Vervago :: Develop effective communication skills with PQ training

Longtime Vervago client Cypress Semiconductor is one of the world's leaders in productivity per employee. How do they do it? One major element contributing to their success is a thorough and routine use of root cause analysis in the wake of any major errors or failures. In the Cypress world, things like "operator error" or "lack of training" or "faulty equipment" are insufficient causes for understanding and eliminating the roots of workplace mistakes. Instead, managers and teams use errors as a chance to probe into team mental models, assumptions, and fact-based analyses of sequences of events that are buried deep in the system's infrastructure. Root cause analysis is also widely used in fields such as aviation, nuclear power, chemical production, and healthcare - where mistakes are not only costly, but potentially deadly.

As the name implies, root cause analysis is a particular form of causal reasoning that emphasizes a search for central factors that occur and re-occur in a system, rather than simply addressing the surface symptoms of problems. Root cause analysis is a discipline inside organizations that adopt it because it involves significant time and effort from cross-functional and cross-level teams. It usually involves working from an unexpected event backward, building a detailed timeline of events that led to the error or failure, supported by data relevant to the case. For instance, in a root cause analysis described by Carroll, Rudolph, and Hatakenaka,[1] cross-functional teams of operators and engineers document the causes of a fire in a chemical plant down to a minute-by-minute timeline that is compared to a similar timeline that documents instances in which the heater was used and fire did not occur.

Precision Questioning & Root Cause Analysis

At the chemical plant described above, the introduction of root cause analysis involved "drilling down" into causes of temperature fluctuations, exactly the kind of thinking and communication supported by Precision Questioning. Root cause analysis requires precision in discussing cause-effect links in ways that are supported by data and analysis. Knowing how to ask precise and careful questions, emphasizing clarification and assumptions, can dramatically improve organizations' root cause analysis practices.

Root Cause Analysis and Organizational Culture

In the research reported by Carroll, Rudolph, and Hatakenaka, the introduction of root cause analysis led to enhanced trust and openness in the work environment of the chemical plant - in part because of the way in which the root cause analysis was introduced and implemented. In order for root cause analysis to become a useful tool in an organization, the implementation of the practice must be tailored to encourage information sharing, respectful interaction, and limited defensiveness. Without such preparation, casual use of root cause analysis can inadvertently reinforce faulty beliefs or assumptions. Root cause analysis can seem threatening at times, when it turns up information that is critical of people's behavior. Managers or executives who offer punitive responses to the identification of root causes can reinforce barriers to communication. Root cause analysis works best when used in combination with analytic reasoning, fact-based investigation, broad participation, and openness to discovery.

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[1]J.S. Carroll, J. W. Rudolph, & S. Hatakenaka. (2002). Lessons learned from non-medical industries: root cause analysis as culture change at a chemical plant. Qualitative Research in Safety in Health Care, 11, 266-269.