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Article
Publication date: 12 November 2020

Coby V. Meyers and Bryan A. VanGronigen

Limited research on root cause analysis exists in educational leadership. Accurately diagnosing and detailing root causes—the why—of organizational failure, as is…

Abstract

Purpose

Limited research on root cause analysis exists in educational leadership. Accurately diagnosing and detailing root causes—the why—of organizational failure, as is relatively common in other fields, could improve principals' ability to devise situationally- and contextually-responsive solutions in their improvement plans. In this study, the authors analyze school improvement plans to provide insight into how principals use root cause analysis to identify their and their school's failures as a way to respond strategically with goals and action steps.

Design/methodology/approach

In this exploratory qualitative study, the authors develop coding schemes and leverage an existing rubric of school improvement plan quality to assess what principals identify as root causes for 216 priorities across 111 school improvement plans.

Findings

The overall quality of root causes submitted by principals was low, typically between “beginning” and “developing” stages. The majority of root causes aligned with priorities and desired outcomes, but fewer than one-third had a systems focus. Moreover, less than half of root causes suggested that school leaders played a part in the organizational failures. The vast majority of plans instead identified teachers as the root cause, foundational fault or “why” of the problem.

Originality/value

An increased understanding of root cause analysis conceptualization and development seems necessary if improvement planning is to be a strategic response to a school's most serious organizational challenges. The predominant approach to school improvement planning has focused almost exclusively on how to succeed or become better with little investment in identifying root causes of organizational decline or failure. This initial study of root cause quality in school improvement planning is a key first step in critically thinking about how improvement is to be achieved when failure is unconceived.

Details

Journal of Educational Administration, vol. 59 no. 4
Type: Research Article
ISSN: 0957-8234

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Article
Publication date: 30 October 2018

Rateb Sweis, Alireza Moarefi, Mahmood Hosseini Amiri, Soad Moarefi and Rawan Saleh

The international energy agency states that the world’s primary energy needs are expected to grow to 55 per cent until 2030. Therefore, oil and gas industry as the main…

Abstract

Purpose

The international energy agency states that the world’s primary energy needs are expected to grow to 55 per cent until 2030. Therefore, oil and gas industry as the main energy source will be more crucial where building or advancing new capacities is required. Because the reports highlight the delay as a recurring problem, thereby, more in-depth investigation to find out the main contributing causes is needed.

Design/methodology/approach

Root cause analysis (RCA) was applied to identify, rank, analysis and categorize the main sources of this problem.

Findings

Based on RCA procedure; Pareto analysis showed that 84.7 per cent of the delay is because: the radar chart indicated no difference in perception of the participants regarding the importance of the root causes, correlation analysis suggested strong relationship among the participants and the cause-and-effect diagram emphasized more on operational, human and equipment categories, which in total account for 51.86 per cent of the delay.

Originality/value

The risk planners of large-scale projects can consider these root causes as the main items to analysis, monitor and control, as they are vitally important for project success.

Details

International Journal of Energy Sector Management, vol. 13 no. 3
Type: Research Article
ISSN: 1750-6220

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Article
Publication date: 9 July 2018

Prashant Gangidi

The purpose of this paper is to go a step further from the traditional 5 Whys technique by adding three more legs during the root cause analysis stage – occurrence, human…

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Abstract

Purpose

The purpose of this paper is to go a step further from the traditional 5 Whys technique by adding three more legs during the root cause analysis stage – occurrence, human and systemic issues that contribute toward the problem, hence the term 3 × 5 Whys. Performing individual 5 Whys for these three components enables to identify deeper root cause(s) that may spawn across multiple groups within an organization.

Design/methodology/approach

Cause-and-effect analysis used during traditional root cause investigations within an 8D or Lean six sigma project is used as a theoretical foundation. Examples from different industries are presented showing the 3 × 5 Why’s framework and advantages it brings to the organization along with identifying shortcomings and suggestions to make it more effective.

Findings

If properly used this integrated methodology will reveal higher order systemic causes (e.g. policies or management decisions) stemming from lower lever symptoms (e.g. defective parts, procedural errors). Effective execution of this methodology can provide tremendous results in defect reduction, yield improvement, operational efficiency improvement and logistics management type of projects. Resolving higher level sources of problems allows an organization to evolve itself and maintain a competitive edge in the market.

Research limitations/implications

Adopting this quality management technique in start-up companies entails some challenges and other implications have been discussed with SWOT analysis.

Practical implications

Examples from various sectors using 3 × 5 Why approach have been presented that show that this methodology provides deeper insight into root causes which could be affecting multiple groups in an organization. Using this technique effectively is found to be beneficial to resolve issues in operations management, logistics, supply chain, purchasing, warehouse operations, manufacturing, etc.

Social implications

This methodology has a human component which often results in some sort of resistance as not all working professionals think alike when it comes to accountability and ownership of issues. This may hinder root cause analysis and subsequent corrective actions implementation.

Originality/value

This study is unique in its in-depth real-world case studies demonstrating the need for taking a deep dive approach to root cause analysis by understanding specific, system and human components responsible for causing the failure mode.

Details

International Journal of Lean Six Sigma, vol. 10 no. 1
Type: Research Article
ISSN: 2040-4166

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Article
Publication date: 22 February 2013

Shri Ashok Sarkar, Arup Ranjan Mukhopadhyay and Sadhan Kumar Ghosh

In implementing Six Sigma and/or Lean Six Sigma, a practitioner often faces a dilemma of how to select the subset of root causes from a superset of all possible potential…

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Abstract

Purpose

In implementing Six Sigma and/or Lean Six Sigma, a practitioner often faces a dilemma of how to select the subset of root causes from a superset of all possible potential causes, popularly known as root cause analysis (RCA). Generally one resorts to the cause and effect diagram for this purpose. However, the practice adopted for identification of root causes is in many situations quite arbitrary and lacks a systematic, structured approach based on the rigorous data driven statistical analysis. This paper aims at developing a methodology for validation of potential causes to root causes to aid practitioners.

Design/methodology/approach

Discussion has been made on various methods for identification and validation of potential causes to root causes with the help of a few real life examples for effective Lean Six Sigma implementation.

Findings

The cause and effect diagram is the frequently adopted method for identifying potential causes out of a host of methods available for such identification. The method of validation depends on the practitioners’ knowledge on the relationship between cause and effect and controllability of the causes.

Originality/value

The roadmap thus evolved for the validation of root causes will be of great value to the practitioners as it is expected to help them understand the ground reality in an unambiguous manner resulting in a superior strategy for cause validation and corrective actions.

Details

The TQM Journal, vol. 25 no. 2
Type: Research Article
ISSN: 1754-2731

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Article
Publication date: 17 July 2009

Jesper Aastrup and Herbert Kotzab

The purpose of this paper is to examine out‐of‐stock (OOS) challenges in the independent grocery sector with a special emphasis on in‐store root causes. The analysis aims…

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3836

Abstract

Purpose

The purpose of this paper is to examine out‐of‐stock (OOS) challenges in the independent grocery sector with a special emphasis on in‐store root causes. The analysis aims to assess the extent and root causes for OOS in the independently controlled retail sector and provide a comparison of these results with the centrally controlled chain sector in Denmark. The paper also seeks to examine the practices and challenges of store ordering and store replenishment processes in the independent sector and identify practical implications for store management and other members of the grocery channels.

Design/methodology/approach

The research design includes two studies. Study‐I surveys and compares the extent and root causes of OOS of 42 stores from eight chains in the two sectors. Study‐II identifies, based on qualitative interviews with 17 store managers/owners of independent stores, specific insights on store operations.

Findings

The quantitative study shows that the OOS rates in the independent sector are significantly higher than in the centrally organized sector. Furthermore, the independent grocery sector faces OOS challenges in more categories than the centrally controlled sector. The study also reveals a very large variation in the performance of independent stores. Contrary to the centrally controlled chain store sector, the major root cause for OOS in the independent sector is found in the store ordering process. The qualitative study shows that the main discriminating issues between stores with a low and a high OOS rate are: store management emphasis and commitment to OOS issues; the resulting priority and managerial guidance in store ordering and store replenishment tasks; the stability of staff and the proper planning for replenishment peaks; the store size and resulting space conditions; and the use of appropriate decision heuristics and use of inventory in store ordering.

Practical implications

The findings have practical implications for store management as it reveals practices to pursue and to avoid. Also, it is argued that the findings have implications for the other members of the grocery channels.

Originality/value

Empirically, this paper explores two issues not being dealt with in depth in previous research, i.e. the OOS challenge in the independent sector and the emphasis on store operations.

Details

International Journal of Retail & Distribution Management, vol. 37 no. 9
Type: Research Article
ISSN: 0959-0552

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Article
Publication date: 7 December 2018

Manuel F. Suárez-Barraza and Francisco G. Rodríguez-González

Some manufacturing and service organizations have made efforts to work on continuous improvement in the form of Kaizen, lean thinking, Six Sigma, etc. The elimination of…

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2356

Abstract

Purpose

Some manufacturing and service organizations have made efforts to work on continuous improvement in the form of Kaizen, lean thinking, Six Sigma, etc. The elimination of problems and waste (MUDA for the Japanese) plays a fundamental role in the reduction of operational costs and quality rejections of finished products both internally in the organization and in the supply chain. Some of these efforts use quality control tools to remedy it. Kaoru Ishikawa proposes seven basic quality tools. In this group of quality tools is the cause-and-effect diagram (CED), also known as “The Fishbone” and “Ishikawa diagram”. Exploring this questioning can shed light on the first indications to ratify the arguments of Ishikawa and Deming, that the main problems of companies are found in their processes and perhaps, in a deep way, in some of these cornerstone root causes that have to do with the way organizations are managed. The purpose of this study is to investigate cornerstone root causes through the application of CEDs in 40 Mexican companies that began an effort to improve some of their organizational processes.

Design/methodology/approach

An exploratory qualitative study was conducted. As a research strategy, the case study method was applied. Using theoretical sampling, the Ishikawa diagrams of 40 companies were analyzed, and 24 semi-structured interviews in depth were conducted.

Findings

The results of this research confirm the main research question: Are there cornerstone root causes that give way to one or several problems or effects of problems in organizations regardless of their sector? In other words, there were at least seven typical patterns that show the first signs of cornerstones root causes in organizations.

Research limitations/implications

The method itself is a limitation; 40 case studies are not enough to generalize the results. In addition, the research was conducted only in a single Latin American country; in some cities of Mexico. However, 60 per cent of these companies are multinationals.

Practical implications

This paper is fundamental to delve into the cornerstones causes that give rise to the problems of organizations of the twenty-first century. The authors understand that these are the first indications, and that they cannot be considered a conclusion of these causes. However, this first theoretical sampling presents a first light on the subject.

Originality/value

The study contributes to the limited existing literature on total quality management and Kaizen in quality control tools and subsequently disseminates this information to provide impetus, guidance and support toward improving the problems of the organizations of twenty-first century.

Details

International Journal of Quality and Service Sciences, vol. 11 no. 2
Type: Research Article
ISSN: 1756-669X

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Article
Publication date: 1 February 1998

T. Finlow‐Bates

Argues that root cause analysis as it is often used is grounded on tools which are weak and confusing. Illustrates this discussion on root cause analysis with examples…

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1873

Abstract

Argues that root cause analysis as it is often used is grounded on tools which are weak and confusing. Illustrates this discussion on root cause analysis with examples. Reviews policy and risk in the light of the discussion. Counsels avoidance of the “mythological absolute” of root cause analysis.

Details

The TQM Magazine, vol. 10 no. 1
Type: Research Article
ISSN: 0954-478X

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Article
Publication date: 12 July 2013

Matthew D. Smith, Julian D. Birch, Mark Renshaw and Melanie Ottewill

The purpose of this paper is to evaluate the common themes leading or contributing to clinical incidents in a UK teaching hospital.

Abstract

Purpose

The purpose of this paper is to evaluate the common themes leading or contributing to clinical incidents in a UK teaching hospital.

Design/methodology/approach

A rootcause analysis was conducted on patient safety incidents. Commonly occurring root causes and contributing factors were collected and correlated with incident timing and severity.

Findings

In total, 65 rootcause analyses were reviewed, highlighting 202 factors implicated in the clinical incidents and 69 categories were identified. The 14 most commonly occurring causes (encountered in four incidents or more) were examined as a key‐root or contributory cause. Incident timing was also analysed; common factors were encountered more frequently during out‐hours – occurring as contributory rather than a key‐root cause.

Practical implications

In total, 14 commonly occurring factors were identified to direct interventions that could prevent many clinical incidents. From these, an “Organisational Safety Checklist” was developed to involve departmental level clinicians to monitor practice.

Originality/value

This study demonstrates that comprehensively investigating incidents highlights common factors that can be addressed at a local level. Resilience against clinical incidents is low during out‐of‐hours periods, where factors such as lower staffing levels and poor service provision allows problems to escalate and become clinical incidents, which adds to the literature regarding out‐of‐hours care provision and should prove useful to those organising hospital services at departmental and management levels.

Details

International Journal of Health Care Quality Assurance, vol. 26 no. 6
Type: Research Article
ISSN: 0952-6862

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Article
Publication date: 27 July 2020

Dharyll Prince Abellana

This paper attempts to develop a hybrid cause and effect diagram (CED) and interpretative structural model (ISM) for root cause analysis in quality management. The…

Abstract

Purpose

This paper attempts to develop a hybrid cause and effect diagram (CED) and interpretative structural model (ISM) for root cause analysis in quality management. The proposed model overcomes the weakness of the CED in reliably articulating hierarchical cause–effect Relationships.

Design/methodology/approach

A focus group discussion (FGD) among quality experts in the case company to establish relationships between the determined causes.

Findings

The hybridization of the CED and ISM allowed the causes to be ordered more clearly to determine potential root causes as well as presenting these causes more comprehensively.

Originality/value

The paper has been one of the very few attempts to improve the CED approach. As such, this paper employs the ability of the ISM to order concepts in a hierarchical structure, which is useful in determining root causes.

Details

International Journal of Quality & Reliability Management, vol. 38 no. 3
Type: Research Article
ISSN: 0265-671X

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Case study
Publication date: 29 November 2020

Rajaram Govindarajan and Mohammed Laeequddin

Learning outcomes are as follows: students will discover the importance of process orientation in management; students will determine the root cause of the problem by…

Abstract

Learning outcomes

Learning outcomes are as follows: students will discover the importance of process orientation in management; students will determine the root cause of the problem by applying root cause analysis technique; students will identify the failure modes, analyze their effect, score them on a scale and prioritize the corrective action to prevent the failures; students will analyze the processes and propose error-proof system/s; and students will analyze organizational culture and ethical issues.

Case overview/synopsis

Purpose: This case study is intended as a class-exercise, for students to discover the importance of process-orientation in management, analyze the ethical dilemma in health care and to apply quality management techniques, such as five-why, root cause analysis, failure mode and effect analysis (FMEA) and error-proofing, in the management of the health-care and service industry. Design/methodology/approach: A voluntary reporting of a case of “radiation overdose” in a hospital’s radio therapy treatment unit, which led to an ethical dilemma. Consequently, a study was conducted to establish the causes of the incident and to develop a fail-proof system, to avoid recurrence. Findings: After careful analysis of the process-flow and the root causes, 25 potential failure modes were detected and the team had assigned a risk priority number (RPN) for each potential incident, selected the top ten RPNs and developed an error-proofing system to prevent recurrence. Subsequently, the improvement process was carried out for all the 25 potential incidents and a new control mechanism was implemented. The question of ethical dilemma remained unresolved. Research limitations/implications: Ishikawa diagram, FMEA and Poka-Yoke techniques require a multi-disciplinary team with process knowledge in identifying the possible root causes for errors, potential risks and also the possible error-proofing method/s. Besides, these techniques need frank discussions and agreement among team members on the efforts for the development of action plan, implementation and control of the new processes. Practical implications: Students can take the case data to identify root cause analysis and the RPN (RPN = possibility of detection × probability of occurrence × severity), to redesign the protocols, through systematic identification of the deficiencies of the existing protocols. Further, they can recommend quality improvement projects. Faculty can navigate the case session orientation, emphasizing quality management or ethical practices, depending on the course for which the case is selected.

Complexity academic level

MBA or PG Diploma in Management – health-care management, hospital administration, operations management, services operations, total quality management (TQM) and ethics.

Supplementary materials

Teaching Notes are available for educators only.

Subject code

CSS 9: Operations and Logistics.

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