Carnival of Quality Management Articles and Blogs – September 2014

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:

A root cause is an initiating cause of a causal chain which leads to an outcome or effect of interest.

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 .

Mark Paradies looks at various elements of the Definition of a Root Cause @ Root Cause Analysis Blog

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:

Part 1: A Conceptual Overview

Part 2: Practical Application

‘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

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.”

Root Cause Analysis (RCA) investigation :

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:

§ Getting started

§ Gathering and mapping information

§ Identifying care and service delivery problems

§ Analysing to identify contributory factors and root causes

§ Generating solutions

§ Log, audit and learn from investigation reports

Templates to record and share investigation findings:

§ Investigation report writing templates

§ Action plan templates

§ Other useful templates

Guidance : Background information and ‘how to’ guides

eToolkit : A framework for NHS investigations

We also have

“Root Cause Analysis for Beginners”

Root Cause Analysis – McCombs School of Business

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:

May 01, 1994

November 02, 1994

October 29, 2007

November 04, 2008

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.”

And then move over to ASQ TV Episode : Creating a Safer Food Supply explore how food safety standards and schemes ensure the safety of our food supply

· Examine the difference between ISO 9001 and ISO 22000

· Apples to Oranges?