Root Cause Analysis

When things go wrong, or systems break down, the tension is to place the blame on the immediate cause of the mishap.

This is normal. Someone forgot to sign and date the document. Who gets blamed? The person who did not sign and date the document will usually be singled out.

While the immediate cause is the fact that the person did not sign and date the document, unless the root cause is determined the chance of the incident reoccurring is probable.

So let's look at a procedure that could help reduce mishaps and break downs of systems. The procedure is called Root Cause Analysis (RCA).

Wikipedia defines Root Cause Analysis (RCA) as “a class of problem solving methods aimed at identifying the root causes of problems or events.”

While Root Cause Analysis is used routinely in industry, in the health-care field it is almost exclusively used after a sentinel event has occurred.

The Joint Commission for the Accreditation of Health Care Organizations (JCAHO) defines a sentinel event as “an unexpected occurrence involving death or serious physical or psychological injury or the risk thereof.” The phrase 'or the risk there includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Such events are called 'sentinel * because they signal the need for immediate investigation and response ”

I believe that Root Cause Analysis is under-utilized in the health-care field because many organizations limit its use to sentinel events. The use of RCA in situations other than sentinel events could go a long way towards greatly reducing the breakdown of systems, which in most cases are seen as being caused by the person or persons directly / immediately involved in the breach.

Scenario Without the Use of Root Cause Analysis:

1. An incident occurs after determining the immediate “culprit” the incident is written up and there may be some corrective action taken. Perhaps an action plan is developed.

2. In many cases the corrective action consists of disciplining the person who was found responsible, without determining the root cause.

3. If the root cause is not determined the breakdown will probably reoccur.

My point is that to find the root cause of a mishap or breakout, RCA should be routinely used. So you may ask if Root Cause Analysis is so effective why is not it used routinely?

Let's examine some of the resistances, to using RCA for mishaps other than sentinel events?
1. Many individuals and organizations do not know what RCA is.
2. Many organizations think that RCA is for sentinel or other very serious events only, and therefore they do not consider its use for more mundane events.
3. The RCA procedure can consume time and other resources, and this allows the procedure to remain unused.
4. RCA may be thought of as “something that we have to do” after a sentinel event and its value for incidents other than sentinel events may be under-valued.
5. Probably the rationale most often used against RCA is the belief that <4we know the reason this has happened and we do not need RCA to corroborate it. "

Whatever the reason why RCA is not routinely employed for routine problems, the fact is, it is not. I am advocating for the routine use of RCA to identify the root cause of many organizational problems, in addition to its use apropos of sentinel events.

So just how is a Root Cause Analysis performed?

First, there is no one-way, or only-way to proceed. Much of how the RCA enfolds depends upon the resources available for the investigation. The RCA could be carried out in a variety of ways, again depending on the resources available. How well the procedure works for your organization depends on how seriously the procedure is accepted by the management and staff.

Perhaps the first, and most important, step is to have a culture that fully endorses the RCA process. This culture begins with the highest ranking staff member and spreads through the organization from the top down.

Root Cause Analysis does not try to identify someone to blame, but it looks for a root cause that if left unattended will probably result in a recurrence of the problem.

RCA believes that it is usually a breakdown in a process that has caused the problem, not the person who was immediately responsible for the problem.

The Process:

Organizational Culture
The ultimate success or failure of the Root Cause Analysis process in any organization is heavily predicated on the culture of that organization.
If the organization can answer in the affirmative to the majority of the above questions it will in all probability be successful in its quest for the root cause of a problem or event.