Basic Problem Solving & Root Cause Analysis

Training

Grasp The Situation

Grasping the Situation is Key to Effective Problem SolvingGrasping the Situation is Key to Effective Problem Solving

Problems Are Treasures

It all starts with a big vague concern How do I know I have a problem? What is the standard? Observe the process?

What should be happening? What is actually happening?

Is there a problem? What is the gap?

Investigate the Concern Break down the problem Determine focus area

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Tech Services QA – ComplaintsRG – Functions

R&D – D/EMFG – ProcessSupply Chain

P-D-C-A

Check – Observing and Assessing Results Against Defined Targets

Adjust – Reflecting on the Results Confirming the Hypothesis or Identifying Needed Adjustments

Plan – The Hypothesis Expressed as Goals, Metrics and Actions

Do – An Experiment, Entails Deployment of Goals and Activities

The Scientific Method

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P-D-C-A Up Close

Deploy

Observe Work

ID Limitation or Waste

“TRYSTORM”

Develop Countermeasures

Success?

Yes

No

GRASP THE SITUATION•Is there a problem?•What is the standard?•What should be happening?•What is actually happening?•Is there a gap? PLANPLAN

Based on what you Observe: 1.Challenge assumptions 2.Ask why its done that way3.Confirm Cause and Effect

Look to “ROOT CAUSES” – take time to understand the real

problem and the root causes!

PLANPLAN•Think of ways to mistake proof - get rid of “pain points” or waste

DODO

Test the idea NOW, not in days or weeks

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Deploy

Observe Work

ID Limitation or Waste

“TRYSTORM”

Develop Countermeasures

Success?

Yes

No

CHECKCHECKDid it work?Have I confirmed Countermeasures?Validate with data!

ADJUSTADJUSTKeep trying improvements until the problem is reduced or gone

DON’T STOP HERE!!

Put the fix in place across the

organization!

Nail it in place….put it in a procedure or make it a

requirement!

P-D-C-A Up Close

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Problem Solving A3

Tells a clear, concise story on one page Used as worksheets to ID problems, root causes, countermeasures Used to report improvement opportunities to management Used as tools to track and close rapid improvements Escalated to management for future project consideration

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Background:•The current sewing process draws the material on an angle, which has caused defects in the past (Rework 20% of time due to non-straight sewn lines)•Worker currently has to keep inventory of supplies at work location in middle of floor•Inventory at location becomes Safety/Tripping issue (2 falls this month)

Target/Goal:

•Lines on sewn straight (defect free) on product >98% of the time

•Zero Injuries due to inventory storage

•Zero unnecessary inventory

Causal Analysis:

•Observed and documented the sewing process

•Conduct a Fishbone and Five Why’s on controllable items

•Findings:

1. Angled product feed to sewing machine causes non-straight lines (defects)

2. Angled product feed designed originally to keep inventory close

Countermeasures:•Using idea of toilet paper roll, designed hanger that would fit the roll of material and provide direct (straight) feed into sewing machine•Developed ledge on end of hanger that would prevent spinning material roll from rolling off and causing additional defects•Removed storage of inventory in walkway that caused excessive motion for worker who had to replace •Designed material storage cabinet next to worker for quick access to material rolls necessary for one shift of work

Action Plan:

•Update material handling process to ensure material is delivered per shift needs

•Standardize solution and deploy across the sewing tasks

Follow-up :•Standardize solution prototype and create standard feed tool for other sewing machines

•Update job instructions to reflect improved process

Author: Version & Date:

Current State:

Worker aligns material to machine

Worker begins sewing

Worker assesses straight feed

Worker sews until roll empty

A3 Example Midmark Investigation Worksheet

Defect?

Replaces from local inventory

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Background:

Target/Goal:

Causal Analysis:

Countermeasures:

Action Plan (Milestone Chart) :

Follow-up :

Author: Version & Date:

Do I know the cause?

Through the

completion of th

is plan . .

.

Have I confirm

ed

countermeasures?

Current State:

Do I have a problem?

Through this plan . .

.

Have I confirmed cause & effect?

Problem Solving A3 Midmark Investigation Worksheet

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Problem Definition Exercise

Begin developing a Problem Solving A3 (ONLY first 3 sections of A3) to determine if you have a problem with one of the frustrations below:

Grocery bill too high Utility bill too high Can’t find tools in work area Can’t find needed work files on PC

Choose Items to Fix That Are Within Your Sphere of ControlChoose Items to Fix That Are Within Your Sphere of Control

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Solving Problems

1. You Grasped the Situation2. You’ve started filling out a Problem Solving A33. You Observed or Documented the process4. You’re pretty sure you have a problem now

What Do You Do Next?What Do You Do Next?

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Check Sheet for Gathering Data

Check Sheet

1st Shift 2nd Shift 3rd Shift Item TotalJuly 6, 2000

Type

of

Errors

A

B

C

D

IIII

II

IIII II

III

17

III

IIII I

I

IIII II

17

II

IIII III

IIII

14

8

10

16

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48 Collected By: JEC Department: Collections

Date: July 6, 2000 Source: Log Sheets

Definition: A list of check-off items that quickly gathers data by type and over time

Purpose: Collect data by providing a standardized format that lends itself to quantitative analysis.

Three types of Check Sheets Counted Measured Location

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Brainstorming

Definition: a method for a team to creatively generate a high volume of ideas on any topic

Non-judgmental process May be used to identify

problems, causes or solutions Assists in ensuring input from

all members Promotes buy-in

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Brainstorming Rules Each idea should be recorded as stated

The scribe should write the idea exactly as spoken, not in his or her words

Get buy-in from the originator of the idea that you have recorded the idea properly

Don’t criticize -- a brainstorming session is used to encourage innovative, off the wall ideas

Build on other people’s ideas No premature decisions or evaluations Don’t sit on ideas – express them

Brainstorming sessions should result in many ideas, which may lead to new directions and solutions!

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Brainstorming Types

Unstructured: Ideas are generated at random, any time within the brainstorming process

Structured: A process in which each team member gives ideas in a round robin format

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Unstructured Brainstorming

Write brainstorming question/topic where all can see it

Team calls out ideas No discussion (positive or negative) No questions Rapid generation is the aim Can be done in “Round Robin” format

Record ideas in exact words

30 second rule Relaxation technique

Review list for clarity, combine duplicates

Free-form

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Structured Brainstorming

Write down question/topic

Each team member writes 3 ideas on a sheet

Every 5 minutes pass to next person, add 3 ideas to list (new or expansions)

Repeat until everyone has had each sheet at least once

Harvest ideas Idea 1 Idea 2 Idea 3

Idea 1 Idea 2 Idea 3

Idea 1 Idea 2 Idea 3

Idea 1 Idea 2 Idea 3

Idea 1 Idea 2 Idea 3

Idea 1 Idea 2 Idea 3

Brain-writing

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Write down question/topic

In turn, team members give ideas May pass and get back in

Record in exact words

Continue until everyone passes

Review for clarity and combine duplicates

Round-robin Brainstorming

Structured Brainstorming

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Nominal Group Technique

Structured brainstorming that focuses on equal participation

Allows for quicker consensus on important issues

Builds commitment from the team

Structured Brainstorming

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NGT < Generating Ideas

Scribe the issue that needs to be resolved Each person should spend a few minutes writing down their

ideas related to the issue Each team member then prioritizes their ideas into the top 2 or

3 per individual The team leader should go around the table, soliciting each

member’s top 2-3 ideas As ideas are given, those with duplicate ideas should cross them

off their finalized list

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Why Look at Root Causes?

What factors are causing our key pain

points?

What factors are causing our key pain

points?

VS.

Treating Symptoms

Treating Causes

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Do I know the cause? I observed the process, asked questions, got the facts I know how the process flows I know how long the process takes Now I need to understand the root cause of the problem!

The 3 types of causes Point of cause: Where was the physical location of the problem? Direct cause: What factors contributed to the problem?

Ask 5 Whys to get to the . . . Root cause: What are the factors that if corrected, would prevent recurrence

of the incident Three types of root cause

Inadequate standard Inadequate adherence to a standard Inadequate system

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Traditional Fishbone Cause Categories Four Ps for

Service/Transactional Plant/technology Policies Procedures People

Six Ms for Manufacturing Materials Measurement Manpower Machinery Methodology Mother Nature

(Environment)

Customize Categories to Fit Your Specific RequirementsCustomize Categories to Fit Your Specific Requirements

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Cause & Effect Diagram (Fishbone)

A structured visual brainstorming tool used to isolate ONE specific defect, problem, or undesirable condition and determine the potential causes

Advantages Predefined categories stimulate thinking Classifies variables as Controllable or Noise

________

________

Problem or Effect

Methodology

Materials

Machinery

ManpowerMeasurement

Environment

________

________

________________

________

________________

________

________________

________________

________

________________

________

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Cause and Effect Step by Step

ER Patient

Dissatisfaction

Hospital Staff Lab/X-Ray

Pharmacy GeneralDoctor

Appointment

Waiting time

Staff friendliness

Staff competence

Attitude of receptionist

Attitude of nurses

Willingness to answer questions

Competence of doctor

Responsiveness of doctor

Ability to get through

Appointment availability

Attitude of phone receptionist

Holding time for main operator

Billing process

Itemized statements

Overall satisfaction

Staff cleanliness

# of Patients Waiting

Wait time

Offer of generic substances

Accuracy filling prescriptions

Warnings about drivingAnd operating machinery

Explanation of diagnosis/treatment

Waiting time/reception area

Wait time/examination room

Concern

Amount of time with doctor

Responsiveness

Time spent with doctor

Friendliness

1. Choose Categories2. Brainstorm Causes3. Classify as “C” or “N”4. Choose ‘top’ Causes using data

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Exercise

Complete a Cause and Effect Diagram on one of the following problems: Car will not start Poor course grade Unable to qualify for marathon race Poor gas mileage Your choice – instructor approval required

Customize Categories to Fit Your Specific RequirementsCustomize Categories to Fit Your Specific Requirements

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5 Whys

Useful for less complex problems Used to generate causes for use in other RCA methods Advantages

Easy to use Identifies more than one cause Identifies causal relationships

Why?Why? Why?

Why?Why?

Why?Why? Why?

Why?Why?

Asking Why 5 Times Often Brings You To The “Real” Root Cause(s). . .One You May Have Never Noticed

Asking Why 5 Times Often Brings You To The “Real” Root Cause(s). . .One You May Have Never Noticed

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5 Whys

How to use it Asking Why simply involves repeatedly asking ‘why’ until

the answer is ‘because that’s the way it is’! At this point, it is likely that you have identified a root

cause of the problem If tackled and removed, the observed symptoms of the problem

should also disappear

Although called ‘Asking Why Five Times,’ or ‘the 5 Whys’, five is a rule of thumb….there may be fewer or more questions depending on the particular situation.

It is important to beware of channelling your analysis down one avenue and completely ignoring other contributing root causes of the same problem

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Developing Countermeasures

Countermeasures Defined An action aimed at root cause of problem so as to prevent

recurrence

Goal of Countermeasures Using wisdom and ingenuity to create devices and

methods that allow you to do your job 100% defect free 100% of the time – mistake proof your countermeasures!

What are the two kinds of countermeasures? Temporary (short-term) Permanent (long term)

Aim for Solutions that Make the Right Way Easyand the Wrong Way Hard!

Aim for Solutions that Make the Right Way Easyand the Wrong Way Hard!

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Countermeasure Criteria

You should be able to answer yes to all of these items Involves the right people? Prevents recurrence? Inexpensive? Made with wisdom and ingenuity? Simple to use? Easy to implement? Durable? Easy to maintain? Does not hinder operator? Reliable?

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Everyday Countermeasures

Choose one of the items below and list all the mistake proofed devices you have seen: Gas Station Lawn Mower Family Car

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Have I confirmed Cause and Effect?

If I remove or block a cause, what happens to the problem? Prototype your solution and try it Make a change and test it Conduct experiments based on data

If you have more than one cause, do one experiment at a time

Do my solutions prevent recurrence?

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….What’s Next?

CHECK To See If It Worked ADJUST If It Did

Standardize the solution Document the solution Share the solution Check solution sustainment regularly

ADJUST If It Didn’t I still have the problem or a new problem pops up in 6 months Develop another countermeasure Trystorm Again!

Sustain the Solution – Make it Stick!Sustain the Solution – Make it Stick!

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Wrap Up – Expectations…..

Your role…… Start “observing” – use the Check Sheet – and measure… Understand the REAL PROBLEM and ROOT CAUSES Develop countermeasure and TRYSTORM Deploy (with procedure) if successful, otherwise, develop alternate

fix…. Complex problems – contact your area Green Belt or Black Belt for

help Report improvements / improvement opportunities to management

on the Problem Solving A3

Fix the Problem if You Can. Ask for Help if You Can’t!Fix the Problem if You Can. Ask for Help if You Can’t!

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