Tag Archives: root cause

Change Management: Create a Culture Seeking Continual Improvement or Use Band-Aids?

Successfully shepherding change within an organization is often a challenge. Often change management strategies are mainly about how to cope with a toxic culture but exclude the option of fixing the toxic culture. Why not address the root causes instead of trying band-aids?

The most effective strategy is to build an organizational culture into one that promotes continual improvement. A continual improvement culture is one that is constantly changing to improve (grounded in long term principles: respect for people, experiment, iterate quickly, etc.).

You can try to push change in an ad hoc basis by adopting some strategies to create a similar feeling about the individual change effort. But that isn’t as effective as establishing them in the culture are. Strategies such as: going the gemba, pdsa, build trust via respect for people…

These tools and concepts build trust within the organization. The do that by showing people are respected and that the change effort isn’t just another in the long line of wasted effort for ineffectual change. The first part can be addressed, normally the second part can’t be addressed effectively. Often that is at the core of the issue with why the change effort isn’t working. It is a bad solutions. It hasn’t been tested on a small scale. It hasn’t been iterated numerous times to take a seed of an idea and grow it into a proven and effective change that will be successful. If it had been, many people would be clamoring for the improvement (not everyone, true, but enough people).

But still you can use strategies to cope with lack of trust in your intentions with the change and lack of trust in the effectiveness and fear of change. Some of those are included in the links below. But mainly my strategy is based on focusing on building the proper culture for long term excellence and the change management strategies are just short term coping mechanisms to help deal with the initial challenges. Using those strategies as a long term solution for dealing with change in a toxic culture isn’t a very sensible way to manage.

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Root Cause, Interactions, Robustness and Design of Experiments

Eric Budd asked on The W. Edwards Deming Institute group (LinkedIn broke the link with a register wall so I removed the link):

If observed performance/behavior in a system is a result of the interactions between components–and variation exists in those components–the best root cause explanation we might hope for is a description of the interactions and variation at a moment in time. How can we make such an explanation useful?

A single root cause is rare. Normally you can look at the question a bit differently see the scope a bit differently and get a different “root cause.” In my opinion “root cause” is more a decision about what is an effective way to improve the system right now rather than finding a scientifically valid “root cause.”

Sometimes it might be obvious combination which is an issue so must be prevented. In such a case I don’t think interaction root cause is hard – just list out the conditions and then design something to prevent that in the future.

Often I think you may find that the results are not very robust and this time we caught the failure because of u = 11, x = 3, y = 4 and z =1. But those knowledge working on the process can tell the results are not reliable unless x = 5 or 6. And if z is under 3 things are likely to go wrong. and if u is above 8 and x is below 5 and y is below 5 things are in trouble…

To me this often amounts to designing systems to be robust and able to perform with the variation that is likely to happen. And for those areas where the system can’t be made robust for some variation then designing things so that variation doesn’t happen to the system (mistake proofing processes, for example).

In order to deal with interaction, learn about interaction and optimize results possible due to interactions I believe the best method is to use design of experiments (DoE) – factorial experiments.

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Root Cause Analysis

Nice post on Root Cause Analysis:

This, more rigorous and long-lasting, approach to solving problems is called Root Cause Analysis. There are several tools that can aid in the process of Root Cause Analysis. One common tool developed by Toyota is called “5-why’s”. Basically, it is a simple approach of asking “why” several times until you arrive at an atomic but actionable item. To visually view the process of the “5-why’s”, a tool called an (Ishikawa Diagram) or a (Cause-and-Effect Diagram) or a (Fishbone Diagram) is often helpful — this tool is referred by either of these.

Find the Root Cause Instead of the Person to Blame

When encountering a problem or defect the inclination of many is to find a person to blame. W. Edwards Deming believed that the system was responsible for 93% of the problems and over time he increased that number to at least 97%. Why did he see it that way, while so many others first inclination is to blame someone?

As I see it the issue has to do with what is the effective way to improve. Often if you ask why do we have this problem or defect, people will point to some error by someone. So you can blame that person (there are reasons this is not a very accurate way to view the situation often but even without accepting that premise the blaming a person strategy is not wise). The reason that blaming a person is a bad idea is that your organization will improve much more effectively if you keep asking why.

Why did they make that error? Why did the process let them make that error? When you follow the why chain a couple more steps you can find root causes that will allow you to find a much more effective solution. You can then pilot (PDSA) an improvement strategy that doesn’t just amount to “Do a better job Joe” or “that is it Joe we are replacing you with Mary.” Neither of those strategies turns out to be very effective.

But investigating a bit more to find a root cause can result in finding solutions that improve the performance of all the workers. What kinds of things? You can apply poka yoke (mistake proofing) concepts. You can institute standard practices so that everyone is using the best methods – not whatever methods they have developed over time. You can rearrange the process to simplify the steps and eliminate chances for errors. These improvements, and many more, are sustainable and can be built upon over time.

In addition, the psychological effects of seeing people as the source of errors and defects instead of seeing people as the source of improvements to process weaknesses are powerful. If you find yourself thinking a problem or defect is the fault of a person, try asking why a couple more times and see if you can find a system improvement that would eliminate or mitigate such problems in the future. That is a much more effective improvement strategy.

I always have had a bias toward finding system improvements but over time that bias has increased as I have applied management improvement concepts. As you gain experience working on improving systems you gain experience showing the wisdom of Deming’s 93-97% figures. My belief is that he increased the percentage of problems attributable to the system over time as he experienced the same thing.