"It's not whether you get knocked down. It's whether you get up again" says Vince Lombardi.
Fault management is a practice to learn from mistakes and avoid its repetition. Any management is run on identified strategies. Strategy is nothing but a series of planned and sequenced tasks to achieve a goal. Strategies must be clearly stated and be observable.
However it is must for an organization to follow strategic models to work out plans or make it well managed. For fault management, i.e. to find out the root cause and correct it, management gurus identified Root Cause Analysis.
Root Cause Analysis
All organizations have problems that plague their operations, reduce profits, and create customer dissatisfaction. Most organizations try to fix these problems quickly without ever finding what caused them in the first place, making the problems reappear.
Root Cause Analysis (RCA) is a structured step by step technique that focuses on finding the real cause of a problem and dealing with that, rather than continuing to deal with its symptoms.
It is a procedure for ascertaining and analyzing the causes of problems in an effort to determine what can be done to solve or prevent them. Only when the root cause is identified and eliminated can the problem be solved. It is a process to help stakeholders understand problem causes well enough to achieve permanent resolution of those problems.
Goal of RCA
The goal is to find out:
- What happened?
- Why it happened?
- What can be done to prevent it from happening again?
Techniques & Tools
There are many less structured problem identification methods; however, in order to develop a logical and repeatable approach, the process of root cause analysis uses more formal techniques such as:
- Change analysis - comparison of an unsuccessful process to a similar process whose outcome was successful.
- Barrier analysis - assessment of the adequacy of installed barriers, or the lack of barriers.
- Events and causal factors analysis - examination of events and related conditions and causal factors in chronological order.
- Tree diagrams - graphic display describing the event's contributing factors.
Decisions can then be made based on data rather than "hunches" and provide lasting solutions rather than relying on "quick fixes" and "band-aid" approaches.
Begin with Brainstorming
- All factors of the problem are considered. "We don't assess for high risk because..."
- Once all factors are listed and developed, they should be categorized.
- Create a "cause and effect" diagram, such as a Fishbone Diagram (explained here).
- General categories for causes include environment, equipment, people, methods (processes), and materials.
According to the "University of Michigan Hospitals and Health Centers", here is a sample of questions that are likely to come out from a detailed brainstorming session.
- What happened; what are the details of the event?
- What was different this time than other times?
- Why did it happen? Repeat why? Why? (i.e. pain in leg, why? Broken bone, why? Cancer of the bone)
- What was the missing or weak link in the process?
- Are there any other factors that directly influenced the occurrence?
- What steps in the patient care process contributed to this event?
- What other area/services does the process impact?
- Did factors outside the control of the organization contribute to the occurrence?
- If so, how can the organization protect against the influence of these factors?
The Fishbone Diagram
- The cause and effect diagram (Fishbone) starts with the problem at the head of the fish.
- Under each general category of the Fishbone, answer the question, "why?" in regards to the problem identified.
- Once the Fishbone Diagram is done, the various causes are discussed to determine the root of the problem - or the real reasons why the problem exists. It is from the result of this discussion that the focus for the improvement plan begins.
Other Quality Improvement Tools
- The Fishbone Diagram is only one example of a quality improvement tool to help you assess your process.
- You may also want to use flow charts or post-it notes to "flow" your process and identify gaps in the process.
Implementation of root cause analysis will help your company in:
- Identifying barriers and the causes of problems, so that permanent solutions can be found.
- Developing a logical approach to problem solving; using data that already exists in most operations.
- Identifying current and future needs for organizational improvement.
- Establishing repeatable, step-by-step processes, in which one process can confirm the results of another.
In short, root cause analysis provides a methodology for investigating, categorizing, and eliminating the root causes of incidents with safety, quality, reliability, and manufacturing process consequences.