Tools to Achieve Performance Excellence

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Tools to Achieve Performance Excellence
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A Thoughtful Approach to Root Cause Analysis

• Andrew Kirsch
• Master Black Belt
• Enterprise Excellence
• ECOLAB

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Two Philosophical Assumptions
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Three Imperfect Definitions

• Effect - A change in a state of being that
  results when something is done, or happens, or
  does not happen.
• Cause Something that contributes to producing
  an effect
• Root Cause One or a few of the most fundamental
  of a chain of causes that product an effect

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5 Whys and the Washington Monument
Problem Washington Monument required frequent,
very expensive repairs. 1. Why?
Frequent washing was damaging the monument. 2.
Why did it need to be washed so much?
Pigeon droppings 3. Why were the pigeons on the
monument? To eat the spiders 4. Why were
there spiders on the monument? To eat the
insects 5. Why were the insects there?
They are attracted to the brightly lit surface at
sunset.
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A Template for 5 Why Analysis
Effect of Interest
1. Why?
2. Why?
3. Why?
4. Why?
5. Why?

• Tips for Use
• There is nothing magic about 5, but push
  yourself to go further than 1 or 2
• At some point you may find yourself going from
  the specific to the general (poor communication,
  political gridlock, lack of motivation) - back
  up and try to be more specific

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Cause and Effect Diagram(Also called Fishbone or
Ishikawa Diagram)
Effect of Interest
Categories of Causes

• Represents the relationship between an effect
  (problem) and its potential causes where causes
  are organized by categories

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Cause and Effect Diagram

• Why - Use of categories ensure a full range of
  potential causes have been considered
• Overcome the theme effect by allowing the group
  to see the categories into which their ideas fall
  and dig deeper on those with fewer items
• How Decide on a set of major categories before
  starting to brainstorm causes
• The traditional categories for manufacturing are
  personnel, environment, machines, materials,
  methods, measurements
• For non-manufacturing use, might use the 4 Ps
  Place, Procedures, People, Policies

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Blending Fishbone and 5 Why Methods
The 5 Why method is often used with a Cause and
Effect Diagram to drill down to a root cause
Effect Cost of maintaining test kits for field
employees too high 1. Why? Must frequently
replace reagents in the kits 2. Why? The
reagents are past expiration date 3. Why? The
shelf life of many of the reagents are a year or
less 4. Why? At the time that the shelf lives
were determined, the software for recording the
official shelf life only had two choices in the
pulldown menu 6 months and 12
months! Corrective Action Qualify and document
a longer shelf life where possible
Effect Same 1. Why? Have to pay a high price
for the reagents in the quantities needed 2. Why?
xxxxxxxxxxxxx 3. Why? xxxxxxxxxxxxxxxxxxx 4.
Why? xxxxxxxxxxxxxxxxxx 5. Why? xxxxxxxxxxxxxx
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Limitations of a Simplistic Analysis

1. An effect may require two or more causes to occur
   in the same place and time
2. The analysis may be limited by the current level
   of knowledge
3. The analysis may be based on conventional wisdom
   or restricted by prejudice
4. The root cause may not be the easiest to fix
5. An effect may be part of a system loop

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A Template for Two or More Causes per Level (per
Why)
Effect 1st Level Why 2nd Level Why 3rd Level Why 3rd Level Why
Cause 1 Cause 1.1 Cause 1.1.1
Cause 1 Cause 1.1 Cause 1.1.2
Cause 1 Cause 1.2 Cause 1.2.1
Cause 1 Cause 1.2 Cause 1.2.2
Cause 2 Cause 2.1 Cause 2.1.1
Cause 2 Cause 2.1 Cause 2.2.2
Cause 2 Cause 2.2 Cause 2.2.1
Cause 2 Cause 2.2 Cause 2.2.2
Cause 3 Cause 3.1 Cause 3.1.1
Cause 3 Cause 3.1 Cause 3.1.2
Cause 3 Cause 3.2 Cause 3.2.1
Cause 3 Cause 3.2 Cause 3.2.2
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Two or More Causes per Level (per Why)
Effect 1st Level Why 2nd Level Why 3rd Level Why 3rd Level Why
Worker hurt his hand and shoulder by slipping on a wet floor, while walking through an area not intended for foot traffic Cause 1 The floor was wet Cause 1.1 The drain was not working Cause 1.1.1 Plugged
Worker hurt his hand and shoulder by slipping on a wet floor, while walking through an area not intended for foot traffic Cause 1 The floor was wet Cause 1.1 The drain was not working Cause 1.1.2 Not checked
Worker hurt his hand and shoulder by slipping on a wet floor, while walking through an area not intended for foot traffic Cause 1 The floor was wet Cause 1.2 The vessel had to be rinsed Cause 1.2.1 SOP requires
Worker hurt his hand and shoulder by slipping on a wet floor, while walking through an area not intended for foot traffic Cause 1 The floor was wet Cause 1.2 The vessel had to be rinsed Cause 1.2.2
Worker hurt his hand and shoulder by slipping on a wet floor, while walking through an area not intended for foot traffic Cause 2 The workers shoes had poor tread Cause 2.1 The shoes were 5 years old Cause 2.1.1
Worker hurt his hand and shoulder by slipping on a wet floor, while walking through an area not intended for foot traffic Cause 2 The workers shoes had poor tread Cause 2.1 The shoes were 5 years old Cause 2.2.2
Worker hurt his hand and shoulder by slipping on a wet floor, while walking through an area not intended for foot traffic Cause 2 The workers shoes had poor tread Cause 2.2 The shoes hadnt been replaced Cause 2.2.1 Thought ok
Worker hurt his hand and shoulder by slipping on a wet floor, while walking through an area not intended for foot traffic Cause 2 The workers shoes had poor tread Cause 2.2 The shoes hadnt been replaced Cause 2.2.2 Busy
Worker hurt his hand and shoulder by slipping on a wet floor, while walking through an area not intended for foot traffic Cause 3 The worker chose to go through this area Cause 3.1 Alternate route takes longer Cause 3.1.1 Plant design
Worker hurt his hand and shoulder by slipping on a wet floor, while walking through an area not intended for foot traffic Cause 3 The worker chose to go through this area Cause 3.1 Alternate route takes longer Cause 3.1.2
Worker hurt his hand and shoulder by slipping on a wet floor, while walking through an area not intended for foot traffic Cause 3 The worker chose to go through this area Cause 3.2 No barrier to prevent Cause 3.2.1 Not expected
Worker hurt his hand and shoulder by slipping on a wet floor, while walking through an area not intended for foot traffic Cause 3 The worker chose to go through this area Cause 3.2 No barrier to prevent Cause 3.2.2
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Considerations beyond Root Cause

• Tradeoffs
• Span of Influence or Control
• Legality, Propriety, Respectfulness

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Two or More Causes Reconsidering the Washington
Monument
Problem Washington Monument repairs. 1. Why?
Frequent washing was damaging the
monument. 2. Why did it need to be washed so
much? Pigeon droppings 3. Why?
Pigeons AND a food source (spiders) 4. Why?
A nearby population of pigeons Spiders AND a
food source (insects) 5. Why? A nearby
population of spiders A nearby population of
insects Attraction for the insects (brightly lit
surface).
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5 Why for an Act of Gang Violence






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Role of Evidence/Data

• Makes all the difference between conventional
  wisdom and sound analysis
• A single instance is not strong proof of root
  cause
• Each link in the chain of causes should be
  verified with evidence/data
• Physical scientific studies (e.g. chemical
  analysis)
• Statistical studies (e.g. clinical trials)
• Behavioral studies (e.g. Hawthorne effect)
• Historical data review (e.g. drunk driving)
• Is/Is Not analysis

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Is/Is Not Analysis

• Consider the what, where, when, extent of the
  problem/deviation
• What specific object has the problem/deviation?
• What is the nature of the problem/deviation?
• What similar object could have the
  problem/deviation but does not?
• What other problems/deviations might reasonably
  be observed but are not?
• Test if possible causes against the is and is not
  facts to rule out some, judge likelihood

IS
IS NOT
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Boiling it down

• Start with a fishbone diagram to enlarge your
  view of possible causes
• Use the 5 Why approach to go deep
• Be open to multiple causes at each level
• Use simple (linear) 5 Why when possible
• Be open to a system loop
• Look for data to support the chain of causes
• Decide on the root cause(s)
• Give preference to prevention at that cause
• Factor in tradeoffs, span of influence, etc. as
  appropriate

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Summary of Tools Discussed

• Fishbone Diagram
• 5 Why (Simple and Multiple Cause)
• Systems Thinking (the Loop)
• See Peter Senge, The Fifth Discipline
• Is/Is Not Analysis
• See Charles Kepner and Benjamin Tregoe, The New
  Rational Manager

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Questions?
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