Analyze causes of

problem
By Milion R (BSc, MScN)

04/13/2025 By:Milion R(BSc, MScN) 1

Outlines

At the end of this session you will be able

to:
Discuss RCA(step, benefit, principles, basics,
way(5why & 4M1E))
Discuss Action plan

04/13/2025 By:Milion R(BSc, MScN) 2

 Root cause analysis (RCA)
- is the process of discovering the
root causes of the problems in
order to identify appropriate
solutions.
It is much more effective to
systematically prevent and solve
for underlying issues rather than
treating symptoms .
It can help with process improvement
and problem prevention in various
context .
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Steps of RCA Methods

RCA method consists of three step

Step 1. target problem detection

Step 2. root cause detection

Step 3. corrective action innovation

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 Benefits of root cause analysis

Helps to discover the root cause of a problem

Helps to fully understand how fix , compensate , or

learn from any underlying issues /causes

Helps to apply what we learn from this analysis to

systematically prevent future issues .

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Principles of RCA
To be effective, RCA must be performed systematically
and conclusions must be backed up by evidence.
There is usually more than one root cause for any
given problem and therefore there may be more than
one corrective action.
Don’t ignore the importance of treating symptoms for
short term relief
Focus on HOW and WHY something happened , not
WHO was responsible
Aiming corrective actions at root causes is more
effective than just treating the symptoms of a problem.
Provide enough information to inform a corrective
course of action
Consider how a root cause can be prevented in the
future
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 General process for performing root
cause analysis
1. Define the problem.
2. Gather data/evidence.
3. Identify issues that contributed to the problem.
4. Find root causes.
5. Identify which causes to remove or change to prevent
repeated problem.
6. Develop solution recommendations that effectively
prevent repeating the problem.
7. Implement the recommendations / changes.
8. Observe the recommended solutions/changes to
ensure effectiveness of eliminating the problem.

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Cause mapping of Root Cause
Analysis
“ROOT” refers to the causes beneath the surface.

It is the system of causes that shows all the options for

solutions.

Do not focus on a single cause as this can limit the

solutions set resulting in missing a better solution.

A Cause Map provides a simple visual look at all the

elements that produced the problem.

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Three Basic Steps of Cause Mapping
1. Define the issue by its impact to overall goals

2. Analyze the cause in a visual map.

3. Prevent any negative impact of the goals by selecting

the most effective solutions.

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 Ways to conduct effective root
cause analysis

1. 5Whys approach :- is one more common techniques

in performing a root cause analysis

For every answer to ask WHY question

Children are surprisingly effective at root cause analysis .

It serves as a way to avoid assumptions.

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 Cont…. Example : 5why
Lets think back to our football concussion , first our player will
present a problem :
1. Why do I have such a bad headache ? This is our first WHY .
First answer : because I can’t see straight .
2. Second WHY : Why can’t you see straight ? Second answer :
because I my head hit the ground .
3. Third WHY : Why did your head hit the ground ? Third answer
: I got hit tackled to the ground and hit my head hard .
4. Fourth WHY : Why did hitting the ground hurt so much ?
Fourth answer : Because I wasn’t wearing a helmet .
5. Fifth WHY : Why weren’t you wearing a helmet ? Fifth answer
: because we didn’t have enough helmets in our locker
room .
Aha . After these five questions , we discover the root cause of
the concussion was most likely from a lack of available helmets
.
• In the future , we could reduce the risk of this type of
concussion
04/13/2025
by making sureBy:Milion
every football player has a helmet.
R(BSc, MScN) 12
 Cont…2)_ 4M1E methods of analysis
The methods help to identify the causes behind the specific effects
It helps to solve the problem
4M1E

1. Material :- is the element that talks about the tangible thing we

need to use to achieve our goal or give a solution to the problem

2. The method :- is the tactics on how we can utilize the materials

to contribute to improving , solving , and achieving the goal

3. The machine :- is a bit similar to the material.

4. Man can utilize all of this material and machines and make all
the methods possible .
1. Enviornment :-the location were the above 4Ms execute their
expected duty.

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The basic question asked during
4M1E RCA
[Link] [Link]
-was the information -was the correct tool used ?
disseminated properly ? -is the equipment affected
-was the documented properly by the environment ?
interpreted ?
-is the equipment being
-did recipient understand the properly maintained?
information ?
-was the machine properly
-was the proper training to
programmed ?
perform the task administered
to the person ? -is the machine the right
-are there distractions in the application for the given
work place ? job? etc
-how much experience does
the individual have in
performing this task ?
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Cont….
[Link] [Link]
-was the material properly -were the workers trained
tested ? properly in the procedure ?
-was the materials -was the testing performed
substituted ? statistically significant ?
-were requirement [Link]
adequate for part function -is the process affected by
? temperature change ?
-was the material handled -is the process affected by
properly ( stored , humidity , vibration , noise ,
dispensed , used and lighting . Etc?
disposed ) ?
-does the process run in
-is the supplier process controlled environment?
defined and controlled ?

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7 Best Practices to Remember

1. Your root cause analysis is only as good as the info

you collect.
2. Your knowledge (or lack of it) can get in the way of a
good root cause analysis.
3. You have to understand what happened before you
can understand why it happened.
4. Interviews are not about asking questions.
5. You can’t solve all human performance problems with
discipline, training, and procedures.
6. Often people can’t see effective corrective actions
even if they can find the root cause.
7. All investigations do not need to be equal

04/13/2025 By:Milion R(BSc, MScN) 16

 selecting high priority problem

Step to selecting high priority problem

1. Make list of problem

2. Identify what's important

3. Highlight what's urgent

4. Prioritize based on importance and urgency

5. Avoid competing priorities

6. Consider effort

7. Review constantly and realistic

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 Action plan
it is a set of Component
measure and 1. Details all required steps
activities required 2. Establish a time frame
to implement a 3. Establish the resources required
project . 4. Define the specific actions
(steps )that must be taken to
identifies the implement the initiative
specific steps that 5. Determine the deliverables (in
will be taken to measurable terms )
achieve the 6. Identify in-process measures to
ensure the processes used to carry
strategic out the action are working as
objectives. intended
It require the 7. Define the expected results and
milestones of the action plan
monitoring .
8. Provide a brief status report on each
step
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 Establishing activity plan per 5W1H

Elements of 5W1H
5W1H method :- an
What ? : is to clearly/define
analysis and the issue in question .
planning tool Who ? : identifying all the
stakeholders to be involved .
help to collect and Where ? : geographical
analyzing all the aspect of the action plan .
When ? : timing
relevant information.
Why ? : analysis the reasons.
5W1H :- who? , what How ? : answer the
procedure to implemented
?, when? ,why ? ,
where ? , and how ?.

04/13/2025 By:Milion R(BSc, MScN) 19

04/13/2025 By:Milion R(BSc, MScN) 20
 GALATOOMA !!!

04/13/2025 By:Milion R(BSc, MScN) 21