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Quality Journey by Nilesh Jajoo
Quality Journey
RCA – Root Cause Analysis Art with experience
Quality Journey by Nilesh Jajoo
RCA
RCA (Root Cause Analysis ) :-
A process for identifying the underlying cause of a problem (including actual or possible occurrence of the
problem ) , and then planning , testing , implementing , learning from and revising solution
RCA is focused on process , not on individuals
All team member
should have the same
goal
Focus on Process , not
on individuals
Open and honest
communication ,&
learn from experience
Decision based on
Facts and Data
Customer Focus
(Internal/external)
Principles
Quality Journey by Nilesh Jajoo
Process
-- Set Rules /Goals
-- Examine pieces , find patterns , and try to fit
them together
-- Continuous observation and assessment –
look for gaps
-- Trail and Error , try something different
keeping Customer into center of focus (
Internal /External )
-- Evaluate results and Process
-- Standardize success , learn from Experience
Quality Journey by Nilesh Jajoo
Steps for RCA
Define problem with facts and data
Share results – Meeting
/Discussion .
Test the best solution &
Implement
Data collection and Analysis – Check sheet
,Parteo Chart ,Flow Chart etc.
--- 5 Why Technique
--- Fish Bone Diagram
RCA
Data
Share
RCA
Test
Repeat
Define
Evaluate results &
Process.
Quality Journey by Nilesh Jajoo
Template for RCA (Check Sheet )
While there is NO set template – as per the process /customer requirement template gets modified , however any
template needs to cover in the template
• Supporting data – all required data needs covered as part of the Template e.g. Incident ID , AHT , # of time repeat
interaction , demographic details
• L1 bucket for the RCA – Agent , Process , Policy , Technology and only in exceptional cases Customer
• Standard L2 reason – e.g. Under agent – Accuracy of Resolution , Complete Resolution , Communication & Tagging
related opportunity
Similarly for Process /Technology process specific standard reason to be added e.g. – Delay in pickup , CRM downtime
• Standard L3 Reason – L3 reason needs to be standardize , it can hand happened through trial and error concept –
reasons can get added and removed basis the experience
• L4 and L5 reason can free text ( not the rule ) . For some process standardize L4 reason can be made available
Note :- While doing the RCA , on one incident multiple opportunity can be there – e.g. Agent error cause the DSAT ,
however trigger point is the Process and Technology failure or vice a versa.
Thumb Rule :- In such situation all the reason needs to be captured , however P0 will be People Error , P1 Process error ,
P2 Policy/Technology failure –Thumb rule is applicable to 90% of the RCA opportunity , in exceptional cases Process gets
P0 priority
Quality Journey by Nilesh Jajoo
6
Fish Bone (Cause and Effect)
Process Policy
People
Plant
Effect
Cause
Cause
People Policy Procedure Plant Environment
ISHIKAWA DIAGRAM or FISH BONE
DIAGRAM
The cause and effect diagram was developed by
Dr. K. ISHIKAWA to represent the relationship
between EFFECT or PROBLEM and all the
possible CAUSES influencing it. For every EFFECT
there are likely to be several CAUSES.
The major causes can be summarized generally
under four categories known as 4M’s
—MAN,MACHINE,MATERIAL & METHOD, OR
4P’s – PLANT,POLICY,PEOPLE,PROCEDURE
• EFFECT is “WHAT?” Happens
• CAUSE is “WHY?” it Happens
• EFFECT = RESULT OR OUTCOME
• CAUSE = REASON(S) OR FACTOR(S) CONTRIBUTING TO
THE EFFECT
5 WHY’s is the additional process aligned
Quality Journey by Nilesh Jajoo
Cause and Effect– Sample
Quality Journey by Nilesh Jajoo
8
Pareto (80/20 principle)
The Pareto analysis is also known as the 80/20 rule because it is based on the idea that 80 percent of a project's benefit can
come from doing 20 percent of the work. Conversely, 80 percent of a situation's problems can be traced to 20 percent of the
causes.
When to Use a Pareto Chart
When analyzing data about the frequency of problems or causes in a process.
When there are many problems or causes and you want to focus on the most significant.
When analyzing broad causes by looking at their specific components.
When communicating with others about your data.
Pareto Chart Procedure
Pareto analysis begins by ranking problems from highest to lowest in order to fix
priority
The cumulative number of problems is plotted on the vertical axis of the graph against
the cause/phenomenon
 Pareto by Causes e.g. Man, Machine, Method etc.
Pareto by Phenomenon e.g. Quality ,Cost, Delivery
Tells about the relative sizes of problems indicates an important message about
biggest few problems, if corrected, a large % of total problems will be solved
Quality Journey by Nilesh Jajoo
Categorization of Cause – Implementation Plan
• No Major Process change e.g. Process
correction
• Minimum people involved in driving
change
• Less people dependent process
Easy to Work – High Impact on project Y Difficult to work -- High Impact on project Y
• Major Process change – Where FMEA is
required to evaluate the Risk of change
e.g. Automation, Application change
• People dependent
• Large team required to drive change
Difficult to work -- Low Impact on project Y
Easy to work -- Low Impact on project Y
Quality Journey by Nilesh Jajoo
10
Continuous Improvement Toolkit
Plan – Do – Check/Study – Act
Identify your
Problem
Test Potential
Solutions
Study
Results
Implement the Best
Solution
Quality Journey by Nilesh Jajoo
11
PDCA
Plan Do Check Act
• The team selects the
problem to be solved
(process to be
improved)
• The Problem and
Objective are clearly
identified
• The current situation
is analyzed
• Solutions alternatives
are identified ,
selected and
scheduled
• The solution is tested
on a small scale basis
• It involves collecting
data for later analysis
• It also involve measure
progress
• Its ensures the
solution is
appropriately tested
and benefits are
validated before
committing to full
implementation
• Involves analyzing the
collected data
comparing the actual
results against the
planned objectives
• Allows evaluating how
well the solution worked
• Allows discussing
whether further
improvements are
possible
• Concerned with
identifying unexpected
issues , their cause , &
gathering , summarizing
the key learnings
• Involves acting on the
feedback and lessons
learned and
implementing the
solution fully
• It is also concerned with-
1. Standardizing
2. Documenting
3. Sustain the improved
process
4. Integrating it into the
organizations system
12
Quality Journey by Nilesh Jajoo
Useful Tools
Act
Check
Do
Plan Gap Analysis ,Fault Tree Analysis ,Waste Analysis , Brainstorming ,Process Mapping
etc.
Gantt Charts , on-the-job training , conflict resolution , data collection methods ,
sampling , control charts etc.
Graphical analysis , Cause and Effect analysis , statistics , Pareto analysis , Group
decision-making technique etc.
Gantt charts , check sheets , control chart , control planning standard work procedure
Quality Journey by Nilesh Jajoo
13
Result Control
 What is the process that is being controlled?
 What measures (numbers) are we monitoring?
 For each measure, what are the “trigger point” values where action should be taken?
 What action should be taken when a“trigger point” is reached? Who is responsible for taking action?
Question to answered while creating Control Plan
Control Plan
Process Documentation Communication Plan
Data Collection Plan Audit/Inspection Plan
Mistake Proofing System Risk Mitigation System
Response/Reaction Plan Statistical Process Control
Quality Journey by Nilesh Jajoo
Meeting/Discussion
14
 Record all pertinent performance and financial data.
 Reference controls (or the control plan).
 Review and resolve any incomplete tasks.
 Obtain signatures (varies by project and organization).
 Finance – Are financial benefits valid?
 Process owners – Do they accept the controls and do they agree the project is complete?
 Environmental, health, and safety – Do they agree that all procedures and policies have been followed?
 Quality systems – Have sufficient verifiable controls been instituted to ensure project success? Have all procedures and
policies been followed?
 Management (for example, Champion) – Does management agree that the project is completed?
 Financial benefits may be soft, which can be difficult to measure (for example, improved product lets us keep a key
customer, reduced order delivery time, reduced environmental
 Etc…………………
Important Points for Discussion
Quality Journey by Nilesh Jajoo

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RCA - Art with Expereince.pdf

  • 1. Quality Journey by Nilesh Jajoo Quality Journey RCA – Root Cause Analysis Art with experience
  • 2. Quality Journey by Nilesh Jajoo RCA RCA (Root Cause Analysis ) :- A process for identifying the underlying cause of a problem (including actual or possible occurrence of the problem ) , and then planning , testing , implementing , learning from and revising solution RCA is focused on process , not on individuals All team member should have the same goal Focus on Process , not on individuals Open and honest communication ,& learn from experience Decision based on Facts and Data Customer Focus (Internal/external) Principles
  • 3. Quality Journey by Nilesh Jajoo Process -- Set Rules /Goals -- Examine pieces , find patterns , and try to fit them together -- Continuous observation and assessment – look for gaps -- Trail and Error , try something different keeping Customer into center of focus ( Internal /External ) -- Evaluate results and Process -- Standardize success , learn from Experience
  • 4. Quality Journey by Nilesh Jajoo Steps for RCA Define problem with facts and data Share results – Meeting /Discussion . Test the best solution & Implement Data collection and Analysis – Check sheet ,Parteo Chart ,Flow Chart etc. --- 5 Why Technique --- Fish Bone Diagram RCA Data Share RCA Test Repeat Define Evaluate results & Process.
  • 5. Quality Journey by Nilesh Jajoo Template for RCA (Check Sheet ) While there is NO set template – as per the process /customer requirement template gets modified , however any template needs to cover in the template • Supporting data – all required data needs covered as part of the Template e.g. Incident ID , AHT , # of time repeat interaction , demographic details • L1 bucket for the RCA – Agent , Process , Policy , Technology and only in exceptional cases Customer • Standard L2 reason – e.g. Under agent – Accuracy of Resolution , Complete Resolution , Communication & Tagging related opportunity Similarly for Process /Technology process specific standard reason to be added e.g. – Delay in pickup , CRM downtime • Standard L3 Reason – L3 reason needs to be standardize , it can hand happened through trial and error concept – reasons can get added and removed basis the experience • L4 and L5 reason can free text ( not the rule ) . For some process standardize L4 reason can be made available Note :- While doing the RCA , on one incident multiple opportunity can be there – e.g. Agent error cause the DSAT , however trigger point is the Process and Technology failure or vice a versa. Thumb Rule :- In such situation all the reason needs to be captured , however P0 will be People Error , P1 Process error , P2 Policy/Technology failure –Thumb rule is applicable to 90% of the RCA opportunity , in exceptional cases Process gets P0 priority
  • 6. Quality Journey by Nilesh Jajoo 6 Fish Bone (Cause and Effect) Process Policy People Plant Effect Cause Cause People Policy Procedure Plant Environment ISHIKAWA DIAGRAM or FISH BONE DIAGRAM The cause and effect diagram was developed by Dr. K. ISHIKAWA to represent the relationship between EFFECT or PROBLEM and all the possible CAUSES influencing it. For every EFFECT there are likely to be several CAUSES. The major causes can be summarized generally under four categories known as 4M’s —MAN,MACHINE,MATERIAL & METHOD, OR 4P’s – PLANT,POLICY,PEOPLE,PROCEDURE • EFFECT is “WHAT?” Happens • CAUSE is “WHY?” it Happens • EFFECT = RESULT OR OUTCOME • CAUSE = REASON(S) OR FACTOR(S) CONTRIBUTING TO THE EFFECT 5 WHY’s is the additional process aligned
  • 7. Quality Journey by Nilesh Jajoo Cause and Effect– Sample
  • 8. Quality Journey by Nilesh Jajoo 8 Pareto (80/20 principle) The Pareto analysis is also known as the 80/20 rule because it is based on the idea that 80 percent of a project's benefit can come from doing 20 percent of the work. Conversely, 80 percent of a situation's problems can be traced to 20 percent of the causes. When to Use a Pareto Chart When analyzing data about the frequency of problems or causes in a process. When there are many problems or causes and you want to focus on the most significant. When analyzing broad causes by looking at their specific components. When communicating with others about your data. Pareto Chart Procedure Pareto analysis begins by ranking problems from highest to lowest in order to fix priority The cumulative number of problems is plotted on the vertical axis of the graph against the cause/phenomenon  Pareto by Causes e.g. Man, Machine, Method etc. Pareto by Phenomenon e.g. Quality ,Cost, Delivery Tells about the relative sizes of problems indicates an important message about biggest few problems, if corrected, a large % of total problems will be solved
  • 9. Quality Journey by Nilesh Jajoo Categorization of Cause – Implementation Plan • No Major Process change e.g. Process correction • Minimum people involved in driving change • Less people dependent process Easy to Work – High Impact on project Y Difficult to work -- High Impact on project Y • Major Process change – Where FMEA is required to evaluate the Risk of change e.g. Automation, Application change • People dependent • Large team required to drive change Difficult to work -- Low Impact on project Y Easy to work -- Low Impact on project Y
  • 10. Quality Journey by Nilesh Jajoo 10 Continuous Improvement Toolkit Plan – Do – Check/Study – Act Identify your Problem Test Potential Solutions Study Results Implement the Best Solution
  • 11. Quality Journey by Nilesh Jajoo 11 PDCA Plan Do Check Act • The team selects the problem to be solved (process to be improved) • The Problem and Objective are clearly identified • The current situation is analyzed • Solutions alternatives are identified , selected and scheduled • The solution is tested on a small scale basis • It involves collecting data for later analysis • It also involve measure progress • Its ensures the solution is appropriately tested and benefits are validated before committing to full implementation • Involves analyzing the collected data comparing the actual results against the planned objectives • Allows evaluating how well the solution worked • Allows discussing whether further improvements are possible • Concerned with identifying unexpected issues , their cause , & gathering , summarizing the key learnings • Involves acting on the feedback and lessons learned and implementing the solution fully • It is also concerned with- 1. Standardizing 2. Documenting 3. Sustain the improved process 4. Integrating it into the organizations system
  • 12. 12 Quality Journey by Nilesh Jajoo Useful Tools Act Check Do Plan Gap Analysis ,Fault Tree Analysis ,Waste Analysis , Brainstorming ,Process Mapping etc. Gantt Charts , on-the-job training , conflict resolution , data collection methods , sampling , control charts etc. Graphical analysis , Cause and Effect analysis , statistics , Pareto analysis , Group decision-making technique etc. Gantt charts , check sheets , control chart , control planning standard work procedure
  • 13. Quality Journey by Nilesh Jajoo 13 Result Control  What is the process that is being controlled?  What measures (numbers) are we monitoring?  For each measure, what are the “trigger point” values where action should be taken?  What action should be taken when a“trigger point” is reached? Who is responsible for taking action? Question to answered while creating Control Plan Control Plan Process Documentation Communication Plan Data Collection Plan Audit/Inspection Plan Mistake Proofing System Risk Mitigation System Response/Reaction Plan Statistical Process Control
  • 14. Quality Journey by Nilesh Jajoo Meeting/Discussion 14  Record all pertinent performance and financial data.  Reference controls (or the control plan).  Review and resolve any incomplete tasks.  Obtain signatures (varies by project and organization).  Finance – Are financial benefits valid?  Process owners – Do they accept the controls and do they agree the project is complete?  Environmental, health, and safety – Do they agree that all procedures and policies have been followed?  Quality systems – Have sufficient verifiable controls been instituted to ensure project success? Have all procedures and policies been followed?  Management (for example, Champion) – Does management agree that the project is completed?  Financial benefits may be soft, which can be difficult to measure (for example, improved product lets us keep a key customer, reduced order delivery time, reduced environmental  Etc………………… Important Points for Discussion
  • 15. Quality Journey by Nilesh Jajoo