What is root
cause analysis?
Root cause
analysis is a structured process that helps healthcare, manufacturing and
service sector managers and leaders in identifying contributing factors or
causes of an accident, error, problem, event or occurrence.
An accident,
error, problem, event or occurrence are usually a result of a system rather
than an individual mistakes. Understanding the system itself and contributing
factors or causes of a system failure can help in preventing recurrences.
Actions that
are taken to address system failure helps in sustaining the improvements or
corrective actions.
What is a
fishbone or ishikawa diagram?
Each and every
outcome or effect is an end result of actions taken/omitted or in general
causes/
A cause and
effect diagram representing this relationship between cause and effect is
called a called a fishbone or ishikawa diagram.
A fishbone
diagram is a visual way to represent cause and effect. It is a more structured
approach for brainstorming causes of a problem.
Fishbone or
ishikawa diagram can be described as a risk visualizer!
How do you
create a fishbone or ishikawa diagram?
In order to
understand the underlying causes of an incident, one needs to understand the
process or system used to obtain the results or outcomes.
Often in a
busy healthcare or manufacturing setting it is not possible to take large chunk
of time to review each and every minute details of a work process to find a
cause or contributing factors. This is when the fishbone can be created with
the help from frontline staff and experts using
a simple brainstorming session to identify possible causes.
To create a
fishbone, the problem/occurrence or effect is displayed at the right hand side
of the diagram as a head or mouth of the fish.
The team
brainstorms the possible contributing factors. Typically these contributing
factors can be naturally grouped into certain categories or headings - known as
"bones" or primary causal
categories.
A fishbone
diagram can be helpful in identifying possible causes for a problem that might
not otherwise be considered by directing the team to look at the categories and
think of alternative causes. Include team members who have personal knowledge
of the processes and systems involved in the problem or event to be
investigated.
How have you used root cause analysis?
There are many
ways to conduct root cause analysis. Which root cause analysis method is your
favorite? Please comment below or join
the conversation on LinkedIn. I have used the fishbone / root cause analysis
process in analyzing risks and evaluating risk controls. If your ERM program is
stuck in neutral and needs a boost to get moving again, contact me to discuss
how you can get a tailored action plan to achieve your ERM goals. We would also
love you to trial our FREE fishbone tool! visit us at www.ermgovernance.com
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