Root Cause Analysis
"It is far better to have a Good Solution for an Exact Problem than to have a Great Solution for the Wrong Problem"
Not long after a new administrator joined a famous hospital, he learned of a room that was rumored to be cursed. The staff of the hospital had given it the nickname, "the last room", not only because it was the last room at the end of a long hall, but also because of the reputation that it was the last room that many of the patients would ever be in. The room had earned a lethal reputation for fatalities.
Unfortunately, just as the administrator learned of the legend of the 'last room', so did the public. In an effort to preserve the reputation of the hospital and respond to the rumors, the administrator promptly conducted an investigation. By analyzing historical records, they quickly discovered a trend life support systems in that room were exhibiting inconsistent results and erratic behavior. Acting swiftly on this news, the administrator promptly replaced the expensive equipment and invested in new upgraded equipment to resolve the issue.
The problem persisted and additional experts were called upon to analyze the data. After thorough investigation of the new equipment, it was discovered that the problem was actually a result of an interruption in power. With this knowledge, the administrator promptly initiated a costly project to replace the cables and power supplies that supported the room. The best electricians were and engineers devised a state-of-the-art regulated and uninterrupted power supply to the last room at the end of the hall.
Shortly after the revamped room was placed back into use, the unfortunate trend began to occur again. This time there were more experts, including a police investigation under the suspicion of foul play. An investigation of the coroner records identified a trend that most fatalities occurred within a 1/2 hour period of 11pm. Several members of the staff were questioned, background searches conducted, and surveillance equipment was installed to monitor hospital activity both day and night.
With the permission of the hospital, one investigator volunteered to pretend to be a patient and spend a night in the cursed room. He lay quietly in the bed, alert for any suspicious intruder or unusual electrical phenomenon. At ten minutes after 11pm, he heard footsteps and a shuffle as something very heavy was dragged down the hall. The investigator closed his eyes and pretended to be asleep. His senses were alert and his muscled tensed as the quiet footsteps came into the room and paused in a corner of the room.
The investigator heard the sound of a chair being pulled aside in the corner of the room near his bed. He cautiously peered into the soft green glow of the hospital room and saw the outline of a shadowy figure behind the chair. Without further delay, the investigator sat up in the bed and swung his feet to the floor, ready for action.
The individual behind the chair stood up, slightly surprised by the commotion, smiled and waved. The investigator rushed to turn on the bright lights in the room and immediately recognized the gentle custodian. Upon questioning it was revealed that the custodian had just finished plugging in the electrical cord for the large buffing equipment used to wax and shine the hospital floors. The extension cord for the equipment was not long enough to reach the far end of the hall, so it was his custom for many years to use the power outlet in the room at the end of the hall. The well-intentioned custodian had not realized that the cords he unplugged to use the outlet were connected to very important equipment used to monitor patients.
New equipment, new power supplies and new cabling had not resolved the problem. A police investigation of the personal lives of the staff had not resolved the issue. The act of monitoring the time and place of the incidents, coupled with the minor investment of an extended power cord for the floor waxing machine, had resolved the problem. Getting close to the situation, location and facts of the issue from the beginning could have avoided significant investments and fatal consequences that resulted from improper conclusions.
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Words of Wisdom
"An appropriate answer to an exact problem is worth a good deal more than an
exact answer to an approximate problem."
- John W Tukey
"A person with an idea and no data is another person with an
opinion."
- John Chapin, co-founder, LifeMinders Inc.
"If people have better information, they make better decisions - period"
- Suzanne Muchin, CEO, Civitas
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About the Author:
John Mehrmann is a freelance writer and President of
Executive Blueprints Inc., an organization devoted to improving
business practices and developing human capital.
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