Safe AF pod ep #3 now live! How well can Learning Teams function against more traditional Root Cause Analysis techniques?
What things do they focus on, what fixes result from the learning activities? Does one focus more on blame and individuals?
Today we explore a paper by Robbins et al., 2021, comparing Learning Teams vs RCAs.
Links below.
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Transcription:
We all want safer workplaces, marked by continual risk reduction.
We investigate incidents, hoping to fix the problem for good.
But sometimes, these investigations feel like Groundhog Day.
Investigating the same things, finding the same things, and fixing, apparently, the same things for good.
Relying on investigations isn’t a proactive cycle for learning and improvement in the first instance.
Since we’re doing it, what if our standard approach only scratches the surface, leaving the core, or even systemic, issues untouched?
Is there a better way?
G’day everyone, I’m Ben Hutchinson and this is Safe As, a podcast dedicated to the thrifty analysis of safety, risk, and performance research.
Visit safetyinsights.org for more research.
Today’s study from Robbins et al., 2021, is titled “Evaluation of Learning Teams vs. Root Cause Analysis for Incident Investigation in a Large United Kingdom National Health Service Hospital.”
It was published in the Journal of Patient Safety.
It compared 22 conventional root cause analysis investigations against 22 learning team approaches.
While the specific root cause analysis methodologies weren’t detailed, the researchers compared their reports and interviewed staff familiar with both approaches.
So what’s a learning team?
It’s defined as a facilitated conversation between those that do the work and those that design the work to share operational intelligence between the two groups and improve system design.
Really not dissimilar to pre- and post-mortems or quality circles.
So what did they find?
Learning team investigations delivered significantly more actions, averaging 7.5 actions per incident, compared to just 3.5 per incident for RCA’s root cause analyses.
Even better, 57% of their learning team actions were systems-focused, versus just 30% for the root cause analyses.
They observed clear differences between the learning teams and the root cause analyses, in personnel involvement, discussion content, cultural aspects, challenges, and outcome.
Let’s explore some of these.
So for personnel involved, the interviewees noted that the learning teams drive different outcomes because they were designed from the outset to be inclusive events, involving all people involved with the processes that have been evaluated.
This brought in better representation from the whole team, not just those directly involved in the incident.
Conversely, people lower the organizational hierarchy when they’re involved in the process.
They were less often invited to the RCA investigations, even though their expertise was highly valued within the learning team framework.
For their content of discussions, what people discussed in the learning teams consistently differed from the root cause analyses.
Learning teams focus more on normal and holistic operational factors, with less reliance on incident-specific details.
What they mean is, how does work normally get done?
What are the things that normally make work difficult or successful?
In contrast, the root cause analyses investigations were seen as focused around a single specific incident, with significant time spent establishing exactly what went wrong.
It was also felt that the root cause analyses often focused only on the last barrier to fail, while learning teams looked more holistically at other barriers and factors influencing operational work.
The RCAs also focused less on the deeper sort of whys within the broader context environment.
Learning teams offered more flexibility for complex themes and multiple perspectives.
While the root cause analyses tended to oversimplify many factors into just a few causal factors, this flexibility in learning teams allowed for better transfer of lessons to other areas and more systems-focused actions.
Cultural Areas
So, interviewees observed a distinct cultural difference.
Learning teams felt more supportive and open to learning, with less fear of interpersonal risk.
They also favoured less technical themes, allowing broader participation.
In contrast, the root cause analyses investigations were believed to foster more blame and focus on individual mistakes.
People described an environment of fear and guilt, where they were less likely to speak truth to power.
Some challenges.
While generally positive about the learning teams, the study emphasised they aren’t suitable for every situation.
They’re one tool among many.
Root cause analyses are well established and familiar, unlike sort of the unknown nature of learning teams at this point.
Also, staff lowering the hierarchy found it harder to get time to attend the learning teams, and the overall time investment for learning teams could be higher.
On the positive side, people who attended the first learning team session were often highly engaged and interested in the second.
Learning teams were seen to challenge the status quo more often too, seeking innovative solutions.
They also focused more on the coalface, the frontline operations.
While the root cause analyses were seen to reflect more of the senior management’s perspective or the work of the staff, they were seen to focus on the coalface more closely.
So, let’s unpack some of the findings more.
In this sample, learning teams delivered more systems-focused actions of higher quality, addressing broader issues compared to the root cause analyses that were compared, which seemed to have a narrower focus on singular incidents.
But importantly, regarding which technique suits which occasion, the paper re-emphasises that learning teams aren’t universally superior.
Other sorts of investigation techniques may be more suitable for a specific incident, less likely to recur outside of its universe.
So, we’re going to look at the findings of the first learning team session.
Also, for a repeat event, if a comprehensive learning team was already done, the root cause analysis might be more efficient to capture any changes since the last learning team.
They conclude that there may not actually be one right investigation method.
Incidents lie on a spectrum, and therefore, judgment needs to be applied to establish which investigative methods to choose.
So, what do we make of the findings?
Well, like any single study, we shouldn’t make too much of the findings.
But rather look for a body of evidence.
It does provide some interesting implications, though, about expanding our adaptive toolboxes.
Like they note, it’s less about one single technique being wholesale superior, but rather fitting the more appropriate approach to that situation.
Learning teams, despite these findings, might still focus too much on lower-level individual factors compared to other systems-based methods.
But, of course, nothing says they can’t be combined.
Since the learning teams’ findings are not consistent, learning teams is more of an approach rather than a specific technique.
Also consider how root cause analyses in this sample were more focused on preventing yesterday’s accident instead of trying to prevent tomorrow’s.
Think about it.
Yesterday’s accident has already happened.
Let’s focus on tomorrow.
Finally, consider the Trojan horse strategy.
If people can’t get permission to attend the learning teams because they’re not seen as legitimate yet, then just schedule a root cause analysis and then interject the learning team philosophies into that.
What are some limitations?
Importantly, learning teams weren’t randomly assigned, but they were selected based on the perceived utility of using that technique, which could introduce some level of bias.
Also, interviews were mainly with those chairing learning teams, potentially introducing some bias, though all of them still had extensive root cause analysis experience.
Finally, no follow-up was possible to assess the long-term changes, if any.
That’s it on Safe As. I’m Ben Hutchinson and hope you found this useful.
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