Root Cause Analysis Understanding

Understanding Root Cause
Analysis
Presented by:
Lean Advisors, Inc
877-778-6413
www.leanadvisors.com
corp@leanadvisors.com

Key to Problem Solving
Go see in
Gemba
Involve the
process
owners
Focus on
root cause
Implement simple
solutions first
Understand
Customer
Copyright ©2012 Lean Advisors Inc.

Lean is a simple
strategy that focuses
on the elimination of
waste, variation, and
work imbalance.
Each step must
create Value for the
Customer.
What is Lean?
Copyright © 2013 Lean Advisors Inc.

Who are the Customers?
• From a Lean perspective we consider the
Customer as the end user of the Product or
Service we provide.
• Internal Customers are important in some
cases, however we must always ensure we are
meeting the end-users needs.

Lean Results
• Lead Time
• Cost
• Resources Required
• Space
• Inventory
• Errors
• Customer Responsiveness
• Capacity
• Employee Satisfaction
• Flexibility

Waste Definition
Waste: Any activity that consumes time, space or
resources but does not add value to the product,
service or other deliverable as viewed from the
perspective of the external Customer.

Types of Waste ( U- WIT – D – MOP )
 Unused Creativity / Talent / Injuries
 WAITING (patients / providers / material)
 INVENTORY / Incomplete / Piles
 TRANSPORTATION / Transactions / Transfer
 DEFECTS / Wrong info. / Rework /
Inaccurate info.
 MOTION / Finding Information / Double entry
 OVERPRODUCTION / Duplication / Extra
info.
 PROCESS / Extra Steps / checks /
workarounds

1. Defining
value from
customer’s
perspective
2. Mapping
the Value
Stream
3. Creating
Flow
4. Working
to the Pull
of the
Customer
5. Seeking
Perfection
How to Eliminate Waste?
Apply The
5
Principles
of Lean

Enterprise Value Stream Map
Understanding of the end-to-end process capturing both Value add
and Non-Value add activities as well as formal and informal
Identify Product/Service Families
Future State
Map
Current State
Map
Develop
Implementation
Plan
Current State
Understanding the Current
State
Future State
Designing a Future State
Implementation
Plan
Develop a plan to achieve the
future state

Problem Recognition
Facing reality is the first step
The 1st
step:
seeing the
problem
Do you
believe it’s
a problem?
“Some
defects are
going to
happen”
“We need to
test”, “we
need to
inspect”
“This is a
tricky
process”
“Cosmetic
defects will
always
happen”
“It’s out of
spec but it
passed the
test”
“The quality
manager
needs to
decide...”

Anything that "goes wrong" is a problem
Problems occur in all parts of all
businesses
Defects (in-house or in the field)
Equipment breakdowns
Injuries
Losing a sale, losing a customer
Losing an important employee
PS & CA can apply to any problem
Problem Recognition
Problems are really opportunities to make
something better

It's probably a "problem" if…
It feels frustrating and annoying
It negatively affects performance
It happens more than once
The process yields a less than desired
outcome
Outputs vary for unknown reasons
Problem Recognition
“Learning to See” is part of both
the lean and PS &CA processes

The 4 steps of the problem solving process

Describe the
Problem
Develop a focused,
specific statement
that describes and
quantifies the
unsatisfactory
situation.
Keep the
statement
simple
Be sure the
statement has
impact
Can everyone
clearly
understand the
unacceptable
condition?
Describe the Problem

Describe the Problem
Three
common
errors in
describing
problems
Stating the solution in the
problem statement
Not: We need to increase our
IVR penetration
Rather: Our customer service
levels are consistently below
our service level agreement
target of 90% with an
abandonment rate of over 40%
Too large a problem
(not adequately scoped)
• Not: Underwriting has a 50%
reject rate
• Rather: Only 40% of all new
transactions are underwritten
automatically through the
scorecard, down from 80%
this time last year
Vague problem
statements
Not: Customers complain about
wait time for customer service
Rather: One of ten customers
experience hold times of > 5
minutes when calling customer
service

Metrics
• Provide an objective measure of the “health” of a
process and provide feedback for problem solving
 Personal health measures: weight, blood pressure, cholesterol levels
 Business measures: profitability, quality, timeliness of service or product delivery
• Metrics tell us if we are solving the “right” problem.
 Without the correct metrics we may be “solving” a symptom and not impacting the
root cause issue
• Tells us if we are getting the desired results from the
solutions we implement
• Help us to maintain our gains and make further
improvements

Example: Fishbone Diagram
Methods Materials Men and Women
Measurement
Machine
Mother Nature
Procedures
not followed
Inadequate
documentation
about similar
problems
Unattended
calls at night
World-
wide
Customers
Constant
interruptions
Inadequate
documentation
Wrong inform-
action provided
Customer questions
versus complaints
Wrong information
provided
Lack of engineer
support to define fixes
Lack of
training
Inexperience
Short of personnel
High
turnove
r
Weekend days counted
in total days
System downtime
System takes 24 hrs to
refresh
All complaints carry
same weight
Why are
customer
complaints
not being
resolved
within 24 hrs?
Source: Transactional Six Sigma and Lean Servicing

5 Whys
• When you need to
implement corrective
action of a problem
and want to be sure
your actions will
address the root
cause and not just the
symptoms of the
problem
• Question “why” a given
situation exists or
condition has occurred
• Document the response
• Evaluate the response
asking “why” did this
happen or “why” is this
true
• Document the response
• Repeat the process until
root cause of original
problem is determined
• Method of breaking
down a problem to the
root cause
• Used for problem
analysis and problem
identification
5 Whys is a method to arrive at the root cause of a problem
Root cause to the problem

Asking of the question Why five
times will uncover the Root Cause of a problem.
Q1. Why did the machine fail?
Answer: The motor burned out.
Q2. Why did the motor burn out?
Answer: The shaft seized.
Q3. Why did the shaft seize?
Answer: There was no lubrication.
Q4. Why was there no lubrication?
Answer: The filter was clogged.
Q5. Why was the filter clogged?
Answer: It was the wrong size mesh!
Root
Cause
32
Ohno’s 5 Why’s

5 Why Considerations
• The “why” asked at each stage needs to be thoughtful
and relevant and capture the “moment of cause”
 see the actual place, parts, process and people
• After each “why” is asked there must be
an exhaustive analysis to arrive at the answer.
• The answer to the discrete “why” should lead to a
logical conclusion or cause.
• These same techniques apply to a state of “non-
detection” where we ask “why” the problem did not
get caught.

When Is 5 Whys Most Useful?
•When problems involve human factors or
interactions.
•In day-to-day business life; can be used within or
without a Six Sigma project

• Why did the problem not get caught?
• Ask “why?” 5 times
• Find the “moment of cause”
• see the actual place
• see the actual parts
• see the actual process
• see the actual people
• Don’t skip this step, it teaches you too
much!
5 Whys-Root Cause of Non-Detection

What to Avoid
“Knowing the answer” coming into the exercise
Rushing through the 5 Why’s
 Not doing sufficient analysis at each stage
of the exercise
 Not investing adequate time in developing
thoughtful questions

Gemba Walks are an important Lean tool that should be used routinely:
 To help you become aware of any existing abnormalities,
 Immediately deal with hazardous and unsafe conditions,
 Verify established standardized processes,
 Solve problems or correct errors and
 Create a more efficient and effective working environment and
workforce.
GEMBA WALK “Go, See, and Observe”

Questions
to ask on
a Gemba
Walk
Is there a Visual Management System in place? Are the problems visible?
Is the working environment safe and Lean? Is the 5S system in place being sustained?
Are the required information, measures, and metrics displayed and updated?
Are there any Standardized Work Sheets (SWS) posted?
Could you easily identify the state of progress?
Is the work ahead or behind schedule?
Is there an efficient level of Work-In-Process (WIP) and Finished-Goods (FG) materials
available?
How are the products and processes developed?
What fulfillment systems are in place from order to delivery?
Is the machinery and equipment running and in good condition?
Do you see any leakage or damage?
Do you hear any abnormal noise?
GEMBA WALK + 5 Whys (Root Cause)

Propose and Implement Countermeasures
How to Solve the Problem
Creative Countermeasures
When implementing the solution, consider the
following:
• What are the consequences/contingencies?
• Who else will be affected (suppliers/customers)?
• What is the implementation plan?
• Who needs to do what? Include time frame

Determine Tasks to be Accomplished
Roles and Responsibility Matrix
New Documents, Checklists
Training Plan
New Reports
Metrics for New Process
Complete Standard Work Sheets
Other Deliverables from Team
Charter

Special Offer
Contact Us:
877-778-6413
corp@leanadvisors.com

Root Cause Analysis Understanding

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