The core of the problem is found in the roots.
In medicine, it’s easy to understand the difference between treating the symptoms and curing the condition. A broken wrist, for example, really hurts! But painkillers will only take away the symptoms; you’ll need a different treatment to help your bones heal properly. However when it is a problem at work, we often are much less prone to differentiate between treating symptoms (the results of a problem in front of us) and resolving the actual cause of the problem. Too many leaders are stuck in quadrant I management where they race from one apparent “emergency” to another addressing the symptoms of problems without making time: to stop, think and identify and then address the root of their reoccurring problems. Addressing the results of a situation is a needed short term plaster, however, quadrant II analysis to work out why it happened and what can be done to prevent its re-occurrence, is the long term solution for real leaders.
Real leaders don’t just cope with problems, they put plans of actions in to prevent their re-occurrence.
Root Cause Analysis (RCA) is a quadrant II technique that helps leaders to answer the question of why the problem occurred in the first place. It seeks to identify the origin of a problem using a specific set of steps, with associated tools, to find the primary cause of the problem, so that you can:
- Determine what happened.
- Determine why it happened.
- Figure out what to do to reduce the likelihood that it will happen again.
RCA assumes that systems and events are interrelated. An action in one area triggers an action in another, and another, and so on. By tracing back these actions, you can discover where the problem started and how it grew into the symptom you’re now facing. It also helps you to interlink symptoms as rarely is a root cause resulting in just one consequence, normally it is causing many. In general there are three basic types of causes:
- Physical causes – Tangible, material items failed in some way (for example, a car’s brakes stopped working).
- Human causes – People did something wrong, or did not do something that was needed. Human causes typically lead to physical causes (for example, no one filled the brake fluid, which led to the brakes failing).
- Organizational causes – A system, process, or policy that people use to make decisions or do their work is faulty (for example, no one person was responsible for vehicle maintenance, and everyone assumed someone else had filled the brake fluid).
RCA looks at all three types of causes and involves investigating the patterns of negative effects, finding hidden flaws in the system, and discovering specific actions that contributed to the problem. This often means that RCA has the added value of addressing interrelated issues.
To understand the value and possible uses of the process above it will help to look at an example. In the case of the car brake scenario, we can do the following root cause analysis:
Even before going through the process above, it is likely that “downsizing” would have been blamed as the cause of the problem but if downsizing were a needed reality and impossible to reverse, this would not be a helpful conclusion to resolving the issue long term. By going more thoroughly into things through RCA, we can break down root causes to identify things we can do something about. For example we identified that procedures were put in place but weren’t followed that is something we can do something about. Likewise if staff weren’t following a procedure and leaders weren’t aware, there is a leadership issue here too which we can also something about. Now that we have the root causes we can fix these issues. First we can get all parties to agree to fine-tune the current procedure into a more workable one here on, one with simple checks done by each driver and a comprehensive check outsourced and in charge of one person. Also each department head will now do periodic checks of the check up sheet which all drivers will now leave in a designated place.
If we have done this RCA with our team, reaching out and including them in both the identification of the root source and more importantly in the conclusion to resolving the issue, we would have gained valuable staff buy for implementing the solution successfully. Likewise by getting staff to do their own versions of RCA you encourage them to take responsibility for preventing similar issues. The biggest benefit of RCA is that when we successfully identify the root cause in one area, the long term solution can inevitably help improve other areas. For example identifying the need to involve staff in setting up suitable safety procedures can be implied to other similar scenarios.
RCA analysis is a quadrant II technique that helps a leader to identify origins of problems.
RCA is applicable to many situations in management. Sometimes it will need in depth written analysis, in terms of a report in case of a failed safety procedure for example, but more frequently it merely requires answering the questions in thought only in order to identify the source. For example identifying the source of negative staff attitude may be done by taking your mind through the stages above. What is important to understand is that problems are frequently layered and your job as a manager is to see through the layers to the real issue and then help your staff with that real root cause. A great leader develops this analysis in part instinctively but always reinforces it by doing it in detail whenever required. The most important role of root cause analysis is it does more than plastering over problems, it takes you to down to the real cause that you can do something about. It is thus no coincidence that RCA is a vital part of the inside out accountability mindset.
Great leaders not only find the root of problems they also get their staff to buy in to doing it themselves.
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