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1JANUARY 22, 2007
RCCM PRESENTATION ENG REV6© 2007 Danaher. All Rights Reserved
Root Cause Assessment &Countermeasure Development
RCCM
2
January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
Goal Of This Training
Increase ability to lead your Increase ability to lead your organization in the identification organization in the identification
of Root Cause and the development of of Root Cause and the development of effective & sustainable Countermeasureseffective & sustainable Countermeasures
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January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
Ice Breaker
4
January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
What RCCM ISN’T
FORM FILLING-OUT CONTESTFORM FILLING-OUT CONTEST
RCCM RCCM isis a process a process
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January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
The Differentiator
Know the Value Stream of Your Business
+The Ability to Lead and Drive RCCM
Process
=Superior Sustainable Results
6
January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
Daily Management Relationship to Policy Deployment
Daily Management (KPIs)Daily Management (KPIs)Measures how we are servingMeasures how we are servingthe customer TODAYthe customer TODAYHow we are meeting current expectationsHow we are meeting current expectations
Policy Deployment MetricsPolicy Deployment MetricsMeasures how we are creatingMeasures how we are creating
sustainable competitivesustainable competitiveadvantage by striving for advantage by striving for world class performanceworld class performance
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January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
DAILYDAILYMANAGEMENTMANAGEMENT
KPI MISSKPI MISS
How Daily ManagementDrives RCCM
RCCM!RCCM!
PLAN ACTUAL
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January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
PD CRITICALPD CRITICALTHINKINGTHINKINGPROCESSPROCESS
ACTIONACTIONPLANSPLANS
RCCM!RCCM!
How Policy Deployment Drives RCCM
9
January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
RCCM Process
VALIDATEVALIDATECORRECTCORRECTMETRICSMETRICS
DRIVE DRIVE TO ROOTTO ROOT
CAUSE CAUSE
DEVELOP DEVELOP COUNTER-COUNTER-
MEASURESMEASURES
Step 2Step 2Step 1Step 1 Step 3Step 3
10JANUARY 22, 2007
RCCM PRESENTATION ENG REV6© 2007 Danaher. All Rights Reserved
Do Your Metrics Measure Up?
1. Validate Correct Metrics
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January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
In this section you will:
Demonstrate the ability to identify correct metrics that support your PD improvement priorities and Daily Management
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January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
Am I measuring the right things?
Remove your personal bias Get a second opinion
Know your “mini business” and major value streams
Do KPI’s have a Causal Relationship? If……Then Examples:
Stock Outs KPI for OTD? PPV for OTD?
Is the Data Actionable?
13
January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
Leading VS. Lagging Indicators
Instructions: In small groups, answer: List 10 metrics you have in your business. Label them as either Leading or Lagging Indicators. Why are they Leading or Lagging How can you turn Lagging to Leading?
Tools to Use: PD Action Plan, PD or KPI Bowler, Other business data you have brought
Time to complete: 15 minutes Report out time per group: 5 minutes Deliverable: One person per group will report out on findings
14JANUARY 22, 2007
RCCM PRESENTATION ENG REV6© 2007 Danaher. All Rights Reserved
Solving the Problem
#2. Drive to Root Cause
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January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
In this section you will:
Demonstrate the ability to drive to root cause when there is a PD or KPI miss
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January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
Root Cause Defined
Root Cause Analysis is a process for identifying and “analyzing” the causes of problems in an effort to determine what actions should be taken to eliminate or prevent them.
17
January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
Essential Elements of Root Cause Analysis Process
Must take advantage of people’s knowledge while preventing their biases from controlling the direction of the process
Focus on process not person!
Must involve pertinent data so that causal relationships can be identified.
Must lead to what actions must be taken to eliminate or prevent the problem. (COUNTERMEASURES)
18
January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
Root Cause Analysis Process(Overview)
1. Clearly define the problem statement
2. Analyze gap data to develop pareto chart
3. Ask 5 Why’s to identify root cause(s)
4. Differentiate between Symptoms and Systems
5. Check your logic and eliminate items that are not causes. Check your trends. Evaluate special vs. common causes
6. What is Actionable?
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January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
Clearly Define the Problem Statement
Rank Order these Examples in terms of how clearly they define a problem:
Valve failed at 250 PSI Sales 15% below target: $178.5 M / $210M Project is 26 days behind schedule Customer Contact Call Abandon Rate is 24%, Target is 2% Seal in solenoid leaks
Using SMART to define a problem makes the countermeasure process relevant and impactful
Specific, Measurable, Actionable, Relevant, Time-Based
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January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
How to Analyze Gap Data
Identify facts surrounding the undesired outcome What has changed? What has not changed? When did the undesired outcome occur? Where in the process did it occur? What conditions were present prior to its occurrence? What controls or barriers could have prevented its
occurrence but did not? What are all the potential causes? Pareto the data
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January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
Run Chart
The simplest display of a trend with observation points over a specific time period
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January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
Pareto Chart
Graphically show drivers in descending order
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January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
The Right Data Analysis
Here is the problem
Sales Miss of $1.5M YTD
Miss by product
Miss by brand
Miss by region/geography
Miss by market/channel
Miss by key account or distribution
• Develop “standard work” for the gathering of the data for the analysis.
• Develop a standard process for working through the data
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January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
Multiple Paretos (5) Are Required to Get to Root Cause
Flow
NA / Row All Brand Trade Sales
-20000
0
20000
40000
60000
80000
100000
120000
$(00
0) PlanActualVariance
Plan 16000 36000 61000 81000 100,000
Actual 15500 35400 60500 80000 98500
Variance -500 -600 -500 -1000 -1500
JAN FEB MAR APR MAY
Pareto of Brand Miss by $
-1600
-1400
-1200
-1000
-800
-600
-400
-200
0
200
400
$(00
0)
$ of Miss
$ of Miss -1500 -200 -100 0 100 200
GLI Hydrolab Lachat ELE Hach ETS
Analysis of Miss by Product
-2000
0
2000Analysis of Miss byProduct
Analysis ofMiss byProduct
-1300 -700 -50 50
pH Cond Chlori Flow
Miss by Region
-1000
-500
0
Miss by Region
Miss by Region -800 -400 -200 -100
Domesti Domesti Internati Internati
pH pH Conductivity Conductivity
Miss by Market
-1000
-500
0
Miss by Market
Miss byMarket
-800 -400 -200 -100
Texas - Michig Korea - China -
Miss by Key Acct/Dist
-1000
-800
-600
-400
-200
0
Series1
Series1 -800 -250 -100 -50 -200 -100
OEM of
ABC of MI
DFG of MI
HIJ of MI
Yuil - Kore
Lost Bids
Problem StatementWhere -#1
Where -# 2Where -# 3
Where -# 4 Where -# 5
25
January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
Problem: Sales Missed Plan by $500K This Month and $1.5M YTD
Where? - GLI sales were 2.0M below plan Where? - pH sales down 1.5M and conductivity down 500K Where? - pH and conductivity domestic sales down 1.3M and
international down 700K Where? – Domestic TX & MI down 1.2M, and Korea and China down
400K in pH and conductivity Where? – Texas down 800K due to poor account coverage at key
OEM, Michigan 400K down due to quality and delivery issues at 3 end-users, Korea – new distribution channel that lacks product and application knowledge, China – low price point pH and conductivity products introduced.
Use the 5 Why’s to drive to Root CauseUse the 5 Why’s to drive to Root Cause
Example
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January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
5 Why Analysis
Systematic method to drive to the true root cause(s) of a problem
Simply ask “why” in a step ladder approach until fundamental root cause is discovered.
Root cause is not simply listing the symptoms of a problem
Normally, after up to 5 steps, the true root cause(s) will be exposed
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January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
5 Whys – Jefferson Memorial Graph
Why?
Why?
Why?
Why?
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January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
Differentiate between Symptoms and Systems Issues
Your child has a fever, is this a symptom or a systems issue?
BE A SYSTEMS THINKER: Understand the Interdependence of everything!
30
January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
Systems vs Symptoms Exercise
Instructions: Break into teams and identify 5 examples of situations where
people fix a symptom rather than looking at the system. Tools to Use:
Fifth Discipline Pre-reading
Time to complete: 10 Min. Report out time per group: 5 Min.
31
January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
Differentiate between Symptoms and Systems Issues
Focus on:What Happened?
Tell the story!Where it Happened?
Give the background!When it Happened?
Be specific!Then go to the How / Why
Play Dominos!
This process will help you do systems thinking!
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January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
Causal Relationships
Check your logic and eliminate items that are not causes.
How? Check your trends. Look for themes Evaluate special vs. common causes. Stick Strictly to If…Then
Remember Quick Fixes often CAUSE unintended consequences Stabilizing the situation 1st allows you to see the
Causes clearly
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January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
Cause & Effect Diagram
Helps facilitate potential causes when data is not available
Used to identify, explore or display possible causes of a specific problem
Problem
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January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
Gas Mileage is less
than Automaker advertised
Machine
Carburetor Transmission
Auto
Manual
Tire Type
Radial
All Wx
Radio
Tire Pressure
Weight
Air Conditioner
2 Wheel vs 4 Wheel Drive
Method
TireRotation
Tune-ups
Ride Brakes
Fast Start
Maint. Sched.
Engine warm-up Time
Measurement
Gauge forTire Pressure
OdometerType
Estimate ofFull Tank
Manpower
DriverTraining
Driver
# of Passengers
Materials
Gas Type
Fuel Additive
Mother Nature
Highway or City
Terrain
A B
Oil Type
A B
Flat
Mou
ntai
nsAl
titud
e
Wind
Weather Conditions
Temperature
Humidity
Precipitation
Ice
Snow
Rain
Cause-And-Effect Diagram (CE) Cause-And-Effect Diagram (CE) ExampleExample
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January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
What is Actionable?
In the Short-Term These are corrective action around
Symptoms
In the Long-Term These are corrective actions around Systems
36
January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
Exercise
Instructions: In small groups, (1) Define the Problem Statement for each
of your PD / KPI misses (2) Identify the top drivers of the miss (3) Complete one 5 Why iteration for one defined problem
statement Tools to Use: PD or KPI Miss Time to complete: 20 minutes Report out time per group: 5 minutes Deliverable: One person per group will report out on
results
37
January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
2 Minute Review
Turn to the person next to you (or discuss by table) and share your key learnings from what has been covered in the session thus far
Each person has about 1 minute to discuss
One person from each pair will report back 1 item to rest of group
38JANUARY 22, 2007
RCCM PRESENTATION ENG REV6© 2007 Danaher. All Rights Reserved
Generate Solutions That Address Root Causes
#3. Countermeasure Development
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January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
In this section you will:
Generate solutions that address root causes
Write effective countermeasuresComplete the countermeasure form
40
January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
Having a PD miss and having to write CMs does not mean that someone has failed.
PD Targets, by their nature, should be aggressive stretch targets
Outstanding DHR organizations will normally be required to write numerous CMs each month
The development of countermeasures is not just a tool for PD. It is a process we should use whenever we miss a target!
Psychology of Countermeasures
41
January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
Good countermeasure preparation will drive an organization to: productive self-criticism more robust systems closer customer contact a higher level understanding of the
marketplaceIs a team effortWill improve our processes
Psychology of Countermeasures
42
January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
Short-term Countermeasure The purpose of Countermeasures is to
develop actions to quickly get back on target
Long-term Countermeasure Needed when the short-term countermeasure
is not sustainable Tend to address & resolve systemic issues
Countermeasure Types
43
January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
Action Plans and Countermeasures
0
50
100
150
200
250
300
350
Goal
ActualAction Plans to hit the target
Countermeasures get you back
on plan
44
January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
= Original Plan x = Progress at Review
Action Step/ Kaizen Events Milestone J an Feb Mar Apr May J une J uly Aug Sept Oct Nov Dec
Target Improvement
Planned Dates
Status (Past Due in Red)
Impact
Policy Deployment Action Plan
Review Team: * Next Review: *
Environmental Situation Summary: *
Improvement Priority Title: *Department/Location:
* Management Owner: * Date: *
2004
Core Objective: *Timeline
Owner (Lead is bold)
BOWLING CHARTBOWLING CHART
1st step in countermeasure development is to go check your action plan to see if you did what you said you would do!
Pro-Active – Action PlansRe-Active - Countermeasures
45
January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
Countermeasure Overview
Writing effective countermeasures requires: A fundamental understanding of the metric
you are trying to improve Pareto analysis of the Right data Root Cause derived from 5 Why’s analysis
The best countermeasures lead to The best countermeasures lead to systemic improvements!systemic improvements!
46
January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
Focus on fixing the processCountermeasures should be actionable
and have specific tasks, assigned owners, and completion dates – TBD, Ongoing, In Progress, are not acceptable
Follow the standard Countermeasure format (see next slide)
Writing Countermeasures
47
January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
2. Visual to miss …
1. What is the miss …
Countermeasure Components
48
January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
3. Visual to where is the miss …
3a. Visual to where is the miss … Next Level …
Countermeasure Components
49
January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
4. Why the miss? … 5 Whys Analysis
5. Action plan w/ owners, timing & impact …
Countermeasure Components
50
January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
Countermeasure Components
51
January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
Focus on the critical few…
May not get to100% of the
“Miss” in 30 days
Must be at“Point ofImpact!”
Run chart ofPlan vs. ActualSame data from
PD Bowler
Clearly defineOwnershipAnd timing!
Quantify theImpact!
Do you haveEnough?
Sometimes youWill have
Short-term andLong-term CMs
May needMore Paretos to“Peel-back-the
Onion”Define the RootCauses and
Quantify amount Of “Miss”
Know the “tie”to PD!
Countermeasure Key Points
52
January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
Countermeasure Checklist
1. Does it “tie” to PD (is the “tie” clear)?2. Does it have a run chart showing plan versus actual data?3. Does the first level Parato show where the miss is?4. Does the second level Pareto show where the Point of Impact of the
miss is (i.e., get to root cause)?5. Is the Root Cause determined based on a 5 why Analysis at the point of
impacts 6. Is the Root Cause Statement made with quantified amount of miss?7. Are the Countermeasures focused on the critical few?8. Are there short-term as well as long-term countermeasures (if
appropriate)?9. Is the Ownership of each Countermeasure identified?10. Is the timing of each Countermeasure identified?11. Is the impact of each Countermeasure quantified and is there enough to
get you back to Plan?
53
January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
Tips for Reviewing your Countermeasures in a PD Meeting
CM Form and Action Plans: Follow the CM form while presenting (run
chart to Pareto to prioritized RC and CM) Reference Action Plans when appropriate
Be Fact-Based: If you don’t know answer, say so and follow-
up laterPrioritize your time:
Focus on biggest impact items
54
January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
Root Cause CountermeasuresTexas OEM down in pH due to poor account coverageTexas OEM - Not seeing the key decision maker and influencers to support price/value proposition, loosing on price
1. Develop/Implement sales call action plan for Texas OEM calling on Jim Carr (Engineering Manager) and Bill Jones (Application Specialist) resulting in being sole source supplier
Product –Attribute,Pricing,Quality & DeliveryExperiencing 15% out of box failures on conductivity probes, due to improper potting.
1.Manufacturing implementing process change to address air pockets in potting process
2.Site visits with new probe communicating process change and results to the 3 customers
Yuil Korea Need to develop sales specialist for pH and conductivity products to support Yuil sales team
1. Implement train the trainer program and forward application manuals
CompetitionBeijing Manufacturing introduced on new pH and conductivity sensor priced 25% below our current offering, lost 100K in order this month
1.Acquire competitive units and test functionality and specification to GLI current design.
2.Develop pricing, promotional, and value analysis for field sales organization and roll-out program
Root Cause to Countermeasures
55
January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
Root Cause/Counter Measure Assessment & Development
Page #10
Focus 1st on Key Performance Indicators (KPI’s) Can’t focus on Policy Deployment if KPI’s are out of control
Daily Management (KPIs)Daily Management (KPIs)Measures how we are servingMeasures how we are servingthe customer TODAYthe customer TODAYHow we are meeting current expectationsHow we are meeting current expectations
Policy Deployment MetricsPolicy Deployment MetricsMeasures how we are creatingMeasures how we are creating
sustainable competitivesustainable competitiveadvantage by striving for advantage by striving for world class performanceworld class performance
Daily Management Relationship to Policy Deployment
Page #12
How Daily Management Drives RCCM
DAILYDAILYMANAGEMENTMANAGEMENT
KPI MISSKPI MISS RCCM!RCCM!
PLAN ACTUAL
Page #11
How Policy Deployment Drives RCCM
PD CRITICALPD CRITICALTHINKINGTHINKINGPROCESSPROCESS
ACTIONACTIONPLANSPLANS
RCCM!RCCM!
Page #13
RCCM Process
VALIDATECORRECTMETRICS
VALIDATEVALIDATECORRECTCORRECTMETRICSMETRICS
DRIVE TO ROOTCAUSE
DRIVE DRIVE TO ROOTTO ROOTCAUSE CAUSE
DEVELOP COUNTER-
MEASURES
DEVELOP DEVELOP COUNTERCOUNTER--
MEASURESMEASURES
Step 2Step 2Step 2Step 1Step 1Step 1 Step 3Step 3Step 3
56
January 22, 2007RCCM PRESENTATION ENG REV 6© 2007 Danaher. All Rights Reserved
First Question is“Did I do what I said I was going to do
in the Action Plan?”
Page #13
RCCM Process
VALIDATECORRECTMETRICS
VALIDATEVALIDATECORRECTCORRECTMETRICSMETRICS
DRIVE TO ROOTCAUSE
DRIVE DRIVE TO ROOTTO ROOTCAUSE CAUSE
DEVELOP COUNTER-
MEASURES
DEVELOP DEVELOP COUNTERCOUNTER--
MEASURESMEASURES
Step 2Step 2Step 2Step 1Step 1Step 1 Step 3Step 3Step 3
Step 1Validate Metrics
Step 2Drive to Root Cause
Step 3Develop Countermeasures
Am I measuring the right things?
Remove your personal bias Get a second opinion
Know your “mini business” and major value streams
Do Metric’s have a Causal Relationship? If……Then
Is the Data Actionable?
Root Cause Analysis Process(Overview)
1. Clearly define the problem statement
2. Analyze gap data to develop pareto chart
3. Ask 5 Why’s to identify root cause(s)
4. Differentiate between Symptoms and Systems
5. Check your logic and eliminate items that are not causes. Check your trends. Evaluate special vs. common causes
6. What is Actionable?
Differentiate between Symptoms and Systems Issues
Focus on:What Happened?
Tell the story!
Where it Happened? Give the background!
When it Happened? Be specific!
Then go to the How / Why Play Dominos!
This process will help you do systems thinking!
How to Analyze Gap Data
Identify facts surrounding the undesired outcome
What has changed?
What has not changed?
When did the undesired outcome occur?
Where in the process did it occur?
What conditions were present prior to its occurrence?
What controls or barriers could have prevented its occurrence but did not?
What are all the potential causes?
Pareto the data
Countermeasure Overview
Writing effective countermeasures requires: A fundamental understanding of the metric you are trying to improve Pareto analysis of the Right data Root Cause derived from 5 Why’s analysis
Focus on fixing the process
Countermeasures should be actionable and have specific tasks, assigned owners, and completion dates –TBD, Ongoing, In Progress, are not acceptable
Follow the standard Countermeasure format (see next slide)
Countermeasure Checklist
1. Does it “tie” to PD (is the “tie” clear)?2. Does it have a run chart showing plan versus actual data?3. Does the first level Parato show where the miss is?4. Does the second level Pareto begin to show the why of the miss
(i.e., get to root cause)?5. Is the Root Cause Statement made with quantified amount of
miss?6. Are the Countermeasures focused on the critical few?7. Are there short-term as well as long-term countermeasures (if
appropriate)?8. Is the Ownership of each Countermeasure identified?9. Is the timing of each Countermeasure identified?10. Is the impact of each Countermeasure quantified and is there
enough to get you back to Plan?
Causal Relationships
Check your logic and eliminate items that are not causes.
How? Check your trends. Look for themes Evaluate special vs. common causes. Stick Strictly to If…Then
Remember Quick Fixes often CAUSE unintended consequences Stabilizing the situation 1st allows you to see the
Causes clearly
Psychology of Countermeasures
Good countermeasure preparation will drive an organization to: productive self-criticism more robust systems closer customer contact a higher level understanding of the
marketplace
Is a team effortWill improve our processes
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