Criteria for evaluating root cause analysis systems
Root Cause Analysis General Definition
Root cause analysis, generally speaking, is a procedure for ascertaining and “analysing” the causes of operations problems in an effort to determine what can be done to solve or prevent them.
An important element in the definition is the word procedure. People in all fields within an organisation routinely seek to solve their problems to overcome the day-to-day obstacles to their goals. All members of an organisation are, in a sense, problem solvers.
When we experience problems in our operations, whether they be injuries, interruptions, obstacles, errors, or counter-quality occurrences, we are all looking for their “root causes” – those causes which we can remove from the picture, and by doing so, prevent the problem from occurring again.
Root cause analysis is a “standard operating procedure,” a formal process for discovering these “root causes,” and thus, understanding what can be done to prevent them.
Nearly all root cause analysis methods would subscribe to this definition. But not all root cause analysis methods are created equal.
Root Cause Analysis Needs to Accomplish
First let’s clarify what it is we are talking about when we say "preventive solutions." We are not talking about sticking a finger into the dike. Repairing things, cleaning up, removing, reworking, redesigning, modifying, and fortifying may temporarily solve the problem but are not preventative measures that provide reliable control into the future. In other words, these temporary fixes are at best “corrective” steps – not preventive measures.
For example, if solving a problem requires that we “redesign,” then reliable prevention of that problem must consider why the design was inadequate in the first place. If a piece of equipment breaks down, then repairing it will correct the problem, but preventing it from happening again requires that we ask why the equipment broke down.
This is not to say that these corrective responses are not important when things go wrong, but it is obvious that the greater benefit will be achieved if we can design our operations so as to avoid repair, rework, clean up, and expensive redesign. We are trying to find something that someone can do to keep the problem from ever happening again. Obviously, the act of cleaning up the mess every time the problem occurs is not prevention.
3 Things Root Cause Analysis Needs to Include
There are many root cause analysis processes and methods on the market. The REASON developers Decision Systems Inc has been researching and developing root cause analysis methodology for over 30 years. In this time, we have discovered that an effective and reliable RCA process must provide three essential qualities.
1. Root cause analysis process must take advantage of people’s knowledge while preventing their biases from controlling the direction of the investigation.
Most people experienced at their jobs, will be able immediately to spot something that might prevent recurrence of a problem. However, in most operations, we will find that if the problem solving is done only through the eyes of experience, the resulting solutions tend to be one-dimensional, workplace wisdom as opposed to evidence based analysis. For example, a maintenance man sees something he can fix to get the machine up and running again. The Engineer sees changing the machine design as a way to avoid the same problem. The Production supervisor sees a way to change the procedure to avoid the problem. The Operations Manager may see an opportunity to farm the job out to a vendor as the best solution to that same problem.
What is needed is a procedure for problem solving that takes advantage of people’s experience and expertise, while at the same time ensuring that these potential assets do not limit the scope of the investigation.
On the other hand, if the analysis process requires the analyst to select the cause(s) judged to be most significant from a prepared list of causes,then it follows that at least part of the causal structure producing the problem will not receive attention.
The same is true if the analysis process itself is geared to identify only one root cause, and the analyst must decide which part of the problem on which to focus his analysis. If part of the causal system that produced the problem is overlooked, then avenues to potential solutions will not be identified. Furthermore, there is no reason to believe that the solutions that are identified are the most effective. In fact, it is even possible that the analyst will choose to focus on a part of the causal structure that leads to no solution whatsoever!
If your root cause method allows analysts to use their own judgment toidentify only what they consider to be the most significant root causes, they are, in effect, being allowed to make management decisions. Management’s broad knowledge of the organisation’s budget, planning, goals and limitations puts them in a position to consider all operational demands as part of the decision making process.
However, management can only do this well if all the options are presented to them. If analysts bring to management only those solutions that made sense to them, they have effectively filtered away all the other solutions available, and in so doing, have usurped the management decision making process.
So in a nutshell, the problem with subjective, fractured approaches is this: They allow investigators to focus on the issues that they are familiar with or those that they simply prefer to look at, and consequently, overlook the rest.
If your root cause analysis method allows an investigator to focus on certain causes or categories of causes and overlook others, there is no guarantee that the investigator will arrive at an effective solution, let alone the best solution.
For these reasons, a complete root cause analysis requires a process that leads you to accurately identify all of the corrective opportunities available to you. You want your decision-makers to have visibility of all of the available avenues toward prevention. And you want to be able to validate, compare and evaluate the available options before allocating the resources of your organisation.
It is not possible to discover every potential solution unless every cause that contributed to the event has been identified, and recorded. For this reason, the root cause analysis methodology must be such that the analyst's personal experience, knowledge, and even biases, are not allowed to limit the scope of the investigation.
A process which ensures that all factors contributing to a problem are identified so that all possible avenues of prevention can be evaluated is an exclusive feature of the REASON root cause analysis system.
2. Root cause analysis process must depict the facts of the case so that the causal relationships are clear and the causal relevance of those facts can be verified.
In is not only important that all of the facts contributing to the problem be included; it is also important that only those facts contributing to the problem be considered.
Including facts which are not causally relevant takes investigators down paths that will not produce solutions to the problem, and in fact obscure the paths toward solution. Effective root cause analysis needs a process which validates our causal reasoning so that we can be sure we have included all of the relevant facts, and at the same time, only the relevant facts.
The REASON rca method orders and displays the facts of the event in a format that makes it easy to check for accuracy and completeness at each step.
3. Root cause analysis process must also help the analyst and management understand what actions must be taken to implement potential solutions and who in the organisation needs to take those actions.
Once every possible avenue toward prevention is identified, the analyst must understand what specific actions need to be taken.
Is there a policy already on the books that attempts to address the problem or is a new policy needed? If a policy already exists, then why wasn’t it effective, and what steps do we need to take to make it effective in the future? And who in our organisation needs to take those steps?
If the appropriate action is not taken at the appropriate level in the organisation, then a sufficient level of control will not be established to insure prevention into the future. These issues are part of the process of identifying preventative measures and must be integrated into the root cause analysis system.
The REASON method teaches the principles governing corrective action and integrates them into the root cause analysis process. A natural consequence of the Reason RCA methodology is that it provides managers with oversight and assurance around what is working and what strengths exist in the current business systems.
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