Workshop - Root Cause Analyses Investigations

“Whatever is worth doing at all, is worth doing well.”
 - Philip Dormer Stanhope, Earl of Chesterfield (1746)

“Doing the right thing right the first time,” is obviously something that all organisations should be striving for and is a common organisational catch-cry.  Getting to the stage however where everything happens right the first time round all the time is needless to say probably a little idealistic.  We all work and live in an environment, where for different reasons ‘things’ go wrong or have the potential for going wrong, therefore a more realistic tenet maybe, “doing the right things right, the second time.”

How do we achieve or get to the stage where we are doing the right things right the second time?  What are the processes?  Do we even need to worry about it, after all ‘things’ have a way of sorting themselves out?

We all know that one reason that we are all employed is to perform some form of continual improvement.  We; each and all are tasked to ensure that practices of the past are always improved upon, regardless of subtlety or magnitude and this requires to varying degrees some form of analysis.

In service and manufacturing industries there is a propensity to do just enough to meet organisational and statutory requirements.  What if for example we were doing the right thing at the right time for 99.9% of the time?  The impact of this 0.1% shortfall will obviously depend on the organisation, but let us consider the following statistics from the United States, which demonstrates what could occur if the right things were getting done at the right time for 99.9% of the time.

• There would be 1 hour of unsafe drinking water per month.
• There would be two unsafe landings at O’Hare International Airport each day.
• 16,000 pieces of lost mail per hour
• 20,000 incorrect drug prescriptions each year.
• 500 incorrect surgical procedures a week.
• 50 newborns dropped at birth each day.
• 22,000 cheques deducted from wrong accounts each hour.
• Your heart fails to beat 32,000 times each year.

Or to look at it from another perspective, consider what would happen if we passed on quality problems to our customers ;

• For every “wronged” customer who complains, 26 others remain silent.
• 91% of dissatisfied customers will never purchase goods or services from you again.
• The average “wronged” customer will tell 8 to 16 others, and
• It costs five times as much to attract new customers as it costs to keep old ones.
The above statements highlight the fact that “living with” problems rather than eliminating them is not continual improvement.  It is NOT why we are employed.

Time and time again the “she’ll be right mate” attitude leads to the phenomena of the “corrective action spiral”, ie organisationally and as managers we fight fires, we put one fire out, then move onto the next one until finally we are back visiting our first fire because the source of the fire or problem was not identified, eliminated and/or negated.

Root Cause Analysis is one technique and one tool of continual improvement.  It provides us with a mechanism from which we can identify problems, analyse them, discover what really caused them, determine one or more solutions and then implement those solutions to make sure that we “do the right thing, at the right time, at either the first or second time and hopefully not at the third.

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