Senior Leadership’s Role in Root Cause Analysis – 7 Tips
What Can Senior Leadership Do
To Improve Root Cause Analysis?
Senior leadership needs effective root cause analysis to stop problems and improve performance. They need this to avoid:
- Calls in the middle of the night about serious accidents.
- Missed quarterly goals.
- Serious cost overruns and schedule slippages.
- Bad press about any of the above poor performance issues.
Thus, senior leadership should be interested in the seven factors they can influence that will improve root cause analysis and performance.
What are these seven factors that senior leadership controls?
- The root cause system that is being used.
- If the root cause system is being applied.
- If the root cause analysis application is effective.
- If the results of the root cause system – the corrective actions – are actually implemented.
- If the corrective actions are effective.
- If the root cause system is effective (trends).
- That, over time, the application of root cause analysis become more proactive and less reactive.
Let’s look at each of these factors and discuss what the factor does for management and how management controls each factor.
The Root Cause Analysis System
All root cause analysis systems are NOT created equal.
Some systems claim to be root cause analysis, but they are slightly better than Spin-A-Cause™.
Spin-A-Cause™ is fast, but it isn’t effective. And the same is true for many other root cause analysis tools. Many tools don’t meet the fundamental requirements of a good root cause analysis system. To see these requirements, view this LINK.
What does senior management need to do to make sure their root cause analysis system meets and exceeds the fundamental requirements for root cause analysis? They need a fundamental understanding of root cause analysis and what an advanced root cause analysis system can do for them. Then they can direct their organization to use the best root cause system that helps them meet their needs.
We’ll discuss how management can get this knowledge later in this article.
Apply Advanced Root Cause Analysis
I’ve seen it happen before. Senior management has a policy developed that requires effective, advanced root cause analysis. But there is a catch. They don’t insist that it is used in the field. Worse yet, they don’t provide the time or the resources (people and training) needed to apply great root cause analysis.
Yes, management undercuts the application of effective root cause analysis.
What should management do? Ensure that people are trained in effective root cause analysis AND that the investigators (or teams) have the time and access they need to perform effective investigations.
Senior management should be interested in:
- The initial training plan.
- The resources allotted to root cause analysis investigations.
- Proof that the tools are being applied.
We will discuss how this happens in the next section.
Effective Application of Root Cause Analysis
If management has chosen an effective root cause analysis tool and required it to be used, they are on the right path.
But, as Admiral Rickover is quoted as saying:
You get what you inspect,
not what you expect.
What does this mean? Senior management has to:
- Ensure that every root cause analysis is reviewed to make sure it is effective.
- Be personally involved in the reviews of the most serious investigations.
To perform effective investigation reviews, senior management needs root cause analysis training.
I’ve had senior managers resist training. After all, they have extensive experience. But if that experience doesn’t include using advanced root cause analysis OR worse yet, their experience is applying a substandard root cause analysis tool, their involvement in a root cause analysis review may be counterproductive.
Thus, senior management should:
- Be trained in advanced root cause analysis.
- Make sure that their policy required root cause analysis reviews (grading).
- Participate in reviews of significant incidents.
By personal review of serious incidents, senior management will know if the tools are being applied effectively and may request feedback from the investigators if they had the resources they needed.
Corrective Action Implementation
What could be sadder than spending resources performing advanced root cause analysis only to have the corrective actions that were developed languish and be forgotten … never to be implemented.
What? You say this could never happen? I’ve seen it happen all too often. And senior management didn’t even know it was happening.
Senior management must put a tracking system in place to ensure corrective actions are implemented in a timely fashion.
Senior management should get periodic reports about the implementation of corrective actions, including:
- Overdue implementation of corrective actions.
- Approval of delays to the implementation of corrective actions.
- Progress and success in implementing corrective actions.
This should be a part of management’s periodic review of the root cause analysis system’s results.
Corrective Action Effectiveness
Once corrective action is implemented, there is one more concern:
Was it EFFECTIVE?
The effectiveness of your root cause analysis system ultimately should be measured by the effectiveness of the corrective actions.
How can you measure the effectiveness of corrective action?
- Face validity: It appears to be effective when it is approved (before being implemented).
- Field verification: People in the field feel the corrective action is effective or test its effectiveness.
- Prevention of repeat incidents: The incident does not happen again (this can take years to verify).
Management should get feedback about corrective action effectiveness as part of their periodic reviews of their root cause analysis system.
Trends
Trends of key performance indicators, root cause analysis data, and corrective action effectiveness should be a key part of management’s performance improvement program reviews.
Unfortunately, many presentations of trends are ineffective or counterproductive because of the trending techniques that are applied.
What should an effective trending program look like? There’s a book on that topic. See:
Book 8: TapRooT® Performance Measures and Trending for Safety, Quality, and Business Management
Somebody who understands this book should help set up management’s trending reports.
Becoming Proactive
An effective senior manager stays ahead of problems. They aren’t reactive … they are proactive.
Therefore, an effective senior manager understands that their most effective root cause analysis tools should be applied proactively to avoid having to apply them reactively.
Proactive root cause analysis is THE MOST EFFECTIVE application of root cause analysis.
Proactive root cause analysis starts with effective root cause analysis of Precursor Incidents.
If incidents that did not produce a serious consequence BUT COULD HAVE if an additional Safeguard (or perhaps, Safeguards) had failed are effectively investigated and corrected, the corrective actions will prevent future serious incidents. This is proactive.
Even MORE proactive is the application of advanced root cause analysis as part of a risk directed audit program. This topic is beyond the scope of this article, but we will publish more about this topic in the future.
Management needs to direct the root cause analysis and performance improvement program so that, over time, the program becomes increasingly more proactive.
Does Your Senior Management Want an Effective Root Cause Analysis System?
Is your senior management ready for:
- An end to fatalities?
- Improved safety and reduced LTIs?
- Consistently meeting production and earnings goals?
- Improved product/service quality?
- Projects to be completed on schedule?
- Improved equipment reliability?
- An end to regulatory violations?
Then it is time to schedule your management for an Executive Briefing.
Use the form below to request an executive briefing for your senior management. We will contact you to set up the briefing you need to make your root cause analysis and performance improvement program world-class.
If you would like a little more information before you schedule your Executive Briefing, see:
