Each month, Walt Hanna, MSQPC's Director of Training, will offer his insight into quality and leadership development issues. This month, Walt looks at Root Cause Analysis.
Root Cause Analysis
What is it and why should I need to know anything about it? First, let’s take a look at the definition: Root cause analysis (RCA) is a class of problem solving tools aimed at identifying the root causes of problems or incidents. The practice of RCA is predicated on the belief that problems are best solved by attempting to correct or eliminate root causes, as opposed to addressing only the obvious symptoms. By directing corrective measures at root causes, it is hoped that the likelihood of problem recurrence will be minimized. However, it is recognized that absolute prevention of recurrence by a single intervention is not always possible. Thus, RCA is considered an iterative process, and is frequently viewed as a tool of continuous improvement.
While working in the Training department of a medical device company, I had numerous opportunities to observe problem-solving modes and behaviors. Even when provided considerable training and practice in active listening, when learners were asked to use a problem-solving model, they often discarded the active listening skills and immediately shifted gears into a directed problem-solving mode. As I circulated through the room, I’d hear lots of “why” questions, which denied participants the opportunity to really listen and to collect valuable data about what the issues were. When it comes to problem solving, many organizations have “fire fighters” on staff when they should have “fire inspectors”. One puts out fires while the other looks for ways to prevent them.
Problem solving involves both skill and a way of thinking. In my former Air Traffic Controller days we would often point to controller error as the root cause of a problem and prescribe some type of training or re-training. What we failed to realize is that our errors were the result of a process failure. Process failures occur when processes are not clearly defined, defective, or they are not followed.
Duke Okes, author of Root Cause Analysis – The Core of Problem Solving and Corrective Action, and a consulting Associate for MSQPC, conducts workshops using his DO IT² Find It-Fix-It 10-step Root Cause Analysis Guide to help participants learn how to solve problems.
The first five steps in model, The Find It – diagnostic phase, include defining the problem, understanding the process, identifying possible causes, collecting data, and analyzing the data. The Fix It – solution phase includes identifying possible solutions, selecting solutions to be implemented, implementing the solutions, evaluating the effects, and institutionalizing the change. The “It” in the model means root cause of the problem.
A number of tools are used with this model including Pareto charts, run charts, problem statements, process flowcharts, logic tree, data collection and analysis, should-be templates, the five why’s, barrier analysis, and change analysis.
In his book, Duke asserts that organizations place insufficient effort on providing guidance on how to carry out an effective diagnosis to identify the causes of problems. He often quotes a workshop participant who stated that a “duct tape solution” approach is common. If money is not an issue to your organization, then “duct tape” may be best for you. If saving money is important, then greater emphasis needs to be placed on finding effective solutions to your problems.
From my perspective, organizations need to create “fire inspectors” and eliminate the need for “fire fighters”. Problem solving using root cause analysis can help “solve” that issue.
"You can buy a person's hands but you can't buy his heart. His heart is where his enthusiasm, his loyalty is." - Steven Covey