6.2 Root Cause Analysis

• Even a good process can be made better.
  • Always errors, misunderstandings, incidents, unnecessary steps and other forms of waste.
• Process analyst`s job: identify and document the issues that plague a process.
  • Different stakeholders have different issues created from their perspective.
  • Same issue can be raised by different stakeholders.
• Root cause analysis = Family of techniques to identify and understand root cause(s) of problems or undesirable events.

Cause-Effect Diagrams (Fishbone diagram)

• Relationship between a given negative effect and its causes.
  • Negative effect = Recurrent issue or undesirable level of process performance.
  • Causes can be divided in:
    • Casual factors = When corrected, eliminated or avoided would prevent the issue from occurring in the future.
    • Contributing factors = Set the stage for/increase chances of a given issue occurring.
    • In this chapter there will be no distinction between those two.
• Factors are grouped into categories
  • Useful in order to guide the search for causes.
  • Well known categorization for cause-effect analysis, 6M:
    1. Machine
       • Factors: Technology used.
       • ex. Software failures, network failures, system crashes
       • Possible sub-categories:
         • Lack of functionality
         • Redundant storage across systems
         • Low performance of IT/network systems
         • Poor user interface design
         • Lack of integration between multiple systems (internal or external)
    2. Method
       • Factors: The way a process is defined, understood or performed.
       • ex. Employee A thinks employee B will send an email to the customer but employee B is not aware of this.
       • Possible sub-categories:
         • Unclear, unsuitable or inconsistent assignment of responsibilities to process participants.
         • Lack of empowerment of process participants.
           • Process participants cannot make decisions without asking permission from the people above them.
         • Lack of timely communication.
           • Between process participants, or them and the customer.
    3. Material
       • Factors: Raw materials, consumables or data required as input.
       • ex. Incorrect data leading to incorrect decisions.
       • Possible sub-categories:
         • Raw materials
         • Consumables
         • Data
    4. Man
       • Factors: Wrong assessment, incorrect performed step.
       • ex. Accepting the claim even though the data and rules suggest it needs to be denied.
       • Possible sub-categories:
         • Lack of training and clear instructions.
         • Lack of an incentive (aansporing) system to motivate.
         • Expecting to much from process participants.
         • Inadequate recruitment.
    5. Measurement
       • Factors: Measurements or calculations made during the process.
       • ex. Amount to be paid to the customer is miscalculated.
    6. Milieu
       • Factors: Environment in which the process is executed.
       • Factors which are outside the control of the company.
       • ex. Faulty data from a police report which is used to handle car insurance claims.
       • Possible sub-categories:
         • Originating Actor
  • Alternative, 4P (Policies, Procedures, People, Plant/equipment).
  • 6M/4P meant as guidelines for brainstorming during root cause analysis.
• Cause-effect diagram (Fishbone diagram)
  • Consists of:
    • Trunk = Main horizontal line (ex. Big blue arrow)
    • Effect that is being analyzed in a box connected to the trunk. (ex. Issue)
    • Main branch = Arrows from the box with one of the 6M`s to the trunk.
    • Primary Factors = Have a direct impact on the issue at hand.
    • Secundary Factors = Have an impact on the primary factors.
  • Ex. Underneath here.

Why-Why Diagrams (Tree diagams)

• Capture series of cause-to-effect relations that lead to a given effect.
• Recursively ask the question: "Why has something happened??"
  • Asking it 5 times allows to pin down the root cause of a given negative effect.
• Structuring brainstorm sessions.
• Examples see page 197