08 Apr 10 – WDM 204 – Session Five

Cape AreaManagement Program

(CAMP)Sponsored by the Cape & Islands

Workforce Investment Board

08 Apr 10 – WDM 204 – Session Five

Today’s Topics

Learning Objectives

Root Cause Analysis Overview

Root Cause Organizational Philosophy

Effectively Define the Problem

The “Five Whys” and Breakout Exercise

The “Fishbone Diagram” and Breakout Exercise

The Challenges and Keys to Success

Questions and Comments

08 Apr 10 – WDM 204 – Session Five 4

Learning Objectives

In this class, students will learn the how to develop a structure and process for continuous quality improvement (C.Q.I.).

The class will understand the challenges essential to effective C.Q.I., and learn the potential solutions. Practical tool(s) will be provided.

They will demonstrate their learning by in class discussion of workplace experiences, and group discussion of case studies.

Additional reading reference(s) will be provided.

WDM 204: Continuous Improvement

Identifying Crucial Processes

Working with Organizational Leaders to Determine NeedProcess Identification

Documenting Your Findings

08 Apr 10 – WDM 204 – Session Five 6

Quality Improvement System Tools

We need tools – a common language – to tell us:– where we stand versus our competition? (S.W.O.T.)

– what do we need to work on (Impact/Maturity Matrix)?

– how are we doing things now? (Process Mapping)

– what we need to do our job? (S.I.P.O.C)

– why isn’t it working? (Root Cause Analysis)

– how can we best do our jobs? (Standard Work)

– what do our stakeholders think? (Stakeholder Feedback)

08 Apr 10 – WDM 204 – Session Five 7

When Do You Need “Root Cause” Analysis?

There isn’t enough time to solve all the problems

Solutions are incomplete

Urgency supersedes importance

Problems reoccur and cascade

Many problems become crises

Performance drops

If three or more of these occur in your organization,

you are a victim of

“firefighting*.”

* Stop Fighting Fires; Bohn, Roger; Harvard Business School Publishing; 2000

08 Apr 10 – WDM 204 – Session Five 8

Root Cause Analysis

Find out why errors occur, to fix them once and for all:

UndesirableResult

Methods

Sub cause 1

Measurement

Sub cause 2

Material

Sub cause 3

Machine

Sub cause 4

Environment

People

40.00

70.00

90.00

100.00

Cause and Effect

# E

rro

rs

Sub cause 4 Sub cause 3 Sub cause 2 Sub cause 1

100

50

0

100%

50%

0%

Why?

Why did that occur?

Why did that occur?

08 Apr 10 – WDM 204 – Session Five 9

Philosophy of Relentless Root Cause

Each problem is a golden nugget or treasure.

Each problem tells a story about why and how it occurred. (There are no isolated incidents.)

Solving problems requires a mindset that is alert, open-minded, patient, tenacious, and persistent.

The “true” problem must be understood from the data before action is taken.

Each problem must be pursued and resolved, rapidly.

08 Apr 10 – WDM 204 – Session Five 10

Symptom Approach vs. Root Cause

Symptom Assumes at any given time a

worker makes a choice to work error-free or not.

Assumes errors are the result of worker carelessness.

The method for improvement is to motivate workers to be more careful.

Root Cause Assumes that errors are the

result of defects in the process. People are only part of the process.

Assumes that there are multiple causes for errors.

The method for improvement involves identifying appropriate ways to improve the process.

08 Apr 10 – WDM 204 – Session Five 11

First, Define the ProblemYour new cookie sales account just called, and they are not happy. Over

the last 30 days, these are the problems they have experienced.

Week Ending

Problems

3/7Damaged packaging (2), late delivery (3), damaged cookies (3), wrong amount of cookies delivered, wrong invoice (2)

3/14 Damaged packaging (3), late delivery (6), wrong amount of cookies delivered, wrong invoice (2)

3/21 Damaged packaging (2) , late delivery (10), wrong amount of cookies delivered, wrong invoice (2)

3/28Damaged packaging (2), late delivery(14), damaged cookies (3), wrong amount of cookies delivered, wrong invoice

4/4 Late delivery (2), wrong amount of cookies delivered(2)

How do you know where to start?

08 Apr 10 – WDM 204 – Session Five 12

Pareto Analysis – Defines Problem

If your customer is not satisfied, what are the reasons? Which is the most important reason?

0

5

10

15

20

25

30

35

40

Late Deliveries Damaged Packaging Wrong Invoice Wrong Amount Damaged Cookies

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

08 Apr 10 – WDM 204 – Session Five 13

Root Cause Analysis Using The “5 Why’s”

Problem

Why?

Why?

Why?

Why?

Why?

Flat Tire in Garage

Nails on garage floor

Box on shelf split

Box got wet

Rain through hole in garage roof

Rain happens

Breakout Session

Form Teams of Three to Five People

08 Apr 10 – WDM 204 – Session Five 15

Break Out Exercise – 5 Why’s

Do a “5 Why” root cause analysis on the problem scenario on the next page

Be sure to use all five “whys”

Be prepared to report out

08 Apr 10 – WDM 204 – Session Five 16

Root Cause Using the “5 Whys”

You’ve looked in to the cookie customer’s Late Deliveries complaints further, and you have the following information. Put it in “5 Why” order:”

The driver is new and doesn’t know the best route

The delivery truck arrives late to the customer

The traffic is much heavier in the Spring

The driver is slowed down by traffic

The driver is a part-time seasonal employee

08 Apr 10 – WDM 204 – Session Five 17

Limitations of the “5 Why” Method

Many people struggle with splitting a problem into exactly five levels

Debates center on which issue is the “real” root cause, and which cause comes first

It assumes problem analysis is “linear” – first this, then that - when sometimes several things happen at once

However, it is a great learning model for this subject!

08 Apr 10 – WDM 204 – Session Five 18

What Are Some Alternatives to “The Five Whys” Root Cause

Analysis? Open Brainstorming

Nominal Group Technique – “yellow stickies”

Fault Tree/Red X Analysis – remember the guess my number game?

Other statistical methods, such as those taught as “Six Sigma”

Ishikawa or “Fishbone Diagram”

08 Apr 10 – WDM 204 – Session Five 19

Root Cause Brainstorming Tool

StudiedBeingProblem

Environment

Measurement

Methods

Material

Machines

Personnel

Cause A

Cause Y

Cause B

Cause Z

Cause C

Cause J

Cause M

Cause D

Cause P

Cause E

Cause F

"Fishbone Diagram"

Then, team votes on 1-3

problem “key drivers” after all ideas are

recorded

First, what are all the “drivers” of this process?

08 Apr 10 – WDM 204 – Session Five 20

What Are the “Bones?” Environment – literally, the working conditions, e.g. light,

heat, humidity

Methods – how we use the tools and resources, e.g. work instructions

Machines – what we use, e.g. computers, printers, copiers

Measurement – how we measure “key drivers”

Material – what stuff we use to create our “product”

Personnel – the people doing the job

08 Apr 10 – WDM 204 – Session Five 21

Let’s Practice – “Mushy Cookies!”

Environment – literally, the working conditions, e.g. light, heat, humidity

Methods – how we use the tools and resources, e.g. work instructions

Machines – what we use, e.g. computers, printers, copiers

Measurement – how we measure “key drivers”

Material – what stuff we use to create our “product”

Personnel – the people doing the job

08 Apr 10 – WDM 204 – Session Five 22

Cookies!Mushy

Environment

Measurements

Methods

Material

Machines

Personnel

Pay Rate Low

New Baker

Refrigerator New

Mixing Bowl New

Spatula Broken

Cookie Sheets New

Oven Is Old

Free Range Eggs

Carob Chocolate Chips

Tap Water

White Sugar

Soy Based Oil

Whole Wheat Flour

Bake for 12 min

Cool for 1 min

Mix for 3 min

Bake at 350

Wall Clock

Kitchen Timer

Oven Thermometer

Eco Lighting

Rainy Morning

Summer Day

"Fishbone Diagram"

Possible Root Causes for “Mushy Cookies”

Breakout Session

Form Teams of Three to Five People

08 Apr 10 – WDM 204 – Session Five 24

We’re Not Happy!

Your new cookie sales account just called, and they are not happy. Over the last month, these are the problems they have experienced.

Week Ending

Problems

3/7Damaged Cookies – one, Wrong Amount Delivered – two, Damaged Packaging – three, and Late Deliveries – eight

3/14Damaged Cookies – one, Wrong Amount Delivered – two, Damaged Packaging – three, Late Deliveries – seven, and Wrong Invoice – three

3/21 Damaged Cookies – one, Damaged Packaging – one, Late Deliveries – 13, and Wrong Invoice – four

3/28 Wrong Amount Delivered – two, Damaged Packaging – two, and Late Deliveries – seven

08 Apr 10 – WDM 204 – Session Five 25

Break Out Exercise – Fishbone

Use the data on the next slide (and previous slides) to determine what to focus on first

Then, use a blank fishbone diagram to lead your team in a root cause brainstorming exercise– you will have to “make up,” using your common sense,

the causes to list

Reach consensus as a team on the three most likely causes

Be prepared to report out

08 Apr 10 – WDM 204 – Session Five 26

Beware of subjectivity

– Realize that you might not think of all the possible root causes while brainstorming

– Set aside personal bias “knowing the answer before you get started”

– Let the data lead you to objective conclusions

Check your data

Test you solution more than once if possible

Do not accept “human error” as an excuse for the root cause of a problem

Cautions

08 Apr 10 – WDM 204 – Session Five 27

How Are Most Organizations Directed?

What do we use to direct the workforce?– metrics (target measurements, such a budgets),

– policies (things you can’t measure, you describe)

If organizations are controlled by metrics and policies, what is the ultimate root cause of (what is now) undesired behavior?

Metrics and policies that conflict with the desired new direction!

08 Apr 10 – WDM 204 – Session Five 28

The Challenge of True Root Cause

Organizational leaders do not intentionally create problems

They vigorously support achieving objectives

They (like all of us) see some questions as “resistance”

They live in a world dominated by Financial information

08 Apr 10 – WDM 204 – Session Five 29

Keys to Success

Question Everything

– Do not stop until you are down to causes that can be tested and attacked

– Ask, “why, why, why?” until you know the fundamental element of the process that failed

Ask the experts—the users of the process

Get other, outside help

– Neutral

– More objective

Be relentless in your pursuit

Enroll your leadership in your solution

Class Discussion

Your Workplace’s Root Cause Analysis

08 Apr 10 – WDM 204 – Session Five 31

Personal Practicum ChecklistProject Charters

What do I need to know to try this at work?

When before the next class will I try?

What is my greatest concern in doing so?

08 Apr 10 – WDM 204 – Session Five 32

Discussion of Personal Practicum Checklists

Any questions on the how?

Let’s hear a couple of examples of the when?

Let’s hear a couple of examples of concern?

Let’s practice working through those concerns…

Questions or Comments Before We End?