If you look at the root cause analysis tools on the market, or the literature on the shelves, you’ll find most RCA methods tailored to address unintended outcomes (accidents) and unintended actions (errors). And those tools generally do an adequate job of guiding a manager, or a quality/safety team through the process of investigation.
Yet, when the actions were more culpable, such as discrimination or bullying, virtually all RCA tools stumble. They simply are not equipped to address the more diverse collection of adverse events that every organization must face. And, consequentially, we don’t learn. From police brutality to predator priests, from workplace bullying to a nurse diverting drugs, we simply don’t learn the lessons to prevent future events. We wash our hands of the “evil” involved, convincing ourselves that improvement is outside our grasp. Send the now ex-employee up the street to another business, or worse, to jail, and then convince ourselves we have solved the problem. It’s not that we don’t hold individuals accountable for their actions, it’s that we impose upon ourselves the commitment to learn – not matter the nature of the event.
Through our unique five-behaviors RCA process, we equip organizations with the tools to investigate all adverse outcomes within the organization, from the accident to the intended. To be a learning organization, you can do nothing less.