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Cause - Effect and Root - Cause Analysis

The document discusses root cause analysis and quality improvement. It introduces fishbone diagrams as a tool to identify and categorize potential causes of problems in order to determine the root causes. The document provides instructions on how to construct a fishbone diagram by determining a problem statement and major cause categories, then brainstorming potential causes. It also discusses how to analyze the fishbone diagram to select items for further investigation and determine which causes are most impactful using a root cause analysis rating form. The overall goal is to use these tools and techniques to systematically examine current processes and identify root causes of issues as part of a quality improvement process.

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zawadzahin
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319 views

Cause - Effect and Root - Cause Analysis

The document discusses root cause analysis and quality improvement. It introduces fishbone diagrams as a tool to identify and categorize potential causes of problems in order to determine the root causes. The document provides instructions on how to construct a fishbone diagram by determining a problem statement and major cause categories, then brainstorming potential causes. It also discusses how to analyze the fishbone diagram to select items for further investigation and determine which causes are most impactful using a root cause analysis rating form. The overall goal is to use these tools and techniques to systematically examine current processes and identify root causes of issues as part of a quality improvement process.

Uploaded by

zawadzahin
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Root Cause Analysis

Welcome!
Objectives
Constructing & Analyzing Fishbone Diagrams
Using a Root Cause Selection Matrix
Q & A
PDSA: A Four-Stage Approach to QI
Act
Do Study
Plan
PLAN
Last week we discussed:
Step One: Getting Started
Identifying areas for improvement
Step Two: Assemble the team
Identify team members
Develop AIM statement
This week we are looking at:
Step Three: Examine the Current Approach
Determine root cause(s) of problem
Fishbone Diagrams
Problem Solving What we usually see is the tip of iceberg The Symptom
The Symptom
The Root Causes
Invisible
Hidden
Fishbone Diagrams
Why Use It?
To allow a team to identify, explore and graphically
display, in increasing detail, all of the possible causes
related to a problem or condition to discover its root
cause(s).
What Does it Do?
Enable a team to focus on the content of the problem
versus the history of the problem or personal interests of
team.
Creates a snapshot of the collective knowledge and
consensus of a team around a problem.
Focuses the team on causes, not symptoms.
Also known as
Ishikawa Diagrams
Cause and Effect Diagrams
Identifies & categorizes issues
Organizes ideas
Shows relationships
Reveals potential problems
Facilitates process understanding
Easy to use
Useful reporting tool
Additional Benefits of
Fishbone Diagrams
Clearly define the problem
Write a short description of problem at box on right
Decide on major areas/headers and write these in
boxes at the end of each spine
Brainstorm for possible causes
Drill down for each cause to think more about Why
does it happen?
Check for Completeness
How to Construct
Determine the problem statement
(a.k.a.your fish head)
Late pizza deliveries
on Friday & Saturday
nights
Determine major cause/header categories
Examples of headers:
People, Plant, Procedures, Policies
Manpower, Machinery, Materials, Methods
Admin, HR, Finance, Operations,
Procurement
Lifestyle, Environment, Forms
Etc.
Late pizza deliveries
on Friday & Saturday
nights
Machinery/
Equipment
People
Methods Materials
Major causes/Fish spines
BrainstormingFilet the fish
Late pizza deliveries
on Friday & Saturday
nights
Machinery/
Equipment
People
Methods Materials
People dont show up
Drivers get lost
Run out of
ingredients
Poor dispatching
Poor handling of
large orders
Unreliable cars
Ovens too small
Fleshing out your fishbone
Late pizza
deliveries on
Fri & Sat
nights
Machinery/
Equipment
People
Methods
Materials
People dont
show up
Drivers get lost
Run out of
ingredients
Poor
dispatching
Poor handling of
large orders
Unreliable cars
Ovens too small
No teamwork
No training
High turnover
Low pay
Inaccurate ordering
Lack of training
Many new streets
Dont know town
High turnover
Lack of
experience
High
turnover
Dont know
town
Rushed
Kids own
junk
Low Pay
Analyzing Fishbone Diagrams
Selecting items to investigate further:
Look for causes that appear repeatedly within
or across major categories
Determine which are inside versus outside of
teams control
Select through consensus
May need to gather data using other tools
(e.g., check sheet, Pareto diagram, surveys)
Root Cause Analysis Rating Form
Potential
Root
Cause
Improved
Quality
Reduced
Costs
Improved
Customer
Satisfaction
Others Total
Score
Ranking
Impact Scoring Scale: Low = 1, Medium = 3, High = 5
Impact on the Problem
Root Cause Analysis Rating Form
Potential
Root
Cause
Improved
Quality
Reduced
Costs
Improved
Customer
Satisfaction
Others Total
Score
Ranking
Impact Scoring Scale: Low = 1, Medium = 3, High = 5
Impact on the Problem
Drivers
dont know
the town
Inaccurate
ordering
Lack of exp
handling
large orders
Drivers own
unreliable
(junkie) cars
Root Cause Analysis Rating Form
Potential
Root
Cause
Improved
Quality
Reduced
Costs
Improved
Customer
Satisfaction
Others Total
Score
Ranking
Impact Scoring Scale: Low = 1, Medium = 3, High = 5
Impact on the Problem
Drivers
dont know
the town
Inaccurate
ordering
Lack of exp
handling
large orders
Drivers own
unreliable
(junkie) cars
3
1
1
3
Root Cause Analysis Rating Form
Potential
Root
Cause
Improved
Quality
Reduced
Costs
Improved
Customer
Satisfaction
Others Total
Score
Ranking
Impact Scoring Scale: Low = 1, Medium = 3, High = 5
Impact on the Problem
Drivers
dont know
the town
Inaccurate
ordering
Lack of exp
handling
large orders
Drivers own
unreliable
(junkie) cars
3
1
1
3
3
5
3
1
Root Cause Analysis Rating Form
Potential
Root
Cause
Improved
Quality
Reduced
Costs
Improved
Customer
Satisfaction
Others Total
Score
Ranking
Impact Scoring Scale: Low = 1, Medium = 3, High = 5
Impact on the Problem
Drivers
dont know
the town
Inaccurate
ordering
Lack of exp
handling
large orders
Drivers own
unreliable
(junkie) cars
3
1
1
3
3
5
3
1
5
1
1
1
Root Cause Analysis Rating Form
Potential
Root
Cause
Improved
Quality
Reduced
Costs
Improved
Customer
Satisfaction
Others Total
Score
Ranking
Impact Scoring Scale: Low = 1, Medium = 3, High = 5
Impact on the Problem
Drivers
dont know
the town
Inaccurate
ordering
Lack of exp
handling
large orders
Drivers own
unreliable
(junkie) cars
3
1
1
3
3
5
3
1
5
1
1
1
NA
NA
NA
NA
Root Cause Analysis Rating Form
Potential
Root
Cause
Improved
Quality
Reduced
Costs
Improved
Customer
Satisfaction
Others Total
Score
Ranking
Impact Scoring Scale: Low = 1, Medium = 3, High = 5
Impact on the Problem
Drivers
dont know
the town
Inaccurate
ordering
Lack of exp
handling
large orders
Drivers own
unreliable
(junkie) cars
3
1
1
3
3
5
3
1
5
1
1
1
NA
NA
NA
NA
11
7
3
5
Root Cause Analysis Rating Form
Potential
Root
Cause
Improved
Quality
Reduced
Costs
Improved
Customer
Satisfaction
Others Total
Score
Ranking
Impact Scoring Scale: Low = 1, Medium = 3, High = 5
Impact on the Problem
Drivers
dont know
the town
Inaccurate
ordering
Lack of exp
handling
large orders
Drivers own
unreliable
(junkie) cars
3
1
1
3
3
5
3
1
5
1
1
1
NA
NA
NA
NA
11
7
5
5
1
2
3*
3*
QUESTIONS?

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