The (over) Enthusiasm of Youth. A long time ago (over quarter of a century), in a Galaxy far, far away (St. Mellons, East Cardiff) I learnt all about Root Cause Analysis (RCA), and my life was enriched. I was freshly equipped with a science degree, doing science based things at work and RCA fitted perfectly.
A large part of my day job involved getting to the ‘root cause’ of the pollution that affected the rivers of South Wales. The basic principle of RCA and techniques like the Ishikawa Fish Bone Diagram approach were exactly what I needed. It provided a common understanding and a language to use with the skeptical Production Managers at the factories I visited. Places where diesel (or any other contaminant) was leaking into the river from an unknown source on site. Lovely! All rewarding detective work involving science and RCA.
Hello 5 Whys. Imagine my excitement around that time when my wife introduced me to the 5 Whys (It’s one of the many reasons I love her so much). She was involved in heath care improvement and it was one of the ‘new’ techniques they were teaching to practitioners.
Our joint enthusiasm for 5 Whys extended to dragging our kids around the Jefferson Memorial in Washington DC on holiday a few years later. The kids were incredulous as we searched for evidence of; midges, spiders, pigeons, pigeon poop and stone damage. They have never really forgiven us, details here in Busman’s Holiday. The Jefferson Memorial and Root Cause Analysis.
A Struggling Padawan Learner. Fast forward a bit to the swamps of Dagobah (Star Wars reference, and possibly a good metaphor for some of the Audit rooms I’ve occupied). I’m now meeting challenges that aren’t as straightforward as ‘find the leaking chemical tank’. Problems can’t be easily reduced down into a single cause using the RCA tools I used to love. Let me explain a bit.
The problems I’d previously encountered usually had defined boundaries – literally in some cases, like the factory fence. There were clearly identified assets; chemical storage areas, transport routes, production areas and points at which chemicals could run into the drains and the river. There was also the human operator side, people with clearly defined roles in the production system, who (should) know what they are doing.
My root cause analysis tools were perfect for that environment.
However, the challenges I was now facing were different. Some were far more complicated – there was a lot more going on. Many were actually complex; unpredictable, dynamic and driven by human behaviours. An entirely different ball game.
This didn’t stop me trying to apply RCA methods though. This was not a good approach. Sometimes it didn’t matter too much, I’d just end up in a mess and getting nowhere. Sometimes it could have been a bit more damaging – coming to a ‘root cause’ conclusion that was actually wrong. Wrong in the sense that it was only one of many possible ‘root causes’ that could have contributed to the outcome I’d seen.
You may have seen this yourself? The focusing down on one ‘answer’ because it ‘fits’ and is ‘convenient’ rather than looking closely at other possibilities? You see it everywhere if you are prepared to look.
Luke… Use the Force… So, I felt like I was in a bit of a mess. At such times its always worth looking beyond your current ‘Universe’ to see what others do. One of the places I looked was at what Dave Snowden had to say. The early 2000’s session he used to do on the ‘Invisible Gorilla’ and Inattentional’ Blindness‘ changed how I thought about things.
The idea of ‘sense-making’ became part of my thinking and is where the title of this post comes from… If a struggling Padawan learner was looking for advice – this is what I imagine a Jedi Teacher might say. Massive apologies to Star Wars enthusiasts…
“Luke… Root Cause Analysis 5 Whys is not the method you are looking for… It’s fine in a controlled and predictable environment (like manufacturing). Be aware of it’s limitations when things get more complicated. But if the situation is complex, be cautious, look towards sense-making, and use the force…”
RCA does have a place. Apologies if I’ve broken any Star Wars etiquette, I just wanted to make the point. I also wanted to say that I’m not against RCA in any way. A while back I even went as far as producing a sketch-note on it – above.
RCA is a very useful tool in the right context, situations where the situation is Clear or Obvious from a Cynefin Framework perspective. Where things are Complicated, you run the risk of focusing too narrowly, when there might be several ‘root’ causes – not just one. That can be quite dangerous in the case of investigations where you are looking for ‘responsible parties’ (…who’s to blame?).
If you want detailed examination of the limitations of RCA in healthcare I suggest looking at this article from the British Medical Journal Quality and Safety publication by Dr Alan J Card, The problem with ‘5 whys’.
Some key points for me:
- 5 Whys is a great teaching tool. But it is based on ‘idealised’ situations that are hard to repeat in real life. Worst of all – the Jefferson Memorial example isn’t actually correct! I’m gutted (wait till I tell the kids).
- “…accidents are seldom the result of a single root cause. So focusing exclusively on one (or even a few) arbitrarily determined ‘root causes’ is not a reliable method for driving improvement—especially in a system as complex as healthcare.” (see my point above)
- RCA and 5 Whys have come from vehicle manufacturing, often referred to as ‘High Reliability Organisations’. It is not applicable to use these techniques in much of healthcare (or many of the situations seen across complex public services). Have a look at what I’ve written about ‘Silver Bullet solutions’.
Well, what does that leave us with? I did mention sense-making earlier… I am planning to follow up on this post and link to some ideas about how RCA can complement a sense-making process. It’s not about finding a ‘root cause’, but probing, learning and making sense of what is actually happening, and what might be possible.
If I dare to still make Star Wars references, it might even be a trilogy (of four posts)…
So, What’s the PONT?
- Root Cause Analysis and 5 Whys are useful methods – in the right context.
- No single method or tool will be useful in all situations. One size never fits all. Always consider what is the most appropriate tool for the job.
- Lifting a successful approach from one industry and dropping it into another is fraught with difficulties. Someone else’s ‘silver bullet’ is unlikely to work in your context.
Great write up, and it reminds me of my learning journey of moving into more systemic ways of sense-making. It also fits in well with complexity and different ways of understanding problems that Grint describes so well.
Thanks very much.
Listening to Keith Grint talk about wicked problems was an important part of shaping how I think about these things.
Only last week I was looking at his example ‘best practice’ for the high jump and how Dick Fosbury smashed it with new practice.
Not sure how a bit of traditional RCA would have resulted in improvement there…
Nicely put Chris.
When I worked in NZ I used to fly regularly as part of my job, probably once a fortnight. At the same time I developed a fixation with watching ‘Air Crash Investigation’ on Nat Geo Channel. (My wife thought this combination somewhat disturbing….).
There is a point to this drivel btw – as shown by my new found TV watching habit – many air accidents are caused not by one problem i.e. no root cause. There are multiple factors which combine in some way to break through all the controls placed on air travel safety. Colloquially known as the swiss cheese model – https://en.wikipedia.org/wiki/Swiss_cheese_model . Its a counter punch to support your article that sometimes there is no one root cause but many, which combine in some way in that particular instance to bring about failure.
The Swiss Cheese Model is a favourite – with its own limitations, but I guess that fits my (biased) view that tools need to be appropriate for the job.
Swiss Cheese beats RCA 5 Why’s when things get complicated.
For complex issues I’m drawn to more of a sense-making approach.
It’s not about finding a ‘root cause’, but probing, learning and making sense of what is actually happening, and what might be possible.
One for a deeper chat,