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  Root
Cause Analyses CHANGE culture. In fact, I doubt that any other
endeavor can change culture faster (and more permanently) than a
comprehensive RCA effort. This is true at work. It's also true
at home. If you sincerely focus on the causes of things that go wrong,
you'll be shocked into a new way of thinking. That's culture
change!
Should culture-changing RCA efforts be
driven from the top-down, or from the bottom-up? This is a very debatable
question. Undeniably, management is often the driver of an RCA effort, but
often for the wrong reasons. If the intent is to merely satisfy a
governmental requirement, a top-down-driven effort is almost worthless.
On the other hand, when the "cry of the people" gets overwhelmingly loud,
management might have little choice but to listen. It's the folks in the
field that can get hurt, even killed. It's the folks in the field who
work in the heat and cold, who fix repetitive failures day after day.
It's the folks in the field who already know why things go wrong in our
businesses, and even what to do about it! Even more, it's the folks in
the field that remain fairly constant. I'm sick and tired of having
"sold" the RCA process to a management team who subsequently is replaced
during the latest merger. I STRONGLY prefer an RCA effort to be driven
from the bottom-up! They are the ones who stay constant.
So, whether you are an enlightened manager
who is driving this from the top-down, or a lower-level person desiring to
drive it from the bottom-up, there is one basic thing you need to
acknowledge before you start down this path: Root Cause Thinking is
something EVERYONE should have at all times and places. It is a way of
"seeing" that habitually looks beyond blame to instead "put ourselves in the
other guy's shoes." It is also an acknowledgement of "what is it about ME
that lead to this problem." It is also an awareness that SMALL THINGS
LEAD TO BIG THINGS. Imagine an organization whose people have achieved
these things!
 Whether
you are a lower-level person, or a manager -- if you see the immense value
in "understanding why things go wrong," PLEASE RECOGNIZE that you'll need
a plan. Don't make the mistake that so many others have made. Don't be
passive. Be aggressive.
Inculcating a Root Cause Mentality within
an organization is probably the most difficult, yet worthy endeavor
imaginable. You'll be confronting issues like blame, discipline,
accountability, fear, pride, and ego -- integral elements of ourselves that
inhibit our ability to "see" what we need to see if we're truly interested
in knowing "why things go wrong." In other words, it's not going to
"just happen."
 You're
going to have to PUSH IT. Failsafe has a lot of experience in helping
prodding people along in this endeavor. We'd like to share our
learning'. Certainly, our plan is far from perfect. In fact, changes
will be made in our approach as we learn from our mistakes. But recognize
that the suggested plan is based on past mistakes -- especially the
mistake of thinking that a root cause mentality will somehow "just happen"
to an organization without any extra effort. With this in mind, the
following is our suggested Site Path to inculcating a Root Cause Mentality
within your organization.
Site Path to Root Cause Discovery
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Expose a cross-section of your
organization to The Latent Cause Experience. Most organizations
do this once a year to insure the effort stays alive and does not
decay. When starting an effort, many organizations do this multiple
times per year.
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Divide your organization into 100 person
areas. For a 500 person organization, this would result in
5 areas. Select a group of passionate, interested people
from amongst the people that have been trained -- one person per area.
Failsafe calls this group a "Mother-Source."
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At this point, you will have identified 5
people to drive the effort into your organization. These 5 people
should do the following:
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Set thresholds (trigger-points) for Maxi,
Midi, and Mini-RCA's in each area. Thresholds should be set with
the Manager of each area.
-
Arrange either live or web-based Mini-RCA training for
area personnel (in groups of 5 to 10), spread bi-monthly over the
quarter. Training is 4 hours per group.
-
Require trainees to do a Mini-RCA within
1 week of training. Collect the Mini-RCA's. (Mini-RCA's take
10% longer than it normally takes to address a problem).
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Critique (coach, mentor) the Mini-RCA's
as they are performed.
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Assure that Maxi and Midi-RCA's are
completed per thresholds.
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Lead Midi-RCA's in the area.
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Lead Maxi-RCA's in another area.
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Identify Common Latent Threads twice per
year.
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Assure action on Common Latent Threads
(this will require approximately 8 hours commitment from key area people
twice per year).
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