Wednesday, May 9, 2007

Root Cause Analysis

Dogs bark, babies cry, system crash....what are you going to do?? Root Cause Analysis (RCA) of course! There are many good reasons for RCA:
  • quality improvement
  • future risk mitigation strategies
some bad reasons:
  • blame (the name of the game is....blame)
  • CYA
  • planned litigation (why get to this point?)
and some required ones:
  • contractual
  • regulations
  • you're an RCA specialist
Prior to starting your RCA - I would recommend:
  • understand the goals of the RCA (and make sure everyone agrees)
  • set the limits of the review: time, cost, etc. - this should be based on the benefit of performing a RCA. If the problem caused $10 of damage and little likelihood of occurring again and the RCA is $1,000....I would think twice prior to proceeding (unless of course - you don't have a choice)
  • set expectations about the RCA: you will return with actionable items, no-blame - just quality improvement, time to report back, etc.
  • set limits of the RCA - I'm sure we can all trace any issue back to societal causes (do you blame the removal of the caveman dance for all problems you encounter??)
  • develop a standard reporting format - preferably a web based RCA so people could share and learn (hey - look Larry stubbed his toe the other day - we should learn from that)
Here's some more 'in-depth' RCA info (WikiPedia of course):

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