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Stage 2: Analyze
Step 5:
Root Cause Analysis
Analyze – Steps
Do Root Finalize
Develop
Cause Improvement
Solutions
Analysis Plans
• Process • Implementation Plan
• Root Cause Analysis
Simplification • Budget and Cost
• Common Mistakes in
• Visual Management Management Plan
Root Cause Analysis
• Good Housekeeping • Resource Plan
• Types of Root Cause
• Mistake Proofing • Risk Management
Analysis
• Idea Generation
• Validation of Root
Technique 6-4
Causes
• Future Process Map
5
Key Message
To address the focused problem statement,
we need to identify the ROOT CAUSE of the
problem and come up with APPROPRIATE
and RELEVANT SOLUTIONS.
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Outline
• Root Cause Analysis
• Common Mistakes in Root Cause Analysis
• Types of Root Cause Analysis
– Cause and Effect Analysis
– Why-why Analysis
– Cause and Effect vs. Why-Why Analysis
• Validation of Root Causes
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What is a Root Cause?
• It is the deepest
underlying cause, or
causes, of problematic
symptoms within any
process.
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Why do Root Cause Analysis?
• Reality - fix symptoms without regard to actual
causes
– Jumping to solutions
• Root Cause Analysis - structured and thorough
review of problem designed to identify and verify
what is causing the symptoms
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Problem vs. Cause
CAUSE PROBLEM
Effect or end - result of a cause
Factor which contributes to the
or combination of causes
occurrence of a problem
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Common Mistakes in RCA
1. Missing link between causes.
2. Focusing on the who, not on the why.
3. Causes that begin with “no”, “none”, “lack of”.
4. Causes identified are non-standard occurrence.
5. Causes that are disguised solutions.
6. Bias in identification of the causes.
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Common Mistake #1
• Missing link between causes.
Students are
unable to correctly Why? Test instructions
follow test are long.
instructions.
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Common Mistake #2
• Focusing on the who, not on the why.
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Common Mistake #4
• Causes identified are non-standard occurrence.
Preparation of
projector in class Why?
take more than 10 Brownout
minutes.
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Common Mistake #5
• Causes that are disguised solutions.
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Common Mistake #6
• Bias in identification of the causes.
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CAUSE AND EFFECT ANALYSIS
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Cause and Effect Diagram
• Also known as the Fishbone
Diagram or the Ishikawa Diagram
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Cause and Effect Diagram
• Visual display of the list of possible causes
• Classify causes into categories and themes
– Examples: 4Ms - materials, machines, methods, and
man; PRIME U – persons, raw materials and
supplies, information, method, equipment, utilities
• Reveals gaps in existing knowledge
• Helps team reach common understanding of
why problems exists
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Steps in constructing the C & E Diagram
1. State the problem (at the right end of the
backbone)
2. Identify major categories
3. Brainstorm sub-causes per category
4. Check for completeness of sub-causes
5. Pinpoint all the root causes (encircle endpoints)
6. Verify all root-causes
7. Identify true and real root causes of the problem
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Cause and Effect Analysis
4M’s
CAUSE EFFECT
Feedback not
Involvement in household chores
given to
Methods students Unable to
Forgetfulness
Problem
Raw Materials
Equipment
And Supplies
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Mistakes in C & E Diagram
1. Too many categories but lack details
2. Too focused on a specific category
3. Limited to a category
4. Lack of depth
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Mistakes in C & E Diagram #1
• Too many categories but lack details
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Mistakes in C & E Diagram #2
• Too focused on a specific category
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Mistakes in C & E Diagram #3
• Limited to a category
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Mistakes in C & E Diagram #4
• Lack of depth
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WHY-WHY ANALYSIS
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Why-Why Diagram
• A Why-Why Diagram is a Tree Diagram where
each child statement is determined simply by
asking 'why' the parent occurs.
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Why-Why Analysis
• A systematic approach in determining all the
contributors to a problem by asking a series of
Why questions.
• Describe the problem in specific terms
• For each likely cause ask, “Why did this happen?”
• Continue for a minimum of five times
• Show logical relationship of each response to the
one that preceded it
• Stop when the team has enough information to
identify the root cause
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“The Five Whys” and Mile-Deep Thinking
Problem Problem Problem Problem Problem Problem Problem Problem Problem Problem Problem Problem Problem Etc.
A B C D E F G H I J K L M
Local focus
“Ask the question on causes
‘Why’ five times”
Why?
1. Why did X happen?
Wider focus
Because of W. on causes
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When answering Why Questions,
you should:
• Visualize the object or situation
• Put the object in front of you
• The why-answers should go smaller and smaller
• Be patient! The end of the chain is your bridge to
the permanent solution
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When is a Cause a Root Cause?
• Would the problem have occurred if the cause
had not been present?
• Will the problem reoccur as the result of the
same cause if the cause is corrected or
dissolved?
• Will correction or resolution of the cause lead to
similar events?
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Why-Why Diagram on
Late Grades Issuance
Teachers are
Teachers are
not concerned
allowed to
on the timely
submit beyond
distribution of
the deadline.
grades
Grades are
distributed to The grades
To check for
the students have to be
computation
beyond the 7 approved by the
errors.
days policy Vice Principal
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Narrowing Explanations in
Why-Why Analysis
Step 2: Evaluate the quality of your explanations (reach consensus on which
ones to keep)
• Criterion: The explanation derives logically from the data
– Can we articulate the connection(s) we see between the data and our explanation(s)?
– Does our explanation reflect a genuine situation, but one that is not related to this data?
– Can we tell the story of how our explanation could lead to the patterns we see in our data?
• Criterion: The explanation is specific enough to be testable
– Is the language specific enough to be clear to someone who was not part of our discussion?
– Are there any vague terms?
– Can we describe how we would we test the explanation?
• Criterion: The explanation is plausible
– Does any research support this thinking?
– If we base any planning steps on this explanation, do we anticipate meaningful results?
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Narrowing Explanations in
Why-Why Analysis
Step 3: Clarify the language used in your explanations
• Consider the following questions to clarify remaining explanations.
– Do our explanations make sense to someone else reading or
hearing them for the first time?
– Is our explanation complex enough to help us to better
understand a complex situation?
– What other questions do our explanations lead us to in order to
make the picture more complete?
– Does this explanation identify an area of concern?
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C & E Analysis vs. Why-why Analysis?
Cause and Effect Analysis Why-why Analysis
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C & E Analysis vs. Why-why Analysis?
Cause and Effect Analysis Why-why Analysis
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Example: Why-Why Diagram for the
Preparation of the Lesson Plan
Get from Baliwagan CES
Inappropriate
Ready-made Extra effort
Lesson Plans
Budgeted Time
quarterly constraint Procedure is
not suited to
Required to follow some learners
the design
Time
Objectives are consuming
Diversity of
not suited to learners
some learners
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Why-Why Diagram for Update/Improve
Instructional Materials
Not geared to
the enhanced
curriculum
Lack of
Learners’
Materials in
Filipino
Lack of
Learners’
Materials in
Filipino Diversity of
learners
Some old
IMs are Time
being used consuming
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Why-Why Diagram for Set
Classroom Environment
Classroom is not
Poor Classroom Structure conducive for learning
No qualified K to 12
Teacher in Grade 1
Improper ventilation
Classroom size is
small
Different Inefficiency in
Diversity of ways in teaching
delivering
learners the lesson
Personal Problem
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Why-Why Diagram for
Evaluating Pupils
Overlooked Test
Results Analysis
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Summary of Why-Why Diagram
Uncontrolled Root Causes Minor Root Causes
● Diversity of Learners ● No ceiling
● Slow readers can’t easily ● Desk are not suitable
cope up for group activities
● Required to follow the
design
● Length of service and
experience
● Lack of Learner’s Materials
in Filipino
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Activity: Root Cause Analysis
Based on your group’s Focused Problem
Statement, Perform a root cause analysis using
either the Fish Bone Diagram (Ishikawa
Diagram) or the Why-Why Diagram.
Time: 15 minutes
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VALIDATION OF ROOT
CAUSES
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Validation of Root Causes
• Plan for data collection (X and Y
relationship)
• Identify data to be collected following the
Apples-to-Apples Comparison Rule
• Collect data for each identified root cause
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Validation of Root Causes
• Analyze and display results using quantified
data and graphs/diagrams (discussed in Step
4: Focused Problem Statement)
– Scatterplot (Continuous vs. Continuous)
– Stratified Histogram (Continuous vs. Discrete)
– Stratified Line Graph (Continuous vs. Discrete)
– Stratified Scatterplot (Continuous vs. Discrete)
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Activity:
Prioritizing Valid Causes and Identifying
Objective Statements
• Using the Validated root causes, arrange
the root causes in order of priority.
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Validation of Root Causes
Team Date Revision No.
Problem Statement
Probable Causes Validation Controllability Conclusion
Class Description Method Result
People
Policy
:
:
:
Procedure
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Closing Point
Now that we have identified the root cause
of the problem, we can think of solutions on
how to address the root cause to reduce or
eliminate the problem.
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