Guest post by John Hunter, author of Management Matters: Building Enterprise Capability.
The idea of looking beyond the most visible problem when seeking to improve is important. If you just address the most visible issue, you often fail to improve the system and instead just add some work to smooth things over if that problem crops up again. You often don’t fix the system to prevent the problem from reoccurring.
A good concept that helps focus efforts on systemic improvement is asking why 5 times. The idea is to get to a “root cause.” Address the root cause and, in so doing, not just reduce the symptom seen in this instance, but improve the overall system so that the specific problem is less likely to occur, but also many other related problems that all stem from that same weakness in the system that leads to many other problems.
I have seen an increasing amount of criticism of fixing the root cause over the last few years. The arguments put forth in these criticisms is that there is no single root cause, that the result is due to a system with many different variables acting together. So, a “root cause” is not really an accurate description. This is true, but I don’t agree with the conclusion that therefore attempting to improve by using the idea of “root cause” is wrong.
I think seeking to find a “root cause” can give focus to us and help us seek underlying systemic problems. In an organization that is applying Deming’s management system well, I don’t think the mistaking of “root cause” separate from a systemic view is a real problem. The problem comes in using the root cause analysis concept when the organization doesn’t have an appreciation for systems. While this is a problem, I think even in that case, “root cause” analysis is a useful concept to focus efforts. Using that idea in a context where systems thinking is not common is best done with a heavy dose of focus on appreciation for a system.
Organizations applying Deming’s ideas often have differing weaknesses in their application of those ideas. That means, when working within an organization, the strengths and weaknesses of that specific management system must be considered (as Deming emphasized). I do believe those criticizing the simplistic application of seeking a “root cause” make a good point when you look at most organizations. My solution to that would not be to get rid of efforts to find a “root cause” (using 5 why analysis, cause and effect diagram, stratified data…) but when using those concepts, to emphasis the importance of an appreciation for systems and interactions.
For me, the effort to find a “root cause” is an effort to seek out underlying systemic opportunities to improve. It isn’t about seeking a root cause for the specific problems that have been observed, but to seek out underlying systemic issues important enough to address. The focus is on such issues that impact the specific problems that sparked this effort. Sometimes the result is finding a systemic issue to address that will also prevent the problems from reoccurring. Other times, it may result in 2 or 3 improvement PDSAs to address system improvements.
The idea that there usually isn’t really a “root cause” that resulted in the specific problem is accurate, but that doesn’t mean the concept behind “root cause” analysis is not useful. Sure, maybe not using the term “root cause” would be a bit better. But for me, the important points to remember are: seek underlying systemic issues to improve; asking why 5 times is a useful concept to seek out those underlying causes; an appreciation for systems thinking and an appreciation for interactions are critical to these efforts.
Related: Optimize the Overall System Not the Individual Components – Root Cause, Interactions, Robustness and Design of Experiments – Distorting the System, Distorting the Data or Improving the System – Improving Problem Solving
Very good points John and Ron. While I am not an advocate of using the 5-Whys as a valid tool for ‘RCA’ on serious, complex events, that doesn’t mean that tool does not serve a meaningful purpose. Even finding one ‘root cause’ that identifies a flaw in an organizational system, is better than not finding any. It still beats stopping at a component level and just changing parts or replacing vendors. I agree with John that finding that one flawed system and correcting it, will likely prevent its potential contribution to other undesirable outcomes, other than the issue we are working on. Thx for highlighting this concept John.
Very good points John and Ron. While I am not an advocate of using the 5-Whys as a valid tool for ‘RCA’ on serious, complex events, that doesn’t mean that tool does not serve a meaningful purpose. Even finding one ‘root cause’ that identifies a flaw in an organizational system, is better than not finding any. It still beats stopping at a component level and just changing parts or replacing vendors. I agree with John that finding that one flawed system and correcting it, will likely prevent its potential contribution to other undesirable outcomes, other than the issue we are working on. Thx for highlighting this concept John.
Such an important reminder in a era where semantics and rebranding of the tried and true attempt to “throw the baby out with the bath water” of root cause investigation and analysis. Quality is an endless pursuit that requires openness and curiosity. If I’ve learned nothing in this life, I’ve learned we can ALWAYS improve. Thanks to John Hunter for sharing his insight.
Such an important reminder in a era where semantics and rebranding of the tried and true attempt to “throw the baby out with the bath water” of root cause investigation and analysis. Quality is an endless pursuit that requires openness and curiosity. If I’ve learned nothing in this life, I’ve learned we can ALWAYS improve. Thanks to John Hunter for sharing his insight.