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Root Cause Analysis

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  1. Root Cause Analysis GRBUS 611, Quality Management Duquesne University Instructor: Hank Sobah

  2. Root Cause Analysis What is it? Understanding problem sources? How does RCA work methods, process, and tools Example of Uses of RCA?

  3. Root Cause is… Defining Root Cause Analysis • The most fundamental reason a problem has occurred • when performance does not meet expectations

  4. Root Cause Analysis (RCA) is… Defining Root Cause Analysis • The determination of the most basic cause of an event which, if corrected, will prevent recurrence.

  5. Root Cause Analysis Goals: Defining Root Cause Analysis • To find out: • What happened? • Why did it happen? • What do you do to prevent it from happening again?

  6. Root Cause Analysis is: Defining Root Cause Analysis • A tool in the systems approach to prevention • not punishment of adverse events • A tool in the effort to build a “culture of excellence” • A process for identifying basic or contributing causes • A process for identifying what we do about it to prevent recurrence

  7. The Role of RCA Champions Defining Root Cause Analysis • Select the RCA team members • Select an appropriate RCA methodology • Provide training to the RCA team on RCA techniques and tools • Establish a schedule • Keep the team on schedule

  8. Defining Root Cause Analysis Characteristics • Inter-disciplinary • Involves those most familiar with the process • Digs deeper by asking, why, why, why??? • Identifies changes that could be made to systems and processes to eliminate error • Impartial as possible

  9. The Whole Point: Defining Root Cause Analysis • Is to help us avoid or eliminate problems now and in the future • By developing action plans to make things better • And moving “beyond blame”

  10. To Be Thorough, RCA must include: Defining Root Cause Analysis • A determination of human & other factors; & related processes & systems • Analysis of underlying systems through a series of “why” questions • Identification of risks & their potential contributions • Determination of potential improvement in processes or systems

  11. To Be Credible, RCA must: Defining Root Cause Analysis • Include participation by the leadership of the organization & those most closely involved in the processes & systems • Be internally consistent • Include consideration of relevant information and related literature

  12. Systems and Processes Understanding the Source of Problems • 85% of problems are the result of the system or process • A process is the sequence of activities which transform inputs into value-added outputs • A system is formed by the grouping of interrelated processes

  13. Procedures and Performance Understanding the Source of Problems • Procedures are written instructions for performing work • Performance is the measure of whether the intent of the written procedures has been met

  14. Attitudes and Behavior Understanding the Source of Problems • Attitudes represent thoughts and emotions which motivate action • Behavior is the visible manifestation of attitudes

  15. Risk Tree Analysis Overview of RCA Methods • Uses a system-based schematic to identify safety-program oversights, errors, and omissions; and optimize allocation of resources to mitigate hazards • Also called MORT, or Management Oversight and Risk Tree Analysis

  16. Events & Causal Factors Analysis Overview of RCA Methods • Uses sequence diagrams and charts as a method to determine events and causal factors contributing to the occurrence of a problem

  17. Fault Tree Analysis Overview of RCA Methods • Uses reliability and logic sequence techniques to identify potential reliability failures for complex and dynamic systems

  18. Barrier Analysis Overview of RCA Methods • Examines the existence of controls to determine if an event was caused by their failure to prevent unwanted action

  19. Change Analysis Overview of RCA Methods • Compares successfully performed activities to those that were unsuccessful to determine differences as a source for problems

  20. RCA and Decision Making Managing the RCA Process • Change systems/processes • Revise/Develop new procedures • Identify the need for training • Identify the need for employee counseling • Insitute a preventive action The results of root cause analysis is used to:

  21. Corrective vs. Preventive Action Managing the RCA Process • Corrective action is taken to mitigate the immediate effects of a deficient condition in order to eliminate a problem or hazard • Preventive action is taken to modify a system or process in order to eliminate or reduce the recurrence of a deficient condition

  22. Monitoring System Effectiveness Managing the RCA Process • Identified root causes, when corrected, prevent recurrence • Proper techniques and tools are utilized • The results of analysis are properly documented RCA systems must be monitored to ensure:

  23. brainstorming flowcharting cause & effect diagrams pareto charts barrier analysis change analysis checklists failure mode, effect & criticality analysis tree analysis interrelationship digraph planning matrix questioning attitude RCA Tools RCA Tools

  24. Basic Brainstorming RCA Tools • Invented by Alex Osborn in the 1950s • Used to generate ideas and stimulate discussion • Can be structured or unstructured

  25. Basic Brainstorming RCA Tools • Exercise You’re on a desert island and all you have is a belt. How do you use it?

  26. Flow Charting RCA Tools • Provides a pictorial representation of a work process • Shows the sequential relationship between tasks or activities • Is used by a team to identify process related causes of problems • Is done using standard symbols to ensure understanding • Is also referred to as process mapping

  27. Start/Stop Decision Inspection Operation NewPage Document Flow Charting RCA Tools Yes No

  28. Alarm Goes Off No Get Up Have Extra Time? Yes Look in Mirror Hit Snooze Button No OK? Yes Brush Teeth andComb Hair Shower Select Clothes A Get Dressed Flow Charting RCA Tools

  29. A Have Time? No Yes No Hungry? Yes Fix Breakfast Leftover Pizza Eggs & Bacon Cereal Eat Breakfast Go to Work Flow Charting RCA Tools

  30. Barrier Analysis RCA Tools • Provides a way for evaluating an idea for advantages and disadvantages • Is used in problem solving to identify issues impacting a proposed solution • Provides a starting point for implementation planning • Is also called Force Field Analysis

  31. Barrier Analysis RCA Tools • Exercise Analyze the ‘value’ of attending an MBA course and obstacles to attaining that value

  32. Cause & Effect Diagrams RCA Tools • Invented by Kaoru Ishakawa in 1943 • Used to represent the relationship between a given “effect” and the possible “causes” influencing it • Used by a team to identify, explore, and display the causes for a specific problem or condition • Use standard headings for sorting the various causes • Are also called fishbone diagrams

  33. Cause & Effect Diagram RCA Tools People Methods Minimal training No Confirmation Forgot to confirm Overbooked Language Room Not Available Other guest extended Computer Down Rooms under repair Furnace Broken Equipment Material

  34. Tree Diagrams RCA Tools • Used to display the relationships between elements of a process or system • Help a team understand how activities in a system or process affect each other • Assist in data collection and organization by providing a way to organize ideas and concepts • Are used by a team to identify system related problems • Are also known as Affinity Diagrams

  35. Tree Diagram RCA Tools QUOTE WORK DO WORK DELIVER WORK Ship Parts Bill Customer Get Sample from Customer Estimate Cost for the Job Send Quote to Customer Receive Customer Response Receive Order Receive Parts Specify Job Requirements Process Parts Audit Completed Parts Package Parts Label Parts

  36. Interrelationship Digraphs RCA Tools • Used to represent inputs and outputs between different items • Assist in identifying communication and information flow paths between functional areas • Help a team understand how activities in a process or processes in a system interact with each other • Assist a team organize ideas and concepts • Also are referred to as system relationship maps

  37. Interrelationship Digraph RCA Tools WorkforceExcellence Leadership CustomerSatisfaction StrategicPlanning ProcessQuality QualityResults Information& Analysis

  38. Quote Work Output/Input Do Work Receive Order Get Sample from Customer Part Requirements Receive Parts Estimate Cost for the Job Specify Job Requirements Problems with Parts Process Parts Send Quote to the Customer Audit Completed Parts Order Details Receive Customer Response Package Parts Label Parts Interrelationship Digraph RCA Tools

  39. Planning Matrix RCA Tools • Helps a team organize multiple tasks • Provides a visual display of individual assignments • Can be used to show tasks vs time or tasks vs responsibility • Scales used must be clearly defined and agreed to • Is often used to track task performance

  40. Planning Matrix

  41. Planning Matrix / Swim Lane Diagram Evaluate Work ID Work Management Get Resources Do Work Cash Check Be Happy Employee Cut Pay Check Payroll

  42. Checksheets RCA Tools • Are used primarily as a tool for collecting data • Identify the data needed by type and source • Provide space for recording data and information • Help ensure all required information is obtained

  43. Questions (6 categories) help guide team Human Factors Communication Human Factors Training Human Factors Fatigue Environmental/Equipment Rules/Polices/Procedures Barriers Questioning attitude to guide process RCA Tools

  44. RCA Process Steps RCA Process • Define the problem • Collect data • Analyze problems for cause • Identify solutions to prevent recurrence • Plan implementation of solution • Present results • Monitor and evaluate actions taken

  45. Problem Definitions RCA Process • Need to be clear and concise • Should use outcome based wording • Should be process or system focused • Must have everyone’s buy-in

  46. Collecting Data RCA Process • Is used to complete the problem definition • Is critical for determining causes and potential solutions • Provides the basis for sound decision making • Helps establish a baseline for improvement • Must be planned

  47. Problem Analysis RCA Process • Provides a method for determining the actual cause from many possible • Helps a team reach consensus on the root cause for a given problem • Helps to sort causes from symptoms

  48. Contributing Factors RCA Process • Additional reasons, not necessarily the most basic reason • Bottom line: if eliminated, would it prevent a similar adverse event or close call

  49. Root Cause Statements RCA Process • The staff violated a procedure by not performing an environmental assessment resulting in construction problems and project delays.

  50. Root Cause Statements (cont) RCA Process • Examples • An informal norm had been created where procedures related to environmental assessments were not followed, which increased the likelihood this procedure was violated, resulting in problems laying the foundation and delaying the project.