1. Root Cause Analysis
Workshop

2. Unstructured
Improvement Process
The Miracle
OccursProblem
Solution

3. Elements of a
Corrective Action System
 Identify problems and decide if
corrective action is required.
 Correct the immediate problem.
 Investigate and determine the root of
the problem.

4. Elements of a
Corrective Action System
 Evaluate solutions and develop a
corrective action plan.
 Implement the corrective action to
eliminate the root cause.
 Verify that the corrective action is
implemented and that it is effective.

5. Basic goals of
Root Cause Training
Being able to:
 Identify the root causes of the current
problem/ opportunity.
 Quantify the impact of the root causes
on the districts operations, products,
and customers.

6. How to do
Root Cause Analysis
 IDENTIFY
 The most likely causes selected based on
facts and data.
 DETERMINE
 The “root cause” identified based on data.

7. Key Actions
1. Identify all possible causes of the
problem or unmet opportunity for
improvement by using these tools.
 Draw Cause-and-Effect Diagram
 Develop an Interrelationship Digraph
 Draw an Affinity Diagram
 Develop a Solution Selection Grid

8. Key Actions
2. Test to determine which of the
possible causes are contributing to the
problem.
 Collect data to decide what are the most
likely causes of the problem.
 Identify most likely root cause based on
data.

9. Investigate & Determine the
Root Cause
 Key Steps:
 List potential causes
 Prioritize root causes
 Verify root causes
 Output:
 Root cause(s) of current situation

10. Tool #1
Cause and Effect Diagram
Cause Cause Cause
Cause Cause Cause
Effect

11. Tool #1 – Constructing a
Cause-and-Effect Diagram
 Draw a fishbone diagram structure
 Label effect and determine cause
categories (manpower, methods,
system, materials, etc.)
 Brainstorm possible causes
 Add branches to each cause by asking
the 5 WHY’s

12. Tool #2
Interrelationship Digraph
Cause
Cause
Cause
Cause
Cause
Cause
Cause
Cause
Cause
Cause

13. Tool #2
Constructing an Interrelationship Digraph
 Put major causes in a circle (don’t draw a circle)
 In a pair wise sequence, ask is there a strong, causal or
enabling relationship between the two causes?
 If there is a causal relationship determine which direction the
relationship is and draw an arrow appropriately.
 Continue examining each cause around the circle until you have
completed looking at all possible pairs – No two-way arrows are
allowed
 When completed, count the number of out arrows and in arrows
and place the numbers by the causes (#out / # in)
 Those causes with the most out arrows are primary causes

14. Tool #3
Affinity Diagram

15. Tool #3
Constructing an Affinity Diagram
 Brainstorm a list of causes for the problem
statement
 Transfer causes to 3x5 cards (use post-its)
 Put cards on wall or table in random order
 Arrange cards into related groups
 Find or create group titles
 Draw boxes around groupings
 Draw complete Affinity Diagram

16. Tool #4
Solution Selection Grid
Solutions Cost/
benefits
Ease to
Implement
Permanent
Solution
Number
of Side
Effects
Score

17. Tool #4
Constructing a Solution Selection Grid
 Determine criteria for a good solution (Be careful not to mix
positive and negative criterion).
 Enter criteria on top row of the grid; enter solutions in far left
column of the grid.
 Determine rating or ranking method. Use the highest rating to
indicate the solution best matching the criterion.
 Starting with the first criterion, determine how well each solution
fulfills the criterion and enter score on the grid.
 Repeat for the remainder of the criterion.
 Add up the total score for each of the solutions. The highest
score is usually the best solution, but apply your judgment –
does it make sense?

18. Cost / Benefit
 Cost / benefit analysis
 Customer impact
 Vendor impact
 Internal impact