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The Importance Of Root Cause Analysis

The Importance Of Root Cause Analysis

Monday, 8 October 2018

As a nation, we’re experts at complaining and expect our grievances to be heard.

Our right to complain against public authorities is enshrined in the Human Rights Act 1998 and as a consequence, government departments, law enforcement, education and health agencies all have a legal obligation to record and respond to complaints. It should come as no surprise then to find these departments have well-established complaints procedures and are adept at handling complaints and providing redress.

Any mishandling of complaints by public sector authorities will typically see cases forwarded on to the Parliamentary and Health Service Ombudsman (PHSO) who will then investigate and uphold, partially uphold or dismiss the complaint. If the level of complaints indicates a wider issue, the Ombudsman will use tools to identify and analyse the underlying reasons for the complaint before delivering its verdict. But there’s no compunction for the public authority to get to the bottom of the matter itself or investigate what the common causes of complaint are, in order to provide a better service.

Surely it would be better if the public authority was able to carry out its own investigation and analysis to help drive improvement? We’re now starting to see some movement towards this way of thinking in the form of the Cross Government Complaint’s Forum which is now encouraging public sector organisations to share best practice on complaints handling. But there’s still very little advice on how public sector bodies can become more proactive and engaged in identifying the cause of citizen complaints.

To get a real understanding of not just the symptoms but the true causes of complaints it’s necessary to use Root Cause Analysis (RCA). RCA is a problem solving method for conducting investigations that seeks to determine the underlying or systemic reasons why a complaint or incident occurred and to prevent recurrence. It differs from other forms of investigation that focus on immediate cause-effect by looking at all contributory factors. Data is collated from across the organisation - from systems, processes and people - and subjected to in-depth post-event analysis, to provide a detailed breakdown of the circumstances that resulted in the complaint.

RCA as a methodology or concept is widely known across public and private sector organisations, however, it is typically actioned across a small minority of organisations.  This is typically due to common limiting factors, like staff failure to understand the key concept and process behind RCA and a technology based limitation in relation to gaining insight from available data. It is applied by HMG’s Online Service Providers and is widely adopted across the NHS to develop recommendations for improvement in response to serious incidents, although even here its adoption can be piecemeal with only some trusts using RCA templates. It is being adopted in other fields because of its inclusion in government guidelines such as the Digital, Data and Technology (DDaT) Capability Framework where RCA comes under the remit of a Problem Manager or senior IT manager who is deemed responsible for “resolving emerging and recurring problems and performing root cause analysis to minimise the adverse impact of incidents caused by errors within the IT infrastructure”. RCA in this context is primarily concerned with problem solving code-based IT problems as opposed to systemic issues.

As an approach, RCA has far greater potential if applied to citizen engagement. Here it has the power to reveal to the organisation both good and bad interactions, from complaints to compliments, and can help determine where further investment is needed, be it in staff training, unifying customer contact across multiple channels, or streamlining processes to eradicate pinch points and bottlenecks. The information this analysis provides can also indicate emerging trends, generating high level organisational insight.

At present, the PHSO asserts that “boards should, as a matter of best practice, consider complaints data” but does not advise how they should go about this, simply promising guidance in the future on the “use of complaints information” and to facilitate shared learning “to inform improvements to their organisation’s complaint handling”. It stops shy of suggesting any formal methodologies.

Yet unless public authorities adopt RCA the danger is they will be destined to make the same mistakes. Complaints can have a positive impact, seeing working practices changed for the better.  However, for that to actually happen, public bodies may consider moving a step beyond legal obligation in regards to management of complaints, and look to gain insight from the data they hold as the result of complaints, to ultimately provide a better service for citizens and process for staff.