Thursday, June 21, 2018


Finding the Cause of a Problem at


Developing a Robust Problem Definition

CATWOE stands for:
Customers    Who are they, and how does the issue affect them?
Actors            Who is involved in the situation? Who will be involved in implementing solutions? And what will impact their success?
Transformation Process    What processes or systems are affected by the issue?
World View   What is the big picture? And what are the wider impacts of the issue?
Owner            Who owns the process or situation you are investigating? And what role will they play in the solution?
Environmental Constraints           What are the constraints and limitations that will impact the solution and its success?

The FOCUS Model
A Simple, Efficient Problem-Solving Approach
Identifying problems is like harvesting fruit.

About the Model
The FOCUS* Model is a structured approach to Total Quality Management (TQM), and it is widely used in the health care industry.

The model is helpful because it uses a team-based approach to problem solving and to business-process improvement, and this makes it particularly useful for solving cross-departmental process issues.  Also, it encourages people to rely on objective data rather than on personal opinions, and this improves the quality of the outcome.

It has five steps:
    Find the problem.
    Organize a team.
    Clarify the problem.
    Understand the problem.
    Select a solution.

Applying the FOCUS Model

Step 1: Find the Problem
·       identify a process that needs to be improved
·       follow the Pareto Principle, where 80 percent of issues come from 20 percent of problems.
·       Start with a simple problem to get the team up to speed with the FOCUS method.
·       If you have several problems that need attention, list them all and use Pareto Analysis, Decision Matrix Analysis, or Paired Comparison Analysis to decide which problem to address first.

Step 2: Organize a Team
·       assemble a team to address the problem
·       bring together team members from a range of disciplines – this will give you a broad range of skills, perspectives, and experience to draw on
·       Select team members who are familiar with the issue or process in hand, and who have a stake in its resolution
·       If your first choice of team member isn't available, try to appoint someone close to them, or have another team member use tools like Perceptual Positioning and Rolestorming to see the issue from their point of view.
·       a diverse team is more likely to find a creative solution than a group of people with the same outlook.

Step 3: Clarify the Problem
·       define the problem clearly and concisely
·       the key to success is to break it down into "sushi-sized" pieces that can be analyzed and solved more easily
·       Use the Drill Down technique to break big problems down into their component parts.  You can also use the 5 Whys Technique, Cause and Effect Analysis, and Root Cause Analysis to get to the bottom of a problem.
·       Record the details in a problem statement, which will then serve as the focal point for the rest of the exercise (CATWOE   can help you do this effectively.)
·       The problem statement must be objective.
·       be on guard against "factoids" – statements that appear to be facts, but that are really opinions that have come to be accepted as fact.

Step 4: Understand the Problem
·       gather data about the problem to understand it more fully.
·       Dedicate plenty of time to this stage, as this is where you will identify the fundamental steps in the process that, when changed, will bring about the biggest improvement.
·       Consider what you know about the problem. Has anyone else tried to fix a similar problem before? If so, what happened, and what can you learn from this?
·       Use a Flow Chart or Swim Lane Diagram to organize and visualize each step; this can help you discover the stage at which the problem is happening.
·       And try to identify any bottlenecks or failures in the process that could be causing problems.
·       As you develop your understanding, potential solutions to the problem may become apparent.
·       Beware of jumping to "obvious" conclusions – these could overlook important parts of the problem, and could create a whole new process that fails to solve the problem.
·       Generate as many possible solutions as you can through normal structured thinking, brainstorming, reverse brainstorming, and Provocation.  Don't criticize ideas initially – just come up with lots of possible ideas to explore.

Step 5: Select a Solution
·       select a solution
·       Use appropriate decision-making techniques to select the most viable option.  Decision Trees, Paired Comparison Analysis, and Decision Matrix Analysis are all useful tools for evaluating your options.
·       Once you've selected an idea, use tools such as Risk Analysis, "What If" Analysis, and the Futures Wheel to think about the possible consequences of moving ahead, and make a well-considered go/no-go decision to decide whether or not you should run the project.

People commonly use the FOCUS Model in conjunction with the Plan-Do-Check-Act   cycle.

Key Points
1.    The FOCUS Model is a simple quality-improvement tool commonly used in the health care industry.

2.    The five steps in FOCUS are as follows:
    Find the problem.
    Organize a team.
    Clarify the problem.
    Understand the problem.
    Select a solution.

3.    People often use the FOCUS Model in conjunction with the Plan-Do-Check-Act cycle, which allows teams to implement their solution in a controlled way.

5 Whys
Getting to the Root of a Problem Quickly

How to use the 5 Whys technique, with James Manktelow & Amy Carlson.
To solve it properly, you need to drill down through the symptoms to the underlying cause.  This article looks at Sakichi Toyoda's 5 Whys technique – a simple but powerful tool for quickly uncovering the root of a problem, so that you can deal with it once and for all.

About the Tool
Sakichi Toyoda, one of the fathers of the Japanese industrial revolution, developed the 5 Whys technique in the 1930s.  He was an industrialist, inventor and founder of Toyota Industries.  His technique became popular in the 1970s and Toyota still uses it to solve problems today.

Toyota has a "go and see" philosophy.  This means that its decision making is based upon an in-depth understanding of the processes and conditions on the shop floor, rather than reflecting what someone in a boardroom thinks might be happening.

The 5 Whys technique is true to this tradition, and it is most effective when the answers come from people who have hands-on experience of the process being examined.  It is remarkably simple: when a problem occurs, you uncover its nature and source by asking "why" no fewer than five times.

When to Use the 5 Whys
You can use the 5 Whys in troubleshooting, quality improvement and problem solving, but it is best for simple or moderately difficult problems.

The simplicity of the 5 Whys tool gives it great flexibility, too, and it combines well with other methods and techniques.  It is often associated with lean manufacturing (also part of the Toyota Production System), where it is used to identify and eliminate wasteful practices.  It is also used in the analysis phase of the Six Sigma quality improvement methodology.

How to Use the 5 Whys
The 5 Whys is a simple, practical tool that is very easy to use. When a problem arises, simply keep asking the question "why" until you reach the underlying source of the problem, and until a robust counter-measure becomes apparent.

1.    The 5 Whys uses "counter-measures," rather than solutions.  A counter-measure is an action or set of actions that seeks to prevent the problem arising again, while a solution just seeks to deal with the situation. As such, counter-measures are more robust, and are more likely to prevent the problem from recurring.

2.    Each time you ask "why," look for an answer that is grounded in fact: it must be an account of things that have actually happened – not events that might have happened.

3.    Keep asking "why" until you feel confident that you have identified the root cause and can go no further.

Key Points
1.    The 5 Whys strategy is an easy to use, effective tool for uncovering the root of a problem. You can use it in troubleshooting, problem solving and quality improvement initiatives.

2.    Start with a problem and ask "why" it is occurring. Make sure that your answer is grounded in fact, then ask "why" again. Continue the process until you reach the root cause of the problem, and you can identify a counter-measure that prevents it recurring.

3.    Bear in mind that this questioning process is best suited to simple to moderately-difficult problems. Complex problems may benefit from a more detailed approach (although using 5 Whys will still give you useful insights.)

Cause and Effect Analysis
Identifying the Likely Causes of Problems
(Also known as Cause and Effect Diagrams, Fishbone Diagrams, Ishikawa Diagrams, Herringbone Diagrams, and Fishikawa Diagrams.)
Cause & Effect Diagrams

Find all possible problems.
When you have a serious problem, it's important to explore all of the things that could cause it, before you start to think about a solution.  That way you can solve the problem completely, first time round, rather than just addressing part of it and having the problem run on and on.

Cause and Effect Analysis gives you a useful way of doing this.  This diagram-based technique, which combines Brainstorming with a type of Mind Map, pushes you to consider all possible causes of a problem, rather than just the ones that are most obvious.

About the Tool
Cause and Effect Analysis was devised by professor Kaoru Ishikawa, a pioneer of quality management, in the 1960s.  The technique was then published in his 1990 book, "Introduction to Quality Control."  The diagrams that you create with Cause and Effect Analysis are known as Ishikawa Diagrams or Fishbone Diagrams (because a completed diagram can look like the skeleton of a fish).  Cause and Effect Analysis was originally developed as a quality control tool, but you can use the technique just as well in other ways.

How to Use the Tool

Step 1: Identify the Problem
·       write down the exact problem.  Where appropriate, identify who is involved, what the problem is, and when and where it occurs.
·       write the problem in a box on the left-hand side of a large sheet of paper, and draw a line across the paper horizontally from the box. This arrangement, looking like the head and spine of a fish, gives you space to develop ideas.
Figure 1 – Cause and Effect Analysis Example

Tip 1:  Some people prefer to write the problem on the right-hand side of the piece of paper, and develop ideas in the space to the left. Use whichever approach you feel most comfortable with.
Tip 2:  It's important to define your problem correctly. CATWOE can help you do this – this asks you to look at the problem from the perspective of Customers, Actors in the process, the Transformation process, the overall World view, the process Owner, and Environmental constraints.

Step 2: Work Out the Major Factors Involved
·       identify the factors that may be part of the problem. These may be systems, equipment, materials, external forces, people involved with the problem, and so on.
·       Try to draw out as many of these as possible. As a starting point, you can use models such as the McKinsey 7S Framework (which offers you Strategy, Structure, Systems, Shared values, Skills, Style and Staff as factors that you can consider) or the 4Ps of Marketing (which offers Product, Place, Price, and Promotion as possible factors).
·       Brainstorm any other factors that may affect the situation.

Step 3: Identify Possible Causes
·       brainstorm possible causes of the problem that may be related to the factor.
·       Where a cause is large or complex, then it may be best to break it down into sub-causes.  Show these as lines coming off each cause line.

Step 4: Analyze Your Diagram
·       Depending on the complexity and importance of the problem, you can now investigate the most likely causes further.

Tip:     A useful way to use Cause and Effect Analysis with a team is to write all of the possible causes of the problem down on sticky notes. You can then group similar ones together on the diagram.

This approach is sometimes called CEDAC (Cause and Effect Diagram with Additional Cards) and was developed by Dr. Ryuji Fukuda, a Japanese expert on continuous improvement.

Key Points
1.    Professor Kaoru Ishikawa created Cause & Effect Analysis in the 1960s. The technique uses a diagram-based approach for thinking through all of the possible causes of a problem. This helps you to carry out a thorough analysis of the situation.

2.    There are four steps to using Cause and Effect Analysis.
    Identify the problem.
    Work out the major factors involved.
    Identify possible causes.
    Analyze your diagram.

Appreciation (Situational)
Understanding the Full Implications of a Fact

Squeeze out as much information as you can, by appreciating the situation accurately.

Sometimes we're given a piece of information that seems straightforward, only to find out later that more was going on than we thought.  As a result, we're then unprepared to deal with the consequences.

One way to deal with these situations is by using Appreciation.  This is a simple but powerful technique for extracting the maximum amount of information possible from a simple fact or statement.

About Appreciation
Appreciation helps us uncover factors that we might have ordinarily missed, and it can be very useful for brainstorming solutions to problems.

It was originally developed by the military to help commanders gain a comprehensive understanding of any fact, problem or situation that it was faced with in battle.

Using Appreciation starts with a fact, you first ask the question "So what?" – in other words, what are the implications of that fact? Why is this fact important?

You then continue asking that question until you have drawn all possible conclusions from it.

1.    Appreciation is similar to the 5 Whys technique. The major difference is that it is often used to get the most information out of a simple fact or statement, while the 5 Whys is specifically designed to drill down to the root of a problem.

2.    also use Appreciation in conjunction with Root Cause Analysis or Cause and Effect Analysis to help you gain a better understanding of the impact of possible solutions.

Bear in mind that Appreciation can restrict you to one line of thinking.  Repeat the Appreciation process several times over to make sure that you've covered all bases.

Key Points
1.    Appreciation was originally developed by the military to give leaders a better understanding of a fact, statement or problem that they were faced with.

2.    You use Appreciation by asking "So what?" repeatedly. This helps you to extract all important information implied by a fact.

3.    Consider using other problem solving techniques with Appreciation, to make sure that you're not limited to one line of thinking.

No comments:

Post a Comment