mini-training: using root-cause analysis for problem management
DESCRIPTION
Understand how to use root-cause analysis to analyze problemsTRANSCRIPT
Using Root Cause Analysis for Problem Management
Training
Purpose of this training
• Show how to use root-cause analysis to understand problems in our context
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Solve problems, not symptoms
• To solve problems, you must make sure that you understand it:
1. Why it needs to be solved
2. How you will know when it is solved
3. What the root cause is.
• Be careful not to mistake symptoms for cause.
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Example
• Problem: Memory leak in server.
• Bad solution: Buy more memory.
• Good solution: Find & fix the source of the memory leak. Implement tests to detect new memory leaks in the future.
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Systemic problems
• Most problems in organizations are systemic. The “system” (the organization) has a glitch that needs to be fixed.
• Until you find the source of the glitch, most attempts to fix the problem will be futile or even counterproductive.
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Problem solving approach
• A3-thinking: yet another output of the « Kaizen » continuous process improvement from Toyota Lean methodology.
Analyze and visualize the root cause before proposing a solution.
You can do this using cause-effect diagrams, or stream maps, or fishbone diagrams
Template: http://www.crisp.se/gratis-material-och-guider/a3-template
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How to use cause-effect diagram
• Here’s the basic process: 1. Select a problem and write it down.
2. Trace “upwards” to figure out the business consequences, the “visible damage” that your problem is causing.
3. Trace “downwards” to find the root cause (or causes).
4. Identify and highlight vicious cycles (circular paths)
5. Iterate the above steps a few times to refine and clarify your diagram
6. Decide which root causes to address and how (i.e. which countermeasures to implement)
7. Follow up and see if it worked. If not, try again.
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Example 1: we always miss deadlines (1/3)
• We have a long release cycle and our releases always occur at a later date than planned. – So what? Who cares if the releases are delayed? What is the
consequence?
– Can we quantify the problem? This data will help us evaluate how much effort it is worth spending to solve this problem.
– How will we know when we’ve solved the problem?
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Example 1: we always miss deadlines (1/3)
• We have a long release cycle and our releases always occur at a later date than planned. – So what? Who cares if the releases are delayed? What is the
consequence?
– Can we quantify the problem? This data will help us evaluate how much effort it is worth spending to solve this problem.
– How will we know when we’ve solved the problem?
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Example 1: we always miss deadlines (2/3)
• Dig towards the roots
– 5 whys • Why are we missing
deadlines?
• Why? Why? Why? Why?
– Vicious cycles / re-enforcing loops should start to appear. Recurring problems almost always involve loops.
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Example 1: we always miss deadlines (2/3)
• Dig towards the roots
– 5 whys • Why are we missing
deadlines?
• Why? Why? Why? Why?
– Vicious cycles / re-enforcing loops should start to appear. Recurring problems almost always involve loops.
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Example 1: we always miss deadlines (3/3)
• Identify the root cause(s)
– Go back and ask a few more whys
• Now it’s time to propose countermeasures
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Example 1: we always miss deadlines (3/3)
• Identify the root cause(s)
– Go back and ask a few more whys
• Now it’s time to propose countermeasures
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Example 2: Lack of TDD or Pair Programming (1/2)
• What is the consequence of not doing pair programming or TDD? Is lack of TDD and pair programming really a problem?
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Example 2: Lack of TDD or Pair Programming (1/2)
• What is the consequence of not doing pair programming or TDD? Is lack of TDD and pair programming really a problem?
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Example 2: Lack of TDD or Pair Programming (2/2)
• Why aren’t you pair programming then?
– 5 Whys
• Identify unexpected root causes
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Example 2: Lack of TDD or Pair Programming (2/2)
• Why aren’t you pair programming then?
– 5 Whys
• Identify unexpected root causes
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Lots of problems
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Practical notes
• Working alone: tool of your choice (powerpoint, visio, paper board…)
• Working in small groups: – You can use sticky notes for issues and a
white board
• Working in larger groups: split in smaller groups focused on a specific problem. Gather regularly to share insights.
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Pitfalls
• Too many arrows and boxes: – Remove redundant boxes
– Focus on “depth first”. Don’t write all causes of a problem, write only the most important one or two, and then keep digging deeper.
– Accept imperfections, a diagram like this will never be perfect.
– Maybe your problem area is too broad, try to limit yourself to a more narrowly defined problem.
– Split the diagram into pieces.
• Getting personal: – Treat all problems as systemic!
– Avoid “blame game”.
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Summary: Why to use cause-effect diagrams
• Create a common understanding
– Cause-effect diagrams are a very practical collaboration technique to create a common understanding of a problem.
• Identify how problems affect the business
– So that you can focus on the most important problems first and make informed decisions.
• Find root causes
– So that you can maximize the effect of your changes.
• Find vicious cycles
– So that you can break them, or turn them into positive reinforcing loops (good stuff leading to more good stuff, instead of bad stuff leading to more bad stuff).
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Reference • http://blog.crisp.se/2009/09/29/henrikkniberg/1254176
460000 – http://www.crisp.se/file-uploads/cause-effect-diagrams.pdf
• http://blog.crisp.se/2012/08/23/henrikkniberg/problem-solving-template
• http://en.wikipedia.org/wiki/5_Whys
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comprising various complementary international brands: Betclic, Everest Gaming, bet-at-home.com, Expekt…
• Active in 100 countries with more than 12 million customers worldwide, the Group is committed to promoting secure and responsible gaming and is a member of several international professional associations including the EGBA (European Gaming and Betting Association) and the ESSA (European Sports Security Association).
• Through our brands, Betclic Everest Group places expertise, technological know-how and security at the heart of our strategy to deliver an on-line gaming offer attuned to the passion of our players.
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