What if you are required to identify a single root cause?

Holly Maher

If you are familiar with the Cause Mapping approach, you know that while performing a root cause analysis, the investigation does not lead you to a single root cause, but reveals a more comprehensive picture of all the causes within the root system.

While you may acknowledge this (and wholeheartedly believe it), you may be working within a process that requires you to name a “root cause”. It could be that the database you use to categorize your incidents requires you to name (perhaps from a drop-down list) a “root” cause category. Perhaps you need to fill out a form for an external, regulatory agency or a customer that requires you to list the “root cause” identified. Although the Cause Mapping process allows us to determine all the causes and intentionally does not identify a “root cause”, these reporting requirements are real and pressing. So, what do you report?

Focus on effective solutions

First, let talk about solutions. A possible solution can be identified for any of the causes identified in the analysis; each cause is a potential control point to reduce the risk. During the evaluation of possible solutions, we can weigh effectiveness vs. cost to determine the relative value of each possible solution. Ultimately, we want to implement the solution(s) that reduce the most risk and at the lowest cost. It may be a combination of solutions that we choose to implement. Once we have gone through the solutions evaluation, we know which cause or causes we have chosen to control via our solutions.

Identify the cause with the “best” solutions

Now, back to the question of what to report as THE “root cause”, if you are required to do so. Instead of differentiating on the causes on the front end, you want to differentiate the causes based on the value of the solutions identified. The best solution is the solution we determined would buy down our risk most effectively. If you are required to list a single “root cause," provide the cause associated with that best solution. This designation is now solely based on what we determined was the best way to mitigate our risk. We are backing into that designation based on the solutions evaluation versus a designation identified during the analysis process.

Give this a shot the next time you are stuck in this dilemma (at least until our systems evolve to keep up!)

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