Thank you Gyuchan. Great video. It is especially interesting to me that Root Cause Analysis, in your video, is framed as an NHS 'performance-management tool' targeting clinician errors. This was never the intention when RCAs were introduced to Australian Healthcare. Instead it was meant as a 'systems-oriented' tool that was supposed to avoid blame. However (aside from the obvious shortcomings of applying RCA methodology in complex systems) there is a fundamental problem that healthcare executives and clinicians have not yet understood: when a serious adverse - analysis for determining accountability, and analysis for preventing future adverse events. Both processes are important and necessary (yes, some unsafe acts _are_ blameworthy), but should be kept separate - otherwise any well-intended systems improvement tool (RCA/London Protocol etc) just becomes another (albeit more sophisticated) blame weapon.
Sorry - there was a gap in my text which should have read "when a serious adverse event occurs, at least two analytical processes are triggered - analysis for determining accountability, and analysis for preventing future adverse events".
I believe in system view. I believe we need the population to notice when a system is effecting the situation, and research specific systems. Also a big part of this view, is understanding the strings between systems. Too many strict examples, we can't see the picture of system vs non-system because you didn't show enough good examples, didn't make it clear the measures taken in comparing the two, and really missed on what make a situation better handled by system view. Thanks anyway for pushing the idea.
