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One of the benefits of building a cause and effect chart on a large problem is that it brings the information together in a way that allows readers to visualize the multiple causes of the problem. It provides a way to show the different contributors and their relationships to each other. It also shows where the information available is most certain – as well as that which is still coming into focus. A high-level analysis should clearly show the systemic risk factors as well as how solution efforts should be prioritized to help minimize the impact of this particular outbreak as well as what can be learned to prevent future outbreaks.
Getting the setup right is extremely important when trying to build a cause and effect chart for a large analysis. I spent 20 – 30 minutes trying different prototypes before I found one that I thought best represented the issue. Notice the focal point in this example is “Global Impact – Ebola Outbreak 2014.” I chose this focal point because it allows me the opportunity to immediately branch off into one cause looking at the global outbreak and another looking at the global response. This made sense to me because total impact is a combination of the impacts of the outbreak, both human and economic, along with the global response to the outbreak, which could either exacerbate or mitigate the total impact.
This is a tactic I use in almost every investigation. I want to examine the error pathway as well as the response pathway. This is because these two combine to equal the impact of the problem. In some cases, examining the response path shows how the response to the issue kept it from getting worse, mitigating the impact in the best way possible. This is a great learning opportunity to share with others, highlighting how the way in which a team responds to an issue actually helped minimize overall impact. There are, of course, other examples where the response didn’t help at all – or even made things worse. Both are good learning opportunities to help improve our ability to recognize and respond to adverse events in the future.
The problem with big issues is knowing when to stop. I stopped at high-level systemic issues for this RCA. But if I were to take the project further, my inclination would be to divide it up with each systemic issue becoming its own RCA. Here is the list of systemic issues I identified, along with an explanation of why I think they warrant the “systemic” label:
Lack of effective Ebola vaccine / treatment:
Progress on such a vaccine has been slow. Four promising vaccines are under development. But there is limited perceived market for these drugs and the companies developing them have invested resources in treatments with greater profit potential. This is a systemic risk because the same can likely be said about other potential pandemic vaccines/treatments. Waiting for an epidemic with pandemic potential to precipitate action is not an effective strategy to prepare the world for a global outbreak.
Belief that Ebola is an "African" disease:
The West was unprepared for Ebola to hit its shores. Ebola in the past seemed remote, and therefore the West feels safe because it is out of reach. But the current outbreak has proven this wrong. Within a matter of hours, a contagious passenger can be transported anywhere in the world. The impacts are not only local, but global. This is a systemic risk because this isolationist mindset can provide a false sense of security.
Western hospitals and staff unprepared for Ebola response:
Texas Health Presbyterian Hospital, the Dallas, TX hospital that treated the first Ebola patient in the USA, was not prepared to recognize or treat a patient with Ebola. Texas Health Presbyterian is considered to be one of the best health care centers in the USA. And their response was based in part on available CDC information, which was also outdated. This represents a systemic risk factor because of the false sense of both isolation and preparedness that exists in the West.
Remote population centers - limited access to knowledge:
Epidemics of this type often start in remote locations. If local populations do not recognize the differences between Ebola and something less dangerous, it is much more difficult to contain an outbreak at its source. And if they do not know the proper protocols, the disease can spread rapidly.
Credibility gap:
In areas where healthcare providers have little credibility with the local population, even if high-quality information gets to those that can benefit from it, it may not be heeded. This is a systemic risk factor because the credibility gap is not limited only to Ebola, but to other health crises as well.
Lack of local government support:
In areas where the local government has limited resources or is crippled by corruption, the level of support will be limited, making response to an Ebola outbreak - or any other health crisis - ineffective. This is a systemic risk because it is a negative causal factor for multiple undesirable events/conditions.
Local medical response inadequate or NOT available:
Those with Ebola cannot be effectively treated in their homes. Therefore, they require transport to medical treatment facilities. In undeveloped countries, these services are often either over-taxed or non-existent. In developed countries, the staff is likely to be unprepared to respond to a disease such as Ebola. This is a systemic risk because it would be a factor in other outbreaks.
Aid groups stretched too thinly - limited personnel/resources:
Aid groups (such as Doctors Without Borders) have both the will and knowledge to respond effectively. However, if their resources are stretched too thinly their ability to respond will be limited. This is a systemic risk because it is not limited to just this specific outbreak.
As you can see, each of these could become an extensive RCA in and of itself. And there may well be others. However, it is certainly true that if these systemic-level issues were effectively countered with high-quality solutions, the chances another Ebola outbreak with impacts such as this would be extremely remote.
Any one of our clients could use this same strategy to attack the high-level issues they are facing. Determine the high-level systemic causes and then assign them as projects to individual teams. As each team completes their part of the analysis, a cohesive picture of the cause and effect relationships is formed. And, most importantly, a detailed course of action based on evidence and logic can be identified and implemented.
We have posted the full Ebola Crisis report in Causelink Enterprise. If you would like to look at the details, sign up for the 30-day trial.
Brian Hughes
Learn more about Sologic RCA
RCA & FMEA TRAINING
Root Cause Analysis and Failure Modes & Effects Analysis training by Sologic provides the tools, skills, and knowledge necessary to solve complex problems and manage risk in any sector, within any discipline, and of any scale.Learn More
SOFTWARE
Sologic’s cloud-based Causelink has the right software product for you and your organization. Choose from Individual, Team, or Enterprise.Learn More