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08 Apr 10 – WDM 204 – Session Five
Cape AreaManagement Program
(CAMP)Sponsored by the Cape & Islands
Workforce Investment Board
08 Apr 10 – WDM 204 – Session Five
Today’s Topics
Learning Objectives
Root Cause Analysis Overview
Root Cause Organizational Philosophy
Effectively Define the Problem
The “Five Whys” and Breakout Exercise
The “Fishbone Diagram” and Breakout Exercise
The Challenges and Keys to Success
Questions and Comments
08 Apr 10 – WDM 204 – Session Five 4
Learning Objectives
In this class, students will learn the how to develop a structure and process for continuous quality improvement (C.Q.I.).
The class will understand the challenges essential to effective C.Q.I., and learn the potential solutions. Practical tool(s) will be provided.
They will demonstrate their learning by in class discussion of workplace experiences, and group discussion of case studies.
Additional reading reference(s) will be provided.
WDM 204: Continuous Improvement
Identifying Crucial Processes
Working with Organizational Leaders to Determine NeedProcess Identification
Documenting Your Findings
08 Apr 10 – WDM 204 – Session Five 6
Quality Improvement System Tools
We need tools – a common language – to tell us:– where we stand versus our competition? (S.W.O.T.)
– what do we need to work on (Impact/Maturity Matrix)?
– how are we doing things now? (Process Mapping)
– what we need to do our job? (S.I.P.O.C)
– why isn’t it working? (Root Cause Analysis)
– how can we best do our jobs? (Standard Work)
– what do our stakeholders think? (Stakeholder Feedback)
08 Apr 10 – WDM 204 – Session Five 7
When Do You Need “Root Cause” Analysis?
There isn’t enough time to solve all the problems
Solutions are incomplete
Urgency supersedes importance
Problems reoccur and cascade
Many problems become crises
Performance drops
If three or more of these occur in your organization,
you are a victim of
“firefighting*.”
* Stop Fighting Fires; Bohn, Roger; Harvard Business School Publishing; 2000
08 Apr 10 – WDM 204 – Session Five 8
Root Cause Analysis
Find out why errors occur, to fix them once and for all:
UndesirableResult
Methods
Sub cause 1
Measurement
Sub cause 2
Material
Sub cause 3
Machine
Sub cause 4
Environment
People
40.00
70.00
90.00
100.00
Cause and Effect
# E
rro
rs
Sub cause 4 Sub cause 3 Sub cause 2 Sub cause 1
100
50
0
100%
50%
0%
Why?
Why did that occur?
Why did that occur?
08 Apr 10 – WDM 204 – Session Five 9
Philosophy of Relentless Root Cause
Each problem is a golden nugget or treasure.
Each problem tells a story about why and how it occurred. (There are no isolated incidents.)
Solving problems requires a mindset that is alert, open-minded, patient, tenacious, and persistent.
The “true” problem must be understood from the data before action is taken.
Each problem must be pursued and resolved, rapidly.
08 Apr 10 – WDM 204 – Session Five 10
Symptom Approach vs. Root Cause
Symptom Assumes at any given time a
worker makes a choice to work error-free or not.
Assumes errors are the result of worker carelessness.
The method for improvement is to motivate workers to be more careful.
Root Cause Assumes that errors are the
result of defects in the process. People are only part of the process.
Assumes that there are multiple causes for errors.
The method for improvement involves identifying appropriate ways to improve the process.
08 Apr 10 – WDM 204 – Session Five 11
First, Define the ProblemYour new cookie sales account just called, and they are not happy. Over
the last 30 days, these are the problems they have experienced.
Week Ending
Problems
3/7Damaged packaging (2), late delivery (3), damaged cookies (3), wrong amount of cookies delivered, wrong invoice (2)
3/14 Damaged packaging (3), late delivery (6), wrong amount of cookies delivered, wrong invoice (2)
3/21 Damaged packaging (2) , late delivery (10), wrong amount of cookies delivered, wrong invoice (2)
3/28Damaged packaging (2), late delivery(14), damaged cookies (3), wrong amount of cookies delivered, wrong invoice
4/4 Late delivery (2), wrong amount of cookies delivered(2)
How do you know where to start?
08 Apr 10 – WDM 204 – Session Five 12
Pareto Analysis – Defines Problem
If your customer is not satisfied, what are the reasons? Which is the most important reason?
0
5
10
15
20
25
30
35
40
Late Deliveries Damaged Packaging Wrong Invoice Wrong Amount Damaged Cookies
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
08 Apr 10 – WDM 204 – Session Five 13
Root Cause Analysis Using The “5 Why’s”
Problem
Why?
Why?
Why?
Why?
Why?
Flat Tire in Garage
Nails on garage floor
Box on shelf split
Box got wet
Rain through hole in garage roof
Rain happens
Breakout Session
Form Teams of Three to Five People
08 Apr 10 – WDM 204 – Session Five 15
Break Out Exercise – 5 Why’s
Do a “5 Why” root cause analysis on the problem scenario on the next page
Be sure to use all five “whys”
Be prepared to report out
08 Apr 10 – WDM 204 – Session Five 16
Root Cause Using the “5 Whys”
You’ve looked in to the cookie customer’s Late Deliveries complaints further, and you have the following information. Put it in “5 Why” order:”
The driver is new and doesn’t know the best route
The delivery truck arrives late to the customer
The traffic is much heavier in the Spring
The driver is slowed down by traffic
The driver is a part-time seasonal employee
08 Apr 10 – WDM 204 – Session Five 17
Limitations of the “5 Why” Method
Many people struggle with splitting a problem into exactly five levels
Debates center on which issue is the “real” root cause, and which cause comes first
It assumes problem analysis is “linear” – first this, then that - when sometimes several things happen at once
However, it is a great learning model for this subject!
08 Apr 10 – WDM 204 – Session Five 18
What Are Some Alternatives to “The Five Whys” Root Cause
Analysis? Open Brainstorming
Nominal Group Technique – “yellow stickies”
Fault Tree/Red X Analysis – remember the guess my number game?
Other statistical methods, such as those taught as “Six Sigma”
Ishikawa or “Fishbone Diagram”
08 Apr 10 – WDM 204 – Session Five 19
Root Cause Brainstorming Tool
StudiedBeingProblem
Environment
Measurement
Methods
Material
Machines
Personnel
Cause A
Cause Y
Cause B
Cause Z
Cause C
Cause J
Cause M
Cause D
Cause P
Cause E
Cause F
"Fishbone Diagram"
Then, team votes on 1-3
problem “key drivers” after all ideas are
recorded
First, what are all the “drivers” of this process?
08 Apr 10 – WDM 204 – Session Five 20
What Are the “Bones?” Environment – literally, the working conditions, e.g. light,
heat, humidity
Methods – how we use the tools and resources, e.g. work instructions
Machines – what we use, e.g. computers, printers, copiers
Measurement – how we measure “key drivers”
Material – what stuff we use to create our “product”
Personnel – the people doing the job
08 Apr 10 – WDM 204 – Session Five 21
Let’s Practice – “Mushy Cookies!”
Environment – literally, the working conditions, e.g. light, heat, humidity
Methods – how we use the tools and resources, e.g. work instructions
Machines – what we use, e.g. computers, printers, copiers
Measurement – how we measure “key drivers”
Material – what stuff we use to create our “product”
Personnel – the people doing the job
08 Apr 10 – WDM 204 – Session Five 22
Cookies!Mushy
Environment
Measurements
Methods
Material
Machines
Personnel
Pay Rate Low
New Baker
Refrigerator New
Mixing Bowl New
Spatula Broken
Cookie Sheets New
Oven Is Old
Free Range Eggs
Carob Chocolate Chips
Tap Water
White Sugar
Soy Based Oil
Whole Wheat Flour
Bake for 12 min
Cool for 1 min
Mix for 3 min
Bake at 350
Wall Clock
Kitchen Timer
Oven Thermometer
Eco Lighting
Rainy Morning
Summer Day
"Fishbone Diagram"
Possible Root Causes for “Mushy Cookies”
Breakout Session
Form Teams of Three to Five People
08 Apr 10 – WDM 204 – Session Five 24
We’re Not Happy!
Your new cookie sales account just called, and they are not happy. Over the last month, these are the problems they have experienced.
Week Ending
Problems
3/7Damaged Cookies – one, Wrong Amount Delivered – two, Damaged Packaging – three, and Late Deliveries – eight
3/14Damaged Cookies – one, Wrong Amount Delivered – two, Damaged Packaging – three, Late Deliveries – seven, and Wrong Invoice – three
3/21 Damaged Cookies – one, Damaged Packaging – one, Late Deliveries – 13, and Wrong Invoice – four
3/28 Wrong Amount Delivered – two, Damaged Packaging – two, and Late Deliveries – seven
08 Apr 10 – WDM 204 – Session Five 25
Break Out Exercise – Fishbone
Use the data on the next slide (and previous slides) to determine what to focus on first
Then, use a blank fishbone diagram to lead your team in a root cause brainstorming exercise– you will have to “make up,” using your common sense,
the causes to list
Reach consensus as a team on the three most likely causes
Be prepared to report out
08 Apr 10 – WDM 204 – Session Five 26
Beware of subjectivity
– Realize that you might not think of all the possible root causes while brainstorming
– Set aside personal bias “knowing the answer before you get started”
– Let the data lead you to objective conclusions
Check your data
Test you solution more than once if possible
Do not accept “human error” as an excuse for the root cause of a problem
Cautions
08 Apr 10 – WDM 204 – Session Five 27
How Are Most Organizations Directed?
What do we use to direct the workforce?– metrics (target measurements, such a budgets),
– policies (things you can’t measure, you describe)
If organizations are controlled by metrics and policies, what is the ultimate root cause of (what is now) undesired behavior?
Metrics and policies that conflict with the desired new direction!
08 Apr 10 – WDM 204 – Session Five 28
The Challenge of True Root Cause
Organizational leaders do not intentionally create problems
They vigorously support achieving objectives
They (like all of us) see some questions as “resistance”
They live in a world dominated by Financial information
08 Apr 10 – WDM 204 – Session Five 29
Keys to Success
Question Everything
– Do not stop until you are down to causes that can be tested and attacked
– Ask, “why, why, why?” until you know the fundamental element of the process that failed
Ask the experts—the users of the process
Get other, outside help
– Neutral
– More objective
Be relentless in your pursuit
Enroll your leadership in your solution
Class Discussion
Your Workplace’s Root Cause Analysis
08 Apr 10 – WDM 204 – Session Five 31
Personal Practicum ChecklistProject Charters
What do I need to know to try this at work?
When before the next class will I try?
What is my greatest concern in doing so?
08 Apr 10 – WDM 204 – Session Five 32
Discussion of Personal Practicum Checklists
Any questions on the how?
Let’s hear a couple of examples of the when?
Let’s hear a couple of examples of concern?
Let’s practice working through those concerns…
Questions or Comments Before We End?