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Bad business practices and processes can normally be traced back to the way a decision was made or process put into place. Quite often leaders make decisions and develop processes without collecting all pertinent information or even exploring possible alternatives (Hammond Keeney & Raiffa, 2006). Many tools exist in business today to allow leaders to not only better understand and identify processes to also bring about change within their organization. One such tool is Root cause analysis. This process allows the opportunity for an entire organization to work together through a team of representatives from different departments to explore processes or events to determine alternatives and outcomes. Root cause analysis also provides an opportunity to build camaraderie and team spirit by providing people a sense of ownership and control over existing problems. When people have a clear understanding of how goals, objectives and problems relate to them personally, production and job satisfaction tend to increase (Moore, 2007).
The slogan of many organizations today is that "our people are our most important asset". Yet the very same organizations don't utilize their people to their fullest potential nor do leaders provide avenues to create improvement. When processes fail and negative events occur, organizations simply dispose of those involved in an attempt to become more efficient and thus more competitive. These actions send a mixed message which in turn demoralizes personnel, shuts down creativity and innovation, lowers expectations, and increase stress. Combined these actions have the propensity to send the organization's moral into a "downward spiral". In order for organizations to succeed, "innovation and continuous improvement must permeate the organization at all levels, and leaders must create an environment where this happens, removing the obstacles to the employees' ability to make those day-to-day improvements. Costs are a consequence of your practices and systems" (Moore, 2007).
"Risk analysis, risk management and [root cause analysis] RCA can do more for due diligence than many realize. Consistent and rigorous application of these analytical decision making tools helps prove that a company is making a genuine effort to reduce risks and prevent problems" (Hughes, Hall & Rygaard, 2009).
In order for an organization to truly excel all personnel must feel ownership for the organization and its' mission. All personnel must believe that their contributions are valuable and valid and that their voices are being heard. Just as every cog in a wheel is important, every person within an organization is important. For change to truly take hold, personnel need to feel free to ask questions and express opinions as well as make recommendations for improvement. This is critical since it is virtually impossible for the CEO of an organization to understand and identify issues/potential problems on the production floor.
A common question asked by people when discussing change is "what's in it for me?" It's not that people aren't willing to accept change but rather people aren't willing to put forth the extra effort to bring about the change if nothing is in it for them (Oakley, 2007).
Leaders should ask themselves this question "What are the benefits of accomplishing our objective for all the stakeholders?" By explaining the benefits to of process improvement to personnel, leaders will take that first step towards employee ownership or "buy-in" (Oakley 54). But how do we get from employee buy in to process improvement? The answer simple in theory, allow employees through an established and understood process to explore and analyze problems in order to develop solutions for improved operations and increased efficiency. The membership of root cause analysis teams must represent a cross section of representatives from various departments and levels in the organization. This will ensure different perspectives of the problems and thus different solution sets and thought processes. People with different expertise will most likely use different reference points when brain storming solutions to a problem (Hammond Keeney & Raiffa, 2006). Also, by including different departments and levels of the organization, leaders are creating a sense of ownership of the problem.
Now that we have discussed the makeup of root cause analysis teams and why it is so important if leaders want to improve processes and bring about change; next let's discuss the process through which root cause analysis is used to identify problems and formulate solutions by focusing on symptoms.
"How do you get to the root cause of a problem by focusing on the symptoms? Examine the process and analyze the root cause."
Gano in his article Apollo root cause analysis: A new Way of thinking defines root cause analysis as a "structured process designed to help an organization define problems that caused past events, understand the causes and prevent their recurrence". They go on to explain the four step process which Hughes, Hall & Rygaard discuss in their article Using Root Cause Analysis to Improve Risk management. While I agree with all of the steps, I view root cause analysis as a six step process once the team has been identified:
1) Provide the team with appropriate training and tools to successfully complete the task. Lack of training and/or insufficient tools sets teams and employees up for failure. Once training is complete the process can begin.
2) Define the problem and develop a problem statement. The problem statement should include the what (the problem), when (when did the problem occur?) and where (location in the process) in an attempt to figure out the why. The problem statement should also include what happened (the outcome) because of the problem (Hughes, Hall & Rygaard, 2009).
3) Develop a list and understanding of the causal factors. The team should focus on the evidence with no surmising. The team may discover branch (interdependent) factors as they review and discuss the evidence. What are the causal relationships among all the branch sets and conditional causes? The group should also drill down to determine lower-level factors. (Hughes, Hall & Rygaard, 2009).
4) Identify solutions. Based upon information discovered and situational understanding of the problem developed in steps 1 and 2, the team will develop solutions to fix the problem and prevent reoccurrence. Solution sets should be tested or gamed in an attempt to identify potential pitfalls.
5) Develop an implementation plan. How will the solutions be implemented to bring about the intended changes? Who will be responsible for implementing the recommended changes and what are the timelines associated with implementation? When developing implementation timelines the group should ensure timelines are realistic.
6) Develop an assessment plan to monitor effectiveness. How will the changes be assessed? What will the indicators of success or failure look like? Who will conduct the assessment? And finally, when will the process be reviewed again? (Gano, 2007).
It takes more than the formation of a team to ensure success of the process. In addition to the team's responsibilities and "buy in", leaders must also "buy in" to the process. This may in fact be difficult for the leaders due to inflated or unrealistic expectation or a fear of failure or loss of control. These are just a few of the pitfalls leaders can encounter when allowing teams to undertake root cause analysis and process improvement.
"What are some of the best practices for ensuring that decision-making will avoid common pitfalls?"
Expectation management and fear of failure
Clearly defined expectations are crucial when working with teams. The team itself and all the way to upper leadership must clearly understand what the team is assigned to accomplish. Also the team must possess the tools, capabilities and skill sets to include training within that team to meet those expectations or failure is most certainly eminent.
Fear of failure is a realistic road block for many leaders. They must remain open-minded and become comfortable with seeking information and opinions from different department and levels with the organization. Do so will widen the leader's frame of reference, "pushing their minds in fresh directions" (Hammond Keeney & Raiffa, 2006). In order to accomplish this, leaders must be cognizant of falling back into what is comfortable. In their article Hammond Keeney & Raiffa suggest that it is ego that causes the tendency to stick with the status quo "rather than explore new ideas; especially if those new ideas are presented by a subordinate" (2006). Self perceived loss of control, the fear of failure and egos quite often cause leaders to "stick with a failing plan vice developing a new one so as not to admit failure of the original plan and thus failure on the part of the leader him/herself" (Hammond Keeney & Raiffa, 2006). Only by giving up control and allowing innovation can leaders open their minds to discover the creativity and innovation within their organizations (Hammond Keeney & Raiffa, 2006).
"What have I learned about root cause analysis that is immediately applicable at work?"
I have spent most of my 24 year career in the Navy flying. As a result I have spent a great of time doing risk management and root cause analysis. It appears that in the civilian world quite often risk management and root cause analysis are viewed as separate and distinct programs overseen by separate individuals from different departments. "After all, risk management focuses on anticipating events and [root cause analysis] focuses on reacting to them, right? Not really. Root cause analysis should be leveraged to proactively manage risk" (Hughes, Hall & Rygaard, 2009). I think hit the nail on the head when he stated that Root cause analysis "should be considered part of the overall risk management process. It is designed to minimize or eliminate risk by solving problems and removing causes that contribute to risk" (Hughes, Hall & Rygaard, 2009). The U.S. Navy's operational risk and crew resource management programs exist to do exactly that. Crews (teams) use a root cause analysis to examine casual factors which lead to mishaps. By reducing the number of mishaps, mission effectiveness is increased. In 1954, 776 aircraft were destroyed due to mishaps (U.S. Navy). The Navy instituted root cause analysis to determine the key causal factors. Causal factors were similar to those encountered in any organization - change, new technology or lack of training thereof, constrained resources and stress. The one thing all of these have in common - human error. Root cause analysis determined the causes and when combined with process improvement and mitigation the operational risk management program was born. By 1996 mishaps had been reduced to 39 (U.S. Navy). Many "world-class organizations" use root cause analysis to operate as efficiently and effectively as possible. "By integrating their [RCA and risk management] programs and investing in people, these organizations are better positioned to prioritize risk management decisions and remain competitive" (Hughes, Hall & Rygaard, 2009). Many articles state the root cause analysis is reactive; however I agree with Hughes, Hall & Rygaard that root cause analysis is proactive in "working to eliminate risk and prevent the same problem from recurring" (Hughes, Hall & Rygaard, 2009).
Bringing about change through root cause analysis
Root cause analysis and process improvement invariably will bring about change. Change brings about fear of failure and while it is difficult to rid one's mind of these ingrained fears one can learn to recognize their existence and compensate (Hammond Keeney & Raiffa, 2006). The saying goes "people don't want to change; they're stuck in their old ways" (Moore, 2007). The saying should say - people will change if it will benefit them, especially if they feel they are in charge of the change. We must remember that succumbing to fear of change will allow "existing problems that go unaddressed allow causes to remain that can end up contributing to hazards the organization aims to avoid" (Hughes, Hall & Rygaard, 2009). As we come full circle in this paper, the ball is in leadership's court to overcome their fears, give up a little control to empower the people who truly drive the organization's destiny (Moore, 2007).