Andrew Castle on root causes

How often do we find ourselves in the same old situations at work? Things are not going ideally, we know what is going to happen and, eventually, it does. How often, when we are in these situations, do we step back and analyse why it has happened and how we arrived at this point?

One trait that world-class organisations in any sector demonstrate is the ability to learn and transfer knowledge quickly and effectively whenever something new is developed or a problem is solved. I am not sure that we do this particularly well in the health sector.

There are two aspects to solving a problem: time and method.

Addressing defects and errors as they occur may save hours or even days of work and meetings to resolve them. When a problem arises, try to take 15 minutes to step back: spend 10 minutes trying to understand what went wrong and five working out how to resolve it.

This is easier said than done, but the alternative is to accept that the problem will continue to occur.

There are dozens of problem-solving methodologies that can be used. One simple approach is the 'five whys' technique.

Five whys was developed by businessman and inventor Sakichi Toyoda as a method to identify the root cause of a problem or defect. The process works by asking why a problem occurred. You work backwards from the known effect through the various symptoms to get back to the original root cause, all the while avoiding making assumptions.

The idea is to ask why once more than feels comfortable in order to delve deeply enough to reach a substantive root cause on which to act.

Here is an example. Problem statement: the operation in theatre has been delayed by 15 minutes because the set was not ready.

Why (1) did theatre not have the set? Sterile services did not know the set was needed.

Why (2) did sterile not know the set was needed? Theatres had not told them.

Why (3) did theatres not tell them? Theatres do not provide sterile with a daily list of procedures.

Why (4) is there not an up-to-date list of sets needed by theatres? There is no standard procedure for providing sterile with an up-to-date list of procedures to be carried out in theatres.

Why (5) is there not a procedure for providing an up-to-date list of sets needed? The computer system used to manage theatre lists does not communicate with the one used by sterile services and, historically, there has never been a procedure.

The solution would be to examine how theatres might be able to notify sterile services what was needed and when, based on the time required to sterilise a set, the number of sets available and demand for particular sets.

This example is elementary. In reality, it is essential to involve people who have input into the relevant processes.

But the five whys does not need to be hugely time consuming or laborious to be extremely powerful.

Andrew Castle is service improvement consultant at the NHS-funded South West London improvement academy.