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Thinking Tools - For Root Cause Analysis

Kelsey van Haaster
Kelsey van Haaster
Kelsey van HaasterThoughtWorker | Change Whisperer | Driving organisational change through research and analysis

A workshop delivered at LAST 2015.

Thinking Tools - For Root Cause Analysis

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T h e o r y o f C o n s t r a i n t s
T h i n k i n g To o l s
ROOT CAUSE ANALYSIS
WORKSHOP
Presented by
Kelsey van Haaster and Tavis Ashton-Bell
kelseyvh@Thoughtworks.com
tavisab@gmail.com
OVERVIEW
Very Brief intro to the Theory of Constraints ( 5 minutes)
A worked example of a Current Reality and a Future Reality Tree (15 minutes)
Introducing the ToC thinking tools (5 minutes)
Step by step practice on a problem of your choosing - (Team activity) (20
minutes)
Sharing back to the group (10 minutes)
2
A VERY BRIEF INTO TO THE THEORY OF CONSTRAINTS
Developed by Dr Eliyahu Goldratt, Physicist and Management
Specialist
Author of The Goal, Beyond the Goal and It’s not luck
A philosophy which seeks to understand a system through the
identification of cause and effect
Applicable in any domain
ToC thinking tools are based on this philosophy and:
Are both systemic and systematic in approach
Produce robust, logically sound analysis and solutions
What to change
What to change to
How to change
3
BENEFITS
Using a picture takes the focus off expertise level and promotes
teamwork and common understanding.
A CRT provides a visual thought process that can easily be
scrutinised for validity and edited for increased buy-in of the
problem & priority.
Can uncover unrecognised needs.
Gets you started on the one thing that has the most impact on the
system as a whole
4
A WORKED EXAMPLE
OF A KNOWN
PROBLEM AND
SOLUTION
5
NOTATION (SIMPLIFIED SUBSET)
6
UDE
Undesirable effect
Precondition
Current Reality Tree
Precondition
Future Reality Tree
DE
Desirable effect
IE
Intermediate effect
Action
Action
Goal
Goal
Edge
AND operator
Both
Solution
Solution
Ad

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Thinking Tools - For Root Cause Analysis

  • 1. T h e o r y o f C o n s t r a i n t s T h i n k i n g To o l s ROOT CAUSE ANALYSIS WORKSHOP Presented by Kelsey van Haaster and Tavis Ashton-Bell kelseyvh@Thoughtworks.com tavisab@gmail.com
  • 2. OVERVIEW Very Brief intro to the Theory of Constraints ( 5 minutes) A worked example of a Current Reality and a Future Reality Tree (15 minutes) Introducing the ToC thinking tools (5 minutes) Step by step practice on a problem of your choosing - (Team activity) (20 minutes) Sharing back to the group (10 minutes) 2
  • 3. A VERY BRIEF INTO TO THE THEORY OF CONSTRAINTS Developed by Dr Eliyahu Goldratt, Physicist and Management Specialist Author of The Goal, Beyond the Goal and It’s not luck A philosophy which seeks to understand a system through the identification of cause and effect Applicable in any domain ToC thinking tools are based on this philosophy and: Are both systemic and systematic in approach Produce robust, logically sound analysis and solutions What to change What to change to How to change 3
  • 4. BENEFITS Using a picture takes the focus off expertise level and promotes teamwork and common understanding. A CRT provides a visual thought process that can easily be scrutinised for validity and edited for increased buy-in of the problem & priority. Can uncover unrecognised needs. Gets you started on the one thing that has the most impact on the system as a whole 4
  • 5. A WORKED EXAMPLE OF A KNOWN PROBLEM AND SOLUTION 5
  • 6. NOTATION (SIMPLIFIED SUBSET) 6 UDE Undesirable effect Precondition Current Reality Tree Precondition Future Reality Tree DE Desirable effect IE Intermediate effect Action Action Goal Goal Edge AND operator Both Solution Solution
  • 7. THE PROBLEM WITH SOFTWARE PROJECTS 7 Relevant undesirable effects and a precondition The Problem to solve
  • 8. A WORKED EXAMPLE - BUILDING THE TREE (1) 8 Which of our UDE (s) explain the problem ? Clarity Reservation Is the cause and effect relationship clear? Entity Existence Reservation Do the cause and effect entities really exist? Causality Existence Reservation Is the causal link valid? Predicated Effect Existence Reservation there is no other effect which negates this one being cause Insufficient Cause Reservation An additional non trivial cause must exist to explain the observed effect Additional Cause Reservation - Neither cause can account for the effect alone Tautology - A cause and effect relationship is redundant Add the contributing UDE’s and apply the categories of legitimate reservation
  • 9. WORKED EXAMPLE - BUILDING THE TREE (2) 9 Add the contributing UDE’s and apply the categories of legitimate reservation
  • 10. BUILDING THE TREE (3) ADDITIONAL CAUSES 10
  • 11. BUILDING THE TREE LOOKING FOR SINGLE CAUSES (4) 11
  • 13. FINDING THE SOLUTION The generation of or more solutions are accomplished using the concept of the Cloud. The underlying assumption behind the concept of the Cloud is that there are no conflicts in nature – only erroneous assumptions. The cloud provides a structured approach to identifying and then testing underlying assumptions. A quick example: Asking for a pay rise 13
  • 15. ADDING IN SOME UNDERLYING ASSUMPTIONS 15
  • 16. INJECTING A POSSIBLE SOLUTION 16
  • 17. BACK TO OUR PROBLEM There are many potential solutions, however lets use a widely understood one to demonstrate the Future Reality Tree as a way of testing and presenting the idea First the solution: We are uncovering better ways of developing software by doing it and helping others do it. Through this work we have come to value: Individuals and interactions over processes and tools Working software over comprehensive documentation Customer collaboration over contract negotiation Responding to change over following a plan That is, while there is value in the items on the right, we value the items on the left more. 17
  • 18. BUILDING A FUTURE REALITY TREE At its simplest level an FRT is a CRT with all the Undesirable Effects transformed into Desirable Effects and the problem statement turned into a goal. We Build an FRT by injecting our solutions into our Current Reality Tree and evaluating whether the solution transforms Undesirable Effects into Desirable ones. This usually requires some refinement and rewording as you go Let’s try this with our example problem 18
  • 19. SOLUTIONS TO BE INJECTED INTO OUR CRT 19
  • 20. BUILDING THE FRT (1) 20 The Current Reality The Future Reality
  • 21. BUILDING THE FRT (2) 21 The Current Reality The Future Reality
  • 22. BUILDING THE FRT (3) 22 The Current Reality The Future Reality
  • 23. BUILDING THE FRT (4) 23 The Current Reality The Future Reality
  • 24. THE COMPLETED TREE 24 We are uncovering better ways of developing software by doing it and helping others do it. Through this work we have come to value: Individuals and interactions over processes and tools Working software over comprehensive documentation Customer collaboration over contract negotiation Responding to change over following a plan
  • 25. THE TOOLSET 25 Tool When to use Current Reality Tree To understand the root cause(s) of the problem When there is disagreement about the nature of the problem When there is disagreement about the extent of the problem Evaporating Cloud (injection) To resolve conflict To gain agreement about the nature of a solution Future Reality Tree To identify a solution To ensure the solution addresses the whole problem To test the logic behind a solution Pre-requisite Tree To identify the pre- conditions for implementing a solution Transition Tree To identify the steps required to implement a solution
  • 26. PROOF READING TOOLS FOR YOUR TREES Clarity Reservation Is the cause and effect relationship clear? Entity Existence Reservation Do the cause and effect entities really exist Causality Existence Reservation Is the causal link valid Predicated Effect Existence Reservation Showing that the cause does not result in the initial effect by using another effect Insufficient Cause Reservation An additional non trivial cause must exist to explain the observed effect Additional Cause Reservation Neither cause can account for the effect alone Tautology A cause and effect relationship is redundant 26 Categories of Legitimate Reservation Intended to raise valid concerns about cause and effect rigour, without raising resistance of defensiveness with others
  • 27. NOW IT’S YOUR TURN Work in groups of 2 - 4 and create a Current Reality Tree for a problem of your choosing. You can use sticky notes on a whiteboard, or any software that lets you draw boxes and line. e.g. Powerpoint, Keynote, Word, even paint Use the cheat sheet to follow the steps and we will be on hand to help. At about 10 minutes before the end of the session, we will ask people to share the problem they looked at and any new insights gleaned from the process. 27
  • 28. REFERENCES AND RESOURCES Books: ToC in General The Theory of Constraints - E. Goldratt The Goal: A process of Ongoing Improvement Critical Chain Books - ToC Thinking Tools Isn’t it Obvious It’s Not Luck Necessary But Not Sufficient Thinking for a Change Web Resources Thinking for a Change handout - (pdf) ToC Thinking tools - Wikipedia link A very comprehensive guide to implementation from Kelvyn Youngman 28