ABSTRACT
This chapter urges those finding ways to redesign a workflow and process in need of improvement to avoid the “blame game” and truly find the fundamental elements that must be addressed to achieve success (Williams 2001). It discusses cause and effect, finding and weighing potential solutions, requirements for performing root cause analysis, and tools and techniques to aid root cause analysis.
The dictionary defines causality as the relationship between an event (the cause) and a second event (the effect), where the second event is understood to be the consequence of the first. The problem is that causality is rarely as simple as it seems; sometimes assumptions must be made about causality, sometimes there are multiple causes, and sometimes there are surprises when the underlying cause is determined. A few examples from outside health care and potentially outside workflow follow:
