicts, arguments, or power politics! This is the promise of Apollo Root Cause Analysis. |
| free root cause analysis training: Root Cause Analysis Handbook ABS Consulting, Lee N. Vanden Heuvel, Donald K. Lorenzo, Laura O. Jackson, Walter E. Hanson, James J. Rooney, David A. Walker, 2014-10-01 Are you trying to improve performance, but find that the same problems keep getting in the way? Safety, health, environmental quality, reliability, production, and security are at stake. You need the long-term planning that will keep the same issues from recurring. Root Cause Analysis Handbook: A Guide to Effective Incident Investigation is a powerful tool that gives you a detailed step-by-step process for learning from experience. Reach for this handbook any time you need field-tested advice for investigating, categorizing, reporting and trending, and ultimately eliminating the root causes of incidents. It includes step-by-step instructions, checklists, and forms for performing an analysis and enables users to effectively incorporate the methodology and apply it to a variety of situations. Using the structured techniques in the Root Cause Analysis Handbook, you will: Understand why root causes are important. Identify and define inherent problems. Collect data for problem-solving. Analyze data for root causes. Generate practical recommendations. The third edition of this global classic is the most comprehensive, all-in-one package of book, downloadable resources, color-coded RCA map, and licensed access to online resources currently available for Root Cause Analysis (RCA). Called by users the best resource on the subject and in a league of its own. Based on globally successful, proprietary methodology developed by ABS Consulting, an international firm with 50 years' experience in 35 countries. Root Cause Analysis Handbook is widely used in corporate training programs and college courses all over the world. If you are responsible for quality, reliability, safety, and/or risk management, you'll want this comprehensive and practical resource at your fingertips. The book has also been selected by the American Society for Quality (ASQ) and the Risk and Insurance Society (RIMS) as a must have for their members. |
| free root cause analysis training: Root Cause Analysis Matthew A. Barsalou, 2014-12-03 Although there are many books on root cause analysis (RCA), most concentrate on team actions such as brainstorming and using quality tools to discuss the failure under investigation. These may be necessary steps during RCA, but authors often fail to mention the most important member of an RCA team the failed part.Root Cause Analysis: A Step-By-Step |
| free root cause analysis training: TapRooT Mark Paradies, Linda Unger, 2000 |
| free root cause analysis training: Root Cause Analysis and Improvement in the Healthcare Sector Bjorn Andersen, Martha Ellen Keyes Beltz, Tom Natland Fagerhaug, 2009-11-09 Healthcare organizations and professionals have long needed a straightforward workbook to facilitate the process of root cause analysis (RCA). While other industries employ the RCA tools liberally and train facilitators thoroughly, healthcare has lagged in establishing and resourcing a quality culture. Presently, a growing number of third-party stakeholders are holding access to accreditation and reimbursement pending demonstration of a full response to events outside of expected practice. An increasing number of exceptions to healthcare practice have precipitated a strong response advocating the use of proven quality tools in the industry. In addition, the industry has now expanded its scope beyond the hospital walls to many ancillary healthcare facilities with little experience in implementing quality tools. This book responds to the demand for a RCA workbook written specifically for healthcare, yet still broad in its definition of the industry. This book contains everything that the typical RCA leader in healthcare requires: A text specific to healthcare, but using the broadest definition of the industry to include not only acute care hospitals, but rehabilitation facilities, long-term care facilities, outpatient surgery centers, ambulatory services, and general office practices. A workbook-style format that walks through the process, step-by-step. Straightforward text without “sidebars,” “tables,” and “tips.” Worksheets are provided at the end of the book to reduce reader distraction within the text. A wide range of real-world examples. Format for use by the most naive of users and most basic of processes, as well as a separate section for more advanced users or more complex issues. Templates, both print and electronic, included for the reader’s use. Ready-to-use educational materials with scripting to enable the user to train others and garner support for the use of the techniques. Background text for users in leadership to understand the tools in the larger context of healthcare improvement. Up-to-date information on the latest in the use of RCA in satisfying mandatory reporting requirements and slaying the myth that the process is onerous and fraught with barriers. Background text and tools/process are separated to facilitate the readers’ specific needs. Healthcare leaders can appreciate the current context and requirements without wading through the actual techniques; end-users can begin learning the skills without wading through dense administrative text. Language and tone promoting the use of the tools for improvement of processes that have experienced exceptions, as opposed to assigning blame for errors. Attention to process ownership, training, and resourcing. And, most importantly, thorough description of the improvement process as well as the analysis. |
| free root cause analysis training: Positive Intelligence Shirzad Chamine, 2012 Chamine exposes how your mind is sabotaging you and keeping your from achieving your true potential. He shows you how to take concrete steps to unleash the vast, untapped powers of your mind. |
| free root cause analysis training: Making Healthcare Safe Lucian L. Leape, 2021-05-28 This unique and engaging open access title provides a compelling and ground-breaking account of the patient safety movement in the United States, told from the perspective of one of its most prominent leaders, and arguably the movement’s founder, Lucian L. Leape, MD. Covering the growth of the field from the late 1980s to 2015, Dr. Leape details the developments, actors, organizations, research, and policy-making activities that marked the evolution and major advances of patient safety in this time span. In addition, and perhaps most importantly, this book not only comprehensively details how and why human and systems errors too often occur in the process of providing health care, it also promotes an in-depth understanding of the principles and practices of patient safety, including how they were influenced by today’s modern safety sciences and systems theory and design. Indeed, the book emphasizes how the growing awareness of systems-design thinking and the self-education and commitment to improving patient safety, by not only Dr. Leape but a wide range of other clinicians and health executives from both the private and public sectors, all converged to drive forward the patient safety movement in the US. Making Healthcare Safe is divided into four parts: I. In the Beginning describes the research and theory that defined patient safety and the early initiatives to enhance it. II. Institutional Responses tells the stories of the efforts of the major organizations that began to apply the new concepts and make patient safety a reality. Most of these stories have not been previously told, so this account becomes their histories as well. III. Getting to Work provides in-depth analyses of four key issues that cut across disciplinary lines impacting patient safety which required special attention. IV. Creating a Culture of Safety looks to the future, marshalling the best thinking about what it will take to achieve the safe care we all deserve. Captivatingly written with an “insider’s” tone and a major contribution to the clinical literature, this title will be of immense value to health care professionals, to students in a range of academic disciplines, to medical trainees, to health administrators, to policymakers and even to lay readers with an interest in patient safety and in the critical quest to create safe care. |
| free root cause analysis training: Root Cause Analysis Handbook ABS Consulting, Lee N. Vanden Heuvel, 2005 Root Cause Analysis Handbook: A Guide to Effective Incident Investigation presents a proven system designed for investigating, categorizing, and ultimately eliminating, rootcauses of incidents with safety, health, environmental, quality, reliability, and production-process impacts.Defined as a tool to help investigators describe what happened, to determine how it happened, and to understand why it happened, the Root Cause Analysis System enables businesses to generate specific, concrete recommendations for preventing incident recurrences.Using the factual data of the incident, the system also allows quality, safety, and risk and reliability managers an opportunity to implement more reliable and more cost-effective policies that result in major, long-term opportunities for improvement.Such process improvements increase a business' ability to recover from and prevent disasters with both financial and health-and-safety implications.Special features include a 17 inch by 22 inch pull-out Root Cause Map, a powerful tool for identifying and coding root causes.The book helps readers to understand why root causes are important, to identify and define inherent problems, to collect data for problem solving, to analyze data for root causes, and to generate practical recommendations.- - - - - - This edition is a reprinting of the 199 edition.- - - - - -ORGANIZATION OF THE ROOT CAUSE ANALYSIS HANDBOOKThe focus of this handbook is on the application of the Root Cause Map to the root cause analysis process. The Root Cause Map is used in one of the later steps of the root cause analysis process to identify the underlying management systems that caused the event to occur or made the consequences of the event more severe. The first five chapters of this handbook are an overview of the root cause analysis process. These provide the context for use of the Root Cause Map. Chapter 6 provides references.Chapter 1, Introduction to Root Cause Analysis, presents a basic overview of the SOURCE (Seeking Out the Underlying Root Causes of Events) root cause analysis process.Chapter 2, Collecting and Preserving Data for Analysis, outlines the types of data and data sources that are available. Chapters 3, 4, and 5 describe the three major steps in the rootcause analysis process.?Chapter 3, Data Analysis Using Causal Factor Charting, provides a step-by-step description of causal factor charting techniques. Chapter 4, Root Cause Identification, explains the organization and use of the Root Cause Map. Chapter 5, Recommendation Generation and Implementation, provides guidance on developing and implementing corrective actions. The references section, Chapter 6, provides additional information for those interested in learning more about specific items contained in the handbook.Appendix A, Root Cause Map Node Descriptions, describes each segment of the Root Cause Map and presents detailed descriptions of the individual nodes on the map. AppendixB is the Root Cause Map itself. |
| free root cause analysis training: Root Cause Analysis (RCA) for the Improvement of Healthcare Systems and Patient Safety David Allison, CPPS, Harold Peters, P.Eng, 2021 The book follows a proven training outline, including real-life examples and exercises, to teach healthcare professionals and students how to lead effective and successful Root Cause Analysis (RCA) to eliminate patient harm. This book discusses the need for RCA in the healthcare sector, providing practical advice for its facilitation. It addresses when to use RCA, how to create effective RCA action plans, and how to prevent common RCA failures. An RCA training curriculum is also included. This book is intended for those leading RCAs of patient harm events, leaders, students, and patient safety advocates who are interested in gaining more knowledge about RCA in healthcare. |
| free root cause analysis training: Root Cause Analysis Mark A. Latino, Robert J. Latino, Kenneth C. Latino, 2019-07-12 This book comprehensively outlines what a holistic and effective Root Cause Analysis (RCA) system looks like. From the designing of the support infrastructure to the measuring of effectiveness on the bottom-line, this book provides the blueprint for making it happen. While traditionally RCA is viewed as a reactive tool, the authors will show how it can be applied proactively to prevent failures from occurring in the first place. RCA is a key element of any successful Reliability Engineering initiative. Such initiatives are comprised of equipment, process and human reliability foundations. Human reliability is critical to the success of a true RCA approach. This book explores the anatomy of a failure (undesirable outcome) as well as a potential failure (high risks). Virtually all failures are triggered by errors of omission or commission by human beings. The methodologies described in this book are applicable to any industry because the focus is on the human being's ability to think through why things go wrong, not on the industry or the nature of the failure. This book correlates reliability to safety as well as human performance improvement efforts. The author has provided a healthy balance between theory and practical application, wrapping up with case studies demonstrating bottom-line results. Features Outlines in detail every aspect of an effective RCA ‘system’ Displays appreciation for the role of understanding the physics of a failure as well as the human and system’s contribution Demonstrates the role of RCA in a comprehensive Asset Performance Management (APM) system Explores the correlation between Reliability Engineering and safety Integrates the concepts of Human Performance Improvement, Learning Teams, and Human Error Reduction approaches into RCA |
| free root cause analysis training: Root Cause Analysis, Second Edition Bjørn Andersen, Tom Fagerhaug, 2006-01-01 This updated and expanded edition discusses many different tools for root cause analysis and presents them in an easy-to-follow structure: a general description of the tool, its purpose and typical applications, the procedure when using it, an example of its use, a checklist to help you make sure if is applied properly, and different forms and templates (that can also be found on an accompanying CD-ROM). The examples used are general enough to apply to any industry or market. The layout of the book has been designed to help speed your learning. Throughout, the authors have split the pages into two halves: the top half presents key concepts using brief languagealmost keywordsand the bottom half uses examples to help explain those concepts. A roadmap in the margin of every page simplifies navigating the book and searching for specific topics. The book is suited for employees and managers at any organizational level in any type of industry, including service, manufacturing, and the public sector. |
| free root cause analysis training: Root Cause Analysis Robert J. Latino, Kenneth C. Latino, Mark A. Latino, 2011-06-17 What is RCA? It seems like such an easy question to answer, yet from novices to veterans and practitioners to providers, no one seems to have come to agreement or consensus on an acceptable definition for the industry. Now in its fourth edition, Root Cause Analysis: Improving Performance for Bottom-Line Results discusses why it is so hard to get such consensus and why various providers are reluctant for that to happen. See what’s new in the Fourth Edition: Human Error Reduction Techniques (HERT) – new chapter Failure Scene Investigation (FSI) – Disciplined Evidence Gathering Categorical versus Cause-and-Effect RCA Tools Analysis Tools Review The Germination of a Failure Constructing a Logic Tree Introduction of PROACTOnDemandSM The Advantages of Software-as-a-Service (SaaS) The Pros and Cons of RCA Templates Three New Client Case Histories The authors discuss evidence collection and strategy, failure scene investigation techniques, the human element, and the contribution of human performance and human factors to poor decision making. They clarify definitions that can be considered ambiguous and underscore the distinctions between applying PROACT manually using a paper-based system versus using an automated software tool. Written by practitioners for practitioners, the book outlines an entire RCA system which involves a cultural paradigm change about how failure is perceived and acted upon in an organization. The authors’ trademark, down-to-earth style provides a step-by-step action plan for how to construct and implement a root cause analysis system that can be applied to any industry. Read MRI Safety 10 Years Later, co-authored by Robert Latino. |
| free root cause analysis training: The Lean Builder: A Builder's Guide to Applying Lean Tools in the Field Joe Donarumo, Keyan Zandy, 2019-08-16 Sam Brooks, a young superintendent with ProCon Builders, has been given responsibility for the largest and most complicated project of his career. He struggles with all of the common difficulties in construction -- lack of communication, coordination issues, and other kinds of wasteful occurrences that rob his project of time and money, while leaving him and his team frustrated and overworked. Luckily, his friend, mentor, and co-worker, Alan Phillips, brings the benefit of his experience and his knowledge of Lean Construction tools and processes to help Sam learn valuable skills for improving the operation of his project. Together, Sam and Alan discuss the merits and explore the practical applications of: Daily Huddles Visual Communication The Eight Wastes Managing Constraints Pull Planning The Last Planner System(TM) Percent Plan Complete |
| free root cause analysis training: The Agile Self-assessment Game Ben Linders, 2019-01-16 The Agile Self-Assessment Game is used by teams and organizations to self-assess their agility. Playing the game enables teams to reflect on their own team interworking, discover how agile they are and decide what they can do to increase their agility to deliver more value to their customers and stakeholders. This is the first book specifically about Agile Self-assessments. In this book, Ben Linders explains what self-assessments are and why you would do them, and explores how to do them using the Agile Self-assessment Game. He's also sharing experience stories from people who played the game. This book is based on his experience as a developer, tester, team leader, project manager, quality manager, process manager, consultant, coach, trainer, and adviser in Agile, Lean, Quality and Continuous Improvement. It takes a deep dive into self-assessments, viewing them from different perspectives and provides ideas, suggestions, practices, and experiences that will help you to do effective agile self-assessments with your teams. The book is aimed at Scrum masters, agile coaches, consultants leading agile transformations, developers and testers, project managers, line managers, and CxOs; basically for anyone who is looking for an effective way to help their agile teams improve and to increase the agility of their organization. With plenty of ideas, suggestions, and practical cases on Agile Self-assessments, this book will help you to apply assessments and help teams to improve. Note: The agile coaching cards needed to play the games described in the book can be downloaded for a nominal fee at benlinders.com/downloads. |
| free root cause analysis training: Operational Risk Management Ariane Chapelle, 2019-02-04 OpRisk Awards 2020 Book of the Year Winner! The Authoritative Guide to the Best Practices in Operational Risk Management Operational Risk Management offers a comprehensive guide that contains a review of the most up-to-date and effective operational risk management practices in the financial services industry. The book provides an essential overview of the current methods and best practices applied in financial companies and also contains advanced tools and techniques developed by the most mature firms in the field. The author explores the range of operational risks such as information security, fraud or reputation damage and details how to put in place an effective program based on the four main risk management activities: risk identification, risk assessment, risk mitigation and risk monitoring. The book also examines some specific types of operational risks that rank high on many firms' risk registers. Drawing on the author's extensive experience working with and advising financial companies, Operational Risk Management is written both for those new to the discipline and for experienced operational risk managers who want to strengthen and consolidate their knowledge. |
| free root cause analysis training: Communities in Action National Academies of Sciences, Engineering, and Medicine, Health and Medicine Division, Board on Population Health and Public Health Practice, Committee on Community-Based Solutions to Promote Health Equity in the United States, 2017-04-27 In the United States, some populations suffer from far greater disparities in health than others. Those disparities are caused not only by fundamental differences in health status across segments of the population, but also because of inequities in factors that impact health status, so-called determinants of health. Only part of an individual's health status depends on his or her behavior and choice; community-wide problems like poverty, unemployment, poor education, inadequate housing, poor public transportation, interpersonal violence, and decaying neighborhoods also contribute to health inequities, as well as the historic and ongoing interplay of structures, policies, and norms that shape lives. When these factors are not optimal in a community, it does not mean they are intractable: such inequities can be mitigated by social policies that can shape health in powerful ways. Communities in Action: Pathways to Health Equity seeks to delineate the causes of and the solutions to health inequities in the United States. This report focuses on what communities can do to promote health equity, what actions are needed by the many and varied stakeholders that are part of communities or support them, as well as the root causes and structural barriers that need to be overcome. |
| free root cause analysis training: What Drives Quality Ben Linders, 2017-09-30 With plenty of ideas, suggestions, and practical cases on software quality, this book will help you to improve the quality of your software and to deliver high-quality products to your users and satisfy the needs of your customers and stakeholders. Many methods for product quality improvement start by investigating the problems, and then work their way back to the point where the problem started. For instance audits and root cause analysis work this way. But what if you could prevent problems from happening, by building an understanding what drives quality, thus enabling to take action before problems actually occur? What Drives Quality explores how quality plays a role in all of the software development activities. It takes a deep dive into quality by listing the relevant factors of development and management activities that drive the quality of software products. It provides a lean approach to quality by analyzing the full development chain from customer requests to delivering products to users. I'm aiming this book at software developers and testers, architects, product owners and managers, agile coaches, Scrum masters, project managers, and operational and senior managers who consider quality to be important. A book on quality should be practical. It should help you, the reader of this book, to improve the quality of your software and deliver better products. It should inspire you and give you energy to persevere on your quality journey. What drives quality tries to do just that, and more. This book is based on my experience as a developer, tester, team leader, project manager, quality manager, process manager, consultant, coach, trainer, and adviser in Agile, Lean, Quality and Continuous Improvement. It takes a deep dive into quality with views from different perspectives and provides ideas, suggestions, practices, and experiences that will help you to improve quality of the products that your organization is delivering. This book views software quality from an engineering, management, and social perspective. It explores the interaction between all involved in delivering high-quality software to users and provides ideas to do it quicker and at lower costs. |
| free root cause analysis training: Root Cause Failure Analysis R. Keith Mobley, 1999-06-16 Root Cause Failure Analysis provides the concepts needed to effectively perform industrial troubleshooting investigations. It describes the methodology to perform Root Cause Failure Analysis (RCFA), one of the hottest topics currently in maintenance engineering. It also includes detailed equipment design and troubleshooting guidelines, which are needed to perform RCFA on machinery found in most production facilities. This is the latest book in a new series published by Butterworth-Heinemann in association with PLANT ENGINEERING magazine. PLANT ENGINEERING fills a unique information need for the men and women who operate and maintain industrial plants. It bridges the information gap between engineering education and practical application. As technology advances at increasingly faster rates, this information service is becoming more and more important. Since its first issue in 1947, PLANT ENGINEERING has stood as the leading problem-solving information source for America's industrial plant engineers, and this book series will effectively contribute to that resource and reputation.Provides information essential to industrial troubleshooting investigationsDescribes the methods of root cause failure analysis, a hot topic in maintenance engineeringIncludes detailed equipment-design guidelines |
| free root cause analysis training: Root Cause Failure Analysis Trinath Sahoo, 2021-05-18 Root Cause Failure Analysis Provides the knowledge and failure analysis skills necessary for preventing and investigating process equipment failures Process equipment and piping systems are essential for plant availability and performance. Regularly exposed to hazardous service conditions and damage mechanisms, these critical plant assets can result in major failures if not effectively monitored and assessed—potentially causing serious injuries and significant business losses. When used proactively, Root Cause Failure Analysis (RCFA) helps reliability engineers inspect the process equipment and piping system before any abnormal conditions occur. RCFA is equally important after a failure happens: it determines the impact of a failure, helps control the resultant damage, and identifies the steps for preventing future problems. Root Cause Failure Analysis: A Guide to Improve Plant Reliability offers readers clear understanding of degradation mechanisms of process equipment and the concepts needed to perform industrial RCFA investigations. This comprehensive resource describes the methodology of RCFA and provides multiple techniques and industry practices for identifying, predicting, and evaluating equipment failures. Divided into two parts, the text first introduces Root Cause Analysis, explains the failure analysis process, and discusses the management of both human and latent error. The second part focuses on failure analysis of various components such as bolted joints, mechanical seals, steam traps, gearboxes, bearings, couplings, pumps, and compressors. This authoritative volume: Illustrates how failures are associated with part integrity, a complete system, or the execution of an engineering process Describes how proper design, operation, and maintenance of the equipment help to enhance their reliability Covers analysis techniques and industry practices including 5-Why RCFA, fault tree analysis, Pareto charts, and Ishikawa diagrams Features a detailed case study of process plant machinery and a chapter on proactive measures for avoiding failures Bridging the gap between engineering education and practical application, Root Cause Failure Analysis: A Guide to Improve Plant Reliability is an important reference and guide for industrial professionals, including process plant engineers, planning managers, operation and maintenance engineers, process designers, chemical engineers, and instrument engineers. It is also a valuable text for researchers, instructors, and students in relevant areas of engineering and science. |
| free root cause analysis training: Training , 1997 |
| free root cause analysis training: Checklist Flip Chart for Root Cause Analysis Teams , 2003 This flip chart is designed to support improved practice in both the clinical and non-clinical work environments and help participants perform systematic root cause analysis to find the real causes of problems.--Verso t.p. |
| free root cause analysis training: Financial Audit United States. Internal Revenue Service, 2003 |
| free root cause analysis training: Remote Team Interactions Workbook Matthew Skelton, 2022-04-26 In the new remote-first and hybrid workplace, many organizations are struggling to catch up with new tooling and ways of working. Many are discovering for the first time that the physical office was covering up poorly defined teams and poorly defined areas of focus, threatening their DevOps transformation efforts and the overall health and success of their business. Matthew Skelton and Manuel Pais, coauthors of the highly successful Team Topologies, provide proven patterns for a successful remote-first approach to teams. Using simple tools for dependency tracking and patterns from Team Topologies, such as the Team API, organizations will find that well-defined team interactions are key to effective IT delivery in the remote-first world. This workbook explores several aspects of team-first remote work, including: •How the new “remote-first” world is highlighting existing poor team interactions within organizations. •Why organizations should use the Team API pattern to define and communicate the focus of teams. •How organizations can track and remove team-level dependencies. •How and why organizations should design inter-team communications consciously. •How and why organizations can use the three team interaction modes from Team Topologies (collaboration, x-as-a-service, and facilitating) to help. The ideas and patterns presented here will help your organization become more effective with a team-based, remote-first approach to building and running software systems. |
| free root cause analysis training: Knowledge Solutions Olivier Serrat, 2017-05-22 This book is open access under a CC BY-NC 3.0 IGO license. This book comprehensively covers topics in knowledge management and competence in strategy development, management techniques, collaboration mechanisms, knowledge sharing and learning, as well as knowledge capture and storage. Presented in accessible “chunks,” it includes more than 120 topics that are essential to high-performance organizations. The extensive use of quotes by respected experts juxtaposed with relevant research to counterpoint or lend weight to key concepts; “cheat sheets” that simplify access and reference to individual articles; as well as the grouping of many of these topics under recurrent themes make this book unique. In addition, it provides scalable tried-and-tested tools, method and approaches for improved organizational effectiveness. The research included is particularly useful to knowledge workers engaged in executive leadership; research, analysis and advice; and corporate management and administration. It is a valuable resource for those working in the public, private and third sectors, both in industrialized and developing countries. |
| free root cause analysis training: Over 200 U.S. Department of Energy Manuals Combined: CLASSICAL PHYSICS; ELECTRICAL SCIENCE; THERMODYNAMICS, HEAT TRANSFER AND FLUID FUNDAMENTALS; INSTRUMENTATION AND CONTROL; MATHEMATICS; CHEMISTRY; ENGINEERING SYMBIOLOGY; MATERIAL SCIENCE; MECHANICAL SCIENCE; AND NUCLEAR PHYSICS AND REACTOR THEORY , Over 19,000 total pages ... Public Domain U.S. Government published manual: Numerous illustrations and matrices. Published in the 1990s and after 2000. TITLES and CONTENTS: ELECTRICAL SCIENCES - Contains the following manuals: Electrical Science, Vol 1 - Electrical Science, Vol 2 - Electrical Science, Vol 3 - Electrical Science, Vol 4 - Thermodynamics, Heat Transfer, And Fluid Flow, Vol 1 - Thermodynamics, Heat Transfer, And Fluid Flow, Vol 2 - Thermodynamics, Heat Transfer, And Fluid Flow, Vol 3 - Instrumentation And Control, Vol 1 - Instrumentation And Control, Vol 2 Mathematics, Vol 1 - Mathematics, Vol 2 - Chemistry, Vol 1 - Chemistry, Vol 2 - Engineering Symbology, Prints, And Drawings, Vol 1 - Engineering Symbology, Prints, And Drawings, Vol 2 - Material Science, Vol 1 - Material Science, Vol 2 - Mechanical Science, Vol 1 - Mechanical Science, Vol 2 - Nuclear Physics And Reactor Theory, Vol 1 - Nuclear Physics And Reactor Theory, Vol 2. CLASSICAL PHYSICS - The Classical Physics Fundamentals includes information on the units used to measure physical properties; vectors, and how they are used to show the net effect of various forces; Newton's Laws of motion, and how to use these laws in force and motion applications; and the concepts of energy, work, and power, and how to measure and calculate the energy involved in various applications. * Scalar And Vector Quantities * Vector Identification * Vectors: Resultants And Components * Graphic Method Of Vector Addition * Component Addition Method * Analytical Method Of Vector Addition * Newton's Laws Of Motion * Momentum Principles * Force And Weight * Free-Body Diagrams * Force Equilibrium * Types Of Force * Energy And Work * Law Of Conservation Of Energy * Power – ELECTRICAL SCIENCE: The Electrical Science Fundamentals Handbook includes information on alternating current (AC) and direct current (DC) theory, circuits, motors, and generators; AC power and reactive components; batteries; AC and DC voltage regulators; transformers; and electrical test instruments and measuring devices. * Atom And Its Forces * Electrical Terminology * Units Of Electrical Measurement * Methods Of Producing Voltage (Electricity) * Magnetism * Magnetic Circuits * Electrical Symbols * DC Sources * DC Circuit Terminology * Basic DC Circuit Calculations * Voltage Polarity And Current Direction * Kirchhoff's Laws * DC Circuit Analysis * DC Circuit Faults * Inductance * Capacitance * Battery Terminology * Battery Theory * Battery Operations * Types Of Batteries * Battery Hazards * DC Equipment Terminology * DC Equipment Construction * DC Generator Theory * DC Generator Construction * DC Motor Theory * Types Of DC Motors * DC Motor Operation * AC Generation * AC Generation Analysis * Inductance * Capacitance * Impedance * Resonance * Power Triangle * Three-Phase Circuits * AC Generator Components * AC Generator Theory * AC Generator Operation * Voltage Regulators * AC Motor Theory * AC Motor Types * Transformer Theory * Transformer Types * Meter Movements * Voltmeters * Ammeters * Ohm Meters * Wattmeters * Other Electrical Measuring Devices * Test Equipment * System Components And Protection Devices * Circuit Breakers * Motor Controllers * Wiring Schemes And Grounding THERMODYNAMICS, HEAT TRANSFER AND FLUID FUNDAMENTALS. The Thermodynamics, Heat Transfer, and Fluid Flow Fundamentals Handbook includes information on thermodynamics and the properties of fluids; the three modes of heat transfer - conduction, convection, and radiation; and fluid flow, and the energy relationships in fluid systems. * Thermodynamic Properties * Temperature And Pressure Measurements * Energy, Work, And Heat * Thermodynamic Systems And Processes * Change Of Phase * Property Diagrams And Steam Tables * First Law Of Thermodynamics * Second Law Of Thermodynamics * Compression Processes * Heat Transfer Terminology * Conduction Heat Transfer * Convection Heat Transfer * Radiant Heat Transfer * Heat Exchangers * Boiling Heat Transfer * Heat Generation * Decay Heat * Continuity Equation * Laminar And Turbulent Flow * Bernoulli's Equation * Head Loss * Natural Circulation * Two-Phase Fluid Flow * Centrifugal Pumps INSTRUMENTATION AND CONTROL. The Instrumentation and Control Fundamentals Handbook includes information on temperature, pressure, flow, and level detection systems; position indication systems; process control systems; and radiation detection principles. * Resistance Temperature Detectors (Rtds) * Thermocouples * Functional Uses Of Temperature Detectors * Temperature Detection Circuitry * Pressure Detectors * Pressure Detector Functional Uses * Pressure Detection Circuitry * Level Detectors * Density Compensation * Level Detection Circuitry * Head Flow Meters * Other Flow Meters * Steam Flow Detection * Flow Circuitry * Synchro Equipment * Switches * Variable Output Devices * Position Indication Circuitry * Radiation Detection Terminology * Radiation Types * Gas-Filled Detector * Detector Voltage * Proportional Counter * Proportional Counter Circuitry * Ionization Chamber * Compensated Ion Chamber * Electroscope Ionization Chamber * Geiger-Müller Detector * Scintillation Counter * Gamma Spectroscopy * Miscellaneous Detectors * Circuitry And Circuit Elements * Source Range Nuclear Instrumentation * Intermediate Range Nuclear Instrumentation * Power Range Nuclear Instrumentation * Principles Of Control Systems * Control Loop Diagrams * Two Position Control Systems * Proportional Control Systems * Reset (Integral) Control Systems * Proportional Plus Reset Control Systems * Proportional Plus Rate Control Systems * Proportional-Integral-Derivative Control Systems * Controllers * Valve Actuators MATHEMATICS The Mathematics Fundamentals Handbook includes a review of introductory mathematics and the concepts and functional use of algebra, geometry, trigonometry, and calculus. Word problems, equations, calculations, and practical exercises that require the use of each of the mathematical concepts are also presented. * Calculator Operations * Four Basic Arithmetic Operations * Averages * Fractions * Decimals * Signed Numbers * Significant Digits * Percentages * Exponents * Scientific Notation * Radicals * Algebraic Laws * Linear Equations * Quadratic Equations * Simultaneous Equations * Word Problems * Graphing * Slopes * Interpolation And Extrapolation * Basic Concepts Of Geometry * Shapes And Figures Of Plane Geometry * Solid Geometric Figures * Pythagorean Theorem * Trigonometric Functions * Radians * Statistics * Imaginary And Complex Numbers * Matrices And Determinants * Calculus CHEMISTRY The Chemistry Handbook includes information on the atomic structure of matter; chemical bonding; chemical equations; chemical interactions involved with corrosion processes; water chemistry control, including the principles of water treatment; the hazards of chemicals and gases, and basic gaseous diffusion processes. * Characteristics Of Atoms * The Periodic Table * Chemical Bonding * Chemical Equations * Acids, Bases, Salts, And Ph * Converters * Corrosion Theory * General Corrosion * Crud And Galvanic Corrosion * Specialized Corrosion * Effects Of Radiation On Water Chemistry (Synthesis) * Chemistry Parameters * Purpose Of Water Treatment * Water Treatment Processes * Dissolved Gases, Suspended Solids, And Ph Control * Water Purity * Corrosives (Acids And Alkalies) * Toxic Compound * Compressed Gases * Flammable And Combustible Liquids ENGINEERING SYMBIOLOGY. The Engineering Symbology, Prints, and Drawings Handbook includes information on engineering fluid drawings and prints; piping and instrument drawings; major symbols and conventions; electronic diagrams and schematics; logic circuits and diagrams; and fabrication, construction, and architectural drawings. * Introduction To Print Reading * Introduction To The Types Of Drawings, Views, And Perspectives * Engineering Fluids Diagrams And Prints * Reading Engineering P&Ids * P&Id Print Reading Example * Fluid Power P&Ids * Electrical Diagrams And Schematics * Electrical Wiring And Schematic Diagram Reading Examples * Electronic Diagrams And Schematics * Examples * Engineering Logic Diagrams * Truth Tables And Exercises * Engineering Fabrication, Construction, And Architectural Drawings * Engineering Fabrication, Construction, And Architectural Drawing, Examples MATERIAL SCIENCE. The Material Science Handbook includes information on the structure and properties of metals, stress mechanisms in metals, failure modes, and the characteristics of metals that are commonly used in DOE nuclear facilities. * Bonding * Common Lattice Types * Grain Structure And Boundary * Polymorphism * Alloys * Imperfections In Metals * Stress * Strain * Young's Modulus * Stress-Strain Relationship * Physical Properties * Working Of Metals * Corrosion * Hydrogen Embrittlement * Tritium/Material Compatibility * Thermal Stress * Pressurized Thermal Shock * Brittle Fracture Mechanism * Minimum Pressurization-Temperature Curves * Heatup And Cooldown Rate Limits * Properties Considered * When Selecting Materials * Fuel Materials * Cladding And Reflectors * Control Materials * Shielding Materials * Nuclear Reactor Core Problems * Plant Material Problems * Atomic Displacement Due To Irradiation * Thermal And Displacement Spikes * Due To Irradiation * Effect Due To Neutron Capture * Radiation Effects In Organic Compounds * Reactor Use Of Aluminum MECHANICAL SCIENCE. The Mechanical Science Handbook includes information on diesel engines, heat exchangers, pumps, valves, and miscellaneous mechanical components. * Diesel Engines * Fundamentals Of The Diesel Cycle * Diesel Engine Speed, Fuel Controls, And Protection * Types Of Heat Exchangers * Heat Exchanger Applications * Centrifugal Pumps * Centrifugal Pump Operation * Positive Displacement Pumps * Valve Functions And Basic Parts * Types Of Valves * Valve Actuators * Air Compressors * Hydraulics * Boilers * Cooling Towers * Demineralizers * Pressurizers * Steam Traps * Filters And Strainers NUCLEAR PHYSICS AND REACTOR THEORY. The Nuclear Physics and Reactor Theory Handbook includes information on atomic and nuclear physics; neutron characteristics; reactor theory and nuclear parameters; and the theory of reactor operation. * Atomic Nature Of Matter * Chart Of The Nuclides * Mass Defect And Binding Energy * Modes Of Radioactive Decay * Radioactivity * Neutron Interactions * Nuclear Fission * Energy Release From Fission * Interaction Of Radiation With Matter * Neutron Sources * Nuclear Cross Sections And Neutron Flux * Reaction Rates * Neutron Moderation * Prompt And Delayed Neutrons * Neutron Flux Spectrum * Neutron Life Cycle * Reactivity * Reactivity Coefficients * Neutron Poisons * Xenon * Samarium And Other Fission Product Poisons * Control Rods * Subcritical Multiplication * Reactor Kinetics * Reactor |
| free root cause analysis training: Financial Audit David M. Walker, 2004-03 Internal Revenue Service (IRS) collections are significant in relation to federal receipts &, in turn, to the consolidated financial statements of the U.S. government. Therefore, the U.S. Congress is very interested in financial management at IRS. The General Accounting Office (GAO) audits IRS's financial statements annually to determine whether: (1) the financial statements IRS prepares are reliable, (2) IRS management maintained effective internal controls, and (3) IRS complies with selected provisions of significant laws and regulations and its financial systems comply with the Federal Financial Management Improvement Act of 1996 (FFMIA). Charts and tables. |
| free root cause analysis training: Simplifying Cause Analysis Chester D. Rowe, 2017-11-20 When the challenge is to get to the heart of a problem, you need a simple and efficient cause investigation methodology. And what would make a real difference would be an interactive map to lead you to the answer every time. Chester Rowe’s Simplifying Cause Analysis: A Structured Approach is your instruction book combined with the included downloadable Interactive Cause Analysis Tool you have been looking for. The author intends this book for professionals like you, who have some familiarity with cause analysis projects and are looking for a simple and efficient cause investigation methodology –is a more effective and insightful way of asking “why?” Introducing his multi-function event investigation tool, Chester Rowe says, “There are already many scientific tools to help us understand the physical causes for machine failures; the challenge now is to find a way of investigating human performance failure modes...humans are often a major source of slips, lapses, and mistakes.” Supporting his instructions with diagrams, charts, and real-world examples from companies like yours, the author takes you step-by-step through planning, completing, and documenting your investigation: Chapter 1 gives you a process to determine the level of effort that your investigation should encompass, assess the level of effort needed, and determine the rigor needed. Your investigation needs to be as risk-informed as possible. Chapters 2 through 5 presents a new and innovative structure –rigorous yet intuitively easy to remember – to identify the underlying causes for the event (Cause Road Maps) and conduct the investigation. Chapter 6 introduces conceptual human performance models and tells you how to begin focusing on the human behaviors involved. Chapters 7 and 8 present you with methods, tools, and techniques for carefully interviewing personnel. Chapters 9 through 13 “put the pieces together,” showing you how to analyze and model the event, determine corrective action, and document the investigations and findings. Chester Rowe developed the Cause Road Map over many years to provide a comprehensive taxonomy for every cause investigation. However, fully implementing the Cause Road Map requires the use of other tools to organize, analyze, and present the final results of your investigation. To get you started, Rowe includes his downloadable Interactive Cause Analysis Tool – an easy-to-use tool in familiar spreadsheet format – free with your verified purchase of the book. |
| free root cause analysis training: The Quality Toolbox Nancy Tague, 2004-07-14 The Quality Toolbox is a comprehensive reference to a variety of methods and techniques: those most commonly used for quality improvement, many less commonly used, and some created by the author and not available elsewhere. The reader will find the widely used seven basic quality control tools (for example, fishbone diagram, and Pareto chart) as well as the newer management and planning tools. Tools are included for generating and organizing ideas, evaluating ideas, analyzing processes, determining root causes, planning, and basic data-handling and statistics. The book is written and organized to be as simple as possible to use so that anyone can find and learn new tools without a teacher. Above all, this is an instruction book. The reader can learn new tools or, for familiar tools, discover new variations or applications. It also is a reference book, organized so that a half-remembered tool can be found and reviewed easily, and the right tool to solve a particular problem or achieve a specific goal can be quickly identified. With this book close at hand, a quality improvement team becomes capable of more efficient and effective work with less assistance from a trained quality consultant. Quality and training professionals also will find it a handy reference and quick way to expand their repertoire of tools, techniques, applications, and tricks. For this second edition, Tague added 34 tools and 18 variations. The Quality Improvement Stories chapter has been expanded to include detailed case studies from three Baldrige Award winners. An entirely new chapter, Mega-Tools: Quality Management Systems, puts the tools into two contexts: the historical evolution of quality improvement and the quality management systems within which the tools are used. This edition liberally uses icons with each tool description to reinforce for the reader what kind of tool it is and where it is used within the improvement process. |
| free root cause analysis training: Root Cause Analysis and Improvement in the Healthcare Sector Bjørn Andersen, Marti Beltz, 2009-11-09 Healthcare organizations and professionals have long needed a straightforward workbook to facilitate the process of root cause analysis (RCA). While other industries employ the RCA tools liberally and train facilitators thoroughly, healthcare has lagged in establishing and resourcing a quality culture. Presently, a growing number of third-party stakeholders are holding access to accreditation and reimbursement pending demonstration of a full response to events outside of expected practice. An increasing number of exceptions to healthcare practice have precipitated a strong response advocating the use of proven quality tools in the industry. In addition, the industry has now expanded its scope beyond the hospital walls to many ancillary healthcare facilities with little experience in implementing quality tools. This book responds to the demand for a RCA workbook written specifically for healthcare, yet still broad in its definition of the industry. This book contains everything that the typical RCA leader in healthcare requires: A text specific to healthcare, but using the broadest definition of the industry to include not only acute care hospitals, but rehabilitation facilities, long-term care facilities, outpatient surgery centers, ambulatory services, and general office practices. A workbook-style format that walks through the process, step-by-step. Straightforward text without “sidebars,” “tables,” and “tips.” Worksheets are provided at the end of the book to reduce reader distraction within the text. A wide range of real-world examples. Format for use by the most naive of users and most basic of processes, as well as a separate section for more advanced users or more complex issues. Templates, both print and electronic, included for the reader’s use. Ready-to-use educational materials with scripting to enable the user to train others and garner support for the use of the techniques. Background text for users in leadership to understand the tools in the larger context of healthcare improvement. Up-to-date information on the latest in the use of RCA in satisfying mandatory reporting requirements and slaying the myth that the process is onerous and fraught with barriers. Background text and tools/process are separated to facilitate the readers’ specific needs. Healthcare leaders can appreciate the current context and requirements without wading through the actual techniques; end-users can begin learning the skills without wading through dense administrative text. Language and tone promoting the use of the tools for improvement of processes that have experienced exceptions, as opposed to assigning blame for errors. Attention to process ownership, training, and resourcing. And, most importantly, thorough description of the improvement process as well as the analysis. |
| free root cause analysis training: Getting Value out of Agile Retrospectives Luis Gonçalves, Ben Linders, 2015-01-28 Getting Value out of Agile Retrospectives helps you and your teams to do retrospectives effectively and efficiently. It's a toolbox with many exercises for facilitating retrospectives, supported with the what and why of retrospectives, the business value and benefits that they bring, and advice for introducing and improving retrospectives. If you are a Scrum master, agile coach, project manager, product manager or facilitator then this book helps you to discover and apply new ways to do Valuable Agile Retrospectives with your teams. With plenty of exercises you can develop your own personal Retrospectives Toolbox to become more proficient in doing retrospectives and get more out of them. |
| free root cause analysis training: Process Implementation Through 5S Drew Willis, 2017-07-27 Process Implementation Through 5S: Laying the Foundation for Lean explains how to implement standardized work and visual controls through Plan Do Check Adjust (PDCA). The author uses PDCA to outline the book and explains how 5S (Sort, Straighten, Shine, Standardize, and Sustain) and Standardization are not only foundational parts of the PDCA for yo |
| free root cause analysis training: School Leader's Guide to Root Cause Analysis Paul Preuss, 2013-09-27 Don’t jump from problem to solution without first investigating root causes. This book helps you more accurately focus on school improvement issues, so you can avoid wasting precious time and resources. It is clearly written, contains lots of real examples, and is presented in a style and format designed for the non-expert. It will help you make decisions which will improve learning for all students. |
| free root cause analysis training: Root Cause Analysis Robert J. Latino, Mark A. Latino, Kenneth Latino, Kenneth C. Latino, 2006-05-05 There is no easy answer to the question, What is RCA? Some will give a general idea of what Root Cause Analysis (RCA) is designed to accomplish, while others will advocate a specific approach. In this third edition of the best-selling Root Cause Analysis: Improving Performance for Bottom-Line Results, acclaimed experts Robert and Ke |
| free root cause analysis training: School Leader's Guide to Root Cause Analysis Paul Preuss, 2013-09-27 Don’t jump from problem to solution without first investigating root causes. This book helps you more accurately focus on school improvement issues, so you can avoid wasting precious time and resources. It is clearly written, contains lots of real examples, and is presented in a style and format designed for the non-expert. It will help you make decisions which will improve learning for all students. |
| free root cause analysis training: Official (ISC)2® Guide to the ISSMP® CBK® Joseph Steinberg, 2011-04-11 As the recognized leader in the field of information security education and certification, the (ISC)2 promotes the development of information security professionals around the world. The Certified Information Systems Security Professional-Information Systems Security Management Professional (CISSP-ISSMP ) examination assesses individuals understa |
| free root cause analysis training: TapRooT , 2007 |
| free root cause analysis training: Lean Materials Planning and Execution Donald H. Sheldon, 2007-11-15 This informative volume explores the roots of high-performance materials management, and enables supply managers to make the right choice of process control at the right time. |
| free root cause analysis training: How to Perform Operative Procedures in Obstetrics and Gynaecology Wai Yoong, Abha Govind, Wasim Lodhi, 2020-06-30 British Medical Association Book Award Winner - Obstetrics and Gynaecology 2021 Trainees in Obstetrics and Gynaecology require robust operative skills, yet factors such as the implementation of structured training and increased litigation concerns have significantly limited training time. Whilst conventional textbooks are sufficient for presenting theoretical knowledge, they are inadequate in explaining practical procedures. How to Perform Operative Procedures in Obstetrics and Gynaecology thoroughly describes many key index operations in the Royal College of Obstetricians and Gynaecologists training syllabus, offering an innovative, media-rich approach to the subject. Written by a team of O&G practitioners, this unique resource combines concise written instructions, full-colour pictures and diagrams, and hours of high-quality video footage of real-life operations, narrated by experienced NHS consultants. Specialty trainees, MRCOG candidates and post-MRCOG doctors are provided clear, easy-to-follow guidance on procedures including assisted vaginal delivery, Caesarean section, abdominal hysterectomy, diagnostic and operative laparoscopy, cone biopsy, rigid cystoscopy and many others. Features a companion website containing more than six hours of video tutorials, vignettes and personal experiences Includes a colour WHO Surgical Safety Checklist Discusses non-technical aspects such as consent and understanding human factors Covers surgical instruments, surgical positioning, and sutures and needles Offers introductions, overviews, and Top Tips for each procedure to highlight important learning points An ideal study guide and reference for individual and group work alike, How to Perform Operative Procedures in Obstetrics and Gynaecology is indispensable for specialty trainees and those preparing for MRCOG examinations. |
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