Friday, February 12, 2010

Finding the Root Cause of Success

It is that time of year when students are heading back to school. Soon enough, report cards will make their way home from school again. Some will make the trip faster than others depending on their contents. A recent research study tackled the topic of student report cards and how we handle the not so stellar grades that sometimes appear. It found that if a student brought home 3 As, 1 C, and 1 F, only six percent of the parents concentrated on the As. The study went on to say that the parents who concentrated on the As as opposed to dwelling on the F saw the next report card improve by bringing up the F while maintaining the As. Conversely, the parents who concentrated on the F did see the F improve, but at the cost of the As.

This study reminded me of many maintenance organizations and the report cards or metrics we give out. Now, when we have a less than adequate reliability report card, it does not have the effect of sending us to our room, cutting our allowance, or providing a little time out, but it does have the same overall effect on both morale and financial security.

In general, we tend to punish for poor performance and only dwell on the negative metrics. Would you execute a Root Cause Analysis (RCA) on a system or machine that performs flawlessly to discover why? The question then becomes: what does it cost us in both metrics and money to ignore the things we are doing right without understanding or leveraging them for success?

Let’s discuss another example of this phenomenon known as “Positive Deviance”, which occurred following the end of the war in Vietnam. In this life or death example from the book Surfing the Edge of Chaos by Pascale, Millemann, and Gioja, the children of Vietnam’s poorer regions were suffering from high levels of malnutrition. This was compounded by the lack of clean water and sanitation, as well as poor health care. The typical solution for this problem in the past was to provide aid in the way of medical clinics and food from other countries. This was a very costly way to address the problem, and when the money dried up and the aid stopped, the people could not sustain their health and returned to the original state of malnutrition. This pattern has been played out over and over in history.

Save the Children understood this situation and asked Jerry and Monique Sternin to go to Hanoi and develop a new method to end the malnutrition. The solution had to be sustainable by the people once the Sternins moved on from the area. The Sternins embraced a concept out of Tufts University called positive deviance. This concept allowed them to facilitate a process for the people of Hanoi to discover their own solution to the problem. It did not start with a preset group of assumptions or rules, and it did not impose food goods from other regions of the world that could not be sustained. Instead, the process they used included an understanding the culture and the knowledge it contained. The Sternins worked with the locals to study not only the sick children, but the healthy ones as well. They struggled with the contradiction that although the children were from similar socioeconomic backgrounds, some were healthy while others were quite ill. They analyzed the living conditions and diets of the healthy children and concluded that the difference was that parents of the healthy children were doing three things differently. They were insuring the children washed their hands, supplementing the rice-based diet with freely available freshwater shrimp and crabs and vitamin-rich sweet potato leaves, and they were feeding their children more times per day than the malnourished children. The key point here is that they were not feeding them more food, but they were feeding them the right food more often. Once this discovery was made, it was easily leveraged across the culture in that area because it was developed from within; it was Hanoi’s solution. After six months, two-thirds of the children had gained weight and the program was a sustainable success. The Sternins did not take this diet to all of Vietnam and decree that “you must eat more shrimp and sweet potato leaves more often”. Instead, they helped each region to study and develop its own solution, leading to a sustainable solution that was owned by the people. The results are still succeeding to this day.

There are three points that are important to take away from these examples: study and learn from your good actors and not just the bad; develop and leverage the solutions from within the applicable area for buy-in and sustainability; and celebrate and encourage the successes and learn from the failures through a true understanding of the issues.

Many reliability improvement efforts traditionally look at equipment that has high levels of failure indicated by high vibration, oil contaminates, or elevated temperature levels, for example. Then, when the equipment fails, a Root Cause Failure Analysis (RCFA) is completed to understand why it failed. With this mentality, we are looking at half of the information that is available. This only shows the failures and why they happen. What about the successes? Why did the successes happen? One suggestion is to change your use of the RCFA process by moving the format to an RCA process that can be used to understand both failures and successes in the same format. Just this one small change will allow you to capture more solutions from your process. If you have 26 pumps in an area and only five have repetitive failure history, why do the others charge on? This is where the different way of thinking comes into play. You could complete an RCA on one of the good actor pumps to understand why it is so successful. You could use change analysis or any of the other applicable root cause tools to ensure you find the Root Cause of Success. What you might discover is a solid operating procedure, a good design, a best demonstrated practice, a better rebuild procedure, or any number of positive deviants that have led to a success, rather than a failure. In many cases, we may have preconceived notions as to what the solution may be before we discover it as a team. The key is to let those go and chase the data as a group until the solution is discovered corporately.

Once uncovered, these good practices are much easier to leverage because they are internal, proven, and owned, just like the dietary changes in Hanoi. There is no easier change to make than the one that was developed by the people who are making the change. They trust the information the change is based on because it is their information. They know it will work because they have seen it with their own eyes. They will force it to succeed because it has their name on it. When we develop solutions that do not involve the group that is affected, we lack the buy-in and data this process provides, making success a difficult goal to attain. This applies to your reliability metrics in two ways: one, it provides solutions that improve metrics such as Overall Equipment Effectiveness (OEE) and Mean Time Between Failure (MTBF); and two, it provides a tool for you to use to address and leverage your areas that excel in certain metrics. Just remember to ask the question, “Why am I succeeding?”

As you start to learn who is causing your positive deviance, make sure you apply positive public feedback to encourage it to continue and propagate. Basically, focus the light on what people are doing right. It has been proven that you should give three or more positive comments to every corrective feedback, and the Root Cause of Success philosophy provides you with an excellent vehicle to make that happen.

Because RCFA conclusions, if incorrectly drawn, can stop at human error, they can easily turn into a very negative tool. The perceived error may be with the equipment vendor’s design team, start up contractor’s installer, production’s operator, maintenance’s technician, or management’s supervisor. Some organizations use the RCFA or RCA results as whipping sticks to punish people, instead of as training, system, and policy correction tools. This defeats the purpose and robs the program of the support and information on which these analyses are based. Always remember that no matter which contributing factors are found during the root cause investigation, at least one of them (if not all) are directly due to management policies and systems. It may be that the management system allowed the equipment to be run above the rated speeds, preventive maintenance to be postponed, training to be ignored, or other contributing causes. With that being said, it is hypocritical and ignorant for management to use the RCFA findings to punish the offenders because in most cases, the system is at fault, not the people, and the system is governed by management. Instead, make the findings a positive tool by supplementing your failure investigations with the Root Causes of Success process and find out who is promoting success in your facility. This will allow you to make sure your RCAs are recognized as a positive tool that leads to praise and change within the organization. After learning from both your successes and failures and implementing the discoveries, you must find a way to ensure that others want to be involved in these types of improvements. We have to spread it to the point that we are constantly developing new ideas. In order to do this, we must create energy around our RCA findings. We can do this by celebrating our successes with our stakeholders. It is important to tailor your celebrations to the team, and even the individuals in some cases, so that you get the most benefit. It may be different with each group of stakeholders, but it has to make them want to do it again.

At the end of the day, it is important to remember that the positive things that are going on day-to-day are just as important to your success as the failures that we try to eliminate. Many times the solutions to our failures are right in front of us, hidden by the day-to-day fires that we fight. Look at the equipment that you forget about. Why are you able to forget about it? Why does it run so well? What are you doing or what did you do right? These are the locator questions for many of the solutions to the reoccurring problems that tear away at the reliability of our equipment, as well as our bottom line. These solutions discovered from within the organization have the buy-in and sustainability that is so often a struggling point for many outside solutions or cookie cutter approaches. Once a home grown, supported, sustainable solution has been put into place and the sweet smell of success is in the air, make sure you celebrate the accomplishment with all the stakeholders in the way that satisfies them the most. This becomes the fuel for many more examples of positive deviance that can really change your organization into a more reliable and profitable enterprise.

Whether it is your son or daughter’s school report card or your equipment reliability report, always acknowledge and celebrate the positive and discover the Root Cause of Success.

May 2005 issue of Maintenance Technology
Wikipedia entry on  Positive Deviance

1 comment:

  1. Thats a great dig on the approach towards solving problems at plant. I was really amazed how you could draw inferences from real-world simple situations and apply them in the field of reliability improvements.
    Kudos !!!