Wednesday, June 20, 2018

SPEAK TO THE PROBLEMS 4.1: Tracing A Problem To Its Origin

Finding the Cause of a Problem at

Root Cause Analysis
Tracing a Problem to its Origins

A powerful five-step problem-solving process.

Root Cause Analysis (RCA) is a popular and often-used technique that helps people answer the question of why the problem occurred in the first place.  Root Cause Analysis seeks to identify the origin of a problem. It uses a specific set of steps, with associated tools, to find the primary cause of the problem, so that you can:

    Determine what happened.
    Determine why it happened.
    Figure out what to do to reduce the likelihood that it will happen again.

RCA assumes that systems and events are interrelated.  An action in one area triggers an action in another, and another, and so on.  By tracing back these actions, you can discover where the problem started and how it grew into the symptom you're now facing.

The three basic types of causes:
1.    Physical causes – Tangible, material items failed in some.
2.    Human causes – People did something wrong, or did not do something that was needed. Human causes typically lead to physical causes.
3.    Organizational causes – A system, process, or policy that people use to make decisions or do their work is faulty.

Root Cause Analysis involves investigating the patterns of negative effects, finding hidden flaws in the system, and discovering specific actions that contributed to the problem.  This often means that RCA reveals more than one root cause.  Root Cause Analysis can be applied to almost any situation.

The Root Cause Analysis Process

Root Cause Analysis has five identifiable steps.
Step One: Define the Problem
Step Two: Collect Data
·       analyze a situation fully
·       look at factors that contributed to the problem
·       get together everyone – experts and front line staff – who understands the situation
·       better understanding of the issues
·       A helpful tool at this stage is CATWOE.
o   look at the same situation from different perspectives: the Customers, the people (Actors) who implement the solutions, the Transformation process that's affected, the World view, the process Owner, and Environmental constraints.
Step Three: Identify Possible Causal Factors
·       identify as many causal factors as possible.
·       tools to help identify causal factors:
o   Appreciation
o   5 Whys
o   Drill Down
o   Cause and Effect Diagrams
Step Four: Identify the Root Cause(s)
·       Use the same tools used to identify the causal factors (in Step Three) to look at the roots of each factor.
Step Five: Recommend and Implement Solutions

Next step

1.    Analyze your cause-and-effect process
2.    identify the changes needed for various systems
3.    important to plan ahead to predict the effects of your solution so as to be able to spot potential failures before they happen.
·       Failure Mode and Effects Analysis (FMEA).  This tool builds on the idea of risk analysis to identify points where a solution could fail.  FMEA is also a great system to implement across the organization; the more systems and processes that use FMEA at the start, the less likely there are to have problems that need Root Cause Analysis in the future.
·       Impact Analysis is another useful tool.  This helps to explore possible positive and negative consequences of a change on different parts of a system or organization.
·       Kaizen or continuous improvement.  Continual small changes create better systems overall.  Kaizen emphasizes that the people closest to a process should identify places for improvement.  With Kaizen alive and well in the company, the root causes of problems can be identified and resolved quickly and effectively.

Key Points

1.    Root Cause Analysis is a useful process for understanding and solving a problem.

2.    Figure out what negative events are occurring.  Then, look at the complex systems around those problems, and identify key points of failure.  Finally, determine solutions to address those key points, or root causes.

3.    Use many tools to support the Root Cause Analysis process.  Cause and Effect Diagrams and 5 Whys are integral to the process itself, while FMEA and Kaizen help minimize the need for Root Cause Analysis in the future.

4.    Root Cause Analysis is an essential way to perform a comprehensive, system-wide review of significant problems as well as the events and factors leading to them.

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