The Types of Actions That Are More and Less Likely to Address Root Causes
Different corrective actions vary in their effectiveness at addressing root causes, ranging from weak reminders to strong systemic redesign. Combining multiple actions that work on the system rather than in the system is more likely to produce lasting change.
THE IDEA
Some actions are more likely to address root causes than others. The table below sets out some pros and cons of different types of actions:
| Examples of corrective actions | Pros and cons |
|---|---|
| Remind staff what to do by email, newsletter or via an intranet | May be quickly forgotten, especially when the workload is high. |
| Regularly train staff on what they need to do | It is more likely to be remembered, but staff may find it boring after a while (which needs to be checked). It may not address practical challenges. However, case studies of real, interesting events can significantly improve the impact of this sort of activity. |
| Run workshops or coaching sessions to discuss real world challenges | It may provide specific, tailored help, but great care is needed around the dynamics of any group meetings so people can speak openly. |
| Offer tools and checklists to guide better decision‐making | It may help if staff have the time and have said they would find this helpful. These short checklists need to be a living document where users are engaged in the design, use and how they are updated. |
| Implement double‐checks or reviews on occasion with a supervisor | Essential to be clear whether double‐checking is going to be preventative, detective or recovery. Role clarity and understanding of what the second check is doing will be necessary. If selected, preventative checking should be based on materiality or risk (e.g. payments above X or certain medical procedures or reviewing critical installations). |
| Offer incentives/penalties for better or less good performance | Shows the matter is being taken seriously, creates an incentive for others to call out poor behaviour, but may also encourage suppression of problems (e.g. due to no breach targets). Incentives for proactive openness about issues and timely action can work well. |
| Discipline or remove staff | Unless implemented in the context of a ‘just culture’ framework, it may lead to a fear culture. Also note that if disciplinary action is kept ‘below the radar screen’, relevant staff will not know what has been done. Therefore, there may be no deterrent effect in practice. |
| Conduct ethical phishing, mystery shopping or other ‘real world’ checks on what is happening (Also CCTV or body cams) | It shows what staff do in the real world when they are working under pressure and provides detective control, but the right lessons need to be learned and privacy concerns need to be thought through. |
| Modify or redesign the equipment/tools/devices in use | It starts to address the environment in which staff operate and may address human factors (e.g. better labelling of medicines) if staff is engaged in the proposed changes. |
| Redesign the overall policies, processes or systems impacting the area | Starting to become more systemic, provided all aspects are considered (systems, policies, processes, human factors and resources). This may include the automating of controls and even decision‐making algorithms, but biases and gaps in information may none the less remain a risk. |
Thus, there will be a hierarchy of ‘weaker’ and ‘stronger’ actions you might take.
And, quite often, if remedial actions come together in a package, working on the system rather than in the system, there will be a greater likelihood of lasting change.
When to use it
In a hospital, after a medication error, the team considers various corrective actions from retraining staff to redesigning the medication dispensing system. Using this hierarchy, they can choose the most effective actions.
In a software company, after a security breach, the team evaluates corrective actions: sending security reminder emails (weak) vs. implementing automated security checks and redesigning the development process (strong).
In a manufacturing plant, after a near miss, the safety team uses this framework to select corrective actions that address root causes, such as modifying equipment and revising standard operating procedures.
FROM THEORY TO EVERYDAY LIFE
In practice
Weak Action: Email Reminder
An email reminder may be quickly forgotten under a heavy workload. Before relying on it, ask why the procedure was missed: a reminder will not fix confusing labels, missing equipment, or an impossible schedule.
Strong Action: Process Redesign
A process redesign can address conditions that contribute to errors, such as confusing tools or missing resources. Its strength depends on whether it addresses the causes found, whether staff can use it, and whether subsequent checks show improvement.
A MOMENT TO REFLECT
Put it to work.
Which corrective actions are currently used in your organization, and are they addressing root causes or just symptoms?
How can you combine multiple corrective actions to create a package that works on the system rather than in the system?
What are the potential downsides of relying on weak corrective actions like training or reminders without complementary changes?
CONTINUE THE CONVERSATION
Source texts
- Beyond the Five Whys Root Cause Analysis and Systems Thinking (James C. Paterson)