Truly great leaders understand that success is achieved by eliminating problems before they happen. This is where a root cause analysis can prove invaluable.
What is Root Cause Analysis?
Root cause analysis (RCA) is a process used to determine the underlying cause of a problem. When the underlying cause or root of a problem is identified and understood, it can be remedied and avoided in the future.
The easiest way to understand root cause analysis is to think about common problems. If we are sick, we will go to a doctor and ask him to look for the cause of our illness. If our car stops working, we will ask a mechanic to find the root cause of the problem.
Root Cause Analysis Objectives
The first goal of root cause analysis is to discover the root cause of a problem or event.
The second goal is to fully understand how to fix, compensate, or learn from any underlying problems within the root cause.
The third goal is to apply what we learn from this analysis to systematically prevent future problems or repeat successes.
Root Cause Analysis Methodology
Root cause analysis can be performed with a collection of principles, techniques, and methodologies that can be leveraged to identify the root causes of an event or trend. Looking beyond superficial cause and effect, RCA can show where processes or systems failed or caused a problem in the first place.
The key to discovering the root cause of a particular problem is to ask "why?" why did that equipment fail? Why did that employee make that decision? And so on. Each "why" question should lead to an additional question until, eventually, a root cause is identified.
Root Cause Analysis Meeting
A root cause analysis meeting has a clear problem, a leader and stakeholders. The most important guideline for the meeting itself is that the purpose is to learn and improve, not to assign blame or vent. It must be assumed that any problem is preventable and worth preventing. Problems are caused by insufficiently robust systems rather than individual incompetence. Even in the event that a person makes a mistake, we must ask ourselves "why do our tools make that mistake so easy to make?"
The person leading the meeting should lead the team in brainstorming each of the selected issues. It is important that the leader is trained to choose one and only one solution for each problem, and then assign it to someone to solve it.
The cost of solutions is proportional to the problem caused. This should facilitate the acceptance of other managers or executives. After all, if it's a serious problem like site service disruption, do they really want to be seen as the person standing in the way of the solution? And if it's a minor issue, will they really oppose a few extra hours of work here and there, if it's for a good cause?
There are some basic principles that guide effective root cause analysis. Not only will this help the quality of the analysis, but it will also help the analyst gain the trust and buy-in of stakeholders.
Focus on correcting and remedying root causes rather than just symptoms.
Do not ignore the importance of treating symptoms for short-term relief.
Keep in mind that there can be, and often are, multiple root causes.
Focus on how and why something happened.
Be methodical and find concrete evidence of cause and effect to support root cause claims.
Provide sufficient information to inform a corrective course of action.
Consider how a root cause can be prevented (or replicated) in the future.
When analyzing deep problems and causes, it is important to take a holistic and holistic approach. In addition to uncovering the root cause, we must strive to provide context and information that results in an action or decision.
One of the most common techniques for performing a root cause analysis is the 5 Whys approach. We can also think of this as the annoying child's approach. For every answer to a Why question, we should follow up with an "Ok, but Why?" Common wisdom suggests that around five Why questions can lead us to most of the root causes.
We can think of an example related to a concussion.
First, a rugby player, subject to the inconvenience, will present a problem: Why do I have such a severe headache? This is our first Why.
First answer: because I can't see well.
Second why: why can't you see well?
Second answer: Because my head hit the ground.
Third why: Why did your head hit the ground?
Third answer: I was hit on the ground and hit my head hard.
Fourth why: Why hit the ground so hard?
Fourth answer: because he was not wearing a helmet.
Fifth why: Why weren't you wearing a helmet?
Fifth answer: because we didn't have enough helmets in our locker room.
Identifyingthe Root Causein 5 easy steps
By following these five steps you will be able to identify not only what went wrong, but also why, and use that understanding to ensure that similar problems and errors are avoided in the future.
Realize the problem
First, you need to identify what really went wrong. What problem do you hope to solve by undertaking a root cause analysis process? There are usually three basic types of problems:
Material-based problems: These problems occur when a specific material element has failed in some way, such as a piece of machinery.
People-based problems: A people-based problem occurs when human error is the cause of the current problem. Often, a people problem will lead to a material problem. For example, a piece of machinery fails because an employee did not perform regular maintenance on it.
Organization-based problems: An organizational problem arises from a company process or policy that causes a problem to occur. Continuing with our example, the maintenance of the defective part of the machinery occurred because the company's process for assigning maintenance tasks is defective.
We decide which of these issues is to blame for the current problem and the symptoms of the problem you are dealing with.
Collect a sufficient amount of data
Now that we know what the surface problem is and the symptoms it is causing, we need to collect as much data as possible.
In this regard, we must ask questions such as: "How long has this problem existed?" and, "What impact is it having on daily operations?"
It is beneficial to get a multitude of opinions at this stage. People who deal with this specific problem area should be asked for feedback on a regular basis. Your perspective will be valuable as we work to identify and eliminate the root cause of a problem.
Identify associated causal factors
Now the analysis aspect of root cause analysis really comes into the picture in full force. Let's start this step by reconstructing an event timeline
What led to this current problem?
What other issues coexist with the current one you're dealing with?
Identifying a timeline and asking these types of questions will allow you to begin to realize specific causal factors.
Tips for conducting an effective root cause analysis
We must ask questions to clarify the information and get closer to the answers.
The more we can dig deeper and interrogate about each potential cause, the more likely we are to find a root cause.
Once we believe we've identified the root cause of the problem (and not just another symptom), we can ask even more questions: Why are we sure this is the root cause instead? How can we fix this root cause to prevent the problem from happening again?
Use simple questions like "why?" "how?" and "what does that mean here?" to carve a path to understanding.
Whether it's a partner or a full team of colleagues, any additional eyes will help us find solutions faster, and will also serve as a check against bias. Receiving input from others will also offer additional insights, helping us to challenge our assumptions. Receiving input from others will also offer additional insights, which will help us challenge our assumptions.
Get a deep understanding of root cause analysis
As we conduct a root cause analysis, it is important to know the process itself. We must find out if a certain technique or method works best for your specific business needs and environments. We need to find out if a certain technique or method works best for your specific business needs and environments.
Conduct root cause analysis not only for problems but for successes
Root cause analysis is a great tool for figuring out where something went wrong. We usually use RCA as a way to diagnose problems, but it can be just as effective in finding the root cause of a success. If we find the cause of a success, it's rarely a bad idea to figure out the root cause of why things are going well. This type of analysis can help prioritize and preemptively protect key factors and we could translate success in one business area to success in another area.
It is important for organizations to strategically share the results of their RCAs through training and follow-up action items with appropriate departments to prevent future errors and reduce costs associated with the risk of errors.
In addition to sharing the results of the RCA, organizations are expected to provide the resources and funds to implement the error prevention interventions recommended from the RCA analysis.
When staff see that these action plans are fully implemented, they are more likely to agree to report incidents, participate in the RCA process, and change their perception of the culture in the organization, bringing them closer to zero harm.
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Foster, P. (2018). 5 Root Cause Analysis Tools for More Effective Problem-Solving. Beacon Quality. https://www.beaconquality.com/blog/5-root-cause-analysis-tools-for-more-effective-problem-solving
“What is Boolean logic?” Lotame. https://www.lotame.com/what-is-boolean-logic/
What is a Fault Tree Analysis? (2002). Quality Progress. http://asq.org/quality-progress/2002/03/problem-solving/what-is-a-fault-tree-analysis.html