It’s Not What, It’s Why
Using root-cause analysis to break the cycle of food safety problems
Think about how many times you have identified a food safety problem at a particular location that was repeated despite your multiple attempts to resolve it. I bet you could come up with a very long list. This reminds me of an old expression from Einstein that the definition of insanity is doing the same thing over and over and expecting different results! One of the reasons that this happens is that food safety professionals are very good at identifying what went wrong, but too often we don’t identify why it went wrong. Regulations and regulatory programs tend to focus on violations of regulations: the whats, such as equipment or physical environment problems, and/or procedural problems. Industry food safety programs often focus on the whats as well. Both programs may have the attitude that it is someone else’s responsibility to figure out why the problem is happening and fix it, and their job is just to find the problem. Outbreak or contamination investigations historically have sought to find the contributing factors for the problem, which typically are related to equipment or physical environment or procedural issues. They also may limit their investigations to possible regulatory violations. Once again, these may be the whats but often are not the whys. Talk about getting back to the basics—is there a better way to think through preventing problems from reoccurring than through understanding why they happened in the first place?
The What and the Why Lead to the Who
So, now you are asking: How do we get to the whys and what are they? We get to the whys by using an approach called root-cause analysis. Root causes are the underlying reason for the whats. This approach is used for problem-solving all over the world in many different settings. Unfortunately, it has had limited use in the world of food safety. If the root causes for the problem are not identified and addressed, the problem probably will repeat or even get worse! Root-cause analysis is part of a larger field called systems analysis. To identify root causes, you need to consider the parts of the food system in a location, which typically includes equipment, processes, foods, economics, and people. It is my contention that ultimately a root-cause analysis will find that people are a major root cause of whatever problem you have identified. People make and implement choices/decisions. People may lack knowledge or be poorly supervised. They may lack motivation, and/or food safety may not be a priority in their minds. They may be operating beyond the capacity and capabilities of the setting they are in. The most common people problem probably is failure to communicate either internally or externally or both. Historically, we may have suspected or inferred these issues, but we have been reluctant to voice or pursue them. We may feel that it is beyond our role or that we do not want to rock the boat by stating that a person or persons are the reasons for the problems.
So, this is the dilemma food safety professionals face. Do we continue to do what we have always done and see little progress in resolving repeated food safety problems, or do we add root-cause analysis to our approach to solving these problems? The first option sounds like the definition of insanity, right? In summary, let’s get back to the basics—focus on figuring out why the what happened in the first place and addressing that root cause, so we can stop the past from repeating itself. Then we can put that phrase from Einstein to rest, once and for all in the food safety arena.
Resources
Pew Charitable Trusts. 2020.
A Guide for Conducting a Food Safety Root Cause Analysis: Approaches for Investigating Contamination Incidents and Preventing Recurrence.
Firestone, M.J., et al. 2018
“Leveraging Current Opportunities to Communicate Lessons Learned from Root Cause Analysis to Prevent Foodborne Illness Outbreaks.” Food Prot Trends 38(2):134–138.
Selman, C.A. and J.J. Guzewich
“Public Health Measures: Environmental Assessment in Outbreak Investigations,” in Encyclopedia of Food Safety, vol. 4, ed. Y. Motarjemi (Waltham, MA: Academic Press, 2014).
John J. Guzewich, RS, M.P.H., is a foodborne disease epidemiology and food emergency response consultant and trainer. He led food outbreak emergency investigation and response at the U.S. Food and Drug Administration, Center for Food Safety and Applied Nutrition. He was responsible for statewide foodborne disease outbreak surveillance and response, foodservice establishment regulation, and statewide training of new environmental health staff at the New York State Department of Health.
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