In August 1854, there was a deadly outbreak of cholera in the Soho district of central London. Cholera leads to diarrhoea, vomiting, dehydration, and in many cases to death. Thousands of people fell ill and over 600 died.
At that time, medical authorities believed that cholera was caused by ‘miasma’ - a type of ‘bad air’ possibly from decaying bodies. But a local doctor, John Snow, was sceptical of this theory. He thought it more likely that cholera was spread through contaminated water supplies. He carefully investigated the outbreak and plotted all the instances of death from cholera on a map of the area. He spoke to many people who had suffered the disease and found that they had all drawn water from the same hand pump on Broad Street. He wrote:
“Within 250 yards of the spot where Cambridge Street joins Broad Street there were upwards of 500 fatal attacks of cholera in 10 days… As soon as I became acquainted with the situation and extent of this irruption of cholera, I suspected some contamination of the water of the much-frequented street-pump in Broad Street.”
Snow showed his research to the local authorities and persuaded them to remove the handle from the pump to make it inoperative. New cases of cholera stopped. He had cut off the problem at the source. It was later found that the pump drew water from a well which had been contaminated by a nearby cesspool. His direct action saved many lives - not just in London but around the world as his theory for the spread of cholera was gradually accepted by medical bodies and town councils.
It is an early example of root cause analysis. There are three key actions in the process:
- Determine the root cause of the problem by asking many basic questions.
- Take immediate action to fix the root cause.
- Check to see where else in the system similar problems might occur and fix them too.
I worked with an organisation which wanted to improve innovation. The top leaders were dissatisfied with the level of creativity, agility and innovation in the business. They had tried offering rewards for good ideas, installing sofas and ping-pong tables; they had even set up an innovation incubator unit. But things had not improved. They had been treating the symptoms of the problem rather than the root cause. We carried out an audit to find out what was really impeding innovation. We found that the root cause was a risk averse culture which was deeply embedded. The leaders were unwittingly sending out signals that success is what matters and that failure is disdained. People were not motivated to carry out experiments or to propose initiatives because the implicit message was that they might fail and be blamed. We implemented a series of actions to change the culture. It took time, effort and constant reinforcement.
Whatever the problem you are facing, try to resist the temptation to just treat the symptoms. Use some problem analysis methods to determine the fundamental cause or causes of the issue. Fix the root cause and then check to see if that has fixed the problem. Then take the learnings throughout the organisation. You have to remove the pump handle!
I have put together an online course with a selection of powerful problem analysis techniques which will help you to get to the bottom of any problem and so to come up with much more effective solutions: Details here.
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