Do people in your organization perceive an investigation as an obligation or an opportunity? The answer to this question will tell us a lot about the reliability within your organization. Unfortunately, all too often the answer is the former. When people view problem solving or a root cause analysis (RCA) as an obligation, the tendency is to stop short at some predefined outcome such as procedure less than adequate or poor communication. They come to a point where they can cite a standard cause and, therefore, officially check the box that the investigation has been completed. This false sense of accomplishment stops short of the good stuff and reveals only generic solutions that do little to prevent recurrence. Does retraining sound familiar?
An Opportunity for Lessons Learned
The ultimate reason you investigate problems is for the opportunity to improve work processes thanks to lessons learned. Problems within your organization pinpoint where gaps or breakdowns exist within your work processes. In order to expose these opportunities, you must conduct a thorough analysis. To get the value, you must get into the specifics of processes that failed. Only then will you get real actionable solutions that will reduce the risk of reoccurrence.
Another opportunity that is missed under the obligatory approach is that there are always multiple causes to an incident, and thus, multiple opportunities for improvement. When we settle on one generic outcome from an RCA, we are leaving additional possible learnings on the table.
Signs of an Obligation Mentality
How can you recognize whether people are taking advantage of the opportunity or settling on the obligation? The signs of the obligatory approach will stand out.... When people ask questions like "How far do we really need to go?" or "How much detail is necessary?", then they see the investigation as an obligation. If the explanation is simply "procedure not followed," "human error" or "lack of situational awareness," then we are missing valuable opportunities to learn from the incident. And finally, if the solutions identified to the problem are "retrain" or "reinforce procedure," then we've stopped short and are wasting our time.
How to Reveal the Opportunities Within an Investigation
Now that you recognize the difference, how do you take advantage of the opportunity?
- Make sure your methodology doesn't drive generic outcomes. If your forms and databases have a list of causes to categorize or pick from, then you are actually facilitating an obligatory approach, as people will stop once they get to one of the items in the list.
- When a generic explanation is cited, challenge it with another Why question. For example, asking why the procedure wasn't followed can reveal variables within the task, tools or environment that played a key role in the outcome. These are opportunities to build specific and actionable solutions.
- Make it visual. One of the benefits of the Cause Mapping® method is that visually, you can see where we are stopping short in the analysis. The visual nature of the Cause Map™ diagram also shows the system of causes required to produce the incident, and thus, revealing more opportunities.
Identifying a problem-solving culture of obligation is the first step to changing it to one of opportunity. By driving RCA investigations past generic outcomes and creating a visual diagram of the incident, your organization can begin to find more opportunities for improvement.