Manage episode 276269253 series 2588664
I recently read an article from the folks over at TapRooT® that I wanted to share. It talks about how to have a successful root cause analysis and lists some best proactices. You can read their full article here.
In order to be successful in completing a root cause analysis you should:
- Provide a complete, clear picture of what happened.
- Identify all the problems (Causal Factors) that led to the incident being investigated.
- Find the real root causes of each problem.
- Find the Generic Causes of each Root Cause.
- Develop effective corrective actions.
- Get management to understand the problems and solutions and take timely action to get the solutions implemented.
The first thing you should do is provide a complete, clear picture of WHAT HAPPENED.
Without a complete, clear picture of what happened, the investigator is just making things up. The results of the investigation will be guesses.
If you need to provide a complete, clear picture of what happened, you need to:
- Know how to collect evidence. (Covered in a previous episode)
- Organize that evidence into a complete, easy to understand story.
- Share that evidence and story with others (management, other investigation team members, or workers).
Identify all the problems (Causal Factors) that led to the incident being investigated.
Many people focus on a single problem (even a single root cause) when they are investigating an incident. If the investigator focuses on a single cause, they will be missing other opportunities to improve performance and stop future incidents. Why? Because usually there is more than one problem (Causal Factor) that leads to an Incident.3rd Root Cause Analysis Best Practice
Find the real root causes of each problem.
Even with all the evidence in front of them, people can get tricked into the wrong root cause. How? There are several common errors but here’s a shortlist of potential problems:
- Confirmation Bias
- No human factors training/guidance
- No systematic process
- Thinking the know the cause
- Picking from a list of causes
Find the Generic Causes of each Root Cause.
Some people stop when they find a root cause. But we’ve found a best practice that goes beyond a simple root cause. We discovered Generic Causes.
Generic Causes start with root causes and then go beyond the root cause to find what is allowing the root cause to exist. Fixing Generic Causes can help you eliminate whole classes of problems. Here is an example…
Let’s say that you have a problem with a procedure that has more than one action in a step. On the Root Cause Tree® you would identify the root cause:
more than one action per step
To fix that procedure, you would rewrite the procedure with just a single action per step.
Once you have finished fixing the one procedure involved in this incident, you might start thinking:
What about our other procedures?
Do those procedures have similar problems?
What if you find that many procedures have “more than 1 action per step?” Then you know there is a Generic Cause. You need to ask what in the system is allowing procedures written with more than one action per step.5th Root Cause Analysis Best Practice
Develop effective corrective actions.
You might think that once an investigator finds the real root causes (and Generic Causes) that we are home free. What could go wrong? But even in the 1990s many people, even when the identified root causes, still didn’t develop effective corrective actions.6th Root Cause Analysis Best Practice
Get management to understand the problems and solutions and take timely action to get the solutions implemented.
- Understand what happened,
- Defined the Causal Factors,
- Identified the all Causal factors root causes,
- Identified any Generic Causes, and
- Developed effective corrective action.
What’s left? Getting management to approve the corrective actions and get the corrective actions implemented.
And that’s where the last best practice comes in. The last best practice is an effective method to present the investigation to management and get their approval to implement effective corrective actions.
Management is much more likely to commit resources to corrective actions when they understand what happened and how the:
- What happened,
- Why it happened, and
- How we can fix it,
All fit together into an easy to understand presentation.
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