Before Doing an RCA, Clarify with Stakeholders What Level of Commitment (and Budget) There Might Be to Taking Action
Before starting a root cause analysis (RCA), confirm with stakeholders their commitment to act on findings, especially if systemic issues are suspected. Without that commitment, the RCA risks becoming 'theatre' that raises expectations without producing change.
THE IDEA
Before Doing an RCA, Clarify with Stakeholders What Level of Commitment (and Budget) There Might Be to Taking Action
On a couple of occasions, I have been involved in ‘calling out’ the danger of an RCA as ‘theatre’, with conversations along the following lines: ‘Before we spend a lot of time and effort doing the RCA, and raising expectations things will be improved, are you prepared to follow‐through? Because there are many who strongly suspect this problem is associated with old systems and poor cooperation with Department X. So, unless you are prepared to act on the findings, it is highly likely that those involved will end up being demotivated if nothing changes. Worst still, they may see the RCA shift into a blame game. So, are we OK to proceed with a commitment to just culture principles, investing in systems changes, etc., if the evidence merits this?’
This sort of questioning has sometimes surprised managers but has usually yielded a greater appreciation of the downside effect of just seeing RCA as a necessary evil, leading to little change. Most of all, you want to avoid a culture in which those involved in RCAs or inquiries, who might be hoping for meaningful improvements, become disenchanted with the gap between rhetoric and reality.
When to use it
A manager in a manufacturing plant wants to investigate a recurring quality defect. Before scheduling the RCA, she asks the VP of operations if they are willing to invest in new machinery if the analysis suggests it.
An HR team is analyzing high turnover in a department. They ask the department head whether they are ready to change policies and improve interdepartmental cooperation before committing to the RCA.
A hospital quality team asks whether the administration will support a just culture: examining system conditions and individual actions fairly rather than defaulting to blame.
FROM THEORY TO EVERYDAY LIFE
In practice
RCA as Theatre Leading to Demotivation
On two occasions, I called out the danger of an RCA being 'theatre'. I asked the manager: 'Before we spend a lot of time and effort doing the RCA, and raising expectations, are you prepared to follow through? Many suspect the problem is associated with old systems and poor cooperation with Department X. Unless you act on the findings, those involved will become demotivated, and the RCA may shift into a blame game. So, are we committed to just culture principles and investing in systems changes if the evidence merits it?' This questioning helped managers see the downside of treating RCA as a necessary evil.
Clarifying Commitment Before RCA
An engineering manager initiates an RCA for a recurring software bug. Before starting, she meets with the product director and asks: 'Are you willing to allocate budget for rewriting the legacy module if the RCA points to that? If not, we risk wasting time and frustrating the team.' The director agrees to a contingency budget, ensuring the RCA is taken seriously.
A MOMENT TO REFLECT
Put it to work.
Before conducting an RCA, have you verified that stakeholders are prepared to fund and implement potential changes based on the findings?
How can you ensure that an RCA remains focused on systemic improvements rather than devolving into a blame game?
What signs might indicate that an RCA is being treated as 'theatre' rather than a genuine effort to improve?
CONTINUE THE CONVERSATION
Source texts
- Beyond the Five Whys Root Cause Analysis and Systems Thinking (James C. Paterson)