Welcome to September 2014 edition of Carnival of Quality Management Articles and Blogs.
Our topic for the blog carnival edition of August 2014 was Corrective and Preventive Action [CAPA]. Among other things one very vital element in designing, planning and implementing CAPA is Root Cause Analysis.
For our present edition we will delve deeper into this subject.
We begin our search with what Wikipedia has to say:
In plain English a “root cause” is a “cause” (harmful factor) that is “root” (deep, basic, fundamental, underlying or the like).
The term root cause has been used in professional journals as early as 1905.
Ivan Fantin (2014) describes the root cause as the result of the drill down analysis required to discover which is the process that is failing, defining it as “MIN Process” (meaning a process that is Missing, Incomplete or Not followed .
The most basic cause (or causes)
that can reasonably be identified
that management has control to fix and,
when fixed, will prevent
(or significantly reduce the likelihood of)
the problem’s recurrence.
The salient aspects that emerge from this definition are:
First, when one finds a root cause, one has found something that management can fix that will prevent the problem’s recurrence. This is a key because it keeps one looking until a fixable solution can be found.
Second, the definition targets problems that are within management’s grasp to fix.
Third, the definition helps answer the always troubling question of how much investigative effort is enough.
Fourth, the definition implies that a problem may have more than one root cause.
Moreover, a root cause has these identifying characteristics:
1. It is clearly a major cause of the problem symptoms.
2. It has no productive deeper cause. The word “productive” allows you to stop asking why at some appropriate point in root cause analysis. Otherwise you may find yourself digging to the other side of the planet.
3. It can be resolved. Sometimes it’s useful to include unchangeable root causes in your model for greater understanding. These have only the first two characteristics.
4. Its resolution will not create bigger problems. Side effects must be considered.
5. There is no better root cause. All alternatives have been considered.
Root cause analysis is an approach for identifying the underlying causes of why an incident occurred so that the most effective solutions can be identified and implemented. It’s typically used when something goes badly, but can also be used when something goes well. Within an organization, problem solving, incident investigation and root cause analysis are all fundamentally connected by three basic questions: What’s the problem? Why did it happen? and What will be done to prevent it?
ASQ considers Root cause analysis as a collective term that describes a wide range of approaches, tools, and techniques used to uncover causes of problems.
ASQ Fellow Jim Rooney walks through the basics of root cause analysis:
‘What is Root Cause Analysis?’ covers ‘The origin of root cause analysis; Understanding root cause analysis; and The Future: Inductive, Intuitive, and Automated RCA’
“DevOps teams often spend far too much time treating recurring symptoms without penetrating to the deeper roots of software and IT issues, making the extra effort to solve problems at their source. But as every doctor knows, plenty of time and money can actually be saved by figuring out exactly why problematic symptoms appear in the first place. Approaching problems with an eye to unearthing such basic casual factors is called root cause analysis, and, as in the case of the smart doctor, it can greatly aid your efforts as a system administrator, developer, or QA professional to prevent a lot of unnecessary suffering.”
The site also offers Further Resources
- Velaction’s 5-Whys Worksheet
- A sample root cause analysis: The Challenger Space Shuttle Explosion
- “Root Cause Analysis for Beginners” (PDF)
- Mind Tools on Root Cause Analysis
- RIMS’ Root Cause Analysis Overview (PDF)
Root Cause Analysis – Tracing a Problem to its Origins notes that “you can use many tools to support your Root Cause Analysis process. Cause and Effect Diagrams and 5 Whys are integral to the process itself, while FMEA and Kaizen help minimize the need for Root Cause Analysis in the future.”
Every day a million people are treated safely and successfully in the NHS.
However, when incidents do happen, it is important that lessons are learned to prevent the same incident occurring elsewhere. Root Cause Analysis investigation is a well recognised way of doing this.
Investigations identify how and why patient safety incidents happen. Analysis is used to identify areas for change and to develop recommendations which deliver safer care for our patients.
RCA investigation resources:
Tools to help with the investigations process:
Templates to record and share investigation findings:
Guidance : Background information and ‘how to’ guides
eToolkit : A framework for NHS investigations
We also have
Finally, Root Cause Analysis of the Failure of Root Cause Analysis is not recommending to abandon root cause analysis and Five Whys, but exhorts to realize that no technique should be automatically applied in every situation.
Before we stop for day, a satirical insight is indeed called for:
We turn to our regular sections now:
In “The Future of Quality: Evolutionary or Revolutionary?, ’ Bill Troy, ASQ CEO has set the stage for a lively debate in the days ahead and looks forward to reporting what he would see and hear from the quality professionals, whom he exhorts by “who hold the keys to our future in your hands”.
Julia McIntosh, ASQ communications reports in Blogger Round Up for August 2014, What’s The Future of Quality?, that the Influencing Voice blogging community is well distributed in for “Evolutionary” and for “Revolutionary, with fairly representative share of “Both / And” as well as “Other” views. The article ends up with a defining statement from Michael Noble : “…that ultimately change will not be driven just from within the professional community because the real driver of change comes from public demand on one issue or another.”
· Examine the difference between ISO 9001 and ISO 22000
Related videos :
- Conversation With a Food Safety Consultant
- A deeper look at HACCP and ISO 22000
- The Lighter Side: A Chef’s Unique Approach to Standards
We have one more video this month: The Culture Craze :“Think your organization has a quality culture because employees faithfully use approaches and methods to improve processes? Think again. In this episode of ASQ TV, we learn the distinction between culture and compliance, and we review key culture findings from a global study by Forbes Insights and ASQ. We also look at ways to “millennialize” your workplace.
Our ASQ’s Influential Voice for the month is – Nicole Radziwill
Nicole Radziwill is an assistant professor in the Department of Integrated Science and Technology at James Madison University. She writes about research in the quality field, quality consciousness, and innovation. 100% of the proceeds from her consulting support the Burning Mind Project. She also enjoys references to quality in fiction & drama. Her blog is Quality and Innovation, exploring quality, productivity & innovation in socio-technical systems.
Here are some of the recent posts on the blog:
- The Power of RCUS
- The Future of Quality is Revolutionary
- What is Innovation? Towards a Universal Definition
- Quality as a Cultural Vision: My Week in Japan
- Continuous Permanent Improvement
- Baldrige as a Micro-Framework for Organizational Planning
- Quality in Education Part 3: Drive Out Fear. Teach Quality Standards.
- Quality in Education Part 2: There is Power in Variation
- Quality in Education Part 1: The Customer Service Mentality is Flawed
- The Best Book Ever on Machine Learning (and Intelligent Systems) in R
- We’re Back Online!
- Is the Manufacturing Outlook Sufficiently Far-Reaching?
- Getting Deep With Value Creation
- Thrivability: A Sneaky Awesome Little Book About Innovation
- What #BIF9 and Burning Man Taught Me About Transformation – Part II (via Deming!)
- What #BIF9 and Burning Man Taught Me About Transformation – Part I
We do not have a fresh insight this month in so far as Curious Cat Management Improvement Carnival category is concerned.
However , in such an event, we do pick up an interesting article posted recently. We pick up Peter Drucker Discussing The Work of Juran, Deming and Himself for our present edition.
“All 3 of us knew quality doesn’t cost, and accounting was a snare and a delusion because it hides the cost of not doing… cost accounting doesn’t measure these things.”
I look forward to your active participation in enriching the blog carnival as we pursue our journey …………….