The Just Audit team
RCA Part 6: Look beyond what happened
(or ‘Don’t blame the dog’)
This is the sixth in a ten-part series of articles on Root Cause Anaylsis, highlighting the principles behind Sologic’s approach to solving complex problems (sologic.com). All articles are based on originals by Ed Wells, author of Sologic’s excellent e-book, ‘Better than Yesterday’.
Put a problem in context and look all around it. Don’t just look at a negative outcome of an action. Look at the action. Consider the environment and everything related to it. What enables this action and outcome to take place?
Imagine spilling water from a bottle. You not only have to tip the bottle over (the ‘what happened’), you also have to have water in the bottle and no top on the bottle to restrict any leak. Usually, when we begin to investigate any problem, big or small, our immediate temptation is to try to understand everything that happened – what decision was made, what action was taken, what change occurred. Ineffective investigations stop there.
Great problem solvers know that these actions (which normally involve a person or group of people) only ever reveal part of the causes of any problem. When we look closely, we realise that the majority of causes are to be found elsewhere, hidden in the conditions that surrounded ‘what happened’. At best, with this approach, with part of the cause, we’ll only ever resolve part of the problem.
Imagine a household with a dog that’s hellbent on escape, causing its owners no end of stress. The issues surrounding this might not have anything to do with the dog actually escaping. Looking at the broader picture it could be that he needs more exercise, the house isn’t secure enough, there’s a particularly nice smelling lady dog across the street, he doesn’t get any attention, he has little training… you can see that the problem (the escape) is not actually the problem. The escape is just the result of the problem so it’s important to step back further. The situation needs weighing up, assessing from all angles and measures put in place to prevent the undesirable behaviour – the dog wanting to escape. Just like the water example, someone needs to work out that the bottle needs a lid on and putting in a different place to create an effective solution to the problem of spillages.
My favourite one is having places in your office or home that become dumping grounds – we all have them. The problem isn’t usually having too much stuff, it arises from lack of suitable storage and not finding ways that make correct storage easy/successful. If everyone dumps their shoes by the front door and you’re falling over them, buy a big basket and store them in there. The problem isn’t the shoes, it’s the lack of effective, well-located and simple storage. And also a system that has buy-in and makes sense for everyone involved.
It’s the same for bigger, work-related issues. The conditions surrounding a problem encompass the hidden players in the game: these could be long established systems, expectations and structures. It could mean the tools, hardware and software we use, or we could mean the more intangible conditions that are at play in any scenario. This might include workspaces, rotas, guidelines, schedules, KPIs, training levels, hierarchies and external regulation. It’s important to consider and challenge everything. It could be time to change processes and how we do things.
Organisations that focus their problem-solving activity on ‘what happened’ tend to gravitate towards people-orientated solutions. These solutions usually fall into one of three categories; re-train, re-write and re-communicate – more rules, more regulations, more guidelines – the very things that were ignored the first time around. These 3-Rs tend to offer medium effectiveness at best and can easily allow a blame culture (come back and read our next article in March). The issue isn’t that the 3-Rs don’t have value, they do! It’s simply that the temptation is to place too many of our solutions in this area – loading even more pressure and stress on our workforce.
Solutions applied to conditions are more robust and far more sustainable. Don’t blame the dog!
Have you looked beyond the obvious?
Have you identified the systemic causes?
Without effective analysis, it’s all too likely that focus orientates towards people and the actions they undertake. Great organisations search for systemic and structural improvements. These are more effective, achieve broader buy-in and are easier to sustain.