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 challenge. 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 IMPORTANT Mindset 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 causes 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 ‘head’ Too Many Discipline Referrals Category 5 Category 4 Category 3 Category 2 Why? Why? Process 5th graders fight in the cafeteria everyday FIVE (5) Why Why? Kids are pushing in the line Why? Process There isn’t a process for coming into the cafeteria so all the kids come in at one time Too Many Discipline Referrals Why? Why? 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 causes 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 Resources. • 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.