There are those problems which flare up unexpectedly when everything was previously steady and in control and there are those which are inherent in the process. Generally we approach the sudden problems by asking 'what has changed?' When we find what it is we can easily remedy the situation. Most managers and medical people are good at this, in fact it is one of their main skills.
However, this approach does not work with the problems which are inherent in the processes. These are persistent, and we generally learn to live with them. They can only be resolved by using the discipline of root cause analysis. In the end we do not notice them and generally we learn to live with them but they are always there and they are costing us money all of the time.
Root Cause Analysis is designed to solve such problems and whenever we do, the process becomes just that bit more efficient, predictable and generally takes less time. The systemic use of root cause analysis techniques in an organised structured way will continually raise the overall performance of the organisation making it progressively more and more competitive.
The absence of Root Cause Analysis leaves the organisation vulnerable to the ever increasing severity of competition form those that do.
Our Root Cause Analysis approach will teach you and your people how to use this discipline with incredible results. The course is just 4 days and totally participative. By the end, your people will almost certainly have solves some problems and the course is usually more than self funding.
People not trained and disciplined in Root Cause Analysis will usually attempt to go directly from Symptom to Solution without first establishing the true cause or causes of their problem. This short cut approach can work if you are lucky or if it is a problem that has occurred many times before and always for the same reasons. Otherwise we might continue this hit and miss process until we stumble upon the cause or give up.
However, even if is a frequent problem that we can 'fix', why was it not properly fool proofed so that it cannot reoccur?This highly participative three day Root Cause Analysis training course which is the core of our 4 day Facilitator course, will show you how to identify the true root causes of problems, find effective remedies and implement solutions that eliminate the problem entirely.
It is most effective when used by self managing work groups. It is also fundamental to the Six Sigma DMAIC process which is only a restatement of its fundamental priciples, therefore it is used in Quality Circles, Gemba Kaizen teams, Six Sigma and Project by Project activities the world over.
Full 4 day Programme contents (one day overviews are also possible) :
- INTRODUCTION TO PROGRAMME & STRUCTURE OF COURSE
OBJECTIVES AND ROOT CAUSE ANALYSIS
- LINKS BETWEEN ROOT CAUSE ANALYSIS AND CORPORATE STRATEGY (HOSHIN KANRI)
- THE PLAN-DO-CHECK-ACT (PDCA) MANAGEMENT CONTROL LOOP
- PRINCIPLES OF SELF DEVELOPING WORK TEAMS AND EXAMPLES OF THEIR USE OF ROOT CAUSE ANALYSIS TECHNIQUES
- ROLES OF COORDINATORS FACILITATORS AND TEAM LEADERS FOR ROOT CAUSE ANALYSIS TRAINING
- BRAINSTORMING POSSIBLE PROBLEMS
- PROJECT SELECTION FOR ROOT CAUSE ANALYSIS
- PROJECT SELECTION MATRIX
- THE PROJECT PROCESS
- ORGANISING FOR ROOT CAUSE ANALYSIS
- PROJECT SCOPE
- INTRODUCTION TO PROCESS RE-ENGINEERING AND PROCESS MAPPING
- PROCESS MAPPING BY TEAMS
- INTRODUCTION TO THE THREE TYPES OF CAUSE AND EFFECT ANALYSIS
- CAUSE AND EFFECT ANALYSIS BY TEAMS
- CONSTRUCTION OF PARETO DIAGRAMS
- SELECTION OF PRIMARY ROOT CAUSES
- PAIRED COMPARISONS TO RANK SUSPECTED ROOT CAUSES
- INTRODUCTION TO DATA GATHERING TOOLS
- USE OF CHECK SHEETS FOR POTENTIAL ROOT CAUSE TESTING
- REMEDIAL JOURNEY
- SELECTION OF POSSIBLE SOLUTIONS
- DEALING WITH PROBLEMS CAUSED BY SOLUTIONS
- OVERCOMING POSSIBLE RESISTANCE TO CHANGE
- CONSTRUCTION AND USE OF PROJECT STORYBOARDS
- MULTISKILLING SKILL MAPPING
- REMEDIAL JOURNEY - CONT. - FOOLPROOFING OR POKE YOKE
- INTRODUCTION TO PRESENTATION SKILLS
- DO’S AND DON’TS IN PRESENTATION TECHNIQUES
- USE OF VISUAL AIDS AND
- USE OF GRAPHICAL TECHNIQUES FOR EFFECTIVE PRESENTATIONS
- PREPARATION OF PRESENTATIONS BY TEAMS
- PRESENTATIONS BY TEAMS
- CONTINUOUS IMPROVEMENT - IDENTIFICATION OF NEW PROJECTS FOR ROOT CAUSE ANALYSIS
- WHERE DO WE GO FROM HERE?
- FINAL QUESTIONS AND ANSWERS,
- GENERAL DISCUSSION
This course on Root Cause Analysis forms the core of several of our other courses such as Six Sigma Yellow Belt training, Quality Circles Facilitator and Team Leader course
and continuous improvement
. It is one of the first courses that we developed 30 or more years ago before any of our competitors and we are proud to say that we have been copied mercilessly.
Extract from David Hutchins latest book Hoshin Kanri - The Strategic Approach to Continuous Improvement
Root Cause Analysis
This discipline is theoretically quite simple but in practice it proves quite a difficult one to apply by those who are only accustomed to firefighting. For a firefighting project, usually we need to get results quickly. If there is an explosion, a pipe has ruptured, the scrap levels in a process have jumped alarmingly the cost hemorrhage will be such that there is no time to lose. In such cases, the firefighter will go straight from SYMPTOM to REMEDY by making a guess at the causes. In many cases, the cause may only be too obvious.
A simple but relevant example might be someone walking into the Doctor’s surgery covered in spots at a time when chicken pox is an epidemic. It can reasonably be assumed to be another such case and will be treated accordingly.
However, maybe it happens not to be chicken pox! Perhaps the symptoms continue to get worse and the patient again sees the doctor. It is possible that he/she may again make assumptions and offer another type of medication. In some cases this may continue for some time on a hit and miss basis until either the patient gets better or seriously worse! On the other hand the Doctor may be more of a diagnostician than this and instead attempts to find the cause before guessing at remedies.
To do this he/she will follow the Root Cause Analysis process which follows the following sequence of events:
- Question the patient about where they have been, what contacts they have had, what unusual activities have they been involved in etc. In an industrial situation this will involve mapping the process from the point where the symptoms are observed backwards as far as possible.
- Analyse the operations along the process one by one from the first through to the last attempting to identify possible causes. This is known as Process Analysis and is covered extensively in Chapter 10 Process Analysis and Process Re-Engineering.
- Identify the most likely major causes. This may involve the technique known as Paired Rankings also covered in Chapter 10.
- Collect and analyse data to verify or reject the potential causes identified in ‘3’ above.
- Those causes found to be relevant may sometimes be taken directly to seeking a remedy or solution. In many cases they will require further break down. Here the technique known as the Fishbone Diagram may be used. This technique enables the possible causes to broken down into the finest detail at which point, the relevant ones can lead to solutions.
The technique is really a more sophisticated form of Brainstorming and enables related causes to be clustered as they are identified which later on assists analysis.
- Data may be collected on the main possible causes identified by the use of the Fishbone Diagram in order to find those which make the most impact.
- Possible solutions are identified and evaluated for both cost and effectiveness. Some of these may be classified as ‘reversible’ and others ‘irreversible’. A ‘reversible’ solution is one where it is possible for those who control the relevant operation to revert back to their previous methods. An ‘irreversible’ solution is one where it is impossible to revert back because the method has been changed in such a way that it this cannot happen. This type of solution is automatically foolproofed. An example where both types of solution are possible is an office operation where it is found that mistakes are being made in filling in the forms. A ‘reversible’ solution might be to provide training for those who fill in the forms or perhaps to give more clear instructions as to how they should be completed. An ‘irreversible’ solution might be to redesign the forms using ‘tick boxes’ to force us of the right terminology and eliminate the possibility of bad handwriting.
- Implement the new method avoiding ‘resistance to change’. Resistance to change is one of the most common reasons why improved methods fail. Care should be taken to involve those who will have to change their habits, to listen to their possible objections (which may be valid) and accommodate their suggestions. Also it is important not to assume that the new proposals have automatically been adopted just because they are being followed whilst you are present. If you leave too quickly, there may be some resentment which may lead to an unwillingness to persevere with the new methods.
- Maintain surveillance and continue to collect data for a realistic period to make sure that the changes made really do produce the hoped for results. It is possible that the improvement may be due to some other factor and it is not unusual for processes to improve as if by magic for no other reason than it is known that someone it taking an interest. In this case, the remedy might not be as good as was thought and once attention has moved elsewhere the problem might reappear. This is demoralizing for all concerned. Do not take it as a negative if this happens. It may be frustrating but what it proves is that the process is capable of performing at a better level even though we may have been mislead. We need to look at it again to find out what it is that might be known to others that when care is taken, can produce the better results.
- Present the results to upper management and formally close the project. Regular presentations to management are a must if there is to be a continuation of the improvement process. It enables upper management to see what is being achieved and by whom. It gives people much needed recognition. It provides an opportunity to give recognition to anyone who might have contributed to the success and in some cases, the opportunity to use the occasion to ‘sell‘ the improvement process to suppliers and to staff from other departments and also to impress customers.