Current Reality Trees A Tool for Root Cause Analysis Bill and Melinda Gates Institute for Population and Reproductive Health

Current Reality Trees Current Reality Trees can help uncover a cause and effect logic that lies beneath a current situation – a “root cause” analysis. This must be a team process with members coming from diverse backgrounds who can bring a broad insight into the problem from the household, community and government perspectives.

Traditional Problem Trees Developing a Master Plan for Health Service Delivery in North Sumatra. World Bank

Limitations of the Usual Problem Trees Diagrams lack criteria for validating connections between one element and another Branches do not bring to the surface the underlying causes of problems

Current Reality Tree Objective: isolate “weakest link” or key constraint Input: The TEAM’S experience and knowledge about the problem Output: identifies the core problem that guides the strategy design

Reality Trees - Help the user to: isolate the “weakest link” in a process or system; identify the most probable chains of cause and effect down to the root causes.

Reality Tree Structure Why is this happening? Undesirable Effect - UDE Undesirable Effect - UDE Undesirable Effect - UDE Undesirable Effect - UDE Undesirable Effect - UDE Undesirable Effect - UDE Undesirable Effect - UDE Undesirable Effect - UDE Root Cause Root Cause and CORE PPROBLEM

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

Eight Proofs for Cause and Effect (See STARGuide for details) Additional Cause Cause and Effect Reversal Predicted Effect Existence Tautology Clarity Entity Existence Cause Insufficiency Causality Existence From Goldratt’s Theory of Constraints A Systems Approach to Continuous Improvement By H. William Dettmer

For Example: Entity Existence Is there a complete sentence(i.e. subject and verb)? Does it make sense? Is it a true statement? Does it exist in my reality? Low staff morale No Quality of care is worse than quantity of care. No Most drugs fail to meet national quality standards Yes

For 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 No Health centers are remote There is underutilization of clinics. Yes Illiteracy rate is very high

Notes on Other Rules of Causality Causality – does the cause, in fact, result in the effect? Cause insufficiency – can the cause produce the effect on its own? Additional cause – can another cause produce the same effect? Cause and effect reversal – is the cause and effect relationship reversed? Predicted effect existence – are there other outcomes besides the stated effect? Tautology – is there circular logic?

Steps to Creating a Reality Tree

Root Cause Analysis For Root Cause Analysis to work, the TEAM should be able to answer “Yes” to the following questions: Do we have intuitive knowledge about the situation? Can we recognize and understand patterns 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: People prefer traditional healers. Service quality is poor. 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.”

Example “Why don’t sick people use existing government health clinics Service quality is poor Clinic supervision is infrequent

Step 4: Identify Intervening Steps That May Be a Part of Your Original Pair Ask yourself “Is this the true cause of this effect, or are there intervening steps missing?” 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.

Example Original Revised Service quality is poor Service quality Staff performance is poor Clinic facilities are disorganized Clinic supervision is infrequent Staff training is inadequate Clinic supervision is infrequent

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.

Example People prefer traditional healers Service quality is poor Staff performance is poor Clinic facilities disorganized Traditional healers are readily available Staff training is inadequate Clinic supervision is infrequent

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”.

Example People prefer traditional healers Service quality is poor Staff performance is poor Clinic facilities are disorganized Traditional healers are readily available Staff training is inadequate Clinic supervision is infrequent Root cause and Core problem There is no community involvement in health Government priorities are always changing Root cause

Step 8- Recognize your “Spheres” When It Comes to Designing a Strategy to Change the Root Cause Sphere of Influence Sphere of Control These may be greater than you think!!!

Why is there a conflict between the TBA & MW? Indonesia – Reality Tree Analysis of Maternity Care Program Why is there a conflict between the TBA & MW? TBA refuse to refer cases to MW Doc & the MOH as a whole do not appreciate TBA Doc/MW don’t know what TBA can/can’t do Doc,/MW see TBA-ruined cases, & their negative ideas reinforced TBA & MW undermine each other’s image & authority TBA & MW refuse to talk directly with each other TBA see MW as taking away their clients (money) MW have better resources (kit, uniform) than TBA MOH policies do not consider TBA have roles, and focus solely on MW Medical/MW education excludes work of TBA MW intimidated by age/relations/ experience of TBA TBA intimidated by knowledge & resources Of MW Age (& experience) are valued in Indonesian culture (in community & families) Policymakers believe “TBA are problem rather than a part of solution.” Undesirable effects -UDE Root Causes - RC Core Problem - CP