Systems Approach |
The Systems Approach
Root cause analysis
has become a buzzword in organizations for trying to get to “the root” of the problem. People sometimes forget the fact that problem solving in their organization will always align with the principles of the scientific method. These were the same principles in the quality movement of the ‘70s and ‘80s, the reengineered business processes of the ‘90s and the recent push to a six-sigma reliability approach. Understanding basic cause and effect relationships was a consistent element throughout all of those “movements.” There were no new principles in any of those methods. Avoiding the program of the month schemes and establishing a principle-based, systems approach to improving performance is a wise plan. An easy experiment to demonstrate this systems approach is to ask a group of people “What is the most important part of a car?” Their responses will vary from the engine, to the transmission, to the key, to the steering wheel, to the battery. In reality the question, “Which part of the car is the most important?” is a poor one. It takes all parts of a car, functioning together to be a car. A car is a system. There is no single most important part. Interestingly, ask anyone within your organization which department is the most important and they will respond with the one in which they work. Their argument will logically be “if we didn’t do our job all of the other stuff wouldn’t matter.” This is the same argument the engine and the transmission people make about the car. An organization is also a system (refs. 1, 2). All parts of an organization must work together for the organization to be effective – to meet its goals. This cooperative systems view – systems thinking - is not always our first choice in an organization. Many departments point to other departments as the “cause” of the problem. Businesses ultimately strive to meet their goals by preventing problems from occurring – how they do this varies. To be effective requires a systems approach that focuses on prevention. Another example of this lack of system thinking is evident in the way organizations view problems and solutions. There is a significant difference between the questions “What’s the right answer to 2 + 7?” and “What’s the right way to improve the safety performance in this department?” There is a convention that dictates a right answer of 9 to the first question. The second question is a systems problem – it has no single right answer (ref. 3). There are many issues that would need to be considered to arrive at an effective solution to the second question. Most of our grade school courses consisted of learning the right answers, from state capitals to memorizing multiplication tables. We developed a bias toward right-answer issues. However, this is not the way the real world functions. We don’t provide our managers with a solution circled at the bottom of our homework. We work, and live, in a world of primarily systems issues – with trade-offs, budgetary constraints, scheduling issues, deadlines, resource limitations, etc. Many people and organizations approach systems issues with a right-answer frame of mind. When people work together to solve a systems problem, but each person is thinking right-answer it can quickly lead to defensiveness, miscommunication and a large waste of time and energy. Listen to the language in organizations for evidence of this. With right-answer problems we say it’s “right” or it’s “wrong.” With systems issues we say, “good, better and best.” Organizations are searching for the best solutions to their problems. If I went to an aircraft manufacturer and asked them for the “right design” their question would be “What do you want to do with this aircraft? - Do you want to carry two buses, do you want to carry 300 passengers or do you want to take-off vertically from a rooftop. They would need to know the specifications – the goals. Notice it is the goals plural. Systems issues are always about balance among goals. The best solutions to systems issues are always driven by the overall goals.
A right-answer approach is also referred to as linear thinking. Linear thinking creates this search for right-answers. The lesson is not that linear, right-answer thinking is “wrong.” Both methods, right-answer and systems thinking are extremely effective when applied to the appropriate type of problem. When linear thinking is applied to a systems problems the analyses begin looking like a straight line of “Why?” questions. This chain of events is a great start, but it is not necessarily a thorough analysis. The common “Five-Whys?” approach is a good start to cause and effect, but we can expand on it. In general people believe that the “root cause” is at the end of the “Why?” questions. . The conventional explanation of the cause and effect principle is “For every effect there is a cause.” A more accurate definition of the cause and effect principle is “For every effect there are causes.” This subtle change produces a significant improvement in our analyses of problems. We know that we can’t just pull the top of the weed growing in our yard because it will grow back. We have to get to the root. Hence the term “root cause analysis” is pervasive in organizations interested in solving problems once and for all. It is important to understand that the root on that weed is a system. Root cause analysis is the identification of the system of causes. As organizations experiment with this approach they recognize the very nature of how they communicate and solve problems changes. The focus of the analysis changes from who’s “right” to what are the specific cause and effect relationships (plural) that created this incident. Organizations realize quickly that the conventional root cause approach is nothing more than a search for the “right-answer” to a systems problem. Experiment with this approach yourself. Ask a several different people “What the root cause was of the Titanic sinking?” Responses will differ, but each person will be able to make the case that they are “right.” Their logic is that if their cause never would have happened the Titanic never would have sank. What they are saying is the truth, but they are not “right.” Right is a binary term– right or wrong. The Titanic incident is not a right-answer problem. It is a systems issue. The Titanic sank because of a system of causes, not a single cause. Removing any one of the causes from the system reduces the probability of occurrence. Hitting the iceberg, late iceberg sighting, small rudder and ignoring iceberg warnings are all causes of the Titanic sinking. Asking for the root cause to a problem is a linear, right-answer question to a systems issue. Most organizations stop their analysis too early, at one of the following – human error, procedure not followed, training less than adequate or equipment failure. It is true that these four things occur in organizations, but they are far too general. There is no specific action that can be taken if an organization identifies the problem to be human error. We must find the specific causes by asking specific “Why?” questions. The systems approach to investigating and solving problems is fundamental because it is based on this principle of cause and effect. The next section provides a method for analyzing and solving problems effectively. |
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