Overcoming Ineffective Problem Solving with Disciplines of Root Cause Analysis

An overwhelming majority of the corrective actions I review do not address the root cause(s) of the problem that initiated the action. More often than not, problems are addressed with “remedial” action that only applies a temporary “band-aid” to the issue. The investigation often does not extend far enough to actually reveal the cause or causes, so that corrective action can be implemented to prevent recurrence. Why is that?

I believe that ineffective problem solving is rooted primarily in three (3) causal areas:

1. Incomplete Problem Definition - Very few organizations see the value in spending time defining the problem.

However, incomplete problem definition is caused by the false belief that the problem is obvious, and we need to hurry up and get it fixed – a rush to find a solution. What I am saying is that we are so “solution oriented” that we fail to define the problem properly, focusing instead on our favorite solutions. The belief that the problem is obvious is the result of the false belief that everyone perceives the same thing; consequently, we don’t even come close to adequately defining the problem.

Example: When a problem is encountered, we often want to blame the problem on human error, and therefore we conclude (without adequately defining the problem) that this person was not adequately trained; so we rush to re-train the individual (the solution). In doing so, we do not look at the causes and effects of the system that may have contributed to the error. Without addressing the systemic issues, the problem is almost guaranteed to re-occur.

2. Causal Relationships Unknown – Unknown causal relationships are based in our failure to understand the

“cause and effect principle” [every effect has a cause]. Causal relationships often remain unknown because we don’t “think causally.” Let’s briefly examine this important principle of problem solving by looking at the illustration of someone experiencing an injury as the result of taking a fall:

Effects:

Causes:

Injury

Caused by

Slip / Fall

Slip / Fall

Caused by

Wet Surface

Wet Surface

Caused by

Leaky Valve

Leaky Valve

Caused by

Seal Failure

Seal Failure

Caused by

No Preventive Maintenance


Notice carefully, it was not until the fifth level of the above investigation that the “systemic” cause of the problem was revealed. Adequate “root cause” analysis requires that we ask “WHY?” at least five (5) times in order to get to the systemic “cause” of the problem. Then…and only then…can we identify and implement corrective action that will actually have a chance of preventing recurrence of the problem.

3. Categorical Thinking– Categorical thinking is a natural human affliction based in the mind’s need to order

what it perceives. The problem is that we fail to understand how categorical thinking induces mental laziness. Instead of seeking to understand, we categorize both the problem and the solution. An example of categorical thinking is blaming recurring problems on “human error” (the category), and always implementing the obvious solution - “re-train” (the category). Upon categorizing, we somehow believe that we have accomplished an understanding, and with this illusion of understanding, we stop questioning. In other words, we haven’t gone far enough to get to the root cause.

One of the most important components of an effective corrective and preventive action system (CA/PA) is the organization’s understanding and discipline applied to root cause analysis.

Jim Colyn & Associates Quality Consultants can help you train your quality personnel in the body of knowledge and disciplines of “Root Cause Analysis.”

Using this body of knowledge and these disciplines, we can also assist you in addressing repetitive and systemic quality problems in your organization by identifying both remedial action (short term containment) and corrective action (long term action to prevent recurrence).

We can also help you successfully answer Audit Findings, FDA 483 Observations, and Warning Letters.
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