Problem solving using the RCA and prioritising in planning
Once a nation is free it must also be free to work …….
A pay cheque maketh a living,
BUT work maketh a life. J Tibane
Activity
What is your vision as a DCST for your district?
10 minutes
The challenge model
Measu
rable resu
lts (ap
pro
priate in
dicato
rs)
DCST VisionImprove maternal neonatal and child
health outcomes in South Africa
Challenge/opportunities = Identified problems/challenges
Current situation = COMPLETED SITUATIONAL ANALYSIS (Based on the MSH Challenge Model)
Root cause analysis of selected priority problems
Priority actions
• Equity considerations• Feasibility
• Acceptability to community• Appropriateness
(effectiveness) • Cost effectiveness
NB Focus on one challenge at a time
Workplan• Targets• Time frames• Resources
etc
A root cause analysis involves asking "Why?" coupled with the determination to find answers that will help permanently resolve or at least improve the situation being dealt with.
WHY!
"Why did the problem happen?". If the answer tells you how to fix the problem but not how to prevent it in the future, then you need to keep asking why.
Root cause analysis is not for the faint-at-heart
Asking probing questions and searching for answers about why things went wrong can make you unpopular, especially if your investigation involves other teams and other managers.
RCA steps
Collect information (situational analysis)
Categories
Causal factor charting
Root cause identification
Recommendations
RCA showing collective responsibility
Assessment done by Haroon Saloojee
Division of Community Paediatrics
"I'll be the first to say someone's head must
roll, but in this instance there is no
basis to fire any human being or
subject anyone to disciplinary
procedures. There is no clear evidence.”
Klebsiella was found in almost all the
feeding bottles, which had not been cleaned
properly.
“Some of the things that parents raised with us were that their children were left with vomit un-
cleaned, babies were left to lie in wet and soiled
incubators, ...same syringes were used more than once ...
nurses not responding to their calls while they were busy gossiping
about each other. These issues are going to be
followed up”
“The team that has done all these things is known by all the parents and the
CEO knows them. Where disciplinary
measures have to be taken, they will be
taken”
A gap analysis – asking why?
High MMR in District A
Late ANC attendance
Ishikawa diagramsMeasurements PersonnelMaterials
EquipmentMethodsEnvironment