1. 08 Apr 10 – WDM 204 – Session Five

2. Cape Area Management Program (CAMP) Sponsored by the Cape & Islands Workforce Investment Board

3. 08 Apr 10 – WDM 204 – Session Five Today’s Topics  Learning Objectives  Root Cause Analysis Overview  Root Cause Organizational Philosophy  Effectively Define the Problem  The “Five Whys” and Breakout Exercise  The “Fishbone Diagram” and Breakout Exercise  The Challenges and Keys to Success  Questions and Comments

4. 08 Apr 10 – WDM 204 – Session Five 4 Learning Objectives In this class, students will learn the how to develop a structure and process for continuous quality improvement (C.Q.I.). The class will understand the challenges essential to effective C.Q.I., and learn the potential solutions. Practical tool(s) will be provided. They will demonstrate their learning by in class discussion of workplace experiences, and group discussion of case studies. Additional reading reference(s) will be provided.

5. WDM 204: Continuous Improvement Identifying Crucial Processes Working with Organizational Leaders to Determine Need Process Identification Documenting Your Findings

6. 08 Apr 10 – WDM 204 – Session Five 6 Quality Improvement System Tools  We need tools – a common language – to tell us: – where we stand versus our competition? (S.W.O.T.) – what do we need to work on (Impact/Maturity Matrix)? – how are we doing things now? (Process Mapping) – what we need to do our job? (S.I.P.O.C) – why isn’t it working? (Root Cause Analysis) – how can we best do our jobs? (Standard Work) – what do our stakeholders think? (Stakeholder Feedback)

7. 08 Apr 10 – WDM 204 – Session Five 7 When Do You Need “Root Cause” Analysis?  There isn’t enough time to solve all the problems  Solutions are incomplete  Urgency supersedes importance  Problems reoccur and cascade  Many problems become crises  Performance drops If three or more of these occur in your organization, you are a victim of “firefighting*.” * Stop Fighting Fires; Bohn, Roger; Harvard Business School Publishing; 2000

8. 08 Apr 10 – WDM 204 – Session Five 8 Root Cause Analysis  Find out why errors occur, to fix them once and for all: Why? Why did that occur?

9. 08 Apr 10 – WDM 204 – Session Five 9 Philosophy of Relentless Root Cause  Each problem is a golden nugget or treasure.  Each problem tells a story about why and how it occurred. (There are no isolated incidents.)  Solving problems requires a mindset that is alert, open-minded, patient, tenacious, and persistent.  The “true” problem must be understood from the data before action is taken.  Each problem must be pursued and resolved, rapidly.

10. 08 Apr 10 – WDM 204 – Session Five 10 Symptom Approach vs. Root Cause Symptom  Assumes at any given time a worker makes a choice to work error-free or not.  Assumes errors are the result of worker carelessness.  The method for improvement is to motivate workers to be more careful. Root Cause  Assumes that errors are the result of defects in the process. People are only part of the process.  Assumes that there are multiple causes for errors.  The method for improvement involves identifying appropriate ways to improve the process.

11. 08 Apr 10 – WDM 204 – Session Five 11 First, Define the Problem Your new cookie sales account just called, and they are not happy. Over the last 30 days, these are the problems they have experienced. Week Ending Problems 3/7 Damaged packaging (2), late delivery (3), damaged cookies (3), wrong amount of cookies delivered, wrong invoice (2) 3/14 Damaged packaging (3), late delivery (6), wrong amount of cookies delivered, wrong invoice (2) 3/21 Damaged packaging (2), late delivery (10), wrong amount of cookies delivered, wrong invoice (2) 3/28 Damaged packaging (2), late delivery(14), damaged cookies (3), wrong amount of cookies delivered, wrong invoice 4/4 Late delivery (2), wrong amount of cookies delivered(2) How do you know where to start?

12. 08 Apr 10 – WDM 204 – Session Five 12 Pareto Analysis – Defines Problem If your customer is not satisfied, what are the reasons? Which is the most important reason?

13. 08 Apr 10 – WDM 204 – Session Five 13 Root Cause Analysis Using The “5 Why’s” Problem Why? Flat Tire in Garage Nails on garage floor Box on shelf split Box got wet Rain through hole in garage roof Rain happens

14. Breakout Session Form Teams of Three to Five People

15. 08 Apr 10 – WDM 204 – Session Five 15 Break Out Exercise – 5 Why’s  Do a “5 Why” root cause analysis on the problem scenario on the next page  Be sure to use all five “whys”  Be prepared to report out

16. 08 Apr 10 – WDM 204 – Session Five 16 Root Cause Using the “5 Whys” You’ve looked in to the cookie customer’s Late Deliveries complaints further, and you have the following information. Put it in “5 Why” order:”  The driver is new and doesn’t know the best route  The delivery truck arrives late to the customer  The traffic is much heavier in the Spring  The driver is slowed down by traffic  The driver is a part-time seasonal employee

17. 08 Apr 10 – WDM 204 – Session Five 17 Limitations of the “5 Why” Method  Many people struggle with splitting a problem into exactly five levels  Debates center on which issue is the “real” root cause, and which cause comes first  It assumes problem analysis is “linear” – first this, then that - when sometimes several things happen at once  However, it is a great learning model for this subject!

18. 08 Apr 10 – WDM 204 – Session Five 18 What Are Some Alternatives to “The Five Whys” Root Cause Analysis?  Open Brainstorming  Nominal Group Technique – “yellow stickies”  Fault Tree/Red X Analysis – remember the guess my number game?  Other statistical methods, such as those taught as “Six Sigma”  Ishikawa or “Fishbone Diagram”

19. 08 Apr 10 – WDM 204 – Session Five 19 Root Cause Brainstorming Tool Then, team votes on 1-3 problem “key drivers” after all ideas are recorded First, what are all the “drivers” of this process?

20. 08 Apr 10 – WDM 204 – Session Five 20 What Are the “Bones?”  Environment – literally, the working conditions, e.g. light, heat, humidity  Methods – how we use the tools and resources, e.g. work instructions  Machines – what we use, e.g. computers, printers, copiers  Measurement – how we measure “key drivers”  Material – what stuff we use to create our “product”  Personnel – the people doing the job

21. 08 Apr 10 – WDM 204 – Session Five 21 Let’s Practice – “Mushy Cookies!”  Environment – literally, the working conditions, e.g. light, heat, humidity  Methods – how we use the tools and resources, e.g. work instructions  Machines – what we use, e.g. computers, printers, copiers  Measurement – how we measure “key drivers”  Material – what stuff we use to create our “product”  Personnel – the people doing the job

22. 08 Apr 10 – WDM 204 – Session Five 22 Possible Root Causes for “Mushy Cookies”

23. Breakout Session Form Teams of Three to Five People

24. 08 Apr 10 – WDM 204 – Session Five 24 We’re Not Happy! Your new cookie sales account just called, and they are not happy. Over the last month, these are the problems they have experienced. Week Ending Problems 3/7 Damaged Cookies – one, Wrong Amount Delivered – two, Damaged Packaging – three, and Late Deliveries – eight 3/14 Damaged Cookies – one, Wrong Amount Delivered – two, Damaged Packaging – three, Late Deliveries – seven, and Wrong Invoice – three 3/21 Damaged Cookies – one, Damaged Packaging – one, Late Deliveries – 13, and Wrong Invoice – four 3/28 Wrong Amount Delivered – two, Damaged Packaging – two, and Late Deliveries – seven

25. 08 Apr 10 – WDM 204 – Session Five 25 Break Out Exercise – Fishbone  Use the data on the next slide (and previous slides) to determine what to focus on first  Then, use a blank fishbone diagram to lead your team in a root cause brainstorming exercise – you will have to “make up,” using your common sense, the causes to list  Reach consensus as a team on the three most likely causes  Be prepared to report out

26. 08 Apr 10 – WDM 204 – Session Five 26  Beware of subjectivity – Realize that you might not think of all the possible root causes while brainstorming – Set aside personal bias  “knowing the answer before you get started” – Let the data lead you to objective conclusions  Check your data  Test you solution more than once if possible  Do not accept “human error” as an excuse for the root cause of a problem Cautions

27. 08 Apr 10 – WDM 204 – Session Five 27 How Are Most Organizations Directed?  What do we use to direct the workforce? – metrics (target measurements, such a budgets), – policies (things you can’t measure, you describe)  If organizations are controlled by metrics and policies, what is the ultimate root cause of (what is now) undesired behavior?  Metrics and policies that conflict with the desired new direction!

28. 08 Apr 10 – WDM 204 – Session Five 28 The Challenge of True Root Cause  Organizational leaders do not intentionally create problems  They vigorously support achieving objectives  They (like all of us) see some questions as “resistance”  They live in a world dominated by Financial information

29. 08 Apr 10 – WDM 204 – Session Five 29 Keys to Success  Question Everything – Do not stop until you are down to causes that can be tested and attacked – Ask, “why, why, why?” until you know the fundamental element of the process that failed  Ask the experts—the users of the process  Get other, outside help – Neutral – More objective  Be relentless in your pursuit  Enroll your leadership in your solution

30. Class Discussion Your Workplace’s Root Cause Analysis

31. 08 Apr 10 – WDM 204 – Session Five 31 Personal Practicum Checklist Project Charters What do I need to know to try this at work? When before the next class will I try? What is my greatest concern in doing so?

32. 08 Apr 10 – WDM 204 – Session Five 32 Discussion of Personal Practicum Checklists  Any questions on the how?  Let’s hear a couple of examples of the when?  Let’s hear a couple of examples of concern?  Let’s practice working through those concerns…

33. Questions or Comments Before We End?