by Denise Robitaille
I recently read a great book that reminded me of an important aspect of audits and corrective actions: root cause analysis. In compelling narrative, The Ghost Map by Steven Johnson (Riverhead Trade, 2007) tells the story of one of the most virulent epidemics to hit Europe in recorded history. What was so devastating about this particular epidemic was its swiftness and per capita mortality rate. In 1854, one case of cholera triggered the rampage of this disease through a small neighborhood in London. A few short weeks later it had killed more than 10 percent of one small neighborhood’s population. By the time it ended it had killed 616 people.
The Ghost Map is about the labor and challenges of two men who battled ignorance and preconceived notions to finally uncover the root cause that led to action that brought an end to the epidemic. A large part of their challenge was to convince the local authorities of the credibility of their assertion—the validity of their data. Herein lies the connection to the problems auditors face every day with root cause analysis.
Johnson sets the stage for mid-19th century London. The air throughout most of the city is redolent with foul odors. There’s an entire subculture employed in various enterprises collecting and selling garbage, scrap, excrement, carcasses, rags, and just about any reeking detritus known to man. Dog feces, for example, were sold to the tanneries. So, we’ve got a lot of people doing really gross things to earn a living. This tidbit is important for the following reason.
The stench in the air was referred to as “miasma” and the local health authorities—an austere governmental body comprised of individuals who did not necessarily have scientific backgrounds—asserted that the miasma was causing the cholera. This group insisted that cholera was an airborne disease and an inherent component of the miasma. People, they concluded, were dying because they were breathing this bad air. This conclusion persisted, notwithstanding the fact that the primitive recyclers of the city’s refuse were not particularly affected by the cholera outbreak. In fact, they were a fairly healthy bunch. If the miasma was so deadly, this group should have been the first to perish.
Two gentlemen, Dr. John Snow and the Rev. Henry Whitehead, had separately determined that cholera was waterborne rather than airborne and, therefore ingested rather than inhaled. They gathered data assiduously, going door to door, attempting to find common denominators to help pinpoint the source. What they finally discovered was that the point of origin was a water pump on Broad Street. Again, common consensus thwarted them. This particular water pump provided the best-tasting water in the neighborhood. Anyone who could get to it or pay a young child to fetch it would get their water from this pump. The conventional wisdom was that the better the taste, the healthier the water.
When Snow and Whitehead presented their findings to the local board their conclusion was met with dissent. Despite the objective evidence, the officials would not budge because they knew that cholera was an airborne disease. It made no sense that foul-tasting water would be less deadly than sweet-tasting water. Our two protagonists were finally able to amass enough evidence to sway the locals and get the water pump shut off. Unfortunately, precious days had elapsed and the epidemic claimed more victims.
This scenario plays itself out frequently with root cause analysis. We dig in our heels. We know what we know. Sometimes, sound data fly in the face of entrenched conceptions. After all, the idea that foul-smelling air must be unhealthy wasn’t without merit. It’s just that in this case, regardless of the putrefying stench, it simply wasn’t the cause of cholera.
This analogy should be helpful to modern organizations. First, although instincts are sometimes reliable, they can often be trumped by objective evidence. Second, just because something is wrong doesn’t mean that it’s the root cause of the problem you’re currently working on. Finally, hints of the root cause will come from unexpected sources. In this case, an interesting anomaly of questionable significance was noted. Childless widows appeared to be less vulnerable to the disease. The answer to the conundrum substantiated Snow and Whitehead’s findings. The reason: Widows didn’t have children to send out for water and were too poor to pay someone else to go, so they drank water from a nearer pump.
So, be thorough in your investigation. Resist the impulse to be swayed by conventional thinking. Go with the objective data.
About the author
Denise Robitaille is the author of 10 books on various quality topics. She’s an internationally recognized speaker who brings years of experience in business and industry to her work in the quality profession. As the principal of Robitaille Associates, she has helped numerous companies in diverse fields to achieve ISO 9001 registration and to improve their quality management systems. Robitaille is vice chair of the U.S. TAG to ISO/TC 176, the committee responsible for updating the ISO 9000 family of standards. She’s also a RABQSA-certified lead assessor, an ASQ Certified Quality Auditor, and a fellow of ASQ.
Her books include Root Cause Analysis, The Corrective Action Handbook, The Management Review Handbook, The Preventive Action Handbook, Managing Supplier-Related Processes, and Document Control, all published by Paton Professional. She also co-authored The Insiders’ Guide to ISO 9001:2008.
Her newest book, 9 Keys to Successful Audits, is available now.