Tag: root cause

Tools

What are the steps to complete a root cause analysis? Guide for beginners.

Root cause analysis is a structured process designed to find what, how, and why an event occurred.  Only when you know the answer to these questions, you will be able to determine the corrective measures to prevent a recurrence. 

A root cause is an underlying cause that management has control to fix, and recurrence prevention is possible by the application of effective recommendations.  RCA drills deeper than symptoms to find the underlying action and conditions that led to the undesired situation.  The goal of RCA is to identify one or two reasons that, if corrected, will reduce recurrence.  RCA has four general steps.

Understand the problem

Understanding why an event occurred is critical for effective corrective actions.  Just as with PDCA, problem definition is the most important part of the RCA process.  Use a team approach whenever it is possible.  It depends on the nature of the problem, but multiple heads are better than one.  Get the background of the current situation and state the problem in clear, concise terms. 

Common errors in describing problems are stating a solution in the problem statement, blaming others, and vague problem statements.

Collect data

When you understand the problem, it is easier to identify what type of data you need to find the root cause.  Gathering data is a vital part of the analysis, and it consumes quite some time.  Go where the action or process happens, where the value is created and observe.  Talk with the people who work there and ask questions to understand the situation.  Be respectful, listen to carefully, and take notes.  Make sure that you do not judge or criticize.  The purpose of your visit is to understand the current process and get information to determine what kind of data is needed.  

Using a team approach, decide what data you will collect, when, how, who will do it, and by when.  Some examples are inspection records, maintenance logs, work instructions, customer complaints, time studies, and process flow charts.

Find the root cause

Now you have all the details and, there are no guessing or loose ends.  Analyze the information,  look for clues that would explain the incident.  Try to find trends or common circumstances every time the problem occurs.  Tools like the fishbone, 5 Why, Mind Map, and Pareto Analysis facilitate this process. 

Plan creation and execution

You are looking for one or two causes that, corrected, will prevent the problem from occurring.  If you have more, it means that you need to keep digging to find the underlying cause.

Once you have it, generate ideas or solutions for the problem.  Ask what preventive actions will stop the event from happening.  Evaluate and prioritize those ideas.  The recommendation should directly address the root causes identified.  Use PDCA to guide you through the plan and execution process.

The four steps presented above are the general steps to complete a root cause analysis.  Each of them has more details and how-to information.  Follow the blog to keep learning about problem-solving, RCA, and how to use for continuous improvement.

Tools

Is human error an acceptable root cause? Find a better root cause to have a more effective corrective action than employee retraining.

I was called to help this company to investigate the root cause of all the non-compliance observations they got on a recent third-party audit.  It turns out that a couple of those observations were recurrent, and the audit agency wanted to see a corrective action preventive action (CAPA) report for each.  The experience was the perfect opportunity to have department and line leaders learning and practicing how to do root cause analysis.

Soon enough, after we start analyzing the first observation, the group concludes that the root cause was human error.  The corrective action to avoid recurrence was retraining.  I moved on to the next two, obtaining similar results.  I know three points are not enough to say there is a pattern, but in this case, it was enough to prove my point.   

It is common to choose employee retraining as a corrective action, but because human error is not the real root cause, it will not prevent the problem from happening again.  RCA requires persistence to keep asking why until finding the end cause.  If you stop digging before finding the underlying cause, the process fails.  You end up working with a symptom or a proximate cause.  In the example above, human error is the symptom or physical source.  The source of it is the real root of the problem.   

Asking why the person made the mistake will help to identify the real root cause.  Keep asking why to dig deeper into the problem.  Human error is often the product of inadequate processes, lack of resources, using the wrong tools, complicated work instructions, too many interruptions, or noisy environment, between others.  

Do you want to find the real reason for human error?  Engage the team, the people who create value, those who actually do the work, and ask why.  I bet you that they will have lots of ideas to improve the process and minimize or eliminate recurrence.  Humans are not perfect, acknowledge that fact and design robust systems that minimize defects or errors.  Visual management and mistake-proofing devices are good tools to accomplish that.  

Next time you find that the cause of the problem is human error, keep digging!  Why humans erred?  Be as curious as a cat, find the real underlying cause and improve your process.

CI Basics

What are the rules to fix problems?

One common mistake for a manager or business owner is trying to “fix” problems by looking at reports. Those reports are full of old information. They are good to know what happened, but they don’t tell the whole story.

Learn from basketball coaches

If you are a basketball coach, you won’t try to call the shots just by looking at your team stats from the office. You will go to the basketball court, where the action is. You will observe how the individual members of the team react to the defense or offense play of the rival team. If you see something wrong, you will ask for a time out to discuss a change in strategy. You are observing every move, focusing on what the team needs to do to improve their game, and win. You can not be effective in doing the same thing looking at the score only.

How to fix problems

As a business owner, when problems arise with a specific process, you need to do the same thing. Always go to the area where the action happens first. If it is a problem with customer service, observe how your employees interact with customers. If it is an issue related to the quality of the food, try it yourself. Does it look and taste as it should?

Sometimes it is not obvious what is wrong. In that case, focus your attention on the process tools, equipment, and standard work. On the food quality example, you confirm something is off with the quality but don’t know what. Focus your attention on how close is the execution to the standard work or recipe. Observe if the cooks are using the right ingredients, the right quantity, or following the recipe steps.

As soon as you find out the issue, take a temporary fix on the spot. This temporary fix will not solve the problem. To fix it, you need to find the root cause of the problem. Do not try to guess or assign a cause based on your experience, engage the team on this exercise. Once you know the cause or causes of the problem, you can plan how to fix it. To prevent a recurrence, you need to update the standard work.

Simple rules to fix problems

To succeed in your continuous improvement journey, follow these simple rules while fixing problems.

  • When a problem arises, go to the place where the action or process happens first
  • Check all the relevant things: equipment, tools, materials, standard work
  • Take temporary solutions on the spot
  • Find the root cause
  • Standardize to prevent a recurrence

To acquire knowledge, one must study; but to acquire wisdom, one must observe. – Marilyn Vos Savant