Senior Leadership & Root Cause Analysis
How Should Senior Leadership Be Involved in Root Cause Analysis?
Senior leadership needs effective root cause analysis to stop problems and improve performance. They need this to avoid:
- Missed quarterly goals.
- Calls in the middle of the night about serious safety accidents.
- Serious cost overruns and schedule slippages.
- Bad press about any of the above poor performance issues.
- Prosecution by ambitious DAs for environmental incidents.
Thus, senior leadership should be interested in the factors they influence that improve root cause analysis and their company’s performance.
What are the factors that senior leadership should be involved in?
- Picking an effective root cause system.
- Making sure that the root cause system is being applied and applied effectively.
- Monitoring the corrective actions to see if they are being implemented and are effective.
- Understanding the root cause of the system’s trends.
- Continuously improving the root cause analysis system and applying it more proactively (less reactive).
Let’s look at each of these factors that senior leadership should be interested in influencing.
The Root Cause Analysis System
All root cause analysis systems are NOT created equal. Many “experts” suggest using substandard root cause analysis tools. We won’t get into why this happens, but if you are interested in comparing a tool that doesn’t produce the results senior managers need to an effective, advanced root cause analysis system, see the article below…
An effective root cause analysis system must include the fundamentals of a root cause analysis. To see these requirements, view THIS LINK.
What should senior management do to ensure they pick the right root cause analysis system that meets or exceeds the fundamental requirements for root cause analysis? First, they need a basic understanding of root cause analysis and what an advanced root cause analysis system should do for them. Then, they can direct their organization to use the best root cause system that meets their needs.
We will discuss how management can get this knowledge later in this article.
Apply Advanced Root Cause Analysis
I’ve seen it happen before. Senior management develops a policy that requires effective, advanced root cause analysis. But there is a catch. Management doesn’t insist that advanced root cause analysis be used in the field. Worse yet, they don’t provide the time or the resources (people and training) needed to apply root cause analysis.
Yes, management can undercut the application of effective root cause analysis.
What should management do? Ensure that people are trained in advanced root cause analysis AND that the investigators (or teams) have the time and access they need to perform adequate investigations.
Senior management should be interested in the following:
- The initial training plan.
- The resources allotted to root cause analysis investigations.
- Selecting incidents/issues to apply advanced root cause analysis to.
- Insisting that the tools are being applied effectively.
We will discuss how this happens in the next section.
Effective Application of Root Cause Analysis
If management has chosen an effective root cause analysis tool and required it to be used, they are on the right track.
But, as Admiral Rickover is quoted as saying:
You get what you inspect,
not what you expect.
What does this mean? Senior management has to:
- Ensure that every root cause analysis is reviewed to ensure it is effective.
- Be personally involved in the reviews of the most serious investigations.
Senior management needs root cause analysis training to perform effective investigation reviews.
Senior managers might resist training. After all, they have extensive leadership experience. But if that experience doesn’t include using advanced root cause analysis OR, worse yet, their experience is applying a substandard root cause analysis tool, then their involvement in a root cause analysis review may be counterproductive.
Thus, senior management should:
- Be trained in advanced root cause analysis.
- Make sure that their policy requires root cause analysis reviews (grading).
- Ensure they have experts to grade investigations and coach people performing root cause analysis.
- Participate in reviews of significant incidents.
By personally reviewing serious incidents, senior management will know if the tools are being applied effectively and may request feedback from the investigators if they have the necessary resources.
Corrective Action Implementation
What a waste of time. Spending valuable resources performing advanced root cause analysis, only to have the corrective actions languish and be forgotten … never to be implemented.
What? You say this couldn’t happen? I’ve seen it happen all too often. And senior management didn’t even know it. They assumed things that had been assigned were being implemented.
But in today’s busy world, you can’t assume work will be completed. Senior management must put a tracking system in place to ensure corrective actions are implemented in a timely fashion. Senior management should get periodic reports about the implementation of corrective actions, including:
- Overdue implementation of corrective actions.
- Approval of delays to the implementation of corrective actions.
- Progress and success in implementing corrective actions.
This should be a part of management’s periodic review of the root cause analysis system’s results.
Corrective Action Effectiveness
Once corrective action is implemented, there is one more concern for senior management:
Were the corrective actions EFFECTIVE?
The effectiveness of your root cause analysis system ultimately should be measured by the effectiveness of the corrective actions.
How can you measure the effectiveness of corrective action?
- Face validity: The corrective actions appear to be effective when they are approved (before being implemented).
- Field verification: People in the field feel the corrective actions are effective or they test the corrective action’s effectiveness.
- Prevention of repeat incidents: The incident does not happen again (this can take years to verify).
Management should receive feedback about the effectiveness of corrective actions as part of their periodic reviews of their root cause analysis system.
Trends
Trends of key performance indicators, root cause analysis data, and corrective action effectiveness should be a key part of management’s performance improvement program review.
Unfortunately, many presentations of trends are ineffective or counterproductive because of the applied trending techniques.
What should an effective trending program look like? There’s a book on that topic. See:
Somebody who understands this book should help set up management’s trending reports. We can help if needed.
Continuous Improvement and Becoming Proactive
An effective senior manager stays ahead of problems. They continuously improve performance with advanced root cause analysis. They aren’t reactive—they are proactive.
Therefore, an effective senior manager looks for ways to keep their improvements world-class. That is why we hold the annual Global TapRooT® Summi: to provide people with the latest best practices and a place where people can benchmark their improvement initiatives.
Proactive senior managers understand that their most effective root cause analysis tools should be applied proactively to avoid having to apply them reactively.
Proactive root cause analysis is THE MOST EFFECTIVE application of root cause analysis.
Proactive root cause analysis starts with effective root cause analysis of Precursor Incidents.
What is a precursor incident? An incident that did not produce a serious consequence but could have if an additional Safeguard (or perhaps, Safeguards) had failed. These precursor incidents should be effectively investigated and corrected. The corrective actions will prevent future serious incidents. This application of root cause analysis is proactive.
Even more proactive is the application of advanced root cause analysis as part of a risk-directed audit program. This topic is beyond the scope of this article, but we will publish more in the future.
Management needs to direct the root cause analysis and performance improvement program so that it becomes increasingly effective and proactive over time.
Does Your Senior Management Want an Effective Root Cause Analysis System?
Is your senior management ready for:
- An end to fatalities?
- Improved safety and reduced LTIs?
- Consistently meeting production and earnings goals?
- Improved product/service quality?
- Projects to be completed on schedule and within budget?
- Improved equipment reliability?
- An end to regulatory violations?
Then, it is time to schedule your management for an Executive Briefing.
Call us at 865-539-2139 to schedule an executive briefing for your senior management.
If you would like more information before you schedule your Executive Briefing, CLICK HERE to contact one of our implementation experts.
Beyond an Executive Briefing
Do you want more than an executive briefing for your senior managers? System Improvements has a course to explore the role of senior management in your root cause analysis program. It is called the TapRooT® Executive Leadership’s Role in Root Cause Analysis Course. CLICK HERE for more information including the course outline.
