When thinking about root cause analysis it is useful to think of whether the problem is stemming from a cultural level or when it may be coming from an operational. We can think of these problems as hazards stemming from three areas:
- Culture/philosophy is the over-arching view of how the organization conducts business from top-level decision-makers on through the corporate culture of an organization.
- Policies are the broad specifications of the manner in which operations are performed. This includes the end-to-end processes.
- Policies lead to the development of process and procedures, which are specifications for a task or series of tasks to accomplish a predetermined goal leading to a high degree of consistency and uniformity in performance.
| Hazards unrecognized (risks not known or correctly appraised) | Hazards forseen (risks anticipated but response not adequate) |
|---|---|
| Culture/Philosophy Quality not source of corporate pride Regulatory standards seen as maxima | Culture/Philosophy Quality seen as source of corporate pride Regulatory standards seen as minima |
| Policy Internal monitoring schemes inadequate (e.g. employee concerns not communicated upwards) Insufficient resources allocated to quality Managers insufficiently trained or equipped Reliance on other organization’s criteria (e.g. equipment manufacturer) | Policy Known deficiencies (e.g. equipment, maintenance) not addressed Defenses not adequately monitored Defenses compromised by other policies (e.g. adversarial employee relations, incentive systems, performance monitoring) |
| Procedures No written procedures | Procedures Documentation inadequate Inadequate, or Loop-hole in, controls Procedures conflict with one another or with organizational policy |
This approach on problems avoids a focus on the individuals involved and avoids a blame culture, which will optimize learning culture. Blaming the individuals risks creating an unsafe culture and creates difficulties for speaking up which should be an espoused quality value. Focus on deficiencies in the system to truly address the problem.
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