• January-February 2016
  • Vol. 16, No. 10

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Root Cause Analysis: Keep the Questions Coming

The following is the monthly research highlight from the Children's Bureau's Capacity Building Center for States, which forms part of the Bureau's Child Welfare Capacity Building Collaborative. Each article focuses on current and emerging topics in child welfare research.

By Liz Quinn, Research Lead, Capacity Building Center for States

Bringing about improvement in systems, programs, and practices starts with identifying and understanding the problem that needs to be addressed. This can be challenging, as it might be tempting to jump in and address what might only be a symptom or might not be the underlying problem. If that happens, the problem will almost certainly return.

Root cause analysis (RCA) is a rigorous, structured approach for identifying why a problem occurred in the first place and what to do so it does not recur. RCA is logical and fact-based, avoids speculation, and dives deeply into the chains of events that cause errors. Guides to RCA are available online, such as a mini-guide that includes techniques and tools1 and a guide that was developed for investigating adverse events in medical facilities.2

RCA has been used to analyze adverse events in airline, military, hospital, and industrial settings, but less often in social services. The complex child welfare environment may make the application of RCA more challenging than in other settings; however, there are some examples of RCA:

Child fatality. Rzepnicki and Johnson (2005)3 used RCA to uncover multilevel factors contributing to child fatalities. They started with a case example of a child fatality and worked backward from the immediate cause through several events in the chain. For each event, the investigator asked, "What led to this event? What allowed it to happen?" The process of identifying root causes in this case led to identification of corrective actions and solution alternatives tailored to the organization's specific needs.

Child injury. The State of Washington used RCA when a loss prevention review team investigated an incident resulting in serious injury alleged to be caused, at least in part, by a State agency. In November 2008, the team reported on an investigation of an incident involving serious injury to a child.4  Identification of the root cause for the injuries led to recommendations to prevent similar incidents in the future.

Many methods are available for conducting RCA. Two examples are the 5-Whys method and the CATWOE method. Both provide structures for developing and asking questions that help drill down into the origin or root of the problem and figure out what to do to reduce the likelihood of its recurrence.

The 5-Whys method involves repeatedly asking "Why?" to drill down into underlying layers of issues and symptoms. Although this method is called "5-Whys," more than five whys may be necessary to ensure that you have arrived at the root cause of the problem. The information collected by this methodology is built into a Why Tree that shows all the uncovered cause-effect branches. For more information, see, for example, "Understanding How to Use the 5-Whys for Root Cause Analysis."5

The CATWOE method builds questions around the following six elements:

  1. Clients (the users of the system or process)
  2. Actors (the people who will implement the change in the system or process)
  3. Transformation process (the processes or systems affected by the issue)
  4. Worldview (big picture of the situation and wider impact of the issue)
  5. Owner (decision-makers with the authority to make changes)
  6. Environmental constraints (limitations on the success of the solution—ethics, resources, regulations, etc.)

For more information about CATWOE, see, for example, "What is CATWOE Analysis?"6

When can the questions stop? A causal chain is stopped when one of the following occurs: (1) an event or situation is reached that could be eliminated through a change in policy, practice, or procedure; (2) the investigator determines that it is not possible to correct the situation; or (3) more data must be collected to continue the analysis.

Interested in getting help to systematically explore the root causes behind an issue or concern in your State? Contact your Center for States' Liaison.

 

1 See http://www.root-cause-analysis.co.uk/images/Green%20RCA%20mini%20guide%20v5%20small.pdf (484 KB).
2 See https://www.cms.gov/medicare/provider-enrollment-and-certification/qapi/downloads/guidanceforrca.pdf (257 KB).
3 See Rzepnicki, T.L., and Johnson, P.R. (2005). "Examining decision errors in child protection: A new application of root cause analysis." Children and Youth Services Review 27: 393-407, available at http://muskie.usm.maine.edu/helpkids/QINetwork/InfoReq/01252013/Rzepnicki_2005_Children-and-Youth-Services-Review.pdf (138 KB) and http://www.sciencedirect.com/science/article/pii/S0190740904002476.
4 See State of Washington, Department of Social and Health Services, Children’s Administration (2008). Incident of March 2007, available at http://www.des.wa.gov/sitecollectiondocuments/riskmanagement/cadshsfinalrpt.pdf (2 MB).
5 See http://www.lifetime-reliability.com/tutorials/lean-management-methods/How_to_Use_the_5-Whys_for_Root_Cause_Analysis.pdf (732 KB).
6 See http://bpmgeek.com/blog/what-catwoe-analysis.

 

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