Root Cause Analysis

Dogs bark, babies cry, system crash....what are you going to do?? Root Cause Analysis (RCA) of course! There are many good reasons for RCA:

• quality improvement
• future risk mitigation strategies

some bad reasons:

• blame (the name of the game is....blame)
• CYA
  
• planned litigation (why get to this point?)

and some required ones:

• contractual
• regulations
  
• you're an RCA specialist

Prior to starting your RCA - I would recommend:

• understand the goals of the RCA (and make sure everyone agrees)
• set the limits of the review: time, cost, etc. - this should be based on the benefit of performing a RCA. If the problem caused $10 of damage and little likelihood of occurring again and the RCA is $1,000....I would think twice prior to proceeding (unless of course - you don't have a choice)
• set expectations about the RCA: you will return with actionable items, no-blame - just quality improvement, time to report back, etc.
• set limits of the RCA - I'm sure we can all trace any issue back to societal causes (do you blame the removal of the caveman dance for all problems you encounter??)
• develop a standard reporting format - preferably a web based RCA so people could share and learn (hey - look Larry stubbed his toe the other day - we should learn from that)

Here's some more 'in-depth' RCA info (WikiPedia of course):
http://en.wikipedia.org/wiki/Root_cause_analysis