Root Cause Analysis - University of Central Oklahoma

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Facilitating
the UCO
Action Project
Process
– Part 4 Analyzing Data –
Office of Planning & Analysis
University of Central Oklahoma
UCO Action Project Process
• Based on PDCA cycle
– Walter Shewhart (Bell Labs); W. Edwards Deming
• Managed by the UCO CQIT
– Continuous Quality Improvement Team
– Cross-functional
• 5 to 10 projects per year
PDCA Cycle
PDCA Cycle
PDCA Cycle
Analyze
Data
• Present findings
–
–
–
–
Benchmarking results
Interview results
Focus group results
Flowchart results
•
•
•
• ID common
issues/problems
Analyze
Data
• Root cause analysis (RCA)
• Process problems
What is Root Cause Analysis?
You can easily see
problems and
(sometimes)
symptoms
Can’t easily see the
underlying “root”
causes very easily
Too Simple Root Cause Analysis
What happened?
Find someone to blame the same way …
Asleep
Lack of
Training
Inattention
to detail
Human Error
Unknown
Act of God
Equipment
failure
Too Simple Root Cause Analysis
Find someone to blame the same way …
Ed
Ed
Ed
Ed
Ed
Ed
Ed
Real Root Cause Analysis
• Seemingly disparate issues and problems may be
arising from common underlying root causes.
• Root Cause Analysis (RCA)is a process:
– Reveals underlying root causes (often more than one).
– Limits attempts to latch on to simple, quick fixes that don’t
address underlying root cause. (Problems will be like
weeds – they keep coming back.)
• Common uses:
– Incident investigation
– Problem solving
– Quality control
RCA: Basic steps
Define
Understand the full
scope of the problem
Analyze
Why does this problem
occur?
Solutions
Develop corrective
solutions to prevent
problem from recurring.
• 5-Whys
Some RCA Techniques
– Start w/ problem or incident.
– Keep asking “Why?” .
• Fishbone or Ishikawa Diagram
– Start w/ problem or incident.
– Ask “Why?” in categories.
• Factor Tree Analysis
– Start w/ problem or incident.
– Use tree structure to trace actions and conditions that
led to problem.
• Many others + hybrids
5-Whys
• Facilitator writes group’s issue or problem on board.
• Facilitator: “What causes this problem?” or “Why does this
problem exist?” or …
• Team members give a reason.
• Facilitator: “Then what causes that problem?” or “Then why
does that problem exist?”
• Keep working down to underlying problem or until reason is
beyond control of group.
5-Whys Example
↑
•
Very simple. Easy to facilitate.
↓
•
•
May only expose one root cause.
Easy to get diverted to a symptom.
Make sure you get down to root
cause.
(If reason is outside control or
influence, good point to stop.)
(Interesting ideas or symptom
solutions can be stored in
“parking lot” for possible later
use.)
Five Whys – Useful questions
•
•
•
•
•
•
•
•
•
•
•
•
What could be causing that?
What underlying skills might he/she be missing?
What has kept the typical interventions from working?
What is interfering with… ?
What is a cause that we can influence or change in school?
Why are we continuing to use this strategy?
What else could be causing or influencing this problem?
Do you think “x,” “y,” or “z” could be the cause?
Why is “X” stopping him/her from learning?
Why do you think he/she is or continues doing that?
What could be the motivation for doing that?
What do you think is happening that keeps him/her from solving
this problem?
http://www.ohioschoolleaders.org/moveAhead/UsingData/docs/Five%20Reasons%20Deep-%20Questions%20You%20May%20Find%20Helpful.pdf
Fishbone (Ishikawa) Diagram
Still using 5-Whys
questioning
Cause Categories:
• Manufacturing (4 M’s): Machine, Method, Material, Manpower
• Service(4 S’s): Surroundings, Suppliers, Systems, Skills
Many others. These can be anything that makes sense to the team.
UCO Fishbones (from NSSE Action Teams)
Why a fishbone?
↑
•
•
Still fairly simple.
Provides pathways to more than one
potential root cause.
↓
•
•
Categories can sometimes be
restrictive – or you may waste time
arguing about which category.
Perceived need to find something in
every category sometimes limits
ability to dive down to root cause
level.
Modified “5 Whys” (factor tree analysis)
Modified “5 Whys” (factor tree analysis)
Modified “5 Whys” (factor tree analysis)
↑
•
•
•
•
Still simple. Easy to get folks to do.
Provides pathways to more than one
potential root cause.
Categories no longer restrictive.
Tree structure is very easy to see and
work with.
↓
•
No categories, so facilitator may need
to stretch people’s thoughts.
Activity
Modified 5-Whys
NSSE 9C:
About how many hours do you spend in a typical 7-day week doing each of the following?
1=0 hrs/wk, 2=1-5 hrs/wk, 3=6-10 hrs/wk, 4=11-15 hrs/wk, 5=16-20 hrs/wk, 6=21-25 hrs/wk, 7=26-30 hrs/wk, 8=more than 30 hrs/wk
FY
SR
2009
2006
2003
2001
4.05
5.22
4.65
5.20
4.26
5.08
5.04
4.93
2009 UCO - 2009 2009 UCO - 2009 2009 UCO - 2009
URBAN
CARNEGIE
NSSE
-1.02
-0.59
-1.44
-0.99
-1.70
-1.49
According to NSSE, both Freshmen and Senior UCO
students spend more hours working off campus
than: students at other schools, students at
Carnegie peers, and students at urban peers
Activity – Modified 5-Whys
UCO’s overall retention rate is only 53% while
our peer average is 74%.
Analyze
Data
• Immediate solutions
• Long range solutions
• Process improvements
The End (last CIF is Apr 16)
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