Understanding Root Cause Analysis


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Understanding Root Cause Analysis

  1. 1. Understanding Root CauseAnalysisPresented by:Lean Advisors, Inc877-778-6413www.leanadvisors.comcorp@leanadvisors.comwww.leanadvisors.com
  2. 2. Key to Problem SolvingGo see inGembaInvolve theprocessownersFocus onroot causeImplement simplesolutions firstUnderstandCustomerCopyright ©2012 Lean Advisors Inc.
  3. 3. Lean is a simplestrategy that focuseson the elimination ofwaste, variation, andwork imbalance.Each step mustcreate Value for theCustomer.What is Lean?Copyright © 2013 Lean Advisors Inc.
  4. 4. Who are the Customers?• From a Lean perspective we consider theCustomer as the end user of the Product orService we provide.• Internal Customers are important in somecases, however we must always ensure we aremeeting the end-users needs.Copyright ©2012 Lean Advisors Inc.
  5. 5. Lean ResultsCopyright ©2012 Lean Advisors Inc.• Lead Time• Cost• Resources Required• Space• Inventory• Errors• Customer Responsiveness• Capacity• Employee Satisfaction• Flexibility
  6. 6. Waste DefinitionWaste: Any activity that consumes time, space orresources but does not add value to theproduct, service or other deliverable as viewed from theperspective of the external Customer.Copyright ©2012 Lean Advisors Inc.
  7. 7. Types of Waste ( U- WIT – D – MOP ) Unused Creativity / Talent / Injuries WAITING (patients / providers / material) INVENTORY / Incomplete / Piles TRANSPORTATION / Transactions / Transfer DEFECTS / Wrong info. / Rework /Inaccurate info. MOTION / Finding Information / Double entry OVERPRODUCTION / Duplication / Extrainfo. PROCESS / Extra Steps / checks /workarounds
  8. 8. 1. Definingvalue fromcustomer’sperspective2. Mappingthe ValueStream3. CreatingFlow4. Workingto the Pullof theCustomer5. SeekingPerfectionHow to Eliminate Waste?Copyright ©2013 Lean Advisors Inc.Apply The5Principlesof Lean
  9. 9. Enterprise Value Stream MapUnderstanding of the end-to-end process capturing both Value addand Non-Value add activities as well as formal and informalCopyright ©2012 Lean Advisors Inc.Identify Product/Service FamiliesFuture StateMapCurrent StateMapDevelopImplementationPlanCurrent StateUnderstanding the CurrentStateFuture StateDesigning a Future StateImplementationPlanDevelop a plan to achieve thefuture state
  10. 10. Problem RecognitionFacing reality is the first stepThe 1ststep:seeing theproblemDo youbelieve it’sa problem?“Somedefects aregoing tohappen”“We need totest”, “weneed toinspect”“This is atrickyprocess”“Cosmeticdefects willalwayshappen”“It’s out ofspec but itpassed thetest”“The qualitymanagerneeds todecide...”
  11. 11. Anything that "goes wrong" is a problemProblems occur in all parts of allbusinessesDefects (in-house or in the field)Equipment breakdownsInjuriesLosing a sale, losing a customerLosing an important employeePS & CA can apply to any problemProblem RecognitionProblems are really opportunities to makesomething better
  12. 12. Its probably a "problem" if…It feels frustrating and annoyingIt negatively affects performanceIt happens more than onceThe process yields a less than desiredoutcomeOutputs vary for unknown reasonsProblem Recognition“Learning to See” is part of boththe lean and PS &CA processes
  13. 13. Copyright ©2012 Lean Advisors Inc.The 4 steps of the problem solving process
  14. 14. Describe theProblemDevelop afocused, specificstatement thatdescribes andquantifies theunsatisfactorysituation.Keep thestatementsimpleBe sure thestatement hasimpactCan everyoneclearlyunderstand theunacceptablecondition?Describe the ProblemCopyright ©2012 Lean Advisors Inc.
  15. 15. Describe the ProblemCopyright ©2012 Lean Advisors Inc.Threecommonerrors indescribingproblemsStating the solution in theproblem statementNot: We need to increase ourIVR penetrationRather: Our customer servicelevels are consistently belowour service level agreementtarget of 90% with anabandonment rate of over 40%Too large a problem(not adequately scoped)• Not: Underwriting has a 50%reject rate• Rather: Only 40% of all newtransactions are underwrittenautomatically through thescorecard, down from 80%this time last yearVague problemstatementsNot: Customers complain aboutwait time for customer serviceRather: One of ten customersexperience hold times of > 5minutes when calling customerservice
  16. 16. Metrics• Provide an objective measure of the “health” of aprocess and provide feedback for problem solving Personal health measures: weight, blood pressure, cholesterol levels Business measures: profitability, quality, timeliness of service or product delivery• Metrics tell us if we are solving the “right” problem. Without the correct metrics we may be “solving” a symptom and not impacting theroot cause issue• Tells us if we are getting the desired results from thesolutions we implement• Help us to maintain our gains and make furtherimprovements
  17. 17. Example: Fishbone DiagramCopyright ©2012 Lean Advisors Inc.Methods Materials Men and WomenMeasurementMachineMother NatureProceduresnot followedInadequatedocumentationabout similarproblemsUnattendedcalls at nightWorld-wideCustomersConstantinterruptionsInadequatedocumentationWrong inform-action providedCustomer questionsversus complaintsWrong informationprovidedLack of engineersupport to define fixesLack oftrainingInexperienceShort of personnelHighturnoverWeekend days countedin total daysSystem downtimeSystem takes 24 hrs torefreshAll complaints carrysame weightWhy arecustomercomplaintsnot beingresolvedwithin 24 hrs?Source: Transactional Six Sigma and Lean Servicing
  18. 18. 5 Whys• When you need toimplement correctiveaction of a problemand want to be sureyour actions willaddress the rootcause and not just thesymptoms of theproblem• Question “why” a givensituation exists orcondition has occurred• Document the response• Evaluate the responseasking “why” did thishappen or “why” is thistrue• Document the response• Repeat the process untilroot cause of originalproblem is determined• Method of breakingdown a problem to theroot cause• Used for problemanalysis and problemidentification5 Whys is a method to arrive at the root cause of a problemRoot cause to the problemCopyright ©2012 Lean Advisors Inc.
  19. 19. Copyright ©2006 Lean Advisors Inc.Asking of the question Why fivetimes will uncover the Root Cause of a problem.Q1. Why did the machine fail?Answer: The motor burned out.Q2. Why did the motor burn out?Answer: The shaft seized.Q3. Why did the shaft seize?Answer: There was no lubrication.Q4. Why was there no lubrication?Answer: The filter was clogged.Q5. Why was the filter clogged?Answer: It was the wrong size mesh!RootCause32Ohno’s 5 Why’s
  20. 20. 5 Why Considerations• The “why” asked at each stage needs to be thoughtfuland relevant and capture the “moment of cause” see the actual place, parts, process and people• After each “why” is asked there must bean exhaustive analysis to arrive at the answer.• The answer to the discrete “why” should lead to alogical conclusion or cause.• These same techniques apply to a state of “non-detection” where we ask “why” the problem did notget caught.Copyright ©2012 Lean Advisors Inc.
  21. 21. When Is 5 Whys Most Useful?•When problems involve human factors orinteractions.•In day-to-day business life; can be used within orwithout a Six Sigma projectCopyright ©2012 Lean Advisors Inc.
  22. 22. • Why did the problem not get caught?• Ask “why?” 5 times• Find the “moment of cause”• see the actual place• see the actual parts• see the actual process• see the actual people• Don’t skip this step, it teaches you toomuch!5 Whys-Root Cause of Non-DetectionCopyright ©2012 Lean Advisors Inc.
  23. 23. What to Avoid“Knowing the answer” coming into the exerciseRushing through the 5 Why’s Not doing sufficient analysis at each stageof the exercise Not investing adequate time in developingthoughtful questionsCopyright ©2012 Lean Advisors Inc.
  24. 24. Copyright ©2006 Lean Advisors Inc.Gemba Walks are an important Lean tool that should be used routinely: To help you become aware of any existing abnormalities, Immediately deal with hazardous and unsafe conditions, Verify established standardized processes, Solve problems or correct errors and Create a more efficient and effective working environment andworkforce.GEMBA WALK “Go, See, and Observe”
  25. 25. Copyright ©2006 Lean Advisors Inc.Questionsto ask ona GembaWalkIs there a Visual Management System in place? Are the problems visible?Is the working environment safe and Lean? Is the 5S system in place being sustained?Are the required information, measures, and metrics displayed and updated?Are there any Standardized Work Sheets (SWS) posted?Could you easily identify the state of progress?Is the work ahead or behind schedule?Is there an efficient level of Work-In-Process (WIP) and Finished-Goods (FG) materialsavailable?How are the products and processes developed?What fulfillment systems are in place from order to delivery?Is the machinery and equipment running and in good condition?Do you see any leakage or damage?Do you hear any abnormal noise?GEMBA WALK + 5 Whys (Root Cause)
  26. 26. Propose and Implement CountermeasuresHow to Solve the ProblemCreative CountermeasuresWhen implementing the solution, consider thefollowing:• What are the consequences/contingencies?• Who else will be affected (suppliers/customers)?• What is the implementation plan?• Who needs to do what? Include time frameCopyright ©2012 Lean Advisors Inc.
  27. 27. Determine Tasks to be AccomplishedRoles and Responsibility MatrixNew Documents, ChecklistsTraining PlanNew ReportsMetrics for New ProcessComplete Standard Work SheetsOther Deliverables from TeamCharterCopyright ©2012 Lean Advisors Inc.
  28. 28. Key to Problem SolvingGo see inGembaInvolve theprocessownersFocus onroot causeImplement simplesolutions firstUnderstandCustomerCopyright ©2012 Lean Advisors Inc.
  29. 29. Copyright ©2013 Lean Advisors Inc.Special OfferContact Us:877-778-6413corp@leanadvisors.comwww.leanadvisors.com