We conclude our week of Sherlock Holmes-themed blog posts today. Over this week’s blog posts, I have been exploring the first five stories from The Casebook of Sherlock Holmes, mining each story for themes and lessons related to the compliance professional, leadership and business ethics. In today’s concluding offering, I consider The Adventure of the Sussex Vampire and it informs a root cause analysis in any best practices compliance program.
Holmes receives an odd letter that makes reference to vampires. Mr. Robert Ferguson, who comes to 221B Baker Street the next morning, has become convinced that his Peruvian second wife has been sucking their baby son’s blood. By his first wife, he has a 15-year-old son named Jack, who suffered an unfortunate accident as a child and now, although he can still walk, he does not have the full use of his legs. After the bloodsucking began, Jack has unaccountably been struck twice by his stepmother, although Mr. Ferguson cannot imagine why. Ever since being found out by her husband, she has locked herself in her room and refused to come out. Only her Peruvian maid, Dolores, is allowed in. She takes Mrs. Ferguson her meals.
Even before Holmes and Watson set off for Mr. Ferguson’s house in Sussex, Holmes has deduced what is going on, and it has nothing to do with vampires. Holmes’s trip is made simply to observe and confirm what he has already deduced.
Upon their arrival in Sussex, Mrs. Ferguson’s maid announces that her mistress is ill, and Dr. Watson offers to help. He finds an agitated woman in the room upstairs – she speaks of all being destroyed, and of sacrificing herself rather than breaking her husband’s heart. She also demands her child, who has been with the nurse, Mrs. Mason, ever since Mr. Ferguson has known about the bloodsucking incidents. Holmes examines the South American weapons displayed in the house and meets the children. While Mr. Ferguson is doting on his younger son, Watson notices that Holmes is gazing at the window. He cannot imagine why his friend is doing this.
Holmes then explains the truth about what has been happening, much to the relief of Mrs. Ferguson as this is exactly what she has wanted: for the truth to come from someone else’s lips. It turns out that the culprit is Jack, Mr. Ferguson’s elder son, who is extremely jealous of his young half-brother. Holmes has deduced this and confirmed it by looking at Jack’s reflection in the window while his father’s attention was on the baby. Jack has been attempting to murder his half-brother by shooting poisoned darts at him, and his stepmother’s behavior of sucking the baby’s neck is thereby explained: she was sucking the poison out. It also explains why she struck Jack, and why she was sick when Holmes and Watson arrived. The wounds, therefore, were caused by the darts, not by her biting.
At one-point Holmes states “‘One forms provisional theories and waits for time or fuller knowledge to explode them.’” Matthew Barsalou has said, “Sometimes a tentative hypothesis may be clear but not fully supported by the data. In such situations it may be necessary to collect more data before taking other actions. If there are no data to collect, perform an experiment to generate data. For example, attempting to re-create the failure under controlled conditions may provide a better understanding of an issue.”
When root cause analysis is done correctly and utilized as a part of your remediation strategy going forward, it is primarily there to develop preventive actions. A preventive action is something to prevent recurrence of the problem. You can adjust with a corrective action, but the ultimate goal is to engineer out or fix the system and processes, so you do not have the opportunity for that flaw to occur again.
Another way to consider it, as stated by Ben Locwin, is “We have a problem. Let’s not run away from it. Let’s embrace it.” What you are really doing is looking at your program from the inside out. Locwin advocates beginning with such questions as “What can we do better? What can we do next?” He explains “you’re looking for examination from an external and not an internal prospective. Internal perspectives tend to follow along the quotas. If you always do what you always did, then you’ll always get what you always got.” He notes, “continuous improvement approaches benefit most from” its “frequent exposures to radical change.”
It is the willingness of a company to look at itself that is the key to continuous improvement. Locwin said, “typically these things come from external pressures and not from internal, incremental changes. If you take a step back, or maybe several steps back to say, what are we actually trying to do, and are we reaping the value that we’re intending to get out of what we have. If we’re not, then we should look for this really systemic overhaul of things, and not just try to tweak a little thing here and a little thing there.”
Locwin provides the example of a root cause analysis, which is typically used after an incident to determine what happened to assess blame, can be used to strengthen the prevention prong of your best practices compliance program. He said that a company must “allow themselves that freedom to appraise things that have gone wrong and then address them rather than just saying, “Well, you know we had someone who made a mistake, let’s fix the person or get rid of the person.” But really, it’s about, let’s understand what’s actually happening here because, for the most part, people are not willfully ignorant and they try to do the right things, so it could just be that there were some clarity issues with how they understood their role or their work for otherwise.”
Locwin notes a root cause analysis should not be used just simply to determine fault but, “It really should be a way to learn more about the process and what’s going wrong so that the systems and process itself can be changed because there is a thinking in the field which basically centers around the theme of, unless you have changed the process, then you’re going to keep getting similar or the same results.”
As Locwin further explained, “Until you change the process and the systems, you can basically expect that you’re going to have some sort of output that is going to repeat itself over and over again. That’s where finding blame doesn’t necessarily help and really you want to get deeper into those root causes. That’s, frankly, why it’s called root cause analysis, so that you can drill down below the superficial pieces of the framework to fix, and into the things that are actually driving the outcomes and the behaviors.” In the healthcare arena, the practice is called Corrective Action and Preventive Action. If you take that some framework into anti-corruption compliance you should be in good stead.
The concludes my initial exploration of The Casebook of Sherlock Holmes and its intersection with compliance and leadership. I hope you have enjoyed reading it as much as I did researching and writing it. But do not worry as I will continue my exploration of the entire Holmes oeuvre.
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