Root cause analysis: the core of problem solving and corrective action

200 Pages·2009·0.549 MB·English

by  Okes, Duke

Root Cause
Analysis
The Core of Problem Solving
and Corrective Action
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Root Cause
Analysis
The Core of Problem Solving
and Corrective Action
Duke Okes
ASQ Quality Press
Milwaukee, Wisconsin
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American Society for Quality, Quality Press, Milwaukee 53203
© 2009 by Duke Okes
All rights reserved. Published 2009
Printed in the United States of America
15 14 13 12 11 10 09 5 4 3 2 1
Library of Congress Cataloging-in-Publication Data
Okes, Duke, 1949–.
Root cause analysis : the core of problem solving and corrective action /
Duke Okes.
p. cm.
ISBN 978-0-87389-764-8 (alk. paper)
1. Problem solving. 2. Decision making. 3. Management. I. Title.
HD30.29.O44 2009
658.4’03—dc22
2008055044
No part of this book may be reproduced in any form or by any means, electronic,
mechanical, photocopying, recording, or otherwise, without the prior written
permission of the publisher.
Publisher: William A. Tony
Acquisitions Editor: Matt Meinholz
Project Editor: Paul O’Mara
Production Administrator: Randall Benson
ASQ Mission: The American Society for Quality advances individual, organiza-
tional, and community excellence worldwide through learning, quality improve-
ment, and knowledge exchange.
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Printed on acid-free paper
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To Karl, a superb teacher.
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Contents
List of Figures and Tables . . . . . . . . . . . . . . . . . . . . . . . . xi
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
Chapter 1 Getting Better Root Cause Analysis . . . 1
The Problem . . . . . . . . . . . . . . . . . . . . . . . 2
The Impact . . . . . . . . . . . . . . . . . . . . . . . . 3
Approaches to Root Cause Analysis . . . . 4
Existing Problem-Solving Models . . . . . . 6
A Proposed Model . . . . . . . . . . . . . . . . . . 7
Chapter 2 Multiple Causes and Types of Action . . . 13
Initial Problem Response . . . . . . . . . . . . . 13
The Diagnosis . . . . . . . . . . . . . . . . . . . . . 14
Actions to Prevent Future Problems . . . . 19
The Need for Filters . . . . . . . . . . . . . . . . . 20
Chapter 3 Step 1: Define the Problem . . . . . . . . . . 23
Selecting the Right Problem . . . . . . . . . . 24
Scoping the Problem Appropriately . . . . . 30
The Problem Statement . . . . . . . . . . . . . . 31
vii
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viii Contents
Chapter 4 Step 2: Understand the Process . . . . . . 37
Setting Process Boundaries . . . . . . . . . . . 37
Flowcharting the Process . . . . . . . . . . . . . 39
Why Process Is So Important . . . . . . . . . . 44
Additional Values of the Flowchart . . . . . 46
Chapter 5 Step 3: Identify Possible Causes . . . . . . 49
Using the Flowchart for Causes . . . . . . . . 50
Using a Logic Tree for Causes . . . . . . . . . 51
Using Brainstorming and the Cause-and-
Effect Diagram for Causes . . . . . . . . . 57
Using Barrier Analysis for Causes . . . . . . 60
Using Change Analysis for Causes . . . . . 61
Eliminating Possible Causes . . . . . . . . . . 62
Sources for Possible Causes . . . . . . . . . . . 63
Chapter 6 Step 4: Collect the Data . . . . . . . . . . . . . 65
A Basic Concept . . . . . . . . . . . . . . . . . . . 66
Types of Data . . . . . . . . . . . . . . . . . . . . . . 67
Using Existing versus New Data . . . . . . . 69
Where to Collect Data . . . . . . . . . . . . . . . 69
Special Tests . . . . . . . . . . . . . . . . . . . . . . . 71
Sample Size and Time Frame . . . . . . . . . 74
Data Collection Tools for Both Low- and
High-Frequency Problems . . . . . . . . . 75
Additional Tools for High-Frequency
Problems . . . . . . . . . . . . . . . . . . . . . . 79
Organizing the Data Collection Process . 80
Chapter 7 Step 5: Analyze the Data . . . . . . . . . . . . 83
Tools for Low-Frequency Data . . . . . . . . 84
Additional Tools for High-Frequency
Data . . . . . . . . . . . . . . . . . . . . . . . . . . 86
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Contents ix
Questioning the Data . . . . . . . . . . . . . . . . 95
Data Analyses Summaries . . . . . . . . . . . . 95
Analyzing Variation . . . . . . . . . . . . . . . . . 97
Where to Go Next? . . . . . . . . . . . . . . . . . 98
Chapter 8 Identify and Select Solutions . . . . . . . . . 99
Step 6: Identify Possible Solutions . . . . . 99
Step 7: Select Solution(s) to Be
Implemented . . . . . . . . . . . . . . . . . . . 106
Chapter 9 Implement, Evaluate, and
Institutionalize . . . . . . . . . . . . . . . . . . . . 113
Step 8: Implement the Solution(s) . . . . . . 113
Step 9: Evaluate the Effect(s) . . . . . . . . . . 115
Step 10: Institutionalize the Change . . . . 117
Chapter 10 Organizational Issues . . . . . . . . . . . . . . . 119
Cognitive Biases . . . . . . . . . . . . . . . . . . . 119
Resistance to Change . . . . . . . . . . . . . . . . 121
Organizational Culture . . . . . . . . . . . . . . . 125
Project Ownership . . . . . . . . . . . . . . . . . . 126
Coaching/Facilitation Skills . . . . . . . . . . . 126
Other Issues . . . . . . . . . . . . . . . . . . . . . . . 131
Chapter 11 Human Error and Incident Analysis . . 133
Human Error . . . . . . . . . . . . . . . . . . . . . . 133
Incident Analysis . . . . . . . . . . . . . . . . . . . 139
Chapter 12 Improving Corrective Action . . . . . . . . 143
Critical Thinking . . . . . . . . . . . . . . . . . . . 145
Buddhism . . . . . . . . . . . . . . . . . . . . . . . . . 145
Stoic Philosophy . . . . . . . . . . . . . . . . . . . 146
Summary of Root Cause Analysis . . . . . . 147
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x Contents
Appendix A Example Projects . . . . . . . . . . . . . . . . . . 149
A Need for Focus . . . . . . . . . . . . . . . . . . . 149
How Would They Know? . . . . . . . . . . . . . 152
How Proficient Is That? . . . . . . . . . . . . . . 153
Getting the Shaft Back . . . . . . . . . . . . . . . 154
Got It in the Bag! . . . . . . . . . . . . . . . . . . . 158
Appendix B Root Cause Analysis Process Guides . . . 161
Generic Process Thinking . . . . . . . . . . . . 161
SIPOC Analysis Form . . . . . . . . . . . . . . . 163
Data Collection and Analysis Tools . . . . . 165
DO IT2 Root Cause Analysis Guide . . . . . 166
DO IT2 Problem-Solving Worksheet . . . . 169
Checklist for Reviewing the Corrective
Action Process . . . . . . . . . . . . . . . . . . 170
Appendix C Additional Resources . . . . . . . . . . . . . . . 173
Books . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
Web Sites . . . . . . . . . . . . . . . . . . . . . . . . . 174
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
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