Understanding and analysing the root causes of a problem.
The first step in responding to a performance concern is to understand what is causing the issue.
A root cause analysis (RCA) will help identify the likely causes and take action to address underlying factors, preventing the issue from recurring.
An RCA can help to produce sustainable solutions, leading to potential improvements in:
- service delivery
- public trust
- officer safety
Forces should conduct an RCA where they identify performance concerns or when performance concerns are identified as part of the policing performance system.
There are several circumstances in which it might be appropriate to perform an RCA, which are not always connected to performance issues. Forces are also encouraged to share their learning where they have found root causes that led to success.
About root cause analysis
RCA is a structured approach to:
- identify the fundamental reasons behind an issue, failure or factors that led to success
- prevent issues from recurring by addressing systemic causes
- improve organisational learning and accountability
Forces in levels one and two are strongly encouraged to conduct analysis to better understand what is working well or issue(s) identified by the policing performance monitoring group (PPMG).
Forces in levels three and four are strongly encouraged to complete an RCA once notified of any performance concerns and to evidence this within their performance improvement plans.
Principles
- Focus on causes, not blame – RCA is about learning, not punishment.
- Evidence-based – use qualitative and quantitative data and insight, either already collected or commission if there are evidence gaps.
- Systemic thinking – look beyond individual error to organisational factors.
- Transparency – document all steps for audit and learning (and sharing where relevant).
When to use root cause analysis
Forces should conduct an RCA where they identify performance concerns as part of the policing performance system, regardless of level. Forces in levels three and four are strongly encouraged to conduct an RCA on performance issues identified by the PPMG.
Outside of the policing performance system, you may wish to use an RCA:
- after critical incidents or near misses
- when patterns emerge in performance data
- following Independent Office for Police Conduct (IOPC) recommendations
- as part of continuous improvement
- in response to His Majesty's Inspectorate of Constabulary and Fire & Rescue Services (HMICFRS) findings
RCA should also be used to understand causes that have resulted in good performance, to ensure these can be continued or replicated.
How to conduct a root cause analysis
The following steps describe how to conduct an RCA. Repeat these steps for each identified performance concern.
Step one: define the problem
- What was the situation or issue identified?
- When and where did it occur?
- Who was involved?
- What was the impact (public, officer, staff, organisational)?
Step two: gather evidence
- Data from performance dashboards.
- Document review, including policies relevant to the subject.
- Interviews or focus groups with officers and staff.
- Interviews or focus groups with subject matter experts.
Step three: map the sequence of events
- Create a timeline of what happened (actions and decisions).
- Identify decision points and influencing factors.
Tools could include:
- flowcharts for process mapping
- cause-and-effect diagrams
Step four: identify contributing factors
Consider:
- human factors, such as training, fatigue, supervision
- procedural gaps, such as unclear policies, conflicting guidance
- technology issues, such as system downtime, poor usability
- cultural factors, such as attitudes towards risk, compliance norms
Contributing factors can include not only failures but also missed opportunities for correction.
Step five: determine root causes
- Ask 'why' repeatedly until you reach a systemic cause.
- Map how combinations of root causes interact and lead to the performance issue.
- Categorise the root causes.
Tools could include:
- fault tree analysis (FTA) to help understand the chain of events behind an issue
- the 'five whys' method
Step six: develop corrective actions
- Develop corrective actions that address the identified root causes, not the symptoms.
- Actions should be specific, measurable, achievable, relevant and time-bound (SMART).
Step seven: monitor and review
- Assign responsibility for actions and set review dates.
- Track outputs and outcomes through performance dashboards.
- Share learning across the force, other police forces and with partners.
Steps six and seven can also be completed as part of a performance improvement plan.