At the 2016 PARMA Conference, Jeff Rush from California Joint Powers Insurance Authority (JPIA) and DeAnn Wagner from York Risk Services Group discussed how identifying the root cause of the workers’ compensation claims leads to a better approach with loss control measures, increased accountability and improved enactment of safety protocols and policies.
Generally, there are three causes to every accident: the immediate cause, the contributing cause and the root cause. For example, if an employee slips on a wet floor and fractures their arm, the immediate cause was the fall, the contributing cause was the wet floor, but the root cause may be a leaking pipe that caused the floor to be wet.
The purpose of a root cause analysis is not to find blame, but instead to focus on loss prevention and control. This is part of developing a safety culture. It is important to not only analyze accidents, but also near-misses which if not corrected could lead to accidents in the future.
Benefits of a Root Cause Analysis:
- Identify trends within departments where improvements can be made.
- Loss control measures can be implemented based on tangible evidence of cause and effect.
- Promotes safety and accountability by involving key stakeholders in analysis
- Provides an avenue to help control future losses by identifying where the process or task failed.
The California JPIA covers 108 state agencies in their pool. They started that their pilot program with eight agencies. The supervisor report was modified to include the root cause analysis. This information was also obtained in conversations with the injured worker. When they first started, “non-preventable” was on the list of root cause choices. They eventually removed this because too many people were selecting that option.
The technique for finding the root cause is to ask “why” at least five times until you reach a point where the root cause is identified. You are trying to find out exactly which “why” was the cause of the accident. It may be something like failure to follow established safety procedures that could have prevented the accident to begin with. There was a lot of training needed to get the supervisors to understand the root cause analysis.
The Five Why’s Technique:
- Developed in the 1930s by Sakichi Toyoda, founder of Toyota. Still used by Toyota today.
- Simplicity of this tool gives it great flexibility, and it combines well with other methods and techniques.
- Each time “why” is asked, look for an answer that is grounded in fact.
- Keep asking “why” until you feel confident that you have identified the root cause and can go no further.
Their top identified root causes were:
- Distractive / Inattentive
- Continuous Trauma / Repetitive Strain
- Third-Party Causation (suspects with police injuries)
- Third-Party Causation
These root causes accounted for 64% of accidents and 65% of paid losses.