root cause analysis
The Superfluous & Untouchable
What does a 19th-century cholera epidemic have in common with businesses today? Both have problems that resist easy answers, and both need root cause solutions.
Cholera was a word that struck terror in the hearts of people throughout the world. Seven cholera pandemics occurred in the past 200 years, and it is still a problem in many parts of the world today. Left untreated, cholera has a mortality rate of up to 50%. It was rampant in places with poor sanitation facilities and the cause was unknown for a long time.
Cholera is an intestinal disease that can cause death within hours after the first symptoms. In prior outbreaks, cholera had killed tens of thousands of people in England. Most doctors and pundits believed that cholera was caused by miasma (bad air). With shared cesspools and raw sewage dumped in the river Thames, it’s easy to imagine just how bad the air must have been! Most people didn’t have running water or indoor plumbing and relied on public water pumps to carry water for cooking, cleaning, and bathing.
Dr. John Snow
John Snow was an obstetrician and anesthetist in London. In 1884, when the cholera outbreak occurred in the Soho district, Dr. Snow believed that contaminated water was the real source of cholera. In one area, there were around 600 deaths from cholera in just ten days! Dr. Snow worked around the clock to track down and map the cases to nearby homes and businesses. He also investigated groups of people in the area who did not get cholera and their sources of water. In a remarkably short time, Dr. Snow knew the precise pump that was spreading the illness. Thanks to Dr. Snow, the Broad Street pump was shut down and the cholera outbreak shuttered. He is credited as a pioneer in the field of public health and his work is a beautiful example of root cause analysis.
The principles of root cause analysis hold true for problems far less severe than the tragic cholera outbreak referenced above. When your business is faced with an event that results in an undesired outcome or a problem that seems entrenched, performing a root cause analysis will help you better understand the true source of the problem. Is the root cause physical, human, environmental, or organizational? There are many tools available online to help you put structure to your analysis. The Five Whys is one methodology and is explained in this video.
To get to the heart of the matter, start with identifying the problem. Next – triage – take swift action to correct the immediate issue. Then – ask questions, listen carefully to responses, and dig deeper – ask why again and again – getting past the many symptoms to the root cause. The five whys help you get closer and closer to the real source of the problem and allow you to craft a better solution than a surface-level fix. Once you know the real source, then look to other parts of your business. Does this same root issue create problems elsewhere? Faulty practices, communication, and beliefs are contagious. So, don’t quit the investigative process too soon.
When conducting your root cause analysis, it is important to create psychological safety. Without it, people may be less likely to speak openly out of fear which will impede your efforts. Second, look for the superfluous and the untouchables. In the category of superfluous are things like manual reports that were needed once but are no longer necessary however the requirement to create them was never dismantled. Superfluous debris is found throughout even the best organizations. A periodic review is essential to prevent them from building up and choking the time and bandwidth of your workforce. The untouchables are trickier. Untouchables are those closely held beliefs that something or someone is not to be questioned. Those beliefs will go unchallenged for as long as you allow them to. Untouchables can spell the death of an innovative culture. Identify and dispel the belief in untouchables early and often.
When you build the practice of root cause analysis into your culture, your team members learn that it is safe to dig deeper, ask questions, and challenge both the superfluous and the untouchable. That just may be the foundation of a team empowered to innovate.