Here are three ways you can insure that Root Cause Analysis (RCA) will never deliver results in your facility. I have seen these in action and they are quite effective.
1. Use it as a stick. In other words use it to punish the people involved in the incident without looking for the latent or systemic issues that allowed them to make the poor choices. (Exceptions given for safety but only after detail analysis) Remember what Deming tells us: “Blame the system not the people”
2. Don’t create RCA triggers. Just request an RCA when it feels right. This one causes people to forget to request RCAs or request too many at once. When you request too many the action of creating many RCA reports gets in the way of implementing the findings and insuring results. Take the time to decide what criteria should warrant an investigation and to what level the investigation should go. Once you decide what criteria then set the triggers so that you get a manageable amount of RCA investigations each month. Start off with one or two RCAs per month per team or area until they are comfortable with the process and then lower the threshold increasing the number as they become more comfortable with the process.
3. Spend lots of time making a pretty and incredibly detailed RCA report documents that will impress everyone with their bulk. Reports don’t solve problems they only communicate them. The are not sold by the pound. They should be concise, preferably fitting on one A3 size sheet of paper. I have a template for this if you send me an email. Spend your time implementing the findings and verifying that you got the results you expected.
Can you think of other ways that you have seen the RCA culture beat out of your facility?
I agree, RCA reports documents should have Brief summary, people involved in the interview, root causes and recommendations (including owner & due date) as an Appendix you can include the Why Tree or 5 Why.
ReplyDelete