Root_Cause_Analysis.ppt

Here is an overview of the course content. We will review the definition of root cause, the benefits of performing root cause analysis, review a recommended problem solving process that contains the root cause analysis step, provide examples of problems addressed to root cause, things to keep in min...

Here is an overview of the course content. We will review the definition of root cause, the benefits of performing root cause analysis, review a recommended problem solving process that contains the root cause analysis step, provide examples of problems addressed to root cause, things to keep in mind when performing this analysis, And finally a summary review of the course Upon completion of this course, participants will be able to: Understand the importance of performing root cause analysis Identify the root cause of a problem using the problem solving process Understand the application of basic quality tools in the problem solving process Root cause definitions. Feel free to add your own Root cause analysis is part of a complete corrective action process. Getting to root cause is only half the battle. Preventing the root cause requires many more additional steps Here are the benefits for why your company should take the time, on every problem, to analyze down to the root cause When should we perform root cause analysis? All the time! When you do not dig deep enough into the detail of these problems, you should expect them to continue to reoccur time and time again Here is the usual versus preferred approach to problem solving. In most companies, when a problem surfaces, we firefight and try to put out the “fire” immediately. This involves some kind of quick fix or work around to keep the process moving. Just as we find an acceptable “band aid” fix that works, another “fire” starts somewhere else and we rush to fix it. We never take the time to revisit these “fires” to figure out why they happened in the first place. We keep dealing with the same problems over and over again. The preferred approach is similar. First, we develop a quick fix for the problem. However, instead of rushing to the next issue of the day, we take some extra time to do root cause analysis so that same problem is not tomorrow’s big “fire” Here is a basic example of how to attack a problem with the problem solving process. These are television sets with a defective screen that escapes to the customer. Customer can be used as the internal customer (another process area) or the typical external customer (who pays for the product or service) Contain the problem. Make certain that the group (customer in this case) that finds the problem does not see it again! Once we better understand where the problem originates, we isolate our containment around that process, and allow the other processes to operate normally. These processes should not see the problem return. Finally, once root cause is determined and prevented through process changes, the containment efforts should be lifted and the new process should no longer create defects resulting from the same root cause. There are three types of corrective actions. Immediate is the action done to “stop the bleeding” Permanent is typically done on a specific area or product to prevent the root cause from recurring. This is where most companies stop. Preventive is changing the process so that problem does not reoccur again in that area, or any other area in the future. This forces departments and groups to break down walls and communicate for the good of the company. Here are some more examples of the difference between Permanent versus Preventive. Class attendees should start to see what we mean by root cause. Feel free to add your own company examples. A common, simple and highly recommended 8 step problem solving process. NOTE: This graphic is used on other slides, so if you customize this graphic, you will have to make changes to the other process steps, or remove those smaller graphics The first, and one of the most important steps, is to identify the problem to address. Meetings can be drawn out and lose focus when the problem is unclear. It is very easy for teams to use the meetings as opportunities to address other issues at the same time. The 5 W’s and 2 H’s approach can help you get there. Simply answer the who, what, where, when, why, how, and how many to help better define the problem. A description of the 5W2H questions In most cases, a team of affected individuals should be brought together to discuss the issue. Problems can arise when the right people are not involved. Try and keep the team between 4-10 people. More than that can slow down the process It is recommended that the team assigns a “Champion” to oversee the problem until it is resolved. They may play an active role in the discussions, or simply make certain the teams are meeting and that progress is being made. May also be responsible for taking issues up to leadership As the problems become more defined and analysis starts to drive the team in one direction, it is normal for the team members to change. Initially, step 1 will have the most team members, and towards the end of this process, maybe only one or two people are still actively working the issue. During the root The following are keys to success for working in a group. The first one is defining roles and responsibilities. Each member must know what they are expected to “bring to the table”. This assures the team that all needed areas are adequately covered before beginning. The second note is to identify external customer needs. What outputs and results are expected from the customer, and how will they be communicated (at the end of the project, during, only when needed?) Identify internal needs. What processes and procedures need to be followed, and what systems are available or required. This may include a corrective action process. Without the appropriate levels of management supporting the effort, the team will have a hard time implementing any actions or activities that will result from The following is a list of roles and responsibilities The third step is to address the immediate action needed to keep the problem from spreading any further. Often times, this involves some sort of band-aid, or containment effort, such as: sorting of parts or paperwork, re-inspection, rework, or recall Whatever immediate action is done, it should only be temporary, and not stay in place after the root cause has been corrected. A check should also be made to see that the containment and immediate action actually kept the problem from spreading any further More info about immediate action Step 4 is defining the root cause. First of all, brainstorm the possible causes of the problem with the team. We recommend the use of the Cause and Effect diagram. After brainstorming, use the pareto principle to determine which causes to focus on. After selecting the most probable cause, there is still more analysis to perform. Use the 5 Why’s methodology until you get to the root cause. The root cause will be a process that initially caused the problem to occur. People, departments, groups or machines are not the root cause. Try to take the root cause one more step to make sure the team addresses the same problems at the company wide level, or outside of their own department or group. Step 4 is defining the root cause. First of all, brainstorm the possible causes of the problem with the team. We recommend the use of the Cause and Effect diagram. After brainstorming, use the pareto principle to determine which causes to focus on. After selecting the most probable cause, there is still more analysis to perform. Use the 5 Why’s methodology until you get to the root cause. The root cause will be a process that initially caused the problem to occur. People, departments, groups or machines are not the root cause. Try to take the root cause one more step to make sure the team addresses the same problems at the company wide level, or outside of their own department or group. Step 4 is defining the root cause. First of all, brainstorm the possible causes of the problem with the team. We recommend the use of the Cause and Effect diagram. After brainstorming, use the pareto principle to determine which causes to focus on. After selecting the most probable cause, there is still more analysis to perform. Use the 5 Why’s methodology until you get to the root cause. The root cause will be a process that initially caused the problem to occur. People, departments, groups or machines are not the root cause. Try to take the root cause one more step to make sure the team addresses the same problems at the company wide level, or outside of their own department or group. Verification involves testing of the proposed solution to make sure it will do what the team thinks it will prior to a full scale implementation. Often times, the solution can create additional problems. If the solution will not work, it is better to find out in a beta test environment, rather than under normal operating conditions. Validation means that the corrective action not only worked, but it was effective long term (withstanding all possible process issues) Step 6 is simply making sure to complete the action plans defined in Step 5. You cannot verify or validate until all actions have been completed. If the actions are not fully completed, or only partially completed, the effectiveness of the solution will be jeopardized Step 7 involves preparing the team for action, once the data analysis of the solution is complete. Who should be collecting the data, and for how long? What type of data results will be deemed acceptable? Finally, the team should review the data results to conclude whether the root cause was adequately defined, or that the corrective action put in place was effective. If the problem still exists. Go back to either Step #4 and redefine the root cause, or Step #5, to readdress the corrective actions put in place. If the problem went away, formally close the problem and celebrate success. It is extremely beneficial if a financial savings impact of resolving the problem is calculated. Many companies will redistribute a percentage of the cost savings back to the team members to further support the importance of solving problems Here are a couple things to keep in mind when performing root cause analysis. Remember, just as one problem may have multiple root cause possibilities, one root cause may be causing multiple problems. When you do root cause analysis on a problem, you will have one root cause. However, if you look at all the “possible” ways in which it could go wrong, you will find multiple things that need to be improved. When you don’t get to root cause, the process that creates it continues to send more problems and the problem will eventually return. Many times a short period of time without reoccurrence does not mean the root cause has gone away When at all possible, brainstorm what possible root causes might be, so that This is what the students should have learned in this course: How to identify the root cause, why it is so important for company success, the proper process for root cause analysis, and how you can apply basic quality tools to the problem solving process This is the first example. We will walk through this example using the quality tools and the problem solving process. The second example is a transactional process example. We highly encourage the use of your own company examples in addition to these. We identify the problem as part polarity reversed on a printed circuit board. This may have been one incident, or a recurring problem identified from a pareto chart The immediate activity implemented after the team gets together… The problem is placed in the first box. We then ask the first why. Why was the part reversed? The team determines that the factory worker was unsure of the correct part orientation when performing the task. Often times, teams will stop and assume that the problem is due to human error. This is NOT an acceptable root cause. Errors will always be made, so teams must dig deeper to find a way of making the process easier, or find a better way of catching the problem sooner. We again ask why. Why was the worked unsure of the correct orientation? Continue with the 5 Why’s process until they reach a defective process The 5 Why’s implies asking why five times, but it could be more than 5. Asking at least five times forces the team to dig beyond their own knowledge of the process and make certain they don’t stop short of the root cause The team determines that the engineering process does not adequately account for manufacturing issues during the selection or specification process. Notice that they did not put the blame on the individual engineer. Here are the permanent and preventive actions. The permanent changes that part for that particular problem. The preventive truly addresses the larger issue of selecting the parts correctly the first time with orientation marks, instead of afterwards when the problem is found.