by Robert J. Latino, CEO of Reliability Center Inc.
In my previous post (RCA has a Public Relations Problem) I described how time pressures on care providers are likely to lead to short cuts or ‘Shallow Cause Analysis” (SCA). Such approaches help explain why RCA efforts fail i.e. they haven’t been done properly in the first place. Here are four common short cuts:
1. We tend to accept hearsay as a fact as we do not have the time to go out and collect hard evidence to back up assumptions/opinions.
2. We tend to ask only “Why” and not “How Could”. While this seems trivial on the surface, think about the difference in the population of answers. I do not consider 5-Whys a valid RCA approach because it asserts A) there is only a linear path to failure, B) opinion serves as fact and 3) there is only one root cause to any event. These are simply not true. The fact is that things happen in parallel (asking ‘How Could’ connotes more than one answer) to cause undesirable outcomes. Unfortunately there are more often than not, multiple root causes and contributing factors to bad outcomes. I don’t know they stop at ‘5’ whys…why not 3 or 8? True RCA will seek to find the multiple paths of failure that combined to cause the bad outcome and use solid evidence to back it up.
3. Time pressure can force us to use ‘pick list’ RCA. This means there are a series of drop down menus where we select the option closest to what we ‘think’ happened. The potential issue with this route is that all the possibilities of what could have happened, will never ALL be in our drop downs. Therefore we will pick what is closest. Eventually this type of RCA drives us to a predetermined conclusion. However, it makes life easier for those compiling the RCA statistics because it is easier to trend across the RCA database. The problem is we are making it easier to trend potentially bad information:-)
4. We tend to use regulatory/standards RCA forms because we believe that by using that form, there is a greater chance the auditor will accept my submittal. On the surface, this is probably true (unfortunately). Most regulatory and standards RCA forms are very similar in format. They are a ‘one-size-fits all’ solution to RCA. We ask the same questions no matter the event. This is called ‘categorical’ RCA in our business. We ask about the standard cause categories and what we felt could have gone wrong in them. Then we fill in the blanks with what we ‘think’ went wrong, because we don’t have the time to collect the real evidence. Such forms are desirable for the receiving agencies for the same reasons as described in the Pick List item (3), it provides consistency of how information is submitted so it is easier to compile statistics. This is fine, but where are the correlations of accepted RCA’s to bottom-line improvements in patient safety?
Whenever anyone is time pressured to do most anything, our natural human tendency is to take shortcuts. This often takes the form of skipping steps in a sequence of tasks. The same is true for effective RCA. When we are time pressured to conduct our RCA’s, we have a tendency of taking shortcuts to produce an acceptable report. Unfortunately, what is often expensed in the RCA is the time to properly and adequately collect the data (evidence) to prove the hypotheses in our analysis are accurate. As a result, we allow hearsay to fly as fact and the integrity of our analysis is therefore compromised.
Two of the keys of High Reliability Organizations (HRO) are reported to be, 1) Preoccupation with Failure and 2) Reluctance to Simplify[i]. To me, these work in unison. Our preoccupation with failure means we will do RCA on failures other than only those required to meet regulatory minimums (e.g. – do RCA’s on chronic failures and high risks). Secondly, when we do RCA, we will not take the path of least resistance. We will not do what is easiest like the 5-Whys for serious events simply because it takes less time, is inexpensive and is acceptable…but produces a less than optimal outcome. When we take the path of simplification, we are opening ourselves to an increased risk of recurrence of the undesirable outcome.
[i] Weick, K.E., Sutcliffe, K.M., Managing the Unexpected; Resilient Performance in an Age of Uncertainty, 2nd ed., Jossey Bass, San Francisco, 2007, 9 [Chap. 1]
Robert J. Latino, CEO of Reliability Center Inc., (RCI). RCI is a Reliability Consulting firm specializing in improving Equipment, Process and Human Reliability. Mr. Latino received his Bachelor’s degree in Business Administration and Management from Virginia Commonwealth University.
Robert has been facilitating RCA & FMEA analyses with his clientele around the world for over 29 years and has taught over 10,000 students in the PROACT® Methodology. Mr. Latino is co-author of numerous seminars and workshops on FMEA, Opportunity Analysis and RCA as well as co-designer of the national award winning PROACT Suite Software Package.
Reliability Center, Inc. Hopewell, Virginia Tel: 804.458.0645 Fax: 804.452.2119 www.Reliability.com
Recently Authored or Co-Authored Books:
Latino, Robert J., Latino Kenneth, C. and Latino, Mark A. Root Cause Analysis: Improving Performance for Bottom Line Results. 4th Ed., 2011, c. 280 pp., ISBN: 9781439850923, Taylor & Francis. Boca Raton.
Latino, Robert J. Patient Safety: The PROACT Root Cause Analysis Approach. 2008, c. 272 pp., ISBN 9781420087277, Taylor and Francis. Boca Raton.
Contributing Author: Error Reduction in Healthcare: A Systems Approach to Improving Patient Safety. 2nd ed, 2011 [Apr], c. 284, ISBN: 1-55648-271-X, AHA Press.
Contributing Author: The Handbook of Patient Safety Compliance: A Practical Guide for Health Care Organizations. 2005, c. 350 pp. ISBN 0-7879-6510-3, Jossey-Bass .
Authored or Co-Authored Papers:
Latino, Robert. (2013). Improving Reliability with Root Cause Analysis. Patient Safety & Quality Healthcare. September/October 2013.
Pil, Tricia MD. (2010). Follow Up:A Deeper Look at Root Cause Analyses. Science and Sensibility Blogpost, Published response by Robert Latino 11/29/10.