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A-Root-Cause-Analysis-TOOLS.pptx
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- 2. screening for businesshealth Root-Cause-Analysis Tools: Brainstorming “Brainstorming" is a frequently used tool - but it is just as often used incorrectly or ineffectively. To get useful results from a brainstorming session, you should follow a structured and moderated process. Brainstorming in Root Cause Analysis is applicable when facing Problem types of simple complexity. Phase 2: Sort and evaluate After a break, all ideas are now read out by the moderator and discussed, evaluated and sorted by the participants. At first, this is only about thematic connections and sorting out ideas that are not relevant to the problem Phase 1: Find Ideas The first step is to search for ideas in a moderated group session. All participants are asked to name topics spontaneously if possible. These are noted on individual pieces of paper or cards. All thoughts are allowed. It is forbidden to criticize, reject or evaluate ideas.
- 3. screening for businesshealth Root-Cause-Analysis Tools: Brainstorming (cont.) To run an effective Brainstorming session, you should stick to 7 basic principles: 02 03 04 05 05 07 01 Maximum 60 Minutes No brainstorming should last more than 60 minutes. A topic should be discussed for a maximum of 25 minutes - after that you should take a break. If necessary, take another 25 minutes afterwards. Save the details Save the details for the end of the brainstorming session. Avoid discussing the benefits of an idea in too much detail in the beginning. This can rob the idea of its energy right from the start and prevent further suggestions Focus Define the task or problem precisely with a targeted statement and make sure that the participants do not deviate from the topic. The first step in solving a problem is always to clearly define the starting position. Boss at the end The safest way to make a brainstorming fail is to let the boss talk first. Employees do not want to contradict. Numbers and Names Number and name the ideas so that they can be referred to again and again in the subsequent discussion without losing the overview. Physically active Use other tools that stimulate other parts of the brain: modelling clay, building blocks, play figures, tape, glue or scissors. Build your ideas. Spread (physically) Spread as many flipcharts or tables around the room as possible so that participants can write down ideas (without having to stand in front of the whole group). 02 06
- 4. screening for businesshealth Root-Cause-Analysis Tools: 5 Whys The 5 Why’s Analysis is a simple tool for drilling down on the problem statement until the root cause is identified asking “WHY” 5 times. It is applicable when you are looking at one major cause and if it needs drill down to arrive at one root cause Avoid intentional or unintentional bias while answering Find the right person who can answer Use other Tools complementary Problem 1. Why 2. Why 3. Why 4. Why 5. Why Because our response time for service inquires is to long The number of customer problems was clearly underestimated There was no systematic end-user testing before the product was launched Customers rate service Quality low Because we don’t have enough people working in Service The product still has numerous teething troubles and was not yet ready for the market Root Cause
- 5. screening for businesshealth Root-Cause-Analysis Tools: 5 Whys (Example II) The 5 Why’s Analysis is a simple tool for drilling down on the problem statement until the root cause is identified asking “WHY” 5 times. It is applicable when you are looking at one major cause and if it needs drill down to arrive at one root cause Avoid intentional or unintentional bias while answering Find the right person who can answer Use other Tools complementary Problem 1. Why 2. Why 3. Why 4. Why 5. Why There is often damage in transit Packaging specifications are incomplete No holistic Quality Strategy Failures in Products are 2 times the industry average Packaging is insufficient There are no technical specifications for packaging in the company Root Cause
- 6. screening for businesshealth Root-Cause-Analysis Tools: 5 Whys (cont.) The Process of the 5 Whys is often subdivided in 4 main steps: Until and unless you define the problem properly, solving it is going to be an uphill task. Spend some time ensuring that you’ve defined the problem well. The detailed your definition of the problem is, the easier will be for you to solve it. Check one layer at a time and keep shooting a “Why” as soon as you come across a problem at every level. Fixing the problem alone is not going to give you the real value. Pay attention to fixing the error and the cause so you a prevent any future occurrences of the problem. Determine if a Cause is the Actual Root Cause. Every time you come across a cause, stop there and take some time to analyze if that is the root cause or not. You may have to repeat Step 2 & 3 a couple of times before coming to a conclusion about the actual root cause. 1 2 3 4 Agree on Problem Execute the Whys Check the Cause Fix it
- 7. screening for businesshealth Root-Cause-Analysis Tools: Affinity Diagram The Affinity Diagram is a simple tool for putting together a large number of details and inter-related causes and group them according to broad topics. This helps in focussing on the bigger picture and major root causes. It is applicable when looking at several, inter-related and detailed causes which have some things in common and can be grouped together to see the major causes 1. Define the Problem Why is our customer service sub-standard? 2. Brainstorm Root Causes Not enough phone lines Not enough Staff Untrained Staff Growth was to fast Staff aren’t compensated Not enough Top-Level Support No Guidelines and no Control Staff not motivated 3. Group inter-related causes Growth was to fast Not enough Staff Untrained Staff No Guidelines and no Control Staff feel unappreciated Staff feel unappreciated Not enough Top-Level Support Staff not motivated Not enough phone lines Staff aren’t compensated
- 8. screening for businesshealth 3. Leadership Issues 4. Resources and Tools 2. Lack of processes 1. Human Resources Issues Root-Cause-Analysis Tools: Affinity Diagram (cont) No Guidelines and no Control 4. Identify the major causes Not enough Staff Untrained Staff Staff feel unappreciated Not enough Top-Level Support Staff not motivated Not enough phone lines Staff aren’t compensated
- 9. screening for businesshealth Root-Cause-Analysis Tools: Pareto Analysis The Pareto Chart is used to show the relative importance of a set of measurements. The Pareto Analysis enables you to: - Identify the most important improvement areas - Identify the most important causes to address - Prioritize the most important solutions to implement - Show improvement over time (when executed and compared regularly) - Identify follow-up actions 44 32 20 13 11 10 4 2 71% 80% 88% 96% 99% 100% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0# 5# 10# 15# 20# 25# 30# 35# 40# 45# Error 1 Error 2 Error 8 Error 7 Error 4 56% Error 3 Error 5 Error 6 32% Cumulative % Frequency
- 10. screening for businesshealth Root-Cause-Analysis Tools: Pareto Analysis (cont.) The Pareto Analysis uses the Pareto Principle – which is also known as the “80/20” rule: Ideas behind the principle: - 80% of problems are traced to 20% of the causes - 80% of the tasks can be completed in 20% of the disposable time. The remaining 20% of tasks will take up 80% of the time - 80% of the productivity can be achieved by doing 20% of the tasks 06 Draw and label the one vertical axis from 0 to 100 percent Draw and label the left-hand vertical axis with the unit of comparison, such as frequency, cost or time 05 02 Total the raw data in each category, then determine the grand total by adding the totals of each category. Determine the categories and the units for comparison of the data, such as frequency, cost, or time. 01 04 Determine the cumulative percent of each category Re-order the categories from largest to smallest. 03 08 Draw a line graph beginning to represent the cumulative percent for each category as measured on the Percentage Axis Beginning with the largest category, draw in bars for each category representing the total for that category 07 Analyze the chart. Usually the top 20% of the categories will comprise roughly 80% of the cumulative total 09
- 11. screening for businesshealth Root-Cause-Analysis Tools: Fishbone Diagrams The Fishbone Diagram is a tool used for identifying the root cause based on Cause & Effect relationship. They are also called “Cause and Effect” or “Ishikawa” Diagrams Fishbone Diagrams are very useful for the analysis of complex problems Grouping the courses can be based on the major cause analysis shown previously The Fishbone Diagram is applicable when looking at numerous major causes and you need drill down to arrive a numerous root causes based on their Cause and Effect Relationships A B A B A B 1 3 5 2 4 6 New Competitor with new technology New Customer Behavior No Change Management No Project Controlling Disregard of R+D Lack of Market Research structure does not correspond to Project Management Lack of Motivation No Standards for Quality Management Contradiction between Duties and Power Lack of Training No Process Controlling External Environment Project Management Management Structure People Process Approach Reduced Competitiveness
- 12. screening for businesshealth Root-Cause-Analysis Tools: Fishbone Diagrams (cont.) To build a good and actionable Fishbone diagram: Be sure everyone agrees on the effect or problem statement before beginning Be succinct For each node, think what could be its causes. Add them to the tree Pursue each line of causality back to its root cause Consider grafting relatively empty branches onto others Consider splitting up overcrowded branches Consider which root causes are most likely to merit further investigation 06 Plan and implement actions to address key causes Discuss why the found causes are there 05 02 Write down the key effect or symptom at the center-right of the page and draw a horizontal spine Form a small team of people with complementary skills to work on the problem 01 04 Use Brainstorming to build the diagram, adding causes or cause areas to the appropriate ribs or sub-ribs as they appear Draw the main cause area 'ribs' 03
- 13. screening for businesshealth Root-Cause-Analysis Tools: Interviewing When interviewing your staff on problems and root causes, it is important to ask the right questions in the right way – otherwise you won’t get actionable information. Open-Ended Ask open ended questions. Current and Future Consider actual and potential problems. Responsibility Focus on the people responsible – but get information from all relevant people. Be prepared Collect relevant data first in order to ask the right questions. All levels Question people on all levels in the responsible functions in order to get a comprehensive view on the problem. No consulting Don’t lead or consult during the interviews – let somebody else conduct the interview if you think your presence might influence.
- 14. screening for businesshealth Root-Cause-Analysis Tools: Fault Trees A fault tree is a graphical representation of the logical structure displaying the relationship between an undesired potential event (top event) and all its probable causes. • Top-down approach to failure analysis • Starting with a potential undesirable event (top event) • Determining all the ways in which it can occur • Mitigation measures can be developed to minimize the probability of the undesired event Terminology Name Form Description AND gate To show that the output event occurs only if all the input events occur OR gate To show that the output event occurs only if one or more of the input events occurs Basic event A basic event requires no further development because the appropriate limit of resolution has been reached Intermediate event An intermediate event occurs because of one or more antecedent causes acting through logic gates Transfer A triangle indicates that the tree is developed further at the occurrence of the corresponding transfer symbol Underdeveloped event A diamond is used to define an event which is not further developed either because it is of insufficient consequence or because of insufficient information
- 15. screening for businesshealth Fault Trees (Steps) Fault tree analysis is a logic diagram for finding deductive failures in which using logic flows to combine different lower-level factors. It is also used for tracing all possible important factors and branches of events. Normally the more complex the case is, the more extensive the framework of fault tree framework will be. Define the system and determine the top event. What’s the scope of the issue or system that you’re analyzing? What constitutes “failure”? “How will this impact my business?” Break down each event as much as possible. If “failure” means having stock left over from a pop up sale, your intermediate events could be 1) venue problems AND/OR 2) stock problems AND/OR 3) seller problems. Explore each branch in successive detail. Continue the top-down process until the root cause for each branch is identified (basically, when you can’t decompose further). Analyze and solve the fault tree. Now that you know all the possible causes of failure, you can analyze the fault tree and create a plan of action to address risk factors. Perform corrections and make decisions. This is the last step in the failure tree analysis method. You have your plan of action–all that’s left to do now is implement it. Define Structure Explore Analyze Decide 1 2 3 4 5 The Fault Tree Analysis is executed in 5 major steps:
- 16. screening for businesshealth Fault Trees (Example) Fault trees can help to: • Quantifying probability of top event occurrence • Evaluating proposed system architecture attributes • Assessing design modifications and identify areas requiring attention • Complying with qualitative and quantitative safety/reliability objectives • Qualitatively illustrate failure condition classification of a top- level event • Establishing maintenance tasks and intervals from safety/reliability assessments Lack of Goods Sales on the Web shop are low Lack of goods People not buying Shop has technical issues Low Inventory / no sufficient stock Availability of product is low Economy slow sales everywhere Price is too high Product Appeal Internet is slow Software is outdated
- 17. screening for businesshealth Fault Trees (Rules) The construction of fault trees is a process that evolved gradually over years – and has been adopted by many different functions and sectors. But what is important: “Successful” fault trees are drawn in accordance of basic rules. Specificity Classifications Distinctive Protectiveness Pinpoint Be as specific as possible Replace abstract events by less abstract events Use classifications Classify an event into more elementary events Identify distinct causes for an event Couple trigger events with “no protective action” Pinpoint a component failure event
- 18. screening for businesshealth Root-Cause-Analysis: Hints and Tips To perform a successful Root Cause Analysis you should observe a few basic rules. • It is important to select the right team to carry out the Root Cause Analysis. Members should have the knowledge of the process and should be able to explore the why, what and how • Don’t jump in with solutions: the problem and the solution may not be obvious • Make sure you are aware of the causal relationships – not just for the issue but also for the solution • Suggest improvements that you can implement and are owned and signed up to by your team • Having a facilitator with experience in the process will make things easier • Practicing the tools and techniques will ensure that you maintain the skills needed • Only take responsibility for actions over which you have control: Don’t agree on an action plan for something you can’t implement
- 19. screening for businesshealth Root-Cause-Analysis Tools: Pitfalls Root Cause Analysis needs some practice - but if you follow the above rules while avoiding the adjacent pitfalls, it is a very helpful tool. • Not understanding the problem and therefore not defining it correctly • Not asking for help (internally and externally) • Not considering all possible failure causes • Not identifying all root causes • Not understanding how the system should operate • Runaway tests and analysis • Adopting a “remove & replace” mentality • Returning the part/product without analysis • Failing to follow-through • Jumping to conclusions • Tearing a system apart without a plan