From the Author
Although this book was written in 1995, I continue to go back to it to remind myself of what I learned during this time period. I wrote the book while conversing with a few "whistle-blowers" who got themselves in serious trouble while trying to reveal serious (potentially fatal) problems in the hospital they worked in. Although I do NOT talk about the conversations directly in this book, I try to discuss what I learned through these marvelous people who were willing to share their frustration with me during their "pain."
During the conversations, it was apparent that few if any people CARE about WHY things go wrong. Those who care are an insignificant anomaly, almost certainly doomed in their careers UNLESS they band together.
This book takes the reader step-by-step through some easy analogies about HOW to make an organization CARE about things that go wrong. The book ends with a plea to form an international organization devoted to supporting the "whistle-blowers" of world.
From the Inside Flap
Although I have tried my best to shed some light on the subject of root cause discovery in these pages, I would not dare suggest that my comments and suggestions are flawless or comprehensive. Any inference to the contrary is incorrect.
I have written this book for two reasons. First, writing helps clarify my thouhgts. In this respect, I never know how little I know until I write about it. On the other hand, I never know how much I know until I write either! It was necessary for me to learn more about root cause discovery. Writing about it has helped me learn more.
Secondly, as I age and encounter more of life's experiences, I am becoming more and more aware of "that which I am being taught" and thus obligated to share. In this respect, I suppose all of us are being taught something unique and valuable -- something that we ought to share. That's how this book should be read -- as one person's attempt to share what he has been taught about root cause discovery.
Finally, a word about the bibical quote on the facing page (of the actual book). When I was searching for a scriptural reference to help capture the essence of this book, I came across Genesis 1:3, along with a drawing of the sunrise. The drawing jumped out at me because of the pleasure I personally obtain in witnessing a sunrise -- especially in a mountainous setting. It reminded me of the Genesis reading, where God said "Let there be Light.." Then, I realized that much of this book is about "light." I also realized that much of it is about separating light from darkness.
But, so that there are no mis-understandings, please recognize that it is not this book which I am holding up as the "light," but rather the Biblical truth which states that "light is good," and that God has already separated it from darkness.
