This article discusses five ways to facilitate root cause analysis (RCA) more effectively through conducting pre-session exchanges, asking powerful questions, using exercises that engage, anticipating disruption, and controlling the tempo. Root cause analysis requires systems thinking because most failures involve a is a collection of interrelated or interacting parts, including physical equipment, humans, and interactions.
Facilitation is defined as a structured session(s) in which the meeting leader (the facilitator) guides the participants through a series of predefined steps to arrive at a result that is created, understood, and accepted by all participants.” The fundamentals of good facilitation as provided in the definition are always essential, including having a structure that includes predefined steps and arriving at results that are created, understood and accepted by all participants.
Facilitating Root Cause Analysis
Root cause analysis is defined as a collective term that describes a wide range of approaches, tools, and techniques used to uncover the causes of problems. The American Society for Quality (ASQ) defines a root cause as a factor that caused a non-conformance and should be permanently eliminated through process improvement.
Root cause analysis is a form of problem solving. Problem solving is a way of thinking and should not be relegated to a singular rule set or limiting collection of approaches. Root cause analysis occurs after a failure (or non-conformance) has occurred. Naturally, human defenses and emotions are elevated. For these reasons, facilitating root cause analysis may be the most difficult form of technical facilitation.
A complete investigation ties back to the work processes. Bob Latino, an RCA guru that has provided many articles and trained more than 10,000 professionals in root cause analysis, provides some tips when facilitating
- Ask the same lead question to all participants
- Explain the purpose and structure of interviews and sessions
- Make your notes visible
- Allow pictures if you cannot understand words
- Be aware of body language
- Use problem frames and block diagrams to keep discussions focused
- Keep sessions short
Root cause analysis expert Mark Galley states that the purpose of a root cause analysis is to identify the best solutions. In this context, Galley provides eight tips for facilitating RCAs:
- The facilitator collects and organizes information
- Focus on the cause-and-effect principle
- Recognize that people see things differently
- Define the incident by its impact on the overall goals
- Prevent arguments about the problem or the cause
- Make the analysis visual
- Use Microsoft Excel to document the entire investigation
- Pick the best solutions from the possible solutions
In previous articles, in-person discussions, virtual discussions, and online surveys are referenced as viable forms of pre-session exchange. Pre-session exchange should also include discussions with the executive sponsor to confirm their goals, sensitivities, and expected outcomes of the facilitated session.
The pre-session exchange for root cause analysis should consist only of live interviews. The reason is that participants’ emotions are always elevated because they expect the root cause analysis to be a “blame game.” This, of course, is not the case but it is a fair assumption. There is a tendency for senior management to blame the front-line worker or the equipment and not address the true root causes, which are usually related to more complex business strategies and the management system itself. In-person pre-session exchanges establish rapport between facilitator and participant and, in turn, produce a more efficient and effective assessment.
An important part of all root cause analysis is conducting interviews. The pre-session exchange should not be confused with, or substituted for, the one-on-one or small group interviews that will be conducted as part of the assessment. The goal of the pre-session exchange is to establish rapport, help participants understand the scope, provide participants with a request for information, prepare the facilitator for sensitivities or conflict points, and answer questions. The point of the pre-session exchange is NOT to solve the problem.
With the limitation that the pre-session exchange is different from the RCA interview, both share some common execution characteristics. These include:
- Schedule the discussion in advance
- Establish a short duration (usually 30 minutes for pre-session exchange) and keep it
- Use a standard format with a clear purpose (use the same standard format for everyone)
- Meet at interviewee’s place of work or neutral ground
- Sit on the same side of the table – simulate that you are working together to solve a problem
- Use visuals or drawings whenever possible to divert any animosity away from you (the facilitator) and to build trust in your neutrality
- Do not find fault or place blame
- Listen for frustration or unusual language or references
- Assume everyone is telling the truth
Great facilitators always use their imagination phrases like “Think about…”, “Imagine…”, and “Consider….” With root cause analysis, it is important to remember to avoid hypotheticals since the issue at hand is to recreate an actual event.
Opening questions that frame probabilities and possibilities are good. A weak question is, “How did the pump fail?” A better question is something like, “Remember when you have seen other pumps like this fail. Think about how those similar pumps failed. Think about how this pump failed. What were some of the similarities? What were some of the differences?”Piercing “5 Whys” is also very important to get to the root cause. The structure of follow-up questions like “And why is that important?” or simple restatement like “what did you mean by that” are important ways to ensure that you are piercing the “5 Whys” rather than merely working through a checklist.
Remember, too, that technical professionals often are biased in their perspective of their “5 Whys.” In some cases, engineers often see only engineering-related reasons and financial professionals attribute everything back to financial reasons. In other cases, personality types bias the “5 Whys” back to people issues and in other cases back to the process or technical issues. Piercing the ‘5 Whys” with powerful questions is important because every participant brings a slightly different perspective.
Exercises That Engage
Developing block diagrams, mapping the business process, creating a cause-consequence diagram are three engaging exercises for any root cause analysis. They are essential tools for every root cause analysis.
The amount of advance information will vary based on the problem. However, fabulous facilitators take a shot at developing the block diagrams, business processes, and cause-consequence diagrams in advance (and hopefully with standard tools) to identify obvious gaps and to help the group sessions move efficiently. The actual diagrams should be developed live with the participants (preferably on a whiteboard or projected on a screen in Excel) to enhance participation, create consensus, and minimize individual biases.
Audience response systems (ARS) are engaging in any form of facilitated session. An ARS is particularly powerful in root cause analysis when considering human factors in a group session. The Human Factors Analysis and Classification System (HFACS) breaks down the human factors into four levels ranging from human error to management system issues. Transferring the aspects of HFACS into a polling system driven through the ARS allows all participants to anonymously share their perspectives related to the sources and roles of human factors in the root cause analysis. It also helps mitigate accusations or blame when there is a need to facilitate in a group setting.
Fear of the “blame game” is present in every root cause analysis. It is not surprising that there should be a heightened anticipation of disruption, if for no other reason than one or more participants may feel cornered by the direction of the fact-finding.
All of the previously discussed approaches in other articles to anticipate and mitigate disruption apply. These approaches include well-defined approaches for creating a “parking lot” of contentious issues, establishing a smaller facilitation advisory team, pivoting to breaks, not engaging in arguments, and projecting interactive information onto a board or screen.
Of special relevance to root cause analysis is “there is a facilitator in every audience.” This is important whether the experienced RCA is doing the facilitation alone or with another experienced facilitator because a calming presence within a disruptive participant’s own ranks is more effective than from outsiders.
Look for formal and informal ways to work with the seasoned participant in the audience to ask clarifying questions and remind all participants of the underlying purpose of the root cause analysis (not blame but continuous improvement).
Controlling the Tempo
Controlling the tempo is especially important in facilitating root cause analysis because, at some point, the participants will start to converge on a root cause quickly. Sam Kaner’s Diamond of Participation should come to mind in facilitation circles. However, the first convergence in most root cause analyses is usually wrong because frequently we look for a single, simple root cause. That initial root cause is often merely a symptom. Plus, there is always more than one root cause.
Root cause analysis requires the facilitator to sense this moment and de-rail convergence. Normally de-railing is most effective in the form of a takeaway question that freezes everyone and therefore controls the tempo. I call this the “Columbo Moment” in practice after the detective character Columbo played by actor Peter Faulk. Faulk’s character was famous for asking “just one more thing” just when the murderer had developed clear logic for their sham alibi. Columbo controlled the tempo by freezing the thinking and sending the logic in a more valid direction.
Thinking About It
The foundations of systems thinking and facilitation apply to root cause analysis. The five ways to more effectively facilitate root cause analysis enhance a facilitator’s ability to guide the participants through a series of predefined steps to arrive at a result that is created, understood, and accepted by all. Seek to make your facilitation of root cause analysis better than most (dirty), or better yet, above all others (filthy).
JD Solomon Inc provides facilitation at the nexus of facilities, infrastructure, and the environment. Contact us for more information about facilitation services ranging from Strategic Plans and Board Retreats to Criticality Analysis, Root Cause Analysis, and Capital Program Development. For more information on JD’s new book or to join the community of technical professionals committed to learning how to get their boss’s boss to understand, visit Communicating with FINESSE or sign-up for updates.
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