Accurately Getting to the Root Cause
I had no idea the difficulty in solving a root cause problem when I was first asked to solve one for a major client. I want to share what I have learned because these insights might be helpful for others who undertake root cause analysis in the future.
I identified some practical pitfalls we experienced. Sometimes what we identify as root causes are actually solutions. Being specific and meticulous about identifying the root cause can reduce variation and prevent the recurrence of the problem.
For this project, I took the initiative to read over five in-depth articles, watched two one-hour webinars, studied one ASQ book on root cause analysis, and researched countless websites. In addition, I received over ten hours of root cause analysis coaching from my senior managers.
Beware of the Solution Masquerading as a Root Cause.
Sometimes solutions are incorrectly accepted as root causes. For example, a mislabeled carton might get assigned a root cause of “all closed cartons look the same.” This implies that the only solution is to make the cartons look different, which locks us into a potentially incorrect solution.
The real cause might be that people do not know what is inside the closed cartons because the label is applied after the cartons are closed.
By phrasing the root cause in this way, we open up the possibility of simply adding the labels before we close the cartons. This saves us from making a costly and unnecessary investment into new cartons.
Avoid the Hasty Conclusion.
I quickly realized that people often have a tendency to want to skip past the root cause phase and jump right into the solution phase.
We might get excited about insight and want to move straight to the solution, but first we have to challenge that root cause in meticulous detail. This is painstaking but we are better off finding flaws in our logic before rather than after implementing a faulty solution.
In our example above perhaps our true root cause is that we have a “just-get-it-done” culture. Employees often do not question what is inside the carton, so they label the cartons as they normally would.
Do Not Rush the Learning Process.
I also observed that many of us may tend to assume that we already have strong root cause analysis skills. In reality, we mostly see the surface level of cause and effect when the root cause could be something much deeper.
In fact, upon closer examination, every one of our knee-jerk solutions to the problem turned out to be ineffective in actually solving the root cause.
By the end of the project, we uncovered seven root causes that fall under the categories of process, design, and culture. Some are more economically feasible than others and some offer greater risk reduction.
Considering the tradeoffs involved, the right decision is going to depend, in part, on collaborating with our clients to work on what works best for their needs and constraints.
Root cause analysis is a skill that must be developed and practiced over a long period of time. As with any skill, deep learning and practicing are critical. Unless you are regularly practicing, you can bet your root cause analysis skills need improving.
Learning takes time. Improving takes time. This first experience was challenging, and realistically I do not expect to reach a point where finding root causes will just be routine and easy. I have a lot of experience and research ahead of me before I can consider myself close to being a root cause analysis expert. My plan is to keep learning and keep sharing so that we improve as an organization.
This article was originally published in the April 2014 edition of ASQ’s Quality Islander newsletter.