School Leader's Guide to Root Cause Analysis

Paul Preuss

• Publisher: Routledge
• Year: 2013
• Print ISBN:
  9781138136700
• eBook ISBN:
  9781317926269
• Topic: Education
• Subtopic: Education General

Don't jump from problem to solution without first investigating root causes. This book helps you more accurately focus on school improvement issues, so you can avoid wasting precious time and resources. It is clearly written, contains lots of real examples, and is presented in a style and format designed for the non-expert. It will help you make decisions which will improve learning for all students.

1

Root Cause Basics

Root cause analysis is an effective tool used both reactively, to investigate an adverse event that already has occurred, and proactively, to analyze and improve processes and systems before they break down.

Root Cause in Health Care: Tools & Techniques,
The Joint Commission on Accreditation of
Healthcare Organizations

Why Root Cause Analysis?

♦ Root Cause Analysis (RCA) helps dissolve the problem, not just the symptom.

Often, schools approach the symptom, e.g., poor attendance, as if it were the problem rather than a result. By focusing on the symptom, strategies are often misdirected and the causes for the problem remain untreated—enabling the symptoms to remain or reemerge.

♦ Root cause analysis eliminates patching and wasted effort.

Symptoms are often “dealt with” by coming up with a patch to cover them or to deal with their consequences. Many so-called compensatory programs are simply patches on a system where the original effort to teach/learn has been unsuccessful. Patches add complexity to the system, require additional resources, and create additional work. All of this amounts to wasted effort.

♦ Root cause analysis conserves scarce resources.

By eliminating fundamental (root) causes, symptoms can be reduced or eliminated, thereby conserving the need for additional resources. Remedies that do not consider root cause often fail to eliminate the symptoms. Resources are usually thought of in terms of time, money, space and personnel. However, such resources as good faith effort, commitment, voluntary participation, and resolve must also be conserved.

♦ Root cause analysis induces discussion and reflection.

Too often, we do not discuss and reflect on our practices. Root cause analysis provides the means whereby discussion and reflection can take place in a nonthreatening and open context. The introspection, quality, and depth of root cause discussions exceed typical problem solving where conversations jump from symptom to solution. Opinions not founded on data are rejected until proven. Knee-jerk reactions to problems are greatly reduced, if not eliminated.

♦ Root cause analysis provides rationale for strategy selection.

We cannot fix something until we know what is wrong. By focusing on dissolving the most fundamental causes for problems, we can then select strategies that are properly targeted on the cause rather than on the symptom. By identifying the cause, one can justify strategies that are aimed at the cause rather than the symptom.

What is “Root Cause”?

Rather than assume knowledge of what a “root cause” is, let’s first look at several definitions:

From the Savannah River Project (a nuclear power station):

Root Cause is “the most basic cause that can reasonably be identified, that we have control to fix, and for which effective recommendations for prevention can be implemented.”

From Medical Risk Management Associates:

Root Causes are “the underlying causes of adverse outcomes.”

From the Joint Commission on Accreditation of Healthcare Organizations:

Root Causes are “the basic or casual factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel (major) event.”

From Business Solutions—The Positive Way:

Root Causes are the “basic cause or causes” of the problem or symptoms.

From “Total Quality Schools,” by Joseph C. Fields:

A Root Cause is “the most basic reason the problem occurs.”

Other organizations differentiate between “contributory” or “proximate” causes and root causes. Often, the most immediate or obvious cause is mistakenly identified as the root cause when, instead, it is simply the most proximate contributory cause, which itself has much deeper roots.

Example: Often, blame is first centered on an individual. Although an individual may have indeed committed an error that resulted in a problem, a deeper cause may be found in areas such as: training of the individual, scheduling of the individual, assignment of duties, clarification of duties, supervision, work environment, or any one of a host of other issues. Most people involved in root cause analysis understand that the vast majority of root causes are system-based rather than individual-based.

For purposes of this guide, the following definition suffices:

Root Cause—the deepest underlying cause, or causes, of positive or negative symptoms within any process that, if dissolved, would result in elimination, or substantial reduction, of the symptom.

Let’s look at this definition again, this time highlighting and commenting on its various essential components:

Root Cause—the deepest underlying cause, or causes, of positive or negative symptoms within any process that if dissolved would result in elimination, or substantial reduction, of the symptom.

♦ Deepest—this means that we really have to dig deep to find most roots. They usually are not the most immediate, obvious, or proximate causes. Often, they are three, four, or five layers down into the system.

Example: A high school has a high number of local (general) diploma graduates. However, the state is requiring that 100 percent of graduates have academic diplomas within a few years. Taking a detailed look at the local diploma recipients, it is found that fully two-thirds either had exceeded academic diploma requirements or were close to them. Upon further investigation, it is found that guidance counselors, and even the high school principal, communicate to parents and students that the academic diploma is not necessary for college acceptance or future success. Emphasis is placed on SAT scores instead. In discussions with the counselors and principal, it is found that the system has never placed emphasis on academic diplomas, and, in fact, the school’s personnel felt they were doing their duty in accordance with what they believed the school system and the community wanted. The district (system) had not communicated this change in goals to its staff.

A few people take issue with the use of the term “root cause” and prefer instead the concept of “causal analysis.” Their reasoning is that the concept of “root cause” came out of an industrial mechanical environment that is not suite...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• About the Author
• Foreword
• Acknowledgments
• Table of Contents
• Introduction
• 1 Root Cause Basics
• 2 Key Indicators of Student Success
• 3 Root Cause Processes
• 4 Using Root Cause Analysis
• 5 Considerations
• 6 Models and Stories
• 7 Resources