3 Tips for Quality Root Cause Analysis

“You get what you ask for,” ever hear that phrase? Well, it is a good lead into root cause tip #1.

#1 Know why you are doing the root cause analysis but DON’T let the reason drive the root cause process and findings itself.

The quality of a root cause analysis report, or in many cases the amount of information contained in the report, is driven by the requirement for the root cause analysis itself.

1. Government Agency Requirement
2. Regulatory Finding Requirement
3. Internal Company CEO/CFO Requirement
4. Internal Company Policy Requirement
5. Supervision Request but no policy requirement

Which one of the requirements above most likely requires a more extensive root cause analysis report, written in a very specific way? Most of us, by experience, would focus on items A-C. Besides the extensive amount of time it takes to produce the regulatory report, how could the report requirement become a driver for poor root cause analysis?

• Report writing drives the actual evidence collection.
• Terminology required in the report forces people to prioritize one problem over another, and in some cases ignore important information because it does not have a place in the report.
• Information is not included or addressed because the report is going to an outside organization.

If A-C root cause analysis requirements could lead to biased or incomplete root cause analyses because of the extensive regulatory requirements, then D-E should be better right? Well, not so fast.

• Less oversight of the root cause analysis report (if there is one) could result in less validated evidence or a list of corrective actions with limited support to substantiate them.
• There is often a higher variability of how the root cause analysis is performed depending on who is performing it and where they are performing it.

So how do you counter the problems of standardization verses non-standardization issues in root cause analysis? The easiest method is to use a guided investigation process and not drive the process itself. Once the root cause analysis is complete, then and only then focus on writing the report.

Below is a list of 7 points with a link to read more if needed that can help reduce bias and variability. 7 Secrets of Root Cause Analysis

1. Your root cause analysis is only as good as the info you collect.
2. Your knowledge (or lack of it) can get in the way of a good root cause analysis.
3. You have to understand what happened before you can understand why it happened.
4. Interviews are NOT about asking questions.
5. You can’t solve all human performance problems with discipline, training, and procedures.
6. Often, people can’t see effective corrective actions even if they can find the root causes.
7. All investigations do NOT need to be created equal (but some investigation steps can’t be skipped).

This is just plain project management advice. If the team and process owner of the issue being analyzed believe that you as the root cause facilitator own the root cause analysis, guess what… You Do! It’s your evidence, your root causes, your corrective actions and your accountability of success or failure. It is easier to pass the buck so to be speak and can also hamper the support that the facilitator needs to ensure an effective investigation.

In most cases the root cause analysis facilitator is just that, the facilitator of information. Keep it that way and establish ownership up front.

#3 As a team, define what finished means for the root cause analysis and if there is a turnover of the root cause analysis, ensure that ownership is maintained by the appropriate people.

Often the root cause analysis facilitators in my courses tell me that once the analysis portion is done at their company, the report is handed off to their supervision to make the actual corrective actions. Not optimal in itself, and should include a validation step handled by the root cause facilitator to ensure that the corrective actions match up to the original findings. The point, however, is that whatever “finished “ is, and wherever a true handoff of information must occur, it needs to be established up front along with the ownership discussed in tip #2.

In TapRooT® Root Cause Analysis, the following would be great investigation steps to focus on with your team and peers when discussing what finished means, hear more about these steps here.

1. After Creating Summer SnapCharT® – Is the SnapCharT® thorough enough or do we need more interviews & data?
2. After Defining Causal Factors – Are they at the right end of the cause-and-effect chain? Was a Safeguards Analysis conducted? Were all the failed safeguards identified as causal factors?
3. After RCA and Generic Cause Analysis – Did they use their tools (Root Cause Tree®, Root Cause Tree® Dictionary, etc.)? Did they find good root causes? Did they find generic causes? Did they have evidence for each root cause?
4. After Developing Corrective Actions – Use corrective action helper to determine effectiveness of corrective actions.

These 3 root cause tips were designed to reduce the barriers to good quality root cause analysis. Comment below if you have additional tips that you would like to pay forward.