Re Thinking Root Cause Analysis. Title. Author

Transcription

1 Click to Play Title Mark Galley Author office 10 min Recorded Presentation

2 Abstract The typical model for root cause analysis is problems are eliminated by solving the root cause. While it seems straightforward, that logic is flawed. Focusing on root cause limits both the analysis and the solutions by giving special emphasis to an artificially narrow set of causes. Impassioned individuals will explain without this root cause the incident never would have occurred. While their statement is true, it s not the whole truth. An incident actually requires all of its causes, not just the ones labeled root cause. A thorough analysis identifies all of the causes required to produce the issue. Each cause then becomes a control point to propose solutions. Problems should not be restricted to a single right answer or root cause. The best solution to a complex problem is usually a combination of a few different actions. That combination produces a cumulative reduction in risk, also known as layers of protection. The right answer thinking of root cause also incorrectly assumes that an analysis with fifteen causes requires fifteen action items. More causes don t necessarily require more solutions. A large, detailed analysis may be conducted to get a small list of action items. This presentation will cover the misunderstood concepts of cause and effect and risk mitigation and provide an example of a basic and detailed level investigation.

3 Lessons to improve the way you investigate and prevent problems. Take aways Root Cause Analysis Explained (Basics of Cause and Effect) Problem Solving Models School versus Work Cause Map Example for your Staff, Customer Documenting and Presenting an Incident

4 How well does your company solve problems? investigate and prevent document and present Problem solving affects results. Problem solving affects culture. Problem solving is a career skill. Organization Individual

5 Analysis To break into parts 1. Problem 2. Analysis 3. Solutions

6 Symptom of the problem The Weed Above the surface, obvious 1 The underlying part The Root a system Below the surface (not obvious) The word root, in root cause analysis, refers to what s beneath the surface, not a type of cause.

7 Question Why did this happen? Problem, Situation, Issue, Event, Disaster Answer Because Producer of the effect EFFECT CAUSE Basic Cause-and-Effect Relationship

8 Question Why did the Titanic sink? Answer Because Titanic sank Ship hit iceberg EFFECT CAUSE

9 SCHOOL PROBLEM SOLVING MODELS Being Right vs. Re Thinking Root Cause Analysis Source of unnecessary disagreement, pointless debate Being Accurate WORK Problem (Question) Answer Problem (Situation, Issue, Event) Answer PREVENTION What is 2 x 7? What is the capital of Texas? 14 Austin Titanic Sank Make sure it doesn t happen again Why did the Titanic sink? What is the atomic weight of carbon? Titanic sank Ship hit iceberg Which month were you born? July What temp does water boil at sea level? 212 F, 100 C Titanic sank Weak rivets One Right Answer Language: Titanic sank Lookouts saw iceberg late NO Right Answer 1 Right or Wrong Titanic sank Water filled hull 1 One question. Different answers.

10 5 Whys Why? Why? Why? Why? Why? Titanic sank Water filled hull Openings in hull Hull plates pulled apart at seams Ship hit iceberg Lookouts saw iceberg late

11 Why did the Titanic sink? Possible Solution: Use stronger rivets. Weak rivets Safety Goal Impacted 1500 people died Titanic sank AND Water filled hull Hull plates pulled apart at seams AND Ship hit iceberg Possible Solution: Improve task to identify objects. Lookouts saw iceberg late Possible Solution: Add more lifeboats Insufficient lifeboats

12 Reducing Risk A combination of solutions produces a Cumulative Reduction in RISK. Layers of Protection Solutions Changes that Reduce Risk Risk Possible Solution: Improve task to identify objects. Possible Solution: Use stronger rivets. Possible Solution: Add more lifeboats Effectiveness of Solutions

13 Documenting and Presenting an Incident Written Report Many words (string) Written at the end of the investigation Utilize visual communication Document that incident as you investigate it

14 Documenting and Presenting an Incident Pencil & Paper One or two people Chart Paper with Post-It notes Use paper on a table or wall Dry Erase Board Microsoft Excel Simple method for storing, sharing, ing Cause Maps Click here to view a demo of the Cause Mapping Template

15 Summary Conventional Problem Solving Investigating and Preventing a Problem Cause-and-Effect Analysis 1. Identify the Problem 2. Identify the Cause (Root Cause) 3. Identify the Solution 1. Identify the Impact to the Goals (Value) 2. Identify the Causes (Basic, Mid, Detailed) 3. Identify the Best Solutions (Risk)

16 Lessons to improve the way you investigate and prevent problems. Take aways Root Cause Analysis Explained (Basics of Cause and Effect) Problem Solving Models School versus Work Cause Map Example for your Staff, Customer Documenting and Presenting an Incident Click to Play Thank you, Mark Galley office Click here to view the list of Cause Mapping Workshops In Person & On Line 10 min Recorded Presentation Click to visit