Senior Management’s role in Root Cause Analysis Investigations
Provide a well-defined and clearly communicated strategy to guide project or investigation team members and other stakeholders
Ensure that project selection or RCA investigations are (internal/external) customer focused
Empower the project or investigation team members to find and implement sustainable solutions
Pick experienced project leaders or investigative team members to ensure success
Select projects or RCA investigations that are consistent with company Strategy
Review projects or RCA investigations and incorporate lessons learned in new projects
Use Define, Measure, Analyze, Improve and Control tools (see table -1) to improve processes, systems, and people issues in relationship to the organizations strategic plans and goals.
# Step Process improvement Process design 1. Define - Identify Problem - Identify problem - Define requirement - Define goal or change vision - Set Goals - Clarify Customer Requirement 2. Measure - Validate Problem - Measure Performance - Refine Goal - Gather Process Efficiencies - Measure Key Performance Inputs - Accountability for KPI’s 3. Analyze - Causal hypothesis - Identify best practices - Identify Root Causes - Access process design - Validate Hypothesis - Value/Non Value Add - Identify bottlenecks or disconnects - Alternative paths - Refine requirements 4. Improve - Remove Root Causes - Design new process - Test Solutions - Challenge assumptions - Standardize fix - Work flow design - Measure results - Implement 5. Control - Standardize measurement - Standardize measurement - Correct as needed - Correct as needed. Table-1: DMAIC Process Overview
The use of the various project improvement tools and Root Cause Analysis investigation tools and techniques will allow you to better meet or exceed your (internal/external) Customers Critical Criteria. Anything that fails to meet the Customer’s Critical Criteria requirements and/or expectations is considered a “defect”.
Defects can occur in your product or service processes, in your human interactions, in your delivery processes, accounts receivable, sales, marketing, R&D, etc. Everything in your business has at least one opportunity for a defect and most have many opportunities.
Again this brings us back to the fundamental principles of improvement project selection or Root Cause Analysis investigation requires that we solve problems, efficiently and effectively. Figure-1 shows the relationship of customers to your business and to your suppliers.
Figure-1: Relationship customers ( Business ( Suppliers
Defects can come from a variety of sources; essentially anywhere there is a supplier to customer chain process.
There are significant benefits to be gained from eliminating the defects that are important to the (internal/external) customer critical criteria and those of your business processes.
Figure-2: Area’s for potential improvement projects
All too often, these defects and improvement opportunities are not considered as part of the Cost of Poor Quality.
Figure 2 shows some of the areas for potential Improvement projects and Root Cause Analysis investigations that should be made using the application of the tools, techniques and methodologies of Six Sigma and Safety. Most of these costs are under the surface, as this figure 2 depicts.
Everything starts with the organizational strategy, goals and plans. As shown in Figure 3, implementation of the Strategic Plan involves two separate implementation paths, which both are essential for success: People Development and Improvement of Processes and Systems.
Figure-3: Path’s for implementation of the Strategic Plan
Following one Strategic Plan implementation path to the exclusion of the other will not be as effective as following both in a synergistic approach. There are distinctly different tools and techniques for each.
A Strategic Plan is the organizational actions in the marketplace that produce a competitive advantage. If not all three elements are present, then we contend that a working strategic plan is not in place.
There are many ambitious statements that direct the development of a strategic plan. However, until you can define the organizational actions intended, the market place where those action occur, and the competitive advantage that will result from taking those actions in the defined market, you do not have a Strategic Plan.
As with most things, the use of Six Sigma tools techniques and methodologies can be very simple, or very complex. We recommend that in all areas you start with the simple approaches first and monitor the results.
Tools and techniques that are more complex can always be brought to bear on a specific situation as the need develops. Our maxim is “Make the tools work for you not you working for the tools.”
The objective is to get to a solution using a process that can be taught to a number of other people so they too can become better problem solvers. There is no value added for using tools and techniques just to demonstrate that you can.
The mark of the professional is to understand what tool or technique is needed for a given situation, and then using them competently.
One of the benefits of Six Sigma is the structure provided for completing projects and Root Cause Analysis Investigations. Six Sigma tools may be used in a variety of places; much of the strength of Six Sigma is in the alignment with the organizations strategic plan and then completing projects in a structured fashion.
And so it is with Root Cause Analysis Investigations. That project improvement process and RCA investigation sequence is; Define, Measure, Analyze, Improve, and Control or (DMAIC).
Listed in the table-2 that follows are the various Six Sigma process improvement and deployment phases, along with some of the tools and techniques that are commonly used during each phase.
Many of these tools have application in multiple areas and the skill sets are transferable. This table is intended as a simple guide for your consideration. It is not intended to be a cookbook.
Most all of us will develop, and elect as a first choice, tools that become our personal favourites for a given situation or circumstance. Do not allow your preferences to prejudice or blind you regarding the selection of other equally important Six Sigma tools or techniques.
The following are potential tools that can be used for each Six Sigma Project execution phase. It should be noted that the tools can be used as needed or desired for any execution phase. Let’s take a brief look into the project phases, the potential tools we can use and the intended deliverables of those tools.
Phase Potential Tool or Technique Deliverables Strategic Planning Values, Beliefs, Principles General Guidance Vision Where the organization is headed Mission What the organization does Vision Elements Key Areas of Focus for the Current Planning Cycle Key Performance Indicators
(KPI) Important Areas for Improvement Objectives General Results for each KPI Goals Objective Measurements of desired KPI levels Plans Details Affinity Diagram Group Common Ideas Matrices Multiple Comparisons SWOT Strengths, Weakness, Opportunity, Threats Market Analysis Competitive Advantages People Development
Behaviour Profile Understanding self and others social styles strengths and weaknesses Versatility Working with different styles, reducing interpersonal tensions and improving productivity Skills Training (See PSM) Demonstrate competence Change Equation Provide understanding of self and others personal values and beliefs Goal Accomplishment Goal setting and achievement process
Team Training Phases of team growth. Forming, Storming, Norming and Collaborating Personal Interest and Values Understanding individual and team interests Communication Skills Skills of Listening, writing, speaking Situational Leadership Leader and subordinates styles of Directing, Coaching, Supporting, and Delegating. Directing Specific formative instruction for new employees or new to the job function Coaching Leaders skills of coaching those who are still developing job and personal competency Supporting Leadership skills designed to build Confidence in individuals who have demonstrated job competency Delegating Leadership Skills for Decision making on an independent level Black Belt Career Path Future Leaders Recognition Reward Systems Motivation, Inspiration, Esteem Meeting Management Purpose, process and pay-off of Planning, conducting and documenting meetings Define Project Charter Scope boundaries, time lines and constraints, team High Level Process Map Start/Stop, Major Process Steps, Customers, Process Name, Process Owner Critical Customer Criteria Things that matter to the customer Market Research Critical Customer Criteria Feasibility and Magnitude Potential Gain, Estimate of Time and Effort Is/Is Not What is included and what is excluded from a project Measure Financial Indicators Cost, Margin, ROI, Comparison to Standard DPU, DPMO Defect Rates Per unit or Opportunity Average and standard deviation Mean and Variation of Data CpK, Sigma Level, MSDT Performance vs. Specifications includes mean and standard deviation Evaluate Measurement System Accuracy and Precision Yield Through Put Yield, Rolled Through Yield Control Charts Difference between Common Cause and Special Cause Variation Customer Critical Criteria Actual Performance Comparison Analyze Identify Key Variables Identify the important things that change Correlation Things that change together Regression Model Parameters FMEA Determine Risk Priority for Potential Failures or Defects Fault Tree Why and incident or defect occurred Detailed Process Map Document all steps in the process reduces complexity Cause and Effect
(Fish Bone Diagram) Potential Causes classified as manpower, methods, machinery and materials Pareto Rank by impact or contribution F ratio Compare Variances t-test Means vs. a Value ANOVA Compare means, model fitting Cycle Time Length of time for all process steps Reliability Engineering Probability that the intended function is not performed for the time specified Histograms Unusual shapes or patterns in data Run Charts Data in time series for patterns trends, etc. TRIZ Learn from other disciplines Relationship Diagram Root Causes 5 Why Root Causes Improve
Gantt Chart Progress vs. Plan Design of Experiments Optimization, Key Variables, Interactions Evolutionary Operations Iteration to better performance Set limits on Parameters Limits to provide optimal performance Management of Change OSHA Documentation Standard Control Control Charts In statistical control Procedures Standard Work Practices Audits Confirm that improvements and results are still in place Story Boards Share project experience with others Customer Critical Criteria Performance over time Presentation Skills Effective Reporting and Sharing of results Training and Testing Demonstrated Competence CpK, Sigma Level, MSDT Maintaining the gains Lessons Learned Project successes and learning opportunities
Many writers and experts have elaborated on the specifics of Six Sigma statistical tools and techniques. Our intent here is not one of rehashing the specifics, but rather it is to remind never to forget the tools and techniques are there to improve your successes as problem solvers regarding your involvement in either improvement projects or root cause analysis investigations.
In and of themselves, none of these tools has any intrinsic value. Do not use these tools and techniques in isolation. Effectively couple the tools with your other training and experiences. For Six Sigma project executions we use the project discipline of Define, Measure, Analyze, Improve and Control -- DMAIC.
All of us have acquired formal education and vast work experiences over the course of our working careers. Combining this knowledge with the tools, techniques and structure of Six Sigma can add to the problem solvers successes regarding efforts to deliver World Class performances.
Additionally, training provides assurance that people have some detailed level of competency and skill in using many of these tools and techniques as part of an improvement project effort.
As with any tool it is possible for the user to become “rusty” if they have not used the tool in awhile. Most of us have heard the saying, “if you do not use it, you will loose it.”
Ten Steps of Continuous Improvement to Achieve Desired Business Advantages
Fix obvious problems with obvious root cause solutions anytime in the opportunity improvement processes.
Identify and select the most important “opportunities” for improvement towards gaining achievement of desired business results as a distinct business advantage.
Team uses process product or service defects, accidents, incidents, surveys, brainstorming and Pareto charts in selecting potential performance improvement opportunity projects.
The team prioritizes select opportunities for release as a performance improvement project.
Brainstorming is used to collect and generate performance improvement opportunity ideas from a team. Steps include:
Team sets basic interaction and code of conduct ground rules.
Facilitator clearly defines the purpose for the listing of ideas to be generated by the brainstorming session.
Facilitator ensures that everyone gets a turn to comment and actively participate during the brainstorming sessions.
Facilitator allows only one idea per turn (verbal or written on 3M Sticky Note).
The facilitator can begin the verbal idea collection process with one team member, recording the idea and then moving in sequential order until each team member has had an opportunity to participate.
During the verbal brainstorming session the team members can say “pass” on a turn when they have no offering and still can comment on the next turn.
Wild ideas are okay.
Facilitator should allow no criticism of ideas.
The team should be encouraged to build on other people’s ideas.
The facilitator should ensure the recording of every idea or the collection of all sticky notes and attaching each to a flip chart.
The facilitator should enforce the teams agreed upon ground rules.
The brainstorming session is over when either all team members pass twice in succession or when the idea pool dries up – no more 3 M Sticky Notes being written for posting.
Team determines their customers, services, and/or their mission
Team then writes out a clear problem statement for the selected improvement opportunity as it currently exists or “Defines” the accident or incident.
Teams should use tools of brainstorming, Pareto charting, the preliminary incident report, and/or survey’s to accomplish this step.
The team identifies the key processes and constructs flowcharts, or process maps, to allow the team to more clearly recognize opportunities for improvement of this defect, accident. Incident or improvement opportunity.
Team should agree on key items for measuring (internal/external) customer satisfaction requirements. (The team must understand Critical Customer Criteria requirements to satisfaction regarding the problem and improvement opportunity.)
Team should establish goals for improvement for the defect, opportunity or incident they have selected as a performance improvement project for execution.
Teams should use the tools of brainstorming, Pareto charting, and flow charting tools to accomplish this step.
Team should agree on aspects of “performance” to measure
Team and their customers should set goals for continuous improvement to meet or exceed Critical Customer Criteria expectations.
Team should take realistic measurements of current performances and set attainable goals for the improvement opportunity (or incident) for which they are currently focused.
Teams should use the tools of brainstorming, fish bone diagramming, and Pareto charting tools to accomplish this step.
The team begins the process of exploration into probable causes and barriers to their identified improvement opportunity or incident.
Team should refer back to their flowcharts, (step three) of the process under investigation for improvement, to locate which steps have the greatest impacts on the desired outcome of the entire process they have under study fro improvement.
Teams should focus on fixing the most critical problem or barrier to performance excellence that would delight the customer as a first priority.
Teams should use the tools of Brainstorming, Fish Bone diagramming and Pareto charting to accomplish this step.
The team gathers and evaluates the data regarding the probable causes and barriers they identified in step five.
Once this information and data is collected it will them be able to provide the team with a benchmark against which they can measure their future performance improvement progress.
Team should use the tools of Pareto charting, Run or Control Charting, and Histogram tools to accomplish this step
The team is now ready to devise and implement a fix of the root causes to the opportunity for improvement they have identified.
Implementation of the “fix” is based on the team’s premises of the problem,
identified probable causes and barriers, and their collection and evaluation of the
data.
Devising a permanent fix to the problem must be the careful and vigilant focus of the team.
Implementation of the permanent fix solutions must be well planned, clearly written, and well executed by the team in order to obtain the desired business results.
This step requires the team to continue to collect data and monitor the implementation process to assure they can confirm their root cause fix is working properly, and is satisfactory in solving the original problem.
Teams should use the tools of Pareto charting, Run or Control Charts, and Histograms to accomplish this step.
The team must decide if the problem has been satisfactorily solved. Only sustainable improvements can be considered “resolved”.
If the problem continues, or the desired improvement has not been fully met, the team should return to steps seven, five or one, of this continuous performance improvement processes.
If the problem has been solved, to the desired levels, the team can proceed on to step ten.
Step ten of the process requires the team to standardize the fix as a part of normal operating practices and operating discipline.
The second half of this step is for the team to celebrate their successes, recognize all contributors and have fun!
Now the team can select the next prioritized item on their improvement opportunity or RCA investigation list as a new project.
Sunset if Team was assembled to provide RCA and Corrective Actions for Customer Critical Criteria Emergency
Good luck and blessings to each of you,
Charles Wilson, Ph.D.
Marco Klootwijk, B. Sc. – Black Belt
http://treqnauniversity.org/default.aspx
About the authors:
Charles E. Wilson, Ph. D. is President/CEO of Lakota Training & Development. As well he owns and operates LTD Publishing and Six Sigma Doctor. Wilson is the author of several books, including "Six Sigma Deployment". He serves on TreQna Board of Directors, the Board of Directors for Brazoria County Dream Center, and has responsibility for knowledge development for TreQna University.
Dr. Wilson holds multiple degrees in Psychology. He is a motivational speaker, training facilitator, training developer, management coach, business improvement consultant, and author. Charlie has 36 years of experience in the business and coaching worlds.
Marco is from the Netherlands. He serves as an Idea-generator for Process Improvements in the broader sentence.
Marco has over 10 years of working experience. Over 4 years of which was spent in the molding industry, where he dedicated most of his time to optimizing the production and programming of CNC-machining for mould cavities.
Marco has also 4 years of experience in developing, implementing and optimizing (production) processes for High-End parts for the Hearing Aid industry. Currently Marco is employed at a High Technical Company in the Netherlands.
Marco holds a Bachelor degree in Precision Techniques is a certified ASQ Black Belt and has followed several trainings in Lean Manufacturing and Change Management.
Root Cause Analysis & Investigation - Data Booklet
Copyright by Charles Wilson, Ph.D. and Marco Klootwijk, B. Sc. & Black Belt
Page 1 of 11 Pages
Additional Costs of Poor Quality
15-20%
Root Cause Analysis Investigations
TreQna University www.treqnauniversity.org