Beyond root cause analysis: How variation analysis can provide a deeper understanding of causation in complex adaptive systems

Abstract

Root cause analysis (RCA) is a recognised approach to understanding causation of adverse events across high-risk industries including healthcare. These methodologies were developed during the early part of the twentieth century when the workplace could be understood as a series of linear processes. Within a complex system these approaches offer limited insight, which has since been recognised within healthcare literature. This paper proposes an approach to understanding of causation that addresses Hollnagel’s ‘hypothesis of different causes’ and integrates Safety I and Safety II approaches. This develops Stretton’s Lilypond Model to conceptualise the relationship between work-as-imagined and work-as-done within a complex system where individual adaptations and variations can be analysed. Understanding variation in such a way creates a shift in methodology from a deterministic to a probabilistic approach, which is more appropriate for understanding causation within complex systems.