Root Cause Analysis Blog

One of the biggest trends in quality improvement was the term “The Cost of Poor Quality” tied with “Zero Defects”, with many COPQ financial models popping up in many Fortune 500 companies. In the safety world there was a similar drive with the term Cost of Compensation tied with “Zero Injuries” and OSHA driven recordables to be tracked.

The Quality Iceberg

The Safety Iceberg

Yet the focus for both safety and quality were lead by lagging visible indicators. In other words good or bad, the findings are just too late. You march your troops with the “Zero Defects” and “Zero Injuries” flags raised and once you reach your destination you turn around and see who and what equipment you have left.

Now don’t get me wrong, identifying and being able to comprehend the end damage is a vital part of the process and unfortunately not realized by some. It is just NOT where you should focus your drive and effort.

So what now you may ask? “Build quality in… do not inspect quality in!”

The phrase above often goes to deaf ears because it is misunderstand. “If you do not assess the quality of your work, then how do you know if it is to standards,” people would ask. “I have to trust everybody’s work?” In the safety world the phrase “Safety must be part of every action we do,” is often trumpeted. But how?!

Start with these 3 steps first:

1. First things first, Quality and Safety are NOT silo’s and they should work together. Setting up a task that can be worked efficiently, correctly and safely by employees is a combined goal and SHOULD NOT be competing goals.

To save money, many companies do not cross-train employee’s from different departments. Why not if it makes sense? For example, while many of our clients started using TapRooT® Root Cause Analysis in their safety departments first, the more people saw the process used, the more operations and facilities come onboard for the same training.

Now this cross-training concept also works in the opposite direction. As the quality department leaders started working with the safety, quality tools from Stakeholder Analysis to Force Field Analysis were also shared with the safety department. After all, inside all world class companies are different departments that are all part of the same company with one goal.

2. Building Quality and Safety into a process starts in the beginning stages of planning but can be recovered after the employees try to use an existing process (it just costs more time and money!).

When our clients use our Root Cause Analysis process to investigate defects and incidents it soon becomes apparent that the opposite of each one of our root causes are best practices that can be implemented proactively.

While most Quality Experts are excellent at mapping out front end value streams, process maps and spaghetti maps, there is often a gap in knowledge of research and industry best practices in human engineering, communication, procedures, training and work direction. So if you were a Quality Professional and had access to multiple experts in front of you everyday, would you utilize them? Here is small list of courses that can give you best practice access: Best Practice Courses

3. No process, no matter how well designed is perpetually stable and it must be audited/assessed periodically based on risk for unknown and known changes…. note: this is not the same thing as “inspecting in quality”!

This is one of the most misunderstood ingredients relating to Inspections.

If you have a hold point inspection that must be completed by an Independent Inspector BEFORE a task can be completed or a part received or shipped, you are admitting that you have a high risk potential that is not capable of being completely mistake proofed.

– OR-

You have a process or task where you have not truly identified the human and equipment behaviors with their associated Root Causes, and have decided that it is worth spending the extra money and time to inspect instead of fixing the problem. You refuse to build in quality.

Now this is not saying that you should not target high risk tasks proactively and continually audit or assess these areas to ensure nothing has changed or is different. This type of inspection must still occur.

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