June 15, 2011 | Barb Carr

Root Cause Analysis Tip: Improving the Use of TapRooT® through Knowledge

If you have ever sat in a TapRooT® Root Cause Analysis Course or Summit, you know that the transfer of knowledge and support from our instructors does not stop when the session ends. To help guide the next steps of continuous improvement, Mark Paradies and Linda Unger added Appendix C in our TapRooT® book, TapRooT®, Changing the Way the World Solves Problems. The tip today comes from “Topic 3: Knowledge” on page 461.

To ensure that TapRooT® Training is not just a one time event, we provide and suggest different knowledge opportunities:

  • Specifically designed on-site training for gaps identified as additional needs in your trending and proactive assessments.
  • Feedback for our investigators through our Advisory Board and one-on-one.
  • A Summit for system experts, which include our clients, to share best practices from multiple industries.

The key concept to using and understanding knowledge is to identify the who, what, how and when as it relates to training. In our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training, key investigation facilitators are introduced to the ADDIE process (Analyze, Define, Develop, Implement, Evaluate). The only way do Analyze and Define is to go out and look at the tasks that people need to perform in order to be efficient. With that in mind let’s start with the following people:

1. Investigators
2. Certified Instructors
3. Managers
4. Improvement Program Leader (Owner/Champion)
5. Coaches/Mentors/Facilitators
6. Hands on Employees/Operators
7. Top Manager (Sponsor)

Start by identifying their core task and skills required to perform the tasks. You may find cross-over of tasks which is not a problem. Actually it gives you more resources to share in times of need.

Once you identify the tasks and possible skills, assess the level of knowledge needed. Here is a template from my U.S. Air Force training Matrix in our CFETP:

Task Performance Levels

1. Can do simple parts of the task. Needs to be told or shown how to do most of
the task. (Extremely Limited)
2. Can do most parts of the task. Needs only help on hardest parts. (Partially
3. Can do all parts of the task. Needs only a spot check of completed work.
4. Can do the complete task quickly and accurately. Can tell or show others how
to do the task. (Highly Proficient)

Task Knowledge Levels

a. Can name parts, tools, and simple facts about the task. (Nomenclature)
b. Can determine step-by-step procedures for doing the task. (Procedures)
c. Can identify why and when the task must be done and why each step is needed.
(Operating Principles)
d. Can predict, isolate, and resolve problems about the task. (Advanced Theory)

Subject Knowledge Levels

A. Can identify basic facts and terms about the subject. (Facts)
B. Can identify relationship of basic facts and state general principles about the
subject. (Principles)
C. Can analyze facts and principles and draw conclusions about the subject.
D. Can evaluate conditions and make proper decisions about the subject.

By identifying the who, what and how, then we need to figure out where your TapRooT® Root Cause students will get to the performance levels needed to reduce or prevent problems (Incidents).

Biggest key here is that you will need to assess the skills of each team member listed above; where it starts:

1. Good Root Cause Analysis starts with a robust and usable method taught by knowledgeable facilitators; do this by sending them to the appropriate course. We teach and then give hands-on exercises; we follow up by working one on one with students as needed.

2-Day TapRooT® Incident Investigation and Root Cause Analysis
5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training
3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Failure Analysis

2. Develop in-house mentors/facilatators and assign those mentors as needed to help newly trained individuals. Some even get certified to teach in-house.

3. Look for systemic issues and identify additional knowledge and performance gaps. Decide who in the list above may need to attend one of the pre-Summit or Summit Activities.

4. Develop in-house group sessions to discuss lessons learned.

5. Schedule refresher training to give competency levels high.

Good luck on your quest for knowledge!

Root Cause Analysis
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