ОКСАНА ГОРОЩУК «Improving Quality Through Root Cause Analysis»
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The document discusses Root Cause Analysis (RCA), a systematic process aimed at identifying the root causes of problems to develop effective solutions and prevent future issues. It outlines key steps in RCA, such as defining the problem, collecting data, identifying root causes, and implementing solutions, along with techniques like the Five Whys, Pareto Chart, and Fishbone Diagram. Additionally, it provides tips for performing effective RCA and the importance of engaging the entire team in the process.
ОКСАНА ГОРОЩУК «Improving Quality Through Root Cause Analysis»
- 1. Improving quality through the Root cause analysis Oksana Horoshchuk Quality control lead at SoftServe
- 2. Agenda What is RCA and it’s main steps? Main RCA techniques Examples of RCA from the real projects How to start RCA on the project Tips for performing effective RCA Today, we’re going to discuss
- 3. RCA Goals What is RCA? Root cause analysis (RCA) is the process of discovering the root causes of problems in order to identify appropriate solutions. RCA assumes that it is much more effective to systematically prevent and solve for underlying issues rather than just treating ad hoc symptoms and putting out fires. 1. Discover the root cause of a problem or event 2. Fully understand how to fix 3. Apply what we learn from this analysis to systematically prevent future issues or to repeat successes
- 4. MAIN RCA STEPS 1. Define the problem. First, make sure that you and your team align on "What happened?" and that you are addressing the same problem. 2. Collect data Focus on "How did this happen?" and collect data around the problem. 3. Identify the root cause Causal factors help to answer "How did this happen?“ Also, in this step, the team should be guided to identify fixable causes. 4. Recommend and test the solution After the root cause has been identified, the team should work to develop a solution that goes to the executive team for approval before testing begins. Once approved, the solution should enter a testing phase, which can be rolled back if unsuccessful. 5. Implement and monitor Once the solution is implemented, teams should continue monitoring it in the production environment to ensure it is working as expected. That’s why RCA is depicted as a cycle—if the solution didn’t resolve the problem, it could be that the problem was a causal factor, and the team needs to begin the RCA process again.
- 5. KEY RCA TECHNIQUES Five WHYs Pareto chart Fishbone diagram
- 6. FIVE WHYs The five whys is a Root Cause Analysis technique used to identify the underlying cause of a problem. The method involves asking "why" questions repeatedly until the root cause of the problem is uncovered.
- 7. EXAMPLE A missed project deadline 1. Problem statement: Why was the project deadline missed? Answer: The final deliverables were not completed on time. 2. Why were the final deliverables not completed on time? Answer: The design phase took longer than expected. 3. Why did the design phase take longer than expected? Answer: There were frequent design changes requested by the client. 4. Why were there frequent design changes requested by the client? Answer: The initial project requirements were not clearly defined. 5. Why were the initial project requirements not clearly defined? Answer: There was a lack of communication and collaboration between the project team and the client during the requirement-gathering phase.
- 8. PARETO CHART In RCA, the Pareto chart helps to identify the 20% of causes that are responsible for 80% of the problems. It works by displaying data in descending order of frequency, with the most frequent causes listed first. This helps you to focus on the most important causes and prioritize your efforts to address them.
- 9. HOW DO I CREATE PARETO CHART 1. Select a problem 2. Collect data 3. Sort data & calculate the cumulative percentage 4. Draw the axes, bars, cumulative percentage line, and labeling 5. Identify priority and plan further actions
- 10. BENEFITS OF USING PARETO CHART ü It allows easily distinguish between Vital Few and Trivial Many ü It displays the relative importance of the causes of the problem ü It helps the team to focus on those causes that will have the greatest impact when solved ü By using 20% of resources, we can solve 80% of problems ü We can easily understand the impact of the defect on production ü It is very easy for an analysis
- 11. FISHBONE DIAGRAM The Fishbone diagram or Ishikawa diagram is a modern quality management tool that explains the cause-and-effect relationship for any quality issue that has arisen or that may arise. A fishbone diagram helps in root cause analysis to identify the causes behind the emergence of difficulty and problems.
- 12. CATEGORIES OF CAUSES For the identification of factors causing a problem, the reasons are classified into the following categories: • Manpower • Method • Machine • Material • Mother Nature • Measurement
- 13. HOW TO BUILD FISHBONE DIAGRAM Step 1. Identify the problem Step 2. Brainstorm the major categories of causes Step 3. Identify possible causes Step 4. Analyze the diagram
- 15. PROS OF USING FISHBONE DIAGRAM ü Visual representation ü Organized brainstorming ü Focus on root causes ü Comprehensive analysis ü Collaboration ü Cost-effective ü Preventive action This technique is widely used in product design, quality improvement, and defect minimization. Overall, the Fishbone diagram is a valuable tool for RCA because it helps teams to identify and understand the underlying causes of problems, leading to more effective problem-solving and prevention of future issues.
- 16. CONS OF USING FISHBONE DIAGRAM • Simplistic view • Over-reliance on brainstorming • Limited data • Time-consuming • May not identify multiple root causes • Limited applicability
- 17. The key questions that should be addressed when conducting RCA of software bugs Why did it appear in our application? Why did we miss this issue (as a QC)?
- 18. Let’s look at a few examples of using RCA in the real projects
- 19. Fast approach how to start RCA
- 20. Analyzing during which SDLC phase the bug was introduced and found
- 21. Possible findings from the analysis
- 22. Presenting to the client the frequency of root causes (PROD issues)
- 23. Analysis of often impacted areas (regression bugs)
- 24. Analyzing each defect found during the sprint
- 25. Analyzing each defect found during the sprint
- 26. STEPS ON INTRODUCING RCA 1. Highlight which exact problem needs to be solved (e.g., PROD issue analysis, a lot of regression bugs appeared, and we need to understand why, etc.) 2. Describe to the team the importance of RCA (what is RCA) 3. Configure the approach 4. Get the agreement on how frequently you will do it 5. Where and to whom the results should be shared (DEV, BA, Client, etc.) 6. Decide how will you track the progress (action items completion)
- 27. QUESTIONS TO ANSWER BEFORE STARTING RCA • Do we have any issues on the project? • If there are multiple issues -> where to start? • RCA goal on our project? • How will we do this RCA (which technique, attendees, frequency, in which area)
- 28. TIPS FOR PERFORMING EFFECTIVE RCA ü Ensure that the whole team understands the RCA goal ü Understand what problem needs to be solved by RCA ü Generate clear action items and track their completion ü Focus on correcting root causes rather than just symptoms ü Don’t ignore the importance of treating symptoms for short-term relief ü Realize there can be, and often are, multiple root causes ü Focus on HOW and WHY something happened, not WHO was responsible ü Consider how the same issue can be prevented in the future ü Remember to perform Root Cause Analysis for success too ü Always track the implementation of RCA action items and their success ü Collect RCA metrics to see the trend (which root cause is predominant) and analyze them systematically ü Make this RCA as a part of Definition of Done on your project ü Configure an additional field in your bug tracking tool and make it required (if possible) ü Don’t overwhelm the RCA process with a lot of activities