A Human Performance Causality Analysis (HPCA) provides the gathering of Human Behavioral data necessary to go beyond a traditional Root Cause Analysis (RCA) that typically only focuses on systemic issues. A complete and comprehensive (RCA) should not only develop accurate and responsive system improvements but focus heavily on the human behavior issues that lead to errors.
HPCA study components include Non-Technical Skills Analysis (NTSA), and Behavioral Error Analysis (BEA). Incorporated in the NTSA is a Cognitive and Communication Analysis. The BEA identifies behavioral responses that would be considered inconsistent with best practices and searches for identifiable entry points for corrective engagement.
The medical world has traditionally operated under a Safety I perspective which is an effort to make sure as few things as possible go wrong. Safety I protocol investigates what went wrong after an incident to understand the cause and prevent recurrence. Humans are viewed as a source of error and variability that needs to be controlled through standardized policies and systems. Root cause analysis is conducted resulting in the implementation of safety standards.
Under Safety I, when an error is discovered, the parties involved are identified and corrective action can be taken to prevent recurrence. This may include retraining or, in some cases, actual punitive action. Unfortunately, over the years a blame culture developed, inhibiting honest reporting and reducing the safety margins. To counter the blame game culture, specific guidance from the Joint Commission (JCO) and the Institute for Healthcare Improvement (IHI) recommend avoiding engaging with the individuals involved in error. The Joint Commission states “. A health care organization’s comprehensive systematic analysis… should not focus on individual health care worker performance”. [1] While this guidance may be well intended it has generated unintended consequences that have created barriers to understanding the true causality behind many errors.
Data contained in the report “To Err is Human” published in the late 1990s indicated an unacceptable rate of patient death due to preventable medical error. Significant recommendations by industry professionals to enhance patient safety through error reduction were instituted in the early 2000s. These changes became institutionalized, to the point where flexibility and agility were lost.
There have been significant improvements made since 2015 developed to reduce error, however these have not been implemented in healthcare. This is due to the rigid nature of corporate and systemic structure in healthcare today. A significant development ignored in healthcare is the concept of Safety II. In 2015 Braithwaite, Hollnagel, and Wears published a white paper defining the concept of Safety II. Safety II is critical in the medical world because it is designed to examine errors in a variable and ever-changing environment. It is based on the concept that a Safety I perspective does not account for why human performance is almost always successful. The premise is that people are successful not because they always do what they are supposed to, but because they adapt and adjust to meet the conditions they face. Safety II embraces the concept of understanding why things usually go right despite the complexities of ambiguity, uncertainty, goal conflicts, and systemic pressures. Safety II therefore is about ensuring that as many things as possible go right. Human Performance Causality Analysis employs Safety II protocols.
A truly resilient High Reliability Organization (HRO) will engage in integrating both Safety I and Safety II concepts in a powerful balance of minimizing exposure to error and enhancing positive error mitigating behaviors. Traditional RCAs or the idea of RCA plus Action are rooted in the Safety I mentality. Problematically they focus on systemic solutions to specific events, negating human behavioral issues that may have been present. While in some cases this may prove entirely effective, there will be many more cases where the analysis is incomplete due to lack of influential data. In following JCO or IHI guidance the individuals involved are protected from evaluation. This is because current evaluation would certainly be engaged as a fault-finding exploration, damaging to the individual and ineffective in gathering the truly relevant data needed for generating a correlated solution for the event in question. If a Safety II approach is incorporated the individual is safe in the recognition and support of all they do right. The goal is to search out what influences pulled the individual away from their effective performance that allowed errors to develop. This is the core of the HPCA.
An HPCA assumes that no individual chooses to come to work and make errors. It also assumes that there are many influences that an individual may not even be aware of that can degrade performance. It is an open-ended assessment of the individual exploring their history including relevant training, rest, diet, work schedule, family environment, and any other significant factors that may impact performance. Work related engagements are explored to determine motivations, positive or negative, as well as procedural benefits and challenges. Professional interaction and communication are explored focusing on deviations from the norm specific to the event, as well as habitual patterns that may induce latent errors into the environment. When all the data is gathered it is then correlated and integrated with the potential for interrelated influences that could have contributed to the behavior that failed to mitigate the developing error.
A follow-up debrief with the individual is essential for several reasons. Primarily, when true causality is identified it is associated with corrective action and personal improvement rather than punitive responses. Under the current JCO process there is no closure for the individual which often leads to unresolved guilt and stress. Providing closure through explanation, causality identification, understanding and, if appropriate, behavior modification, moves the individual back to positivity and enhances performance motivation. In many cases it can be shown that the combination of external factors and systemic pressures drives behavior that will be repeated by others without this identification and analysis. This brings the individual forward as part of the solution rather than being blamed as the problem. All investigation is conducted in a Just Culture environment.
Once the HPCA is completed, the results can be integrated into the RCA process. The essential part of this process is proper causality identification. If a systemic change is recommended by an RCA without understanding the underlying causal influences at the individual level, changes may be made that can create unintended challenges in other areas for individuals during implementation. Additionally, procedural requirements may be instituted that are not necessary resulting in additional performance pressures and obligations on providers to solve a “systemic” problem that was local in nature.
Adding a fully integrated HPCA to a patient safety program brings current tools and techniques to the forefront, reduces unnecessary changes, creates focused functional improvements, and reinforces the value of providers while improving motivation and performance. This type of Just Culture integration has been shown to improve retention and performance while reducing errors and the resultant associated costs.
[1] https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/2025/se-2-camhomecare_se_jan_2025.pdf