Root cause analysis is a system for analyzing and creating a plan to correct problems within your organization or workplace. Created by the Nevada Division of Public and Behavioral Health.
What the medical industry will discover through root cause analysis, as I did over nearly 3 decades of being involved with quality management, is that there is no such thing as "Root Cause" relative to a process failure. Operational process are a complex assembly of many working bits, not simply a single operational entity (like machines). Therefore, thinking that there is a single root of causation which lead to a process failure is ludicrous. The single best tool that the medical industry could use to discover process failure is to map the process in swim lane format with all of the relative players involved. This map becomes a picture of the process, and all of its inherent points of failure. This is a time consuming process, so its very often ignored and replaced with a more inefficient activity such as 5 why or fishbone analysis (aka guess the causes). The whole of the point is that rarely do organizations ever understand the complexity of their interacting processes. Further, since such processes are not well understood, they often fail and they do such repeatedly. Secondly, I have learned through experience, that its accountants (not quality professionals) who understand and apply process controls most effectively. ----- The healthcare industry could learn quite a bit from: Quality folks about variation Insurance folks about risk assessment Accounting folks about Process control
excellent comment, thank you. Yes, so far (studying RCA for about a month now) seems to come closest to a "who can we blame" game. I see some value in it, but it's not the whole picture. I need to look up the "swim lane" tool you mentioned. Sounds interesting and valuable.
