Our view is organizations should not try to differentiate problem solving, root cause analysis or common cause analysis. All of these methods are based on cause-and-effect. The cause-and-effect principle should be the basis for all reliability, problem solving and patient safety issues.We’ve been leading investigations and presenting workshops to clients in manufacturing and process industries for years. Our root cause analysis methodology is called Cause Mapping. We use this term since a map is a visual representation of the actual terrain. A Cause Map, therefore, should look like the actual incident. Besides the term Cause Mapping we use no other terminology. Our method is based on the fundamental principle of cause-and-effect and the definition of the word cause from the dictionary.
The more an organization focuses on the underlying principles the more effective they become. The opposite of this approach is called the program-of-the-month or acronym-of-the-month. Cause-and-effect analysis doesn’t change from big issues to small issues. The cause-and-effect principle is the same for a medication error as it is for the loss of the Columbia shuttle. The reason it’s called a principle is because it doesn’t change. A principle is independent of the problem, the industry and the magnitude of the issue.
When organizations focus on techniques and jargon they inadvertently create “method confusion.” We un-complicate things. Our approach helps organizations develop a clear understanding of the relationships between risk, reliability and root cause analysis. The people who are actually perform the work are the key. They are the experts on improving the reliability of healthcare processes. Tools such as FMEA, 5S, 8D, Six-Sigma, RCM, RCA, Kaizen etc. can be applied effectively and they can be applied ineffectively. The tools are sound, not because of the technique itself, but because of the underlying principles. When individuals believe that common cause analysis is different from root cause analysis which is different from problem solving and troubleshooting it creates unnecessary confusion, wastes huge amounts of time and unfortunately doesn’t improve the reliability of the system.
The focus of all problem solving should be to first understand the basics of cause-and-effect. From this point people realize that RCA is simply cause-and-effect analysis for what DID happen and FMEA or risk mitigation is cause-and-effect analysis for what COULD happen. Most organizations make their problem solving too complicated. Several intelligent individuals in a group doesn’t necessarily result in an intelligent group. An important aspect of an root cause analysis is how well the group communicates. This is why our clients consider the Cause Mapping method to be such a valuable tool, creating a visual dialogue, to utilize all of the knowledge within an organization.
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