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ca 10 minutes on
root cause analysis
Solving the real problem
Marcus Hammarberg
Yayasan Pelalayan
Kesehatan Bala
Problems
By Photo credited to the firm Levy & fils by this site. (It is credited to a photographer "Kuhn" by another publisher [1].) (the source was
not disclosed by its uploader.) [Public domain], via Wikimedia Commons
California Palace of the Legion of Honor, Lincoln Park/34th Avenue, San Francisco, California
The Thinker (Le Penseur) by Auguste Rodin
6
Finance data lost
to virus
Finance data lost to
virus
So what?
Why?
Finance data lost to
virus
Lost financial history
Can’t do proper tax
reporting
Illegal
Finance data lost to
virus
Lost
financial
history
Can’t do
proper tax
reporting
Illegal
Spend a lot time
recover data
Waste time Waste money
Doing the wrong
thing
“Real job” losing
quality
Finance data lost to
virus
Lost
financial
history
Can’t do
proper tax
reporting
Illegal
Spend a lot time
recover data
Waste time
Waste money
Doing the wrong thing
“Real job” losing
quality
Can’t do “real”
investments
Finance data lost to
virus
Lost financial history
Can’t do proper tax
reporting
Illegal
Spend a lot time
recover data
Waste time Waste money
Doing the wrong
thing
“Real job” losing
quality
Can’t do “real”
investments
Finance data lost to
virus
Hate the sin
Love the sinner
Blame the process
not the people
Finance data lost to
virus
No virus protection
No backup done for
computer
We don’t understand
the risk / consequence
Finance data lost to
virus
No virus protection
No backup done for
computer
We don’t understand
the risk / consequence
Thought IT department
would do this
IT-department doing
many other things
Fail to prioritise Don’t know our real
work
Finance data lost to
virus
No virus protection
No backup done for
computer
We don’t understand
the risk / consequence
Thought IT department
would do this
IT-department doing
many other things
Fail to prioritise Don’t know our real
work
Lack basic computer
knowledge
Not sufficient trained
Finance data lost to
virus
No virus protection
No backup done for
computer
We don’t understand
the risk / consequence
Thought IT department
would do this
IT-department doing
many other things
Fail to prioritise Don’t know our real
work
Lack basic computer
knowledge
Not sufficient trained
No virus protection
No backup done for
computer
We don’t
understand the risk
/ consequence
Thought IT
department would
do this
IT-department
doing many other
things
Fail to
prioritise
Don’t know our real
work
Lack basic
computer
knowledge
Not sufficient
trained
So what?
Why?
Finance data lost
to virus
Lost financial
history
Can’t do
proper tax
reporting
Illegal
Spend a lot
time recover
data
Waste time
Waste
money
Doing the
wrong thing
“Real job”
losing quality
Can’t do
“real”
investments
Visual
Collaborative
System focused
20
Visual
21
Collaborative
Mexican Standoff by Martin SoulStealer
used under CC2.0
22
System focused
Respect for
individuals
23
System focused
Regardless of what we discover, we understand and tru
No virus protection
No backup done for
computer
We don’t
understand the risk
/ consequence
Thought IT
department would
do this
IT-department
doing many other
things
Fail to
prioritise
Don’t know our real
work
Lack basic
computer
knowledge
Not sufficient
trained
Finance data lost
to virus
Lost financial
history
Can’t do
proper tax
reporting
Illegal
Spend a lot
time recover
data
Waste time
Waste
money
Doing the
wrong thing
“Real job”
losing quality
Can’t do
“real”
investments
38
ca 10 minutes on
root cause
analysis

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10 minutes on root cause analysis

  • 1. ca 10 minutes on root cause analysis Solving the real problem Marcus Hammarberg Yayasan Pelalayan Kesehatan Bala
  • 2. Problems By Photo credited to the firm Levy & fils by this site. (It is credited to a photographer "Kuhn" by another publisher [1].) (the source was not disclosed by its uploader.) [Public domain], via Wikimedia Commons
  • 3.
  • 4. California Palace of the Legion of Honor, Lincoln Park/34th Avenue, San Francisco, California The Thinker (Le Penseur) by Auguste Rodin
  • 5.
  • 6. 6
  • 8. Finance data lost to virus So what? Why?
  • 9. Finance data lost to virus Lost financial history Can’t do proper tax reporting Illegal
  • 10. Finance data lost to virus Lost financial history Can’t do proper tax reporting Illegal Spend a lot time recover data Waste time Waste money Doing the wrong thing “Real job” losing quality
  • 11. Finance data lost to virus Lost financial history Can’t do proper tax reporting Illegal Spend a lot time recover data Waste time Waste money Doing the wrong thing “Real job” losing quality Can’t do “real” investments
  • 12. Finance data lost to virus Lost financial history Can’t do proper tax reporting Illegal Spend a lot time recover data Waste time Waste money Doing the wrong thing “Real job” losing quality Can’t do “real” investments
  • 13. Finance data lost to virus Hate the sin Love the sinner Blame the process not the people
  • 14. Finance data lost to virus No virus protection No backup done for computer We don’t understand the risk / consequence
  • 15. Finance data lost to virus No virus protection No backup done for computer We don’t understand the risk / consequence Thought IT department would do this IT-department doing many other things Fail to prioritise Don’t know our real work
  • 16. Finance data lost to virus No virus protection No backup done for computer We don’t understand the risk / consequence Thought IT department would do this IT-department doing many other things Fail to prioritise Don’t know our real work Lack basic computer knowledge Not sufficient trained
  • 17. Finance data lost to virus No virus protection No backup done for computer We don’t understand the risk / consequence Thought IT department would do this IT-department doing many other things Fail to prioritise Don’t know our real work Lack basic computer knowledge Not sufficient trained
  • 18. No virus protection No backup done for computer We don’t understand the risk / consequence Thought IT department would do this IT-department doing many other things Fail to prioritise Don’t know our real work Lack basic computer knowledge Not sufficient trained So what? Why? Finance data lost to virus Lost financial history Can’t do proper tax reporting Illegal Spend a lot time recover data Waste time Waste money Doing the wrong thing “Real job” losing quality Can’t do “real” investments
  • 21. 21 Collaborative Mexican Standoff by Martin SoulStealer used under CC2.0
  • 23. 23 System focused Regardless of what we discover, we understand and tru
  • 24. No virus protection No backup done for computer We don’t understand the risk / consequence Thought IT department would do this IT-department doing many other things Fail to prioritise Don’t know our real work Lack basic computer knowledge Not sufficient trained Finance data lost to virus Lost financial history Can’t do proper tax reporting Illegal Spend a lot time recover data Waste time Waste money Doing the wrong thing “Real job” losing quality Can’t do “real” investments
  • 25. 38 ca 10 minutes on root cause analysis

Editor's Notes

  1. Problems Or what has happened when your hear: Ooooops. They appear daily in our work, in our processes and in our work places.
  2. Every process, every company have problems. We can’t escape them. BUT - It’s what we do when we encounter them that decides if we will improve or not. Do nothing to your problem, or solve the wrong problem, and you will be stuck at the same place. Solve the actual problem, by solving the root cause, the real reason of the problem and you can improve faster than others.
  3. In order to properly solve a problem you first need to properly understand the problem at hand. Far to often we are solving what we THINK is the problem, only to face the same problem again shortly thereafter.
  4. Root cause analysis is a great tool to not only find the real reason behind the problem but also, very importantly, make sure that we understand why this problem is important to solve in the first place.
  5. My name is Marcus Hammarberg and I work for the Salvation Armys Health Foundation in Indonesia. We have 6 hospitals and 16 clinics spread out through Indonesia. During the last couple years of we have been talking a lot about mission, vision and strategic plans. I have create a couple of presentations with tools that can help you in your daily work trying to fulfilling the vision and strategies of your company. Root cause analysis, the theme of this presentation, is one of those tools. It easy to learn. In fact - let’s jump right in.
  6. Here’s a problem that sometimes happen. All of the sudden someone get virus on their computer and the data is gone. Wiped out. Sadly this was the computer with some important financial data. So this is easy right: tell the owner of the computer to get their act together and find someone that can help us recover the data. But…will that really solve the problem. Let’s dig a little deeper. Let find the root cause
  7. First we scribble the problem at hand down on a post it note and put it in the middle of a white board or a flip chart. When you do a root cause analysis, we approach the problem in two aspects: first, going upwards we ask “So what?” to really understand why this problem is important to solve. Secondly, working downwards, we ask “Why?” to understand how the problem have occurred. Let’s focus on the “So what”-part first. We zoom in on that part of the board
  8. “Finance data lost to virus” - So what? Why is this a problem? Well the first that popped into our heads was that we loose the financial data history. So what? Well, that means that we can’t do proper reporting, for taxes for example. So what? Really - that is illegal. So what? At one point you’ll reach a point where it feels very stupid to ask the next question. Everyone knows why this is bad. So we stop. “It’s illegal”. Let’s circle that
  9. Let’s go back to the outset: So we lost some financial data? So what? Well… we will spend a lot of time trying to recover the data. Maybe even recreate. Ok, who cares? Well that means that we waste time. And money. So what? Why is that bad? Well, we are doing the wrong thing. Just fixing something that we broke rather than working on our real job. So what? That’s wasteful, and it means that our “real job” loses focus and quality. Let’s circle that.
  10. For wasting money: that is bad since it means that we cannot use the money we spent on fixing, recovering our files, on the thing we want to spend it on. Which, again, means that our real job loses quality.
  11. Let’s zoom out and take a look on all of the things we created. We have learned a lot more about this problem. The REAL reason we need to fix this is because it’s actually Illegal not to. And if we don’t fix it our “Real job loses quality”. Of course there’s much more to dive into here, but let’s stop here in our example. Now we move to the lower part and see if we can understand WHY this has happened.
  12. Why did this happen? When asking these question I’ve found that finding someone to blame is NOT fruitful to understand the real problem. In Toyota they often say: Blame the process - not the people. Or in the words of William Booth, founder of the Salvation Army: Hate the sin. Love the sinner. In other words: Let’s keep people outside and instead ask our questions from a system perspective. Without blaming anyone. Blame people to handle a single person Blame system to handle systems problem
  13. Ok, so why did this happen? Well there was not virus protection on the computer. And also, no Backup has ever been done on the computer. That sounds bad. Why? Well, no one thought that it would happen. We thought we could be safe. And also, now after doing the “So what”-part, we realise that we didn’t get the consequences of loosing data too.
  14. Why didn’t we get the consequences? Well… as an accountant I thought that IT would handle this? I have no clue how to manage my computer. The IT department didn’t do that because they are swamped with other actives. But fixing this computer was of course very important. Yeah, but how can they know? Ah, it sounds like “Fail to prioritise” is a problem here. May also be that there’s too many things to do, and that they are doing the wrong things
  15. Let’s back up a bit and see Why we don’t understand the risks and consequences? Well, I’m an accountant. I don’t know much about computers. I don’t know that USB-sticks can have viruses for example. We lack basic computer knowledge. Why? How can we have people working with computers everyday that don’t have sufficient computer skills? Ehrm… because we have not trained them? So Why didn’t we train them? Because we, the company, didn’t realise the risk and consequences of having untrained staff.
  16. Can you see how those lines form a loop. This means that if we don’t break this loop, the problem with just get worse and worse. And the root cause is …. well that’s a bit hard to see in a loop. But we are not sufficiently trained. That’s a base cause. The probably the root cause of the problem Let’s zoom all the way out and see the entire map we have created and use that as a summary.
  17. Now we get a better picture of the problem at hand. See how we first of all understand why we need to fix this problem. By asking So What? Secondly we went to the root of the problem by following the problem down to the root causes, by asking WHY
  18. Why does this work? What are the things that are important to make Root Cause Analysis work for you. To me that is summed up in three words: Visual Collaborative System focused Let me explain what I mean.
  19. By making a big, visual, touchable map over the problem, like we have just done, a connection is made between the people create this map and the problem. This feel “real”, since it is real. You can touch it. Also we have “created” this by writing the post its and moving them into place. Erasing the arrows and changing the name. I have many times seen how this makes the exercise feel more real than if we had done it as a discussion.
  20. Another important aspect is making this exercise collaboratively. That means, for best effect, you need the people that have the best knowledge of the problem at hand in the room. This is sometime referred to as having the “Three amigos” in the room. The people you need to solve the problem. You can do this by yourself but it will be incomplete and also that means that you, yourself, own the problem. Also but doing it together we create a stronger feeling of this being OUR problem that WE have solved TOGETHER. Rather than THEIR problem that THEY create a solution for that THEY are forcing on us.
  21. Finally Root Cause Analysis works best if it’s focus on solving the problems in the system rather than to blame the people in it. Companies doing Lean are great at this and it’s been built in as a foundation for how Toyota work since the 1950, with their principle “Respect for individuals” This is very understandable since these type of companies are ALWAYS looking for better ways. They do that by continuously and relentlessly attacking problems and do their best to make them go away. In fact: root cause analysis and the 5 why’s was pioneered in Toyota. We are just borrowing it from them
  22. When you facilitate a root cause analysis exercise you therefor need to make sure that people feel safe. Make sure they understand that the goal is to fix the systemic errors and not find people to blame. Remind everyone about this before you start. One way could be to say or display something like this: Regardless of what we discover, we understand and truly believe that everyone did the best job they could, given what they knew at the time, their skills and abilities, the resources available, and the situation at hand.
  23. The example that we created before is a bit tidy, so let’s take a look, as a summary, at another example. This time it’s a real exercise that we did a couple of weeks back when talking about our clinics. I’ll go faster this time, since you know the basics. And pardon the handwriting - it’s me.
  24. The problem we where facing here is in the middle. A store close to the clinic has started to sell medicine. And they have lower prices than the clinic. So people goes there instead. SO WHAT? Why is this a problem?
  25. First of all the clinic looses money Which means that we run with deficit. Which, in the long run means that we have to close the clinic. Our owners can not pay for clinics (or other businesses for that matter) that runs with deficit for a long time
  26. If the clinic looses money it means that we cannot hold the stock of medicine. That medicine is needed to be able to treat the diseases our patients might have. We need a basic level so of medicine in store. We stopped there for awhile and went on to the next So What part.
  27. We came up with the problem that patients use the cheaper drugs, that might not be the right one for them. So what? Well that’s, in best case, no helping their problem. In worst case it might be dangerous for the patient That means that the patient gets sicker and might even die.
  28. At this point someone said that not having the right medicine might actually make the patient sicker too. So we added a connection for that.
  29. If patients get sicker by coming to us and, in the good case, just don’t get well, then we loose our reputation. This is really bad since that leads to fewer Patients. Which of course means that we will have to close the clinic. We forgot that line. It goes here.
  30. We then circled the base reasons we need to solve this problem. And they are pretty basic. If we don’t do something about this we are risking the health of our patients foremost, but also stand the risk of closing the clinic
  31. Let’s find the root cause of this problem. A new store has opened with lower prices. WHY? Because the store owner saw a business opportunity. WHY did he see a business opportunity. Well he heard about the complaints about our prices, most likely. And thought that he could do it cheaper.
  32. Why? Well our prices are higher, but WHY? Because he are using drugs of lower quality, or at least generic brands. Which, without knowing, probably is part of the business opportunity he saw Most likely the business owner is also ignorant about the risks with drugs of lower quality. In this case, we know that he lack medical training. Which is of course very dangerous for the patients as we saw before.
  33. We then went back to the top and asked ourselves why our prices are higher. We talked about that already but this time we focused a little bit more on US. WHY are our prices higher? Well it turns out that the biggest cost for this remote clinic is around transportation? Why? Because the staff cannot do the transportation. They are too few
  34. So we need to hire someone else Also with expensive transports we have a small stock. We cannot afford to keep a big stock since the medicine goes bad But WHY do we have too few staff and cannot afford to keep our stock? Well our business is to small. To put it frankly: we have to few patients. Here we stopped. This is probably a reinforcing loop here but we realised that we need to increase the number of patients served or we stand the risk of being outmanoeuvred by some one selling lower quality drugs and offer no medical expertise. This is dangerous.
  35. Again, going through the steps of root cause analysis gave us a better understanding about why this problem is important. But also the underlying reasons
  36. Let’s summarise: Root cause analysis is a problem solving technique. It approaches the problem in two aspects: by going upwards, asking So What-question, to understand why this problem is important to solve. By going downwards, asking Why-questions, to learn about the root cause of the problem. Root cause analysis works best when it’s done visually, collaborative and focus on fixing the problems in the system rather than to blame people.
  37. My name is Marcus Hammarberg. This has been ca 10 minutes on root cause analysis. Thank you for listening. Tuhan Memberkati Anda - God Bless you.