October 3, 2005 | Mark Paradies

Systems, Root Cause Analysis, & Performance Improvement

What do systems, root cause analysis, and performance improvement have in common?

First, you have to understand what a “system” is.

Paul Fitts, a human factors expert, defined a system as:

“..An assemblage of elements that are engaged in the accomplishment of some common purpose(s) and are tied together by a common information flow network, the output of the system being a function not only of the characteristics of the elements, but of their interactions or interrelationships.”

If the PhD definition seems a little complex, lets try something more straightforward. Here is a definition given in Webster’s Dictionary:

an organized or established procedure : METHOD

Or you might like the definition of systematic:

methodical in procedure or plan : marked by thoroughness and regularity

Thus a systematic process is one that is planned, proceduralized, organized, consistent, and regular. The outcome of a systematic process is known in advance. It can be predicted. Thus success is assured.

What does this have to do with root cause analysis and performance improvement?

Common Characteristic 1. The TapRooT(R) Root Cause Analysis System IS a systematic process to find root causes. Therefore, it is proceduralized, organized, and consistent when used by different investigators. You might think this is true of all root cause analysis tools, but you would be wrong. Most root cause analysis tools are based on some kind of brainstorming – cause-and-effect – experienced based troubleshooting process that is NOT very systematic.

Thus to have this common characteristic of a system (and be repeatable), a root cause analysis tool must be well thought out and overcome a common human tendency to jump to conclusions and to only collect evidence that verifies the investigator’s hypothesis.

The tapRooT(R) Software adds to the systematic process of finding and fixing root causes by making the system easier to use (for example, by providing easy access to the definitions in the Root Cause Tree(R) Dictionary) and by providing a systematic way to develop corrective actions by using the Corrective Action Helper(R) Module.

Common Characteristic 2: The TapRooT(R) Root Cause Analysis System looks for weaknesses in the way we perform work to find root causes. This is essentially examining the way work is done to look for a lack of systematic processes or weakness in systematic processes. The TapRooT(R) System examines typical “work systems” like:

  • procedures
  • training
  • quality control
  • management systems
  • preventive/predictive maintenance
  • work direction

Even a process like communicating verbally can be observed for weaknesses in the “system” of communication.

We can systematically review the way work is performed and find “traps” that lead to problems and poor performance.

By spotting problems and recommending improvements, we can recommend better, well thought out systematic processes to perform work and thereby achieve superior, consistent, predictable results – PERFORMANCE IMPROVEMENT.

Thus “systems” are at the heart of root cause analysis and performance improvement – both by making root cause analysis better and by making performance improvement possible.

Would you like to learn more about systems? Then I would recommend two things …

1) See Kevin McManus’ web site: Great Systems! (His web site even has a blog.)

2) Attend Kevin’s talk – “Using Systems to Improve Quality” – at the TapRooT(T) Summit in Gatlinburg, TN, on April 5-8, 2006.

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