• Root Cause Analysis
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Kaizen Implementation
This is also known as the Shewhart
cycle, Deming cycle, or PDCA. Other
techniques used in conjunction with
PDCA include 5 Whys, which is a form
of root cause analysis in which the user
asks "why" to a problem and finds an
answer five successive times. There
are normally a series of root causes
stemming from one problem, and they
can be visualized using fishbone
diagrams or tables.
1
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DMAIC Analyze
1
A large number of potential root causes
(process inputs, X) of the project
problem are identified via root cause
analysis (for example a fishbone
diagram)
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ISO/IEC 27007
1
Management reviews, including those
conducted routinely as part of an
operating ISMS to check that
everything is in order, and Ad Hoc
audits following information security
incidents, as part of the root cause
analysis to generate corrective actions.
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Problem - Examples
In business and engineering, a problem is
often defined as a difference between actual
conditions and those that are required or
desired. Consider the case of the asset
manager who aims to reallocate cyber capital
to best serve the needs of the client.
Sometimes, the causes of a problem here are
not known, in which case root cause analysis
is employed to find the causes and identify
corrective actions.
1
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Reliability engineering - Reliability operational assessment
The reliability program also includes a
systematic root cause analysis that
identifies the causal relationships involved
in the failure such that effective corrective
actions may be implemented
1
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Reliability engineering - Further reading
1
Gano, Dean L. (2007), "Apollo Root
Cause Analysis" (Third Edition),
Apollonian Publications, LLC.,
Richland, Washington
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Safety
1
Root cause analysis to identify causes of a
system failure and correct deficiencies.
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Information Technology Infrastructure Library - Root cause analysis
1
Others have since developed more
advanced root cause analysis
methodologies, some with
corresponding software applications.
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Information Technology Infrastructure Library - Root cause analysis
1
Benefits from employing a standard, structured root
cause analysis methodology include:
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Information Technology Infrastructure Library - Root cause analysis
Common terms,
language, and structure
with respect to root cause
analysis
1
https://store.theartofservice.com/the-root-cause-analysis-toolkit.html
Development Testing - Key Principles of Development Testing
1
Practices that prevent as many defects
as possible through a Deminginspired approach that promotes
reducing the opportunity for error via
root cause analysis.
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Incident management - Incident management process, as defined by ITIL
1
After service restoration, correction of
underlying root causes is done by the
Problem Management team by a
process called Root Cause Analysis
(RCA)
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Incident management - Human factors
This text will not go into depth on
human factors, but will mention a
couple of poignant areas that can
assist in ensuring after action root
cause analysis comes to an effective
conclusion, after taking into
consideration all the aspects of the
cause and effects of an
accident/incident
1
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RPR problem diagnosis - Standards alignment
COBIT also defines a problem
management process (DS10) with key
activity of Perform root cause analysis.
RPR is a superset of this step in that it
defines a process that covers all of the
activities needed to perform Problem
investigation amp; diagnosis, including
Root Cause identification.
1
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Problem analysis - Computer Science and Algorithmics
In computer science and in the part of
Artificial Intelligence that deals with
algorithms (algorithmics), problem solving
encompasses a number of techniques known
as algorithms, heuristics, root cause analysis,
etc. In these disciplines, problem solving is
part of a larger process that encompasses
problem determination, Data
deduplication|de-duplication, analysis,
diagnosis, repair, etc.
1
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Problem analysis - Problem-Solving Strategies
1
* Root cause analysis: identifying the
cause of a problem
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Sustainability and systemic change resistance - The change resistance and
proper coupling subproblems
Jack Harich's 2010 paper on Change
Resistance as the Crux of the Environmental
Sustainability Problem argues there are two
separate problems to solve.Jack Harich,
[http://www.thwink.org/sustain/articles/009/Ch
angeResistanceAsCrux.htm “Change
Resistance as the Crux of the Environmental
Sustainability Problem”], System Dynamics
Review, January 2010. A root cause analysis
and a system dynamics model were used to
explain how:
1
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Sustainability and systemic change resistance - Overcoming systemic change
resistance
Taking a root cause analysis and
system dynamics modeling approach,
Harich carefully defined the three
characteristics of a root cause and
then found a main systemic root cause
for both the change resistance and
proper coupling subproblems
1
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Operational Intelligence - Purpose
1
In addition, these metrics act as the starting
point for further analysis (drilling down into
details, performing root cause analysis —
tying anomalies to specific transactions and of
the business activity).
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Operational Intelligence - Features
1
** Root cause analysis
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ITIL - Root cause analysis
Others have since developed more
advanced root cause analysis
methodologies, some with corresponding
software applications.
1
https://store.theartofservice.com/the-root-cause-analysis-toolkit.html
ITIL - Root cause analysis
* Common terms,
language, and
structure with
respect to root cause
analysis
1
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Configuration management database
CMDBs are used to keep track of the
state of different things that are normally
referred to as assets, such as products,
systems, facilities, software, facilities
and people as they exist at specific
points in time. The maintenance of such
state related information allows for
things like the reconstruction of such
assets, at any point in their existence, as
well as for things such as impact
analysis, in the cases of root cause
analysis or change management.
1
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Granular configuration automation - Driving factors
1
But the core activity is still handled by
a technical specialist “nosing around”
the system trying to “figure out” what
is wrong based on previous
experience and personal expertise.[
http://hosteddocs.ittoolbox.com/GJ10
2105.pdf Root Cause Analysis for IT
Incidents Investigation], IT Toolbox.
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Corrective and preventive action - Concepts
1
* Root cause analysis to identify the cause of a
discrepancy or deviation and suggest
corrective actions of a problem which is
identified.
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Serviceability (computer)
It refers to the ability of technical
support personnel to install, configure,
and monitor computer products,
identify exceptions or faults,
Debugging|debug or isolate faults to
root cause analysis, and provide
hardware or software maintenance in
pursuit of solving a problem and
restoring the product into service
1
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Process improvement - Process owner
1
Improvement actions may include the
use of problem solving tools that would
include risk assessment and root cause
analysis
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Patient safety organization - Functions
1
#Analyze sources of error by root
cause analysis.
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Patient safety organization - Canadian Patient Safety Institute
1
Together with the Institute For Safe
Medication Practices Canada and
Saskatchewan Health, a Canadian
Root cause analysis|Root Cause
Analysis Framework is offered to
healthcare organizations to analyze
the contributing factors that led to a
critical incident or close call.
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Patient safety organization - Joint Commission on Accreditation of Healthcare
Organizations
1
The Commission defines a sentinel
event as any unexpected occurrence
involving death or serious physical or
psychological injury, or the risk
thereof.JCAHO: The heath care
facility experiencing the sentinel
event is expected to complete a
thorough root cause analysis, make
improvements to the underlying
processes, and monitor the
effectiveness of the changes
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Revenue assurance - Maturity of Revenue Assurance
1
* Managed: At this level with the use of
process metrics, management can
effectively control the Revenue
Assurance AS-IS process (e.g., for
Issue Detection, Root Cause Analysis,
Closure)
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Revenue assurance - Detective Processes
1
Root Cause Analysis (RCA) is a method
of problem solving that tries to identify the
root causes of faults or problems that
cause operating events
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Accident
Accidents of particularly common types
(crashing of Automobile
accident|automobiles, events causing fire,
etc.) are investigated to identify how to avoid
them in the future. This is sometimes called
root cause analysis, but does not generally
apply to accidents that cannot be
Determinism|deterministically predicted. A
root cause of an uncommon and purely
random accident may never be identified, and
thus future similar accidents remain
accidental.
1
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Strategic planning - Tools and approaches
1
Once an understanding of the desired
endstate is defined, the ATM approach
uses Root cause analysis|Root Cause
Analysis (RCA) to understand the
threats, barriers, and challenges to
achieving the endstate
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Configuration management - Configuration management database
1
The benefits of CMDBs include being
able to perform functions like root
cause analysis, impact analysis,
change management, and current state
assessment for future state strategy
development.
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Alternative PHP Cache - Zend Platform
1
It also includes detailed PHP monitoring
and root cause analysis support to help in
tuning and debugging, session fail-over
support for HA (High Availability) needs
and other integration capabilities including
Java integration.
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Occupational injury
There are many methods of
preventing or reducing industrial
injuries, including anticipation of
problems by risk assessment, safety
training, control banding, personal
protective equipment safety guards,
mechanisms on machinery, and
safety barriers. In addition, past
problems can be analyzed to find their
root causes by using a technique
1
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Root cause analysis
'Root cause analysis' ('RCA') is a
method of problem solving that tries
to identify the root causes of faults or
problems.
1
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Root cause analysis
Root cause analysis is not a single,
sharply defined methodology; there are
many different tools, processes, and
philosophies for performing RCA.
However, several very-broadly defined
approaches or schools can be identified by
their basic approach or field of origin:
safety-based, production-based, processbased, failure-based, and systems-based.
1
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Root cause analysis
Despite the different approaches
among the various schools of root
cause analysis, there are some
common principles. It is also possible
to define several general processes for
performing RCA.
1
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Root cause analysis - General principles of root cause analysis
# The primary aim of root cause
analysis is to identify the factors that
resulted in the nature, the magnitude,
the location, and the timing of the
harmful outcomes (consequences) of
one or more past events in order to
identify what behaviours, actions,
inactions, or conditions need to be
changed to prevent recurrence of
similar harmful outcomes and to
identify the lessons to be learned to
promote the achievement of better
1
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Root cause analysis - General principles of root cause analysis
1
# To be effective, root cause analysis
must be performed systematically,
usually as part of an investigation,
with conclusions and root causes that
are identified backed up by
documented evidence. Usually a team
effort is required.
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Root cause analysis - General principles of root cause analysis
# Root cause analysis can help
transform a reactive culture (that reacts
to problems) into a forward-looking
culture that solves problems before
they occur or escalate. More
importantly, it reduces the frequency of
problems occurring over time within
the environment where the root cause
analysis process is used.
1
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Root cause analysis - General principles of root cause analysis
1
# Root cause analysis is a threat to many
cultures and environments. Threats to
cultures often meet with resistance. There
may be other forms of management
support required to achieve root cause
analysis effectiveness and success. For
example, a non-punitive policy toward
problem identifiers may be required.
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Nimsoft - History
In May 2009 Nimsoft acquired the
intellectual property assets of Cittio. Its
product capabilities included network
discovery, topology mapping, and root
cause analysis (RCA) utilizing graph
theory.Ellen Messmer, Network World.
[http://www.infoworld.com/t/application
s/nimsoft-acquires-assets-cittio-027
Nimsoft acquires the assets of Cittio].
May 19, 2009.
1
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Zend Studio
Zend Studio is tightly integrated with Zend
Server, Zend's pre-integrated, tested PHP
application stack. The integration enables
developers to quickly set up a complete PHP
environment and speed up root cause analysis
of problems detected in testing or in the
production environment.
1
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Analysis of competing hypotheses - Weaknesses
1
This is a form of root cause
analysis.
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Scrum pattern
A 'scrum pattern' defines a specific
problem an IT team development may
encounter throughout the life-cycle of an
application. Each pattern is created based
on the Root cause analysis of project's
failure or success:
1
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Enterprise asset management - Why is EAM important?
Asset registers, risk registers, work
planning and scheduling, life cycle costing
and systematic methods for problem
identification, root cause analysis and
continuous improvement are increasingly
seen as prerequesites for a robust asset
management system.
1
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Stockout - Identifying and reducing retail out-of-stocks
1
Improving On-Shelf Availability Through Store-Level
Root Cause Analysis: LOG-HSG
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Never events - Recommended actions following a never event
1
# perform a root
cause analysis
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RCA (disambiguation) - Technology, science and medicine
1
* Root cause analysis in
maintenance engineering
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Kaisen - Implementation
1
Another technique used in conjunction
with PDCA is the 5 Whys, which is a
form of root cause analysis in which
the user asks a series of 5 why
questions about a failure that has
occurred, basing each subsequent
question on the answer to the previous.
There are normally a series of causes
stemming from one root cause, and
they can be visualized using Ishikawa
diagram|fishbone diagrams or tables.
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Lean accounting - Lean performance measurements
1
These boards show the value stream
performance measurements, pareto
charts (or other root cause analysis),
and information about the CI projects
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System safety - Root cause analysis
Others are Event and Causal Factor
Analysis (ECFA), Multilinear Events
Sequencing, Sequentially Timed Events
Plotting Procedure, Savannah River
Plant Root Cause Analysis System.
1
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Trizics - Overview
Unlike Classical TRIZ,
TRIZICS can be used for
root cause analysis
1
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Trizics - Overview
1
*'Type 1'- Use: The Root Cause Analysis
incorporating TRIZ tools Algorithm, CauseEffect Chain Analysis (similar to WhyBecause analysis) and Subversion
Analysis
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Sham peer review - Development of the Patient Safety Organization (PSO)
1
In PSOs, root cause analysis and near
misses are evaluated in an attempt to
avert major errors. Participants in PSOs
are immune from prosecution in civil,
criminal, and administrative hearings.
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Event correlation - Step-by-step decomposition
1
Event correlation can be decomposed
into four steps: event filtering, event
aggregation, event masking and root
cause analysis. A fifth step (action
triggering) is often associated with
event correlation and therefore briefly
mentioned here.
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Event correlation - Root cause analysis
1
Root cause analysis
is the last and most
complex step of
event correlation
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Bleiburg tragedy - Number of victims
* British political scientist David B.
MacDonald|D. B. MacDonald wrote a
comprehensive root cause analysis of
the inflated numbers in his 2003 book:
1
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Process area (CMMI) - Quantitative Project Management (QPM)
** SP 2.3 Perform
Root Cause Analysis
1
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Computerized physician order entry - Features of CPOE systems
;Management :The system delivers
statistical reports online so that
managers can analyze patient census
and make changes in staffing, replace
inventory and audit utilization and
productivity throughout the
organization. Data is collected for
training, planning, and root cause
analysis for patient safety events.
1
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Medical peer review - Overview
The Patient Safety and Quality
Improvement Act of 2005 (Public Law 10941) created Patient Safety Organizations,
whose participants are immune from
prosecution in civil, criminal, and
administrative hearings, in order to act in
parallel with peer review boards, using
root cause analysis and evaluation of near
misses in systems failure analysis.
1
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Joel Spolsky - Biography
1
It implies a quick, immediate solution for
fixing an incident and a second, slower fix
for preventing the same problem from
occurring again by targeting the Root
cause analysis|root cause
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3DiTeams - Purpose
1
The Joint Commission|Joint Commission
on Accreditation of Healthcare
Organizations recognizes lapses in
teamwork and communication as a Root
cause analysis|root cause in nearly 70
percent of sentinel events.
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Production support - Production job/program code correction
If the Production error occurred due to
programming errors then a request is created
for the Development team to correct
programming errors. Problem is identified,
defined and root cause analysis is performed.
The programming error is fixed using normal
SDLC process analysis/design/programming/QA/testing/rele
ase. The new version of the Production
job/program is deployed and
verified/validated.
1
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Patient Safety and Quality Improvement Act - Definitions
1
Patient safety work product includes
any data, reports, records, memoranda,
analyses (such as root cause
analysis|root cause analyses), or
written or oral statements (or copies of
any of this material), which could
improve patient safety, health care
quality, or health care outcomes, that
are assembled or developed by a
provider for reporting to a PSO and are
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List of perception-related topics - Problem solving
** Root cause
analysis ndash;
identifying the cause
of a problem
1
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List of acronyms in oil and gas exploration and production - R
*RCA – Root cause
analysis|Root Cause
Analysis
1
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