Analysis Paralysis: Why It’s Still Broken
If you ask why the Titanic sank, most will say it’s because it struck an iceberg. Yet, when you analyze the case from an engineering angle, we find many causative factors from a small rudder to brittle rivets.
In simple terms, “root cause analysis,” or RCA, is a concept whereby if you find and eliminate one singular “root cause” of an event, you will prevent its recurrence. In reality, rarely is there a “root” cause, as the Titanic proves.
Instead, causation is multi-factored with many cause-and-effect relationships. The analyst must understand how to ferret out all those pathways to understand effectively why and how failures occur. Only then can an effective corrective action plan be designed.
Untrained staff — irrespective of position or title — do not make good causation analysts, and the knee-jerk solution of firing the nurse at the sharp point of error is a useless solution.
RCA is not a new process. We see its use in disasters from train derailments to aviation. A small army of engineering types descend upon the crash site to dissect what happened. From that data, they figure out how to fix it.
While I doubt we’ll see an O.R. reconstructed from the “wreckage” of an adverse patient event like we do with aircraft debris, the only real difference between the analytics necessary to dissect a health care versus aviation disaster is the subject matter.
Health care operations are no less complex than that of a space shuttle with one obvious difference: With a shuttle disaster, a team of specialists converge to dissect the cause from start to finish. No similar creature exists in health care.
The lack of specialists to perform RCA in health care settings means it is not always well executed. We have no standardized training, certification or required qualifications to perform “causation analytics,” and therein lies the reason many “corrective” action plans aren’t corrective.
In simple terms, an incomplete analysis often leads to erroneous conclusions. Fault engineering courses are not part of the physician or nursing curriculum, and those professionals comprise a great majority of the RCA workforce in the health care world.
Untrained staff — irrespective of position or title — do not make good causation analysts, and the knee-jerk solution of firing the nurse at the sharp point of error is a useless solution. It demonstrates why the same problems recur when the causes are poorly understood.
To fix what’s broken, we must have standards that qualify those who perform RCA as a specific skill set. We need a standardized cause-mapping methodology universally taught and understood across the health care spectrum. The process should be the same regardless of titles and institutions.
Think about the next time you board an airplane. Aren’t you glad every nut, bolt, and screw was made to a specific engineering standard based on known design criteria so you don’t end up on the local news?
Don’t we want the health care machine equally engineered? Our patients deserve and expect that standard. It’s overdue, considering the 400,000 patient disasters we have each year. Until this is a regulated standardized skill, we will continue to perpetuate repetitive patient harm.