Root Cause Analysis (RCA) Practice Improvements

Reflections from Managers Who Have Improved Their RCA Practice

Ian Brimicombe (SVP, Specialist Finance, and Projects, Burberry):

‘Improving RCA in areas such as finance and IT requires a few key ingredients. First, you need to train and coach staff. Second, you need to recognise the time it can take to do a good RCA. Third, you need to be prepared to dig into small details from time to time, especially when there can be a cumulative impact from minor errors. Fourth, you must have a culture that accepts openness and speaking up about issues and doesn't blame staff for raising issues.

The goal should be about process excellence and continuous improvement and “fixing forward”.’

Sandeep Das (Head of Internal Audit, St John Ambulance):

‘When you are involved in an emergency or crisis, don't expect to start a full‐blown RCA first thing. In situations like this, you often need to implement some “quick‐fix” solutions. So, as long as stakeholders know that this is step one, then you can turn to an RCA review when things have calmed down.

But don't let the fact that the fire has been put out stop you from turning to the RCA stage. If necessary, remind everyone how much time and effort it took to deal with the crisis and the value of heading off problems in advance.’

Martin Falck‐Hansen (Former Head of Internal Audit, KMD A/S – an NEC Company):

‘Never forget how often people will fear getting the blame. So, always engage the sponsors of an RCA investigation to establish whether this will be a “point the blame” review or a learning RCA. Show them the just culture framework if you need to.

The more people know that the RCA is for learning, the more likely you are to get all the facts and angles and a robust RCA.’

Nancy Haig (Principal, PIAC LLC):11

‘I would expect any risk or compliance team to have looked at RCA and to have trained key personnel involved in monitoring how to understand the difference between cause types. You also need to recognise that RCA may highlight gaps in policies and training that were previously thought to be unimportant.

You may find that pragmatic “concessions” that were agreed to in the past have come back around and need to be addressed. Don't be reluctant to have the discussion. Saying that “We discussed this in the past, and I gave you the benefit of the doubt, but now I can see that it's led to issues, so we need a resolution” shows flexibility and builds transparency and credibility.’

Jerome Lobet (Audit Director, Euroclear):

‘My advice is don't over‐engineer your RCA methodology or RCA cause categories. Some colleagues I know are using the Bowtie framework, it's basic, but it does seem to be yielding results.’

Norman Marks (Author, Speaker and Thought Leader):12

‘When you're doing an RCA, you need to go deep down enough to get a decent understanding of what individual people are doing because if you don't get to this level of detail, you won't understand what it's like from the perspective of the person who's carrying out specific tasks. Getting to this level means you must be disciplined in gathering evidence during any investigation or inquiry.

1. You need active listening skills.
2. You need to exhaust the information that person can give you.
3. You also need to understand any problems from their perspective.

RCA is about adopting a childlike perspective on things, asking why, why, why, why, and why.’

Andrew Pal (Leadership Coach and Organisation Consultant):13

‘When you are thinking of the team who will carry out the RCA, make sure that they, and the key stakeholders, are mentally ready for what they come up with.

Make sure you are tuned in to the cultural and political sensitivities that may be in play. Don't do the RCA in a technical silo ignoring this side of the equation.’

Dr Mohammad Farhad Peerally (Associate Professor, University of Leicester):14

‘Improving RCA should be part of a bigger learning journey for an organisation. It should also be about the positive benefits of improvement actions, not just the negatives that have been avoided.

Don't be surprised if you uncover key improvements at the point where different systems and processes interact.

Remember the importance of the “just culture” framework when working on RCA. If this framework isn't understood and accepted, an organisation can easily get pulled into a “blame game” mindset.

In a healthcare context, the “just culture” mindset is especially important when someone has been impacted negatively when being cared for (directly or by a family member). In these situations, you may need to provide an apology on behalf of a care provider, explaining what has been learned and giving assurances that improvement actions will be implemented, so the same thing can't happen again. Here it's crucial that stakeholders recognise that the person responsible for apologising on behalf of the institution is not the same as them personally accepting blame.

Interestingly, when you speak to people who have been badly affected by a medical incident, many recognise that the medical staff will have been trying to do their best. So, very often, their main concerns are (i) to get an acknowledgement that things went wrong and (ii) to be confident that lessons have been learned.

This is where there is an interesting link between root cause analysis and the whole “restorative justice” movement.’

Richard Taylor (Audit Support Director Aegon Investment Management):

‘Don't underestimate how easy it is for everybody to say, let's do root cause analysis, but to find that it's not that high quality. Recognise that ingredients such as the maturity of the team involved, the maturity of the organisation and cultural factors all play a part.

The people aspect to root cause is often underestimated; if you don't have a sponsor and a team lead with the right mindset, you may have very basic RCA.’

In my experience, senior executives and board members often support RCA when it is introduced step by step and its benefits are demonstrated. Political resistance may remain, but sharing useful results can help build support.