Tuesday, May 1, 2018

Time to Retire the 16th Century Root Cause Phrase and Thinking  An Update

Systems thinking has destroyed the idea of single cause thinking from the 16th century. Systems thinking has been on a roll since Bertalanffy wrote General Systems Theory in 1968. In spite of systems thinking, the use of "root cause" phrase persists.

Psychologically, there is an upside and downside of the phrase “Root Cause Analysis (RCA).” The upside, the illusion of single cause thinking gives people hope. It sends the message that one thing is going on and they can handle that. On the downside, the mental image of a “root cause,” leads people to finding a cause. I once watched in horror as a Master Black Belt (MBB) led a group of engineers in a high-tech company through a multi-voting exercise on an Ishikawa Diagram. Once the MBB had all the votes, they focused on the “top cause.” There was a short plan put together to investigate this single "cause."  Since I was visiting, I was silent until someone asked me what I thought. I asked a question about the possible covariance of factors for the application being discussed. After one engineer that the factors do indeed interact, they got back to reality. Rather than one factor, they needed to consider multiple factors in a designed experiment.

There is hope. People are waking up! In 2015, The National Patient Safety Foundation exposed many of the problems with the myth of "Root Cause Analysis:" From the report:

"RCA itself is problematic and does not describe the activity’s intended purpose. First, the term implies that there is one root cause, which is counter to the fact that health care is complex and that there are generally many contributing factors that must be considered in understanding why an event occurred. In light of this complexity, there is seldom one magic bullet that will address the various hazards and systems vulnerabilities, which means that there generally needs to be more than one corrective action. Second, the term RCA only identifies its purpose as analysis, which is clearly not its only or principal objective, as evidenced by existing regulatory requirements for what an RCA is to accomplish. The ultimate purpose of an RCA is to identify hazards and systems vulnerabilities so that action scan be taken that improve patient safety by preventing future harm.

The term RCA also seems to violate the Chinese proverb “The beginning of wisdom is to call things by their right names,” and this may itself be part of the underlying reason why the effectiveness of RCAs is so variable. While it might be better not to use the term RCA, it is so imbedded in the patient safety culture that completely renaming the process could cause confusion."

The last line is tragic, unlearning is usually the first step in learning for many (some try to avoid it at all costs). From this line, the authors are in effect protecting people from learning. Cognitive Dissonance is a natural part of how we learn, adapt and change. The paper on RCA2 can be found here:


The effort to restore systems thinking and 21st century science continued in February, 2017 with publication by Kiran Gupta, MD, MPH, and Audrey Lyndon, PhD, entitled Rethinking Root Cause Analysis. This paper has some great tables that describe the various problems associated with RCA. The authors are working with reference to 2015 paper referenced before.
Recently, Duncan Mackillop observed on LinkedIn: "I wonder what the "root cause" is of something that's gone right? After all, things go right and things go wrong for the same reasons." Typically, "root cause" thinking is only invoked when something has gone wrong. Duncan's reframing shows how limited single cause thinking is to any endeavor beyond the very simplistic.  


1. http://www.ihi.org/resources/Pages/Tools/RCA2-Improving-Root-Cause-Analyses-and-Actions-to-Prevent-Harm.aspx