Root Cause Analysis - New Mexico State Department of Education

Root Cause Analysis
Vicki K. Chávez
Executive Director, SWREC #10
Turnaround Leader, PPE
District Shepherd, UVA Turnaround Program
Action Planning Workbook, Page 5
DEFINITION of Root Cause
• Statements describing the deepest underlying
cause, or causes, of performance challenges,
that, if dissolved, would result in elimination, or
substantial reduction, of the performance
Why Conduct a Root Cause Analysis?
• It is impossible to solve a problem in a complex
system without a good understanding of the
problem and its causes.
• Wisdom is essentially connecting consequences
(effects) and actions (causes).
Why Conduct a Root Cause Analysis?
“If you don’t ask the right questions, you don’t
get the right answers. A question asked in the
right way often points to its own answer. Asking
questions is the ABC of diagnosis. Only the
inquiring mind solves problems.”
Edward Hodnett
Root Cause Analysis is about identifying breakdowns in
systems and processes, NOT people.
An individual may be causing a problem, but a deeper
cause could be found in training, scheduling,
clarification or duties, etc.
Steps to Perform a Root Cause Analysis
• Identify the Performance Problem (data study - prioritize)
• Brainstorm Possible Causes
• Organize Possible Causes into Common Themes
(Big Why, Affinity Process)
• Fishbone to Organize Categories & Possible Causes
• Five (5) Why’s (Eliminate Causes that are not in Our Control)
• Root Cause!
Root Cause or Contributing Cause?
1. Would the problem have occurred if the cause had not been
present? If no, then it is a root cause. If yes, then it is a
contributing cause.
2. Will the problem reoccur as the result of the same cause if the
cause is corrected or dissolved? If no, then it is a root cause. If
yes, then it is a contributing cause.
3. Will the correction or dissolution of the cause lead to similar
events? If no, then it is a root cause. If yes, then it is a
contributing cause.
When is a Cause a Root Cause?
• You run into a dead end asking what caused the
proposed root cause.
• Everyone agrees that this is a root cause.
• The cause is logical, makes sense, and provides clarity
to the problem.
• The cause is something you can influence and control.
• If the cause is dissolved, there is realistic hope that the
problem can be reduced or prevented in the future.
Guided Practice
Identify the Performance Problem
Too Many Discipline Referrals
Brainstorm Possible Causes
Write 1 possible cause per sticky note
Each person, Write a MINIMUM of TWO possible
Guided Practice
Organize the Possible Causes (Affinity Process)
Each person share their cause
Decide as a team which causes “go together” and
have a similar theme or idea
Label the grouped causes with an overarching
category (ex: Process, Curriculum, etc.)
Create a Fishbone Diagram
Category 3
Category 2
Category 1
Place the category
you think is most
likely the root cause
closest to the fish
Too Many
Category 5
Category 4
Category 3
Category 2
5th graders fight in the
cafeteria everyday
FIVE (5) Why
Kids are pushing in the line
There isn’t a process for coming into
the cafeteria so all the kids come in at
one time
Too Many
Category 5
Category 4
Five (5) Why Process
Use Post-It’s for each ‘Why’ Level
Ask “Why is XYZ causing the performance problem?”
Write on post-it, stick it under the category
Ask “Why is XYZ causing the Why above?”
Write on post-it, stick it under the previous why
Continue process up to 5 Why’s or until the root has
been identified
Group Work: Scenario Practice
One team member reads the Scenario to the Group
Each team member writes a minimum of 2 possible
The team follows the Root Cause Analysis process to
organize causes using the Fishbone Diagram and 5Why Process to determine root cause.
Be Ready to Share Out
Workshop Prep
Think about a priority Performance Problem at your
school. You will be working through the Root Cause
Analysis process to identify a possible Root Cause.
References & Resources
• Ammerman, M. (1998). The Root Cause Analysis Handbook: A Simplified Approach to
Identifying, Correcting, and Reporting Workplace Errors (pp 66-67). New York: Quality
• Clark County School District: Assessment, Accountability, Research and School
Improvement. (2012). School Improvement Planning Basics: Root Cause Analysis. Clark
County, NV.
• Georgia Leadership Institute for School Improvement (GLISI); Board of Regents of the
University System of Georgia; and Georgia Partnership for Excellence in Education. (2010).
Leading a Team to Analyze Root Causes Using Quality Tools. Georgia.
• Goal/QPC. (2000). The Problem Solving Memory Jogger. Salem, NH: Goal/QPC.
• Preuss, P.G. (2003). School Leader’s Guide to Root Cause Analysis: Using Data to Dissolve
Problems. Larchmont, NY: Eye on Education.