Current Reality Current Reality TreesTrees

A Tool for Root Cause A Tool for Root Cause AnalysisAnalysis

Bill and Melinda Gates Institute for Population and Reproductive Health

Current Reality TreesCurrent Reality Trees

Current Reality Trees can help uncover a Current Reality Trees can help uncover a cause and effect logic that lies beneath a cause and effect logic that lies beneath a current situation – a “root cause” analysis.current situation – a “root cause” analysis.

This This must be a team processmust be a team process with members with members coming from diverse backgrounds who can coming from diverse backgrounds who can bring a broad insight into the problem from bring a broad insight into the problem from the household, community and government the household, community and government perspectives.perspectives.

Traditional Problem TreesTraditional Problem Trees

Developing a Master Plan for Health Service Delivery inNorth Sumatra. World Bank

Limitations of the Usual Problem TreesLimitations of the Usual Problem Trees

Diagrams lack criteria for validating Diagrams lack criteria for validating connections between one element and connections between one element and anotheranother

Branches do not bring to the surface the Branches do not bring to the surface the underlying causes of problemsunderlying causes of problems

Current Reality TreeCurrent Reality Tree ObjectiveObjective: isolate : isolate

“weakest link” or key “weakest link” or key constraintconstraint

InputInput: The TEAM’S : The TEAM’S experience and experience and knowledge about the knowledge about the problemproblem

OutputOutput: identifies the : identifies the core problem that guides core problem that guides the strategy designthe strategy design

Reality Trees -Reality Trees -

Help the user to:Help the user to:– isolate the “weakest link” in a isolate the “weakest link” in a

process or systemprocess or system;;

– identify the most probable chains of identify the most probable chains of cause and effect down to the root cause and effect down to the root causes.causes.

Reality Tree StructureReality Tree Structure

Undesirable Effect - UDE

Undesirable Effect - UDE

Undesirable Effect - UDE

Undesirable Effect - UDE

Root Cause

Undesirable Effect - UDE

Why is this happening?

Undesirable Effect - UDE

Undesirable Effect - UDE

Undesirable Effect - UDE

Root Cause and CORE PPROBLEM

Reality Trees Reality Trees

Apply a series of rules (“proofs”) Apply a series of rules (“proofs”) that test the logic of the that test the logic of the connections between “causes and connections between “causes and effects” (Undesirable Effects) .effects” (Undesirable Effects) .

Eight Proofs for Cause and EffectEight Proofs for Cause and Effect(See STARGuide for details)(See STARGuide for details)

ClarityClarity Entity ExistenceEntity Existence Cause Cause

InsufficiencyInsufficiency Causality Causality

ExistenceExistence

Additional CauseAdditional Cause Cause and Effect Cause and Effect

ReversalReversal Predicted Effect Predicted Effect

ExistenceExistence TautologyTautology

From Goldratt’s Theory of Constraints ASystems Approach to Continuous Improvement By H. William Dettmer

For Example: Entity ExistenceFor Example: Entity Existence

Is there a complete Is there a complete sentence(i.e. subject sentence(i.e. subject and verb)? and verb)?

Does it make sense?Does it make sense?

Is it a true statement? Is it a true statement? Does it exist in my Does it exist in my reality?reality?

Low staffmorale

Quality of care is worse than quantity of care.

Most drugs fail to meet nationalquality standards

No

No

Yes

For Example: ClarityFor Example: Clarity Would I need to add

any verbal explanation if seeking to explain to someone else?

Is the connection between cause and effect convincing at face value?

Are intermediate steps missing?

There are barriers to services

Yes

Clinics lack vaccines

Health centers are remote

No

There is underutilization of clinics.

Illiteracy rate is very high

Yes

Notes on Other Rules of CausalityNotes on Other Rules of Causality CausalityCausality – does the cause, in fact, result in the – does the cause, in fact, result in the

effect? effect? Cause insufficiencyCause insufficiency – can the cause produce the – can the cause produce the

effect on its own?effect on its own? Additional causeAdditional cause – can another cause produce the – can another cause produce the

same effect?same effect? Cause and effect reversalCause and effect reversal – is the cause and effect – is the cause and effect

relationship reversed?relationship reversed? Predicted effect existencePredicted effect existence – are there other – are there other

outcomes besides the stated effect?outcomes besides the stated effect? TautologyTautology – is there circular logic? – is there circular logic?

Steps to Creating a Reality Tree

Root Cause AnalysisRoot Cause Analysis

For Root Cause Analysis to work, the TEAM For Root Cause Analysis to work, the TEAM should be able to answer “Yes” to the should be able to answer “Yes” to the following questions:following questions:

Do we have intuitive knowledge about the Do we have intuitive knowledge about the situation?situation?

Can we recognize and understand patterns Can we recognize and understand patterns and interactions in your system?and interactions in your system?

Step 1: Select Your Key Question

First, select your “Key Question.” This question begins with “Why …? This is the issue around which you will build your Reality Tree.

For example, “Why don’t sick people use existing government health services?”

Step 2: Creating a List of Undesirable Effects (UDEs)

Now think of reasons (statements) that confirm your statement of the problem. For example:

1. People prefer traditional healers.

2. Service quality is poor.

3. Government clinics are poorly equipped.

Now determine if these are truly negative conditions. If not, there is no problem.

Step 2: Creating a List of Undesirable Effects (UDEs) continued

The negative statements are known as “Undesirable Effects” (UDEs).

• They are negative or bad conditions and are therefore “undesirable”.

• They are also “effects” because they are caused by something else.

List up to 10 UDEs for the issue you have selected.

Step 3: Connect Your UDEs

Write each of your UDEs on a Post-it note (or index card).

Now look for relationships among the UDEs.

Decide if one may be the cause of another.

Then arrange these two vertically with the “cause” below the “effect.”

ExampleExample“Why don’t sick people use existing government health “Why don’t sick people use existing government health

clinics?”clinics?”

Service qualityis poor

Clinic supervisionis infrequent

Step 4: Identify Intervening Steps That May Be a Part of Your Original Pair

These may be:

• UDEs already in your list.

• New causes (UDEs) not in your original list.

• UDEs that have been placed in in the wrong sequence.

Ask yourself “Is this the true cause of this effect, or are there intervening steps missing?”

ExampleExample

Service qualityis poor

Clinic supervisionis infrequent

Original Revised

Service qualityis poor

Clinic supervisionis infrequent

Staff performance is poor

Staff trainingis inadequate

Clinic facilitiesare disorganized

Step 5: Repeat This Process With Remaining UDEs From Your Original

Group

Connect all possible remaining UDEs together.

Connect the remaining UDEs to the first pair or to other clusters where possible.

Look for multiple causes for a single UDE.

Example: Look for Multiple Causes for a Single UDE

Many Intermediate Causes (IC) can be grouped together with the ellipse symbol. When this symbol is used it means that all the grouped causes must be present to produce the effect in question. UDE

IC IC IC

Step 6: Review and Trace

If you are lucky you will have connected all 10 of your UDEs. What is more likely is that you have groupings of unconnected “branches” in your Current Reality Tree.

ExampleExample

Service qualityis poor

Clinic supervisionis infrequent

Staff performance is poor

Staff trainingis inadequate

Clinic facilitiesdisorganized

People prefer traditional healers

Traditional healers are readily available

Step 6: Review and Trace continued

Now your objective is to trace the cause and effect chain downward in each branch until you reach an end point or Root Cause.

Choose a single branch and start building downward.

At the lowest UDE always ask “why does this exist?” The answer will be the next lower UDE.

Step 6: Review and Trace continued

To speed up the connection process look for lateral or intermediate connections. These are connections that can join two groups of branches together.

Step 7: Pruning your Tree

Look at your original UDE list one more time. Have they all been used?

Prune any entities not required to connect all the UDEs.

Look for unrelated UDEs or “Facts of Life”. Since these are not in the causal chain, they will not be dealt with in this analysis.

Step 8: Identify Root Causes and Core Problem

Locate all “Root Causes” (entities with arrows coming out but with none going in).

Determine if any Root Cause accounts for more than 70% of the UDEs; if so then that is your “Core Problem”.

ExampleExample

Service qualityis poor

Clinic supervisionis infrequent

Staff performance is poor

Staff trainingis inadequate

Clinic facilitiesare disorganized

People prefer traditional healers

Traditional healers are readily available

Government priorities are always changing

There is no communityinvolvement in health Root cause

Root causeand

Core problem

Step 8- Recognize your “Spheres” When It Comes to Designing a Strategy to Change the

Root Cause

Sphere of Control

These may be greater than you think!!!

Sphere of Influence

Why is there a conflict between the TBA & MW?

TBA refuse to refer cases

to MW

TBA & MW undermine eachother’s image &

authority

Doc/MW don’t know what

TBA can/can’tdo

Doc & the MOH as a whole do not appreciate TBA

MW have better

resources(kit,

uniform)than TBA

Age (& experience)are valued in

Indonesian culture(in community & families)

Age (& experience)are valued in

Indonesian culture(in community & families)

TBA intimidatedby knowledge& resources

Of MW

MW intimidatedby age/relations/

experience ofTBA

TBA & MW refuse to talkdirectly witheach other

MOH policiesdo not considerTBA have roles,

and focus solely on MW

Medical/MW educationexcludeswork of

TBA

Doc,/MW see TBA-ruined

cases, & theirnegative ideas

reinforced

Policymakers believe “TBA are problem

rather than a part of solution.”

Policymakers believe “TBA are problem

rather than a part of solution.”

Undesirable effects -UDE

Root Causes - RC

Core Problem - CP

TBA see MW as taking away

their clients(money)

Indonesia – Reality Tree Analysis of Maternity Care Program