Tuesday, June 05, 2007

Root Cause Analysis - Part IV


Root Cause Analysis - Part III
Breaking Down and Defining the Four Phases

Preparation, Analysis, Verification and Implementation


Along with each phase of Root Cause Analysis come barriers. The following barriers are not meant to be all encompassing, but serve as the most likely to cause an analysis and solution from being complete and successful:

1) Facilitator Not Prepared - The person(s) conducting the analysis must be versed in Problem Solving techniques and have experience in Group Dynamics and Facilitation. It is not important that the facilitator be an expert on the process being investigated, in fact if the facilitator is too close to the subject he/she will inhibit the thought process. The Root Cause Facilitator is like an investigator who continuously searches for facts and experiences by asking process probing questions and using analytical tools/techniques.

Overcome this barrier by requesting the assistance of a Process Improvement Specialist if a member of the analysis group is not versed or skilled in facilitation techniques.

2) Wrong People for Analysis - This barrier takes many shapes, not enough people, and too many people, not the correct people. How does one know who should be involved. The best way is through a critical event or process flow map. These two tools will help identify the end-to-end process (including process owner) that should be involved in the analysis.

Problem Solution to this barrier is creating a Critical Event Process Map that stratifies a process down to the events or task where the Root Causes are embedded so that the appropriate people can be identified for analysis.

NOTE: The first two barriers directly affect the Roles and Responsibilities of a facilitator and group members. Having the appropriate mix of talent and experience is vital to the success of the analysis. Having just a team of specialists (i.e.; Service Reps) in a single area and not end-to-end process experts can produce less than desirable results. Instead use process experts from each area of the process, along with a facilitator/leader than is versed in process improvement group dynamics and effective meetings will enhance the team’s chances of finding problems.

The Human Factor of why workers make mistakes is often the most neglected by management facilitators. Without some understanding of why workers makes errors or won't follow procedures usually results in the worker being blamed for the problem. This lack of understanding and knowledge to identify real actionable root causes of why workers make mistakes will only continue the behavior of workers despite management's messages that workers need to be empowered, work smarter and be accountable for their quality of work.

3) Incident/Problem Too Large - Based on years of experience this is the number one barrier to Root Cause Analysis. Analysis groups continually try to tackle large processes and Pareto categories at a single Root Cause Session. It is very difficult to get to actionable root causes at such a high level of analysis. Analysis needs to take place at the root of the problem (events/tasks) not the surface (Pareto Categories). Too many groups want to solve world hunger with this technique.

In order to analyze many different incidents/problems the group may need to do multiple analyses. Stratification and process identification is the key. This can be done by driving the incident to a process statement based on the pain (output) caused to the customer.

4) No Verification After Session - Many analysis groups do very well at brainstorming potential root causes. However, they often fall short when it comes to verifying, measuring or observing process events to determine how many of the root causes are contributing to the problem or if they were removed/reduced after solutions are implemented.

One way to avoid this barrier is to create a measurable fact based problem statement that the group can analyze. This will create an output base by which the fact finders can determine how much a potential root cause is affecting the overall problem.

5) No Management Support - This barrier is common among all process improvement activities. Without the "active" support and commitment to allow liberated change and process improvement to take place no actionable solutions or corrective action can take place.

Avoid this barrier by including include the Process Owner at each phase of the analysis that the team feels support and coaching is required.

The best way to overcome many of the above barriers and others is by developing an Action Plan that visions the outcome of a smoothly run customer focused process. Without a blue print or road map of what a finished analysis looks like, nothing more than a brainstorming session will take place with a group suggesting to add additional measures and procedures to an already overcrowded process.


Anonymous said...

Do you ever do any training or speak to companies about Quality?


Anonymous said...


I did a lot of speaking engagements/presentations in the past. Most of the training was done in-house for the companies I worked for and the College I taught at for a number of years.

Todat I would rather concentrate on just sitting down with workers at all levels to discuss Quality and answering Email (qualityg@comcast.net) questions.