Root Cause Problem Solving

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– Because the “start work” form requires the sales director’s approval before work can begin and slows the manufacturing process (or stops it when the director is out of the office).4.

Why does the form contain an approval for the sales director? – Because I lost it all last night in a poker game.5.

A Cause Map is a simple diagram showing how and why a particular issue occurred.

It begins with a few Why questions (5 Whys), then expands into as much detail as necessary to (thoroughly) explain even the most challenging issues (30 Whys).

When using the Cause Mapping method, the word root in root cause analysis refers to causes that are beneath the surface.

Most organizations mistakenly use the term “root cause” to identify one main cause.– Because the sales director needs to be continually updated on sales for discussions with the CEO. Why did you lose your money in last night’s poker game?In this case only four Whys were required to find out that a non-value added signature authority is helping to cause a process breakdown. – Because I didn’t buy any gas on my way to work.3. – Because I’m not very good at “bluffing” when I don’t have a good hand.Why did manufacturing build the products to a different specification than that of sales?– Because the sales person expedites work on the shop floor by calling the head of manufacturing directly to begin work.The Cause Map creates a visual dialogue, making it easier to communicate what’s known and what needs a little more digging.People can see how all of the pieces fit together to produce a particular incident.These are low-resolution investigations that result in weak solutions. Cause Mapping flattens problem solving by deferring to the people in the organization who know how well current processes actually work.A strong prevention culture makes it easier for people to share what they know.Prevent or mitigate any negative impact to the goals by selecting the best solutions.Effective solutions should make a change to how people execute work process.

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