Root cause analysis is a structured team process that assists in identifying underlying factors or causes of an adverse event or near-miss. Understanding the contributing factors or causes of a system failure can help develop actions that sustain the correction.
Goals:
- To identify the underlying cause of a problem or event.
- To gain a comprehensive understanding of how to address, rectify, or learn from the underlying issues associated with the root cause.
- To utilize insights derived from this analysis to systematically prevent recurrence of future issues or replicate successful outcomes.
Techniques such as the “5 Whys”, Change Analysis/Event Analysis, and Cause and effect Fishbone diagram are often used to analyze problems and identify corrective actions.
- “5 Whys”
“5 Whys” approach is most effective when used to resolve simple or moderately difficult problems.
- Change Analysis/Event Analysis
This method is especially handy when there are a large number of potential causes.
There are a few steps involved when analyzing the problem through Change Analysis/Event Analysis approach:
- List out every potential cause leading up to an event.
- Categorize each change or event by how much influence we had over it.
- Go event by event and decide whether or not that event was an unrelated factor, a correlated factor, a contributing factor, or a likely root cause. This is where other techniques like the 5 Whys can be used.
- look to see how we can replicate or remedy the root cause.
Example:
Let’s say the event we’re going to analyze is an uncharacteristically successful day of sales in New York City, and we wanted to know why it was so great so we can try to replicate it. 1) We’d list out every touch point with each of the major customers, every event, every possibly relevant change. 2) In our great Sales day example, we’d start to sort out things like “Sales representative presented new slide deck on social impact” (Internal) and other events like “Last day of the quarter” (External) or “First day of Spring” (External). 3) Within our analysis we discover that our fancy new Sales slide deck was actually an unrelated factor but the fact it was the end of the quarter was definitely a contributing factor. However, one factor was identified as the most likely root cause: the Sales Lead for the area moved to a new apartment with a shorter commute, meaning that she started showing up to meetings with clients 10 minutes earlier during the last week of the quarter. 4) While not everyone can move to a new apartment, our organization decides that if Sales reps show up an extra 10 minutes earlier to client meetings in the final week of a quarter, they may be able to replicate this root cause success.
- Cause and effect Fishbone diagram
There are a few steps involved when analyzing the problem through Fishbone diagram approach:
- Agree on the problem statement. This is written at the mouth of the “fish.” Be as clear and specific as you can about the problem. Beware of defining the problem in terms of a solution (e.g., we need more of something).
- Agree on the major categories of causes of the problem (written as branches from the main arrow). Major categories often include: equipment or supply factors, environmental factors, rules/policy/procedure factors, and people/staff factors.
- Brainstorm all the possible causes of the problem. Ask “Why does this happen?” As each idea is given, the facilitator writes the causal factor as a branch from the appropriate category (places it on the fishbone diagram). Causes can be written in several places if they relate to several categories.
- Again asks “Why does this happen?” about each cause. Write sub-causes branching off the cause branches.
- Continues to ask “Why?” and generate deeper levels of causes and continue organizing them under related causes or categories. This will help you to identify and then address root causes to prevent future problems.
Example:
Source: