Root-cause analysis might be shallow-cause analysis

Many risk managers who think they are conducting a root-cause analysis (RCA) really aren't, says Robert Latino, vice president of The Reliability Center, a risk management consulting firm in Hopewell, VA. Instead, they often are conducting what he calls a "shallow-cause analysis" (SCA) that doesn't reach as far as a true RCA.

"Most people have been conditioned by the quality tools like the fishbone diagram, and they think that if they're using those tools they're doing an RCA," he says. "The fishbone is just one tool and it comes with real limitations, which can be overcome if you use it properly and with the right other tools. A lot of people, however, think they're doing a real RCA as long as they're using those familiar tools."

But that approach isn't always a bad thing, Latino says. There are many situations in which a true RCA is not worthwhile, but some lesser investigation still is warranted, he says.

A good rule of thumb is that you should be conducting a true RCA on the 20% of events that cause 80% of more of your losses, Latino says. "Those will differ from one organization to another, and they warrant the full breadth and depth of a true RCA," he says. "For everything else, I would use less stringent methodologies."

Latino says many of the tools that are commonly used for RCAs fall short of the goal of finding the true root cause of a problem. Typical tools in this category are the 5-Whys, the fishbone diagram, brainstorming, troubleshooting, and problem solving. Those tools can be useful even if they don't fulfill the needs of an RCA, he notes. You just need to know which tools to use for which investigations, he says.

Brainstorming has limits

One example of how risk managers can think they are doing a RCA when they aren't is brainstorming. This activity usually involves a collection of experts throwing out ideas about the causes of a particular event, but Latino says usually such sessions are not structured in a manner that explores cause-and-effect relationships. Instead, people just express their opinions and come to a consensus on solutions.

"When comparing this approach to the essential elements needed for an RCA, brainstorming falls short of the criteria to be called RCA and therefore falls into the shallow-cause analysis category," he says.

Troubleshooting is another example. It usually is a bandage type of approach to fixing a situation quickly and restoring the status quo, Latino says. Typically, troubleshooting is done by individuals as opposed to teams and requires no proof or evidence to back up assumptions.

"This off-the-cuff process is often referred to as RCA, but clearly falls short of the criteria to qualify as RCA," he says.

The 5 Whys is a simple approach that is supposed to lead the analyst to the root cause by asking the question "Why?" five times, but Latino says the main flaws with this concept are that failure does not always occur in a linear pattern. Multiple factors combine laterally to allow the undesirable outcomes to occur. Also, there is never a single root cause and this is a misleading aspect of this approach, Latino says. He also notes that people tend to use this tool by themselves and not in a team and rarely back up their assertions with evidence.

The fishbone diagram uses a diagram in which the spine of the fish represents the sequence of events leading to the undesirable outcome. The fishbones themselves represent categories that should be evaluated as to having been a contributor to the sequence of events. Latino explains that as a brainstorming technique, this tool is less likely to depend on evidence to support hypotheses and more likely to let hearsay fly as fact.

This process is also not cause-and-effect based, but categorically based, Latino says. "The users must pick the category set they wish to use and throw out ideas within that category," he says. "If the correct categories for the event at hand were not selected, key root causes could be missed."

One risk manager familiar with the differences between RCA and SCA is Anne Flood, MA, RN, director of quality, risk, and patient safety at Union Memorial Hospital/Medstar in Baltimore. She says it is easy for health professionals to become accustomed to a bandage approach to fixing problems, and she realized two years ago that she often was using SCA when she thought she was doing an RCA.

She then switched to using the logic tree advocated by Latino, and she says the investigations now yield more reliable results. Flood began using the logic tree methodology only in her department but soon provided it to all departments in the hospital so they can use it without direct involvement from risk management. Union Memorial now is using the logic tree to investigate urinary tract infections, which hospital leaders think are too high.

"One of the strengths of this approach is that you don't have to wait for a catastrophic event to occur," Flood says. Instead, you can use it when you detect a chronic problem, she says.

The hospital's maintenance department also is using the technique to study the cause of flooding in the facility and the potential costs and savings from various interventions, she says.

"In the past we would have used some of the common quality tools and stopped at the more obvious causes," Flood says. With the logic tree, "we feel like we're digging deeper and getting the real causes more often," she says.


For more information on shallow-cause analysis or logic trees, contact:

  • Anne Flood, Director of Quality, Risk, and Patient Safety, Union Memorial Hospital/ Medstar, 201 E. University Parkway, Baltimore, MD 21218-2895. Telephone: (410) 554-2676. E-mail:
  • Robert Latino, Vice President, The Reliability Center, P.O. Box 1421, 501 Westover Ave., Hopewell, VA 23860. Telephone: (804) 458-0645. Web site: