Root Cause Analysis—Facts, Validity, Truth, and Consequences, Part 2
In part one, the emphasis was on attempting to make sure that a problem was adequately and soundly delineated before root-cause analysis is implemented. In part two, examining the illusory concepts of facts, validity and truth will be examined. Here again, just as with the problem statement, individuals often take these concepts for granted. But again, as with the problem statement, these apparently simple concepts often hold a considerable level of complexity that is often not understood. It is that which we will concern ourselves in the next few paragraphs.
Frequently not just in long-term care, but in many areas of life, I will hear people say, "you cannot dispute it; it is fact." Many often think that fact is tantamount to truth. However this is far from true. A fact is something that exists, but facts do not hold anything inherent in them that make them true or false. Let us use a few examples from the typical long-term care environment to further illustrate what is being stated. In the first scenario resident Jane Doe has an ulcer on her leg, but does that mean the staff has not provided good, sound care?
Quite possibly this could be true but it could also be false. The fact that exists is that she has acquired an ulcer on her leg that measures 3 centimeters by 2 centimeters and has been staged as a stage III ulcer. That is the only fact that we know at this time. Although decubiti are often associated with poor care, anything that extends beyond the facts just mentioned is speculation. Upon further examination Ms. Jane Doe is turned every two hours, gets frequent skin message from the staff and has excellent care provided to her. However, her diabetic and cardiovascular condition has led to an unavoidable stasis ulcer that is due to the severe vascular occlusions found in her peripheries. Here the fact is that she acquired an ulcer. Is the ulcer due to poor care? Other facts have to be ascertained. In this example she 1) had very good care and 2) had physical conditions that led to an unavoidable occurrence.
Scenario two deals with an administrator who gets a call and is informed by the president of the company that his operating margin for the month is a negative 19 percent! The administrator says that this cannot be true and that his numbers show that his operating margin was a positive 15 percent. The president adamantly says that the accounting facts show this is not the case and that he must demonstrate dramatic improvement in the next month or else. The administrator goes back and checks the financial data that he has and compares it with the financial data that the president had and he finds out that there is $200,000 instead of $20,000 in entries that were not coded properly to wage expenses, including his director of nursing who had an erroneous monthly wage expense posting of $100,000. As one can see the facts on paper existed, but they did not reflect the true reality.
Often facts do not reflect the true reality of a situation. In both of the situations above, a root cause analysis had to be employed to determine further facts. Moreover in both cases the analysis found other facts that countered the abrupt and often quick attributions that others made regarding the initial set of facts. Furthermore, at times people will mistakenly use the concept of validity to buttress their conclusions about a particular finding. In reality validity only means that the extrapolation of the data fits with the initial problem or premise that was formed. For instance, here is an example of something that has validity, but does not demonstrate any truth.
All dogs have three legs,
Lassie is a dog,
Therefore Lassie has three legs.
This is a perfectly valid argument that is logically sound, but due to the initial premise that was incorrect, so was the final conclusion. Or using a long-term care example:
All skin ulcers are the result of poor care,
Jane Doe has an ulcer,
Therefore Jane had poor care.
Again, this is a perfectly valid argument that is logically sound, but again, due to the initial premise, is totally incorrect for Jane Doe. Jane had very good care as we mentioned. If one read Part I of the series, you will remember how important it is to have a well defined problem and look at many alternatives in formulating a sound problem statement. A well thought out and structured problem is the driving force behind sound implementation of finding cause.
I hope part two was able to convey the importance of failing to fall into the trap of semantics that often leads to illusory assumptions. Facts and validity do not necessarily guarantee truth. Yet, the power behind these words often makes individuals assume truth and reality without checking further and determining whether truth and cause is actually being captured. Long-term care practitioners often hear these terms and take them for granted. However, as has been demonstrated, taking them for granted can lead to a path of erroneous root cause analysis. Please share any thoughts you may have.