One Page Overview of Root Cause Analysis (RCA) KEY AREAS POINTS TO CONSIDER DEFINITION & GOALS OF ROOT CAUSE ANALYSIS (RCA) HOW AND WHY •  RCA iden)fies how and why problems and issues occur •  A process for iden)fying what can be done to prevent recurrence AREAS FOR CHANGE RCA is used to iden)fy areas for change & to develop recommenda)ons which deliver improved solu)ons RCA BEST PRACTICES KEEP IT SIMPLE •  Use short sentences and bullet points •  Consider small changes that can make a difference RCA PROCESS TYPE OF CAUSES 1. Physical (something stopped working) 2. Human (people did wrong ac)on or did not do ac)on 3. Organisa)onal (system, process, policy not working) RCA GOALS •  To focus on preven)on, not blame •  To iden)fy changes that can be made in systems that will reduce or remove the problem •  What happened? •  Why did it happen? •  What to do to prevent it from happening again? •  How to know the change made a difference? FOCUS AREAS Focuses on system & process weaknesses •  Communica)on •  Environment •  Equipment •  Training •  Policies & processes LEADERSHIP •  The success of RCA ini)a)ves depends upon visible leadership support and par)cipa)on •  Ensure full and ac)ve par)cipa)on and commitment by key stakeholders to the RCA process and iden)fied preventa)ve ac)ons POSITIVE & CREATIVE Be posi)ve, objec)ve and crea)ve about solving problems with “no blame” aVtude or finger poin)ng RCA EFFECTIVENESS RCA ac)ons will be measured via aligned metrics for effec)veness in preven)ng future issues RCA FACILITATOR •  A facilitator ensures a “no blame” approach •  Ensure team focus on solu)ons not the problem •  Can also provide training & ongoing consulta)on •  Keeps the team on task to ensure root causes are found and effec)ve ac)ons are developed •  Ensure informa)on captured into RCA document 1. TEAM Organise small team of stakeholders and subject maXer experts (SME’s) 2. DEFINE PROBLEM •  Create map of “what happened? •  What are the specific symptoms? •  Use ques)ons to expand this view 3. COLLECT DATA •  What proof is that the problem exists? •  How long has the problem existed? •  What is the impact of the problem? 4. FIND CAUSES •  What order of events leads to the problem? •  What context allow the problem to occur? •  What other problems occur with this problem? 5. FIND ROOT CAUSE Use RCA tools such as 5 Why’s and Fishbone diagram to find causes 6. CREAT ACTION PLAN & METRICS •  Develop an aligned ac)on plan to fix problem •  How will the solu)on be implemented? •  Who will be responsible for the solu)on and sign-­‐off •  What are the risks of implemen)ng the solu)on? •  How will the effec)veness of the solu)on be measured & communicated? THE 5 WHY’s TOOL PURPOSE The purpose of this tool is to constantly ask Why? through the various layers of causes of a problem to determine the root cause STARTING POINT Use the iden)fied problem as the star)ng point of the root cause analysis process THE PROBLEM •  Use brainstorming to iden)fy main features of the problem •  If more than one problem analyse separately PROBLEM CAUSES •  Ask what is this cause of the original problem? •  Generate further and deeper reasons as to why the problem exists MAP PROCESS •  Map the process on a flip chart or white board •  For each cause ask what is this cause of the original problem? •  Map the process on a flip chart or white board •  Un)l no more causes are iden)fied then you should have found the root of the problem FISHBONE RCA TOOL PURPOSE A fishbone diagram is used to iden)fy all of the contribu)ng root causes likely to be causing a problem CAUSE CATEGORY GROUPS Causes are usually group into these tradi)onal categories •  People: Anyone involved with the process •  Methods: How the process is performed and the specific requirements for doing it •  Materials: Raw materials used to produce the final product •  Measurements: Data generated from the process that are used to evaluate its quality •  Environment: The condi)ons, such as loca)on, )me, and culture in which the process operates MARKETING CAUSE GROUPS •  Product/Service •  Price •  Place •  Promo)on •  People/personnel •  Posi)oning •  Packaging 5 WHY’s CAUSE GROUPS •  Who •  Where •  What •  When •  Why KAIZEN PURPOSE & OBJECTIVES A prac)ce that focuses upon con)nuous improvement of processes which can be used to con)nuously improve solu)ons iden)fied by RCA •  Standardise an opera)on and ac)vi)es •  Measure the opera)on •  Gauge measurements against requirements •  Innovate to meet requirements and increase produc)vity •  Standardise the new, improved opera)ons •  Con)nue cycle of process improvement KAIZEN 10 STEP PROCESS 1.  Define the problem 2.  Document the current situa)on 3.  Visualize the ideal situa)on 4.  Define measurement targets 5.  Brainstorm solu)ons to the problem 6.  Develop Kaizen plan 7.  Implement plan 8.  Measure, record and compare results to targets 9.  Prepare summary documents 10.  Create short term ac)on plan 5 KEY ELEMENTS OF KAIZEN These are the 5 success factors for Kaizen: 1.  Teamwork where staff work as a team towards achieving the desired improvement goal 2.  Staff discipline contributes to Kaizen success 3.  Staff Morale from good working condi)ons, promo)ons and other benefits give staff a sense of belonging and mo)va)on 4.  Quality Group where staff can share knowledge, ideas and skills 5.  Staff sugges)ons for improvement where all sugges)ons are welcomed, appreciated and considered You can leverage other popular process improvements such as PDCA to perform Kaizen process improvements RCA USES •  Iden)fy areas for change •  Develop recommenda)ons •  Iden)fy new solu)ons THE 5 WHY’s The process normally requires five rounds of the ques)on “Why?” to elicit the root of a problem but not cast in stone THE FISHBONE PROCESS •  Use a a flip chart or white board to get started. •  Draw the "backbone of the fish •  Write the problem to be solved as detailed as possible the head of fish (right hand side of fishbone diagram) •  The next step is to decide how to categorise the causes. •  Use "Post-­‐it" notes to move causes around as you decide on categories for your fishbone. •  You can use the tradi)onal cause categories or decide your own •  Brainstorm by team members to iden)fy causes within the agreed cause category groupings PDCA •  PDCA is a popular approach for doing KAIZEN improvements •  PDCA (plan–do–check–act) is an itera)ve four-­‐step method used for con)nuous process improvement •  Plan is to establish the objec)ves and processes necessary to deliver results in accordance with the goals •  Do is to implement the plan and collect data for char)ng and analysis •  Check the actual results (measured and collected in "DO”) and compare against the expected results (goals from the "PLAN") to determine any differences •  Act is to recommend ac)ons on differences between actual and planned results. Further analyse the differences to determine their root causes and determine where to apply changes that will improve the performance of the process under inves)ga)on