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Root Cause Analysis
from BSA Today Issue 2
by bsatoday
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When an incident occurs within an organisations, it maybe necessary to investigate how and why it happened so that the most appropriate solutions can be implemented.
Root Cause Analysis is a set of tools and approaches that can be used, as part of this investigation, to establish:
WHAT happened?
HOW it happened?
WHY it happened?
If undertaken well, a Root Cause Analysis investigation will go beyond the obvious symptoms and get to the bottom of why an incident happened.
It can be easy to identify the obvious symptoms of an incident, however there may be deeper reasons as to why the incident occurred: the root cause.
It is important that time is taken to determine the root cause of an incident. If you try and fix the problem too quickly, you may only be dealing with the symptoms.
Think of an issue such as a broken leg, symptoms such as pain can be fixed with painkillers, however, unless the broken leg is fixed the symptoms of pain will continue.
Blue Stream Academy believe that Root Cause Analysis should be seen as a learning and development tool, that allows organisations to learn how and why an incident happened so that appropriate solutions can be implemented to ensure that the incident does not occur again.
Providing a Root Cause Analysis toolkit will give organisations the information and guidance they may require when undertaking a Root Cause Analysis investigation.
Our toolkit gives information and provides examples of how the '5 Whys' and 'Fishbone' (cause and effect) diagrams can be used as part of the Root Cause Analysis process.
The 5 Whys
By repeatedly asking the question Why? you can quickly identify the root cause of a problem allowing you to focus resources in the right areas.
Fishbone Diagrams
By using a fishbone diagram, you can think through the causes of a problem, including possible root causes, before you start to think of a solution.
By identifying all possible causes and not just the most obvious, you can walk towards removing the problem.
At the request of NHS England, Blue Stream Academy have been working with Devon Training Hub to develop our Root Cause Analysis Toolkit.
We recently had a Q&A session with Roland Gude on the topic of Root Cause Analysis.
Roland Guide
Strategic Director at Sentinel Healthcare Southwest Community Interest Company
How has RCA benefited your organisation?
RCA is a blameless process that can be as simple or as complicated as you need it to be. It provides us with a structured approach to dealing with issues. It is a clear and concise methodology that has brought simple clarity in some difficult situations.
Has there been a specific incident where RCA was used?
Yes, we use it for all of our Serious Incident Reviews but also for some of our minor challenges for example in understanding how our telephone systems work.
Why is RCA important?
I think it is extremely important because it provides a simple and consistent methodology. Teams can see that it is a blameless process and will be able to use the processes in all aspects of their work.
