What happens in your organization when an error is identified or a process produced unexpected results? How do you go about correcting the issue?
If your answer is that your organization simply corrects the error/outcome, has the issue been truly addressed? Have you spared your organization from similar issues occurring in the future?
A way to ensure that you eradicate the issue is by identifying and addressing through the application of “root cause analysis” (RCA) to determine what is driving the issue. Without understanding and addressing the root cause, future like issues will continue to occur. RCA is a method of problem solving intended to define the issue, understand what has caused it, and most importantly remediate the underlying cause in order to prevent future like incidents. An RCA performed properly provides you the means to identify the breakdown (e.g., processes, people, and/or systems) that resulted in the issue and how to prevent it in the future. The purpose of an RCA is to find out what happened, why it happened, and make changes to prevent future occurrences. The best way to determine the root cause is to ask the “5 Whys.” By repeatedly asking the question “why” (five is a good rule of thumb), you peel away the layers of symptoms and get to the root cause of the issue. Once the root cause is known, defining an appropriate solution becomes much easier. This technique was created by Sakichi Toyoda, the founder of Toyota, during the evolution of its manufacturing methodologies.
In general, there are three basic root causes:
- Physical causes – A tangible or material item failed in some way. For example, a car's brakes failing due to the pads becoming overly worn and no longer being functional.
- Human causes - The responsible individual(s) did something outside of expected practice or did not do something that was required. Human causes typically lead to physical causes. For example, the mechanic failed to inspect and change the brake pads, which led to the brakes failing.
- Organizational causes - A system, process or policy that is followed in order to make decisions related to the execution of tasks is flawed. For example, no specific mechanic was responsible for inspection of the brakes, and all of the mechanics assumed someone else inspected the brake pads.
The following is a high-level approach to conducting a root cause analysis:
- Verify the incident and define the problem – Ask the “5 Whys”
- Identify critical events in the process
- Map the timeline of critical events
- Analyze each critical event’s cause and impact against expected results
- Identify root causes (critical events which produced outcomes that were unexpected)
- Support each root cause with evidence
- Identify and select the best solutions
- Develop recommendations based on solutions proposed
- Select desired solution(s)
- Implement solution(s) and monitor outcomes
Conducting a root cause analysis is a critical aspect of problem-solving, and Schneider Downs’ Risk Advisory Services practice can assist your process by conducting or advising on a root cause analysis or advising on related matters. Our risk advisory professionals are six sigma certified have experience helping organizations with these activities. Contact us to find out how we can help your organization with root cause analysis and issue management solutions.