Ep 3: Learning Teams vs Root Cause Analyses

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 rather than systems factors?

Today we explore a paper by Robbins et al., 2021, comparing Learning Teams vs RCAs.

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Study link: https://www.researchgate.net/profile/Satya-Ramachandran/publication/340141827_Evaluation_of_Learning_Teams_Versus_Root_Cause_Analysis_for_Incident_Investigation_in_a_Large_United_Kingdom_National_Health_Service_Hospital/links/647f4c552cad460a1bf9f853/Evaluation-of-Learning-Teams-Versus-Root-Cause-Analysis-for-Incident-Investigation-in-a-Large-United-Kingdom-National-Health-Service-Hospital.pdf

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Episode Transcript

(00:06):
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

(00:27):
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? Good everyone.
I'm Ben Hutchinson, This Is Safehas podcast dedicated to the
thrifty analysis of safety, riskand performance research.

(00:49):
Visit safetyinsights.org for more research.
Today's study from Robbins ET al, 2021 is titled Evaluation of
Learning Teams versus Root CauseAnalysis 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

(01:09):
cause analysis investigations against 22 learning team
approaches. All 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

(01:31):
operational intelligence betweenthe two groups and improve
system design. Really not dissimilar to pre and
postmortems or quality circles. So what did they find?
Learning team investigations delivered significantly more
actions, averaging 7 1/2 actionsper incident compared to just 3
1/2 per instant for RCAS recallsanalysis?

(01:52):
Even better, 57% of the learningteam actions were systems
focused versus just 30% for the root cause analysis.
They observed clear differences between the learning teams and
the root cause analysis in personal involvement,
discussion, content, cultural aspects, challenges, and
outcome. Let's explore some of these.

(02:12):
So if you're personal 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
organisational hierarchy were less often invited to the RCA

(02:36):
investigations, even though their expertise was highly
valued within the learning team framework For the content of
discussions, what people discussed in the learning teams
consistently differed from the root cause analysis.
Learning teams focus more on normal and holistic operational
factors, with less reliance on instance specific details.
What they mean is how does work normally get done?

(02:59):
What are the things that normally make work difficult or
successful? In contrast, the root cause
analysis 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 analysis often focused
only on the last barrier to fail, while learning things

(03:19):
looked more holistically at other barriers and factors
influencing operational work, The Rcas also focus less on the
deeper sort of wires within the broader context environment.
Learning things offered more flexibility for complex themes
and multiple perspectives, whilethe root cause analysis tended
to oversimplify many factors into just a few causal factors.

(03:40):
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.

(04:02):
In contrast, the root cause analysis 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.

(04:24):
They're one tool among many. Recourse analysis are well
established and familiar, unlikesort of the unknown nature of
learning teams at this point. Also, staff lowering the
hierarchy then 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 teamsession were often highly

(04:46):
engaged and interested in the second.
Learning teams were seen to challenge the status quo more
often too, seeking innovative solutions.
They also focus more on the coalface, the frontline
operations. While the root cause analysis
were seen to reflect more of thesenior management's perspective
more the work has imagined. So let's unpack some of the
findings more. In this sample, learning teams

(05:09):
delivered more systems focused actions of higher quality,
addressing broader issues compared to the root cause
analysis that were compared, which seemed to have a narrower
focus on singular incidents, butimportantly regarding which
techniques suit which occasion. The paper reemphasizes that
learning teams aren't universally superior.
Other sorts of investigation techniques may be more suitable

(05:30):
for a specific incident, less likely to recur outside of its
unique context. Also, for a repeat event, if a
comprehensive learning team was already done, the recourse
analysis might be more efficientto 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, andtherefore judgement needs to be

(05:54):
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 interestingimplications though about
expanding our adaptive tool boxes.
Like they know it's less about one single technique being

(06:15):
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 is more of an approach rather than a specific

(06:36):
technique. Also consider how root cause
analysis in this sample, we're 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

(06:57):
legitimate yet, then just schedule and 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
that was selected based on the perceived utility of using that
technique, which could introducesome level of bias.
Also, interviews were mainly with those sharing learning

(07:19):
teams, potentially introducing some bias, so all of them still
had extensive root cause analysis experience.
Finally, no followu was possibleto assess the long term changes,
if any. That's it on Safe as I'm Ben
Hutchinson and hoe you found this useful.