By: Davis Balestracci
11/18/2014
During my recent travels speaking at conferences and consulting, root cause analysis (RCA) seems to have taken on a life of its own and is now a well-established subindustry in any organization, regardless of its chosen approach to improvement.
There are many things that “shouldn’t” happen. Why not consider such incidents as undesirable variation and get back to basics? One of Deming’s principles was that there are two kinds of variation—common cause and special cause—and that treating one as the other makes things worse.
And the human tendency is to treat virtually all variation as special cause—of which RCA is another example.
Has anyone considered whether things that “shouldn’t” happen might be common cause—as in, one’s organization is “perfectly designed” to have them occur? What might be the effect of multiple RCAs in such cases?
‘Because we worked so hard!’
I was at a conference where one of the poster sessions proudly declared that they had reduced infections in a pediatric unit. It used the following display:
