"Ask'why'fivetimesabouteverymatter.

"
released on March 2006

Taiichi Ohno,
Former Executive Vice President of Toyota Motor Corporation

We come across problems in all sorts of situations in life, but, according to Taiichi Ohno,
pioneer of the Toyota Production System in the 1950s, "Having no problems is the biggest
problem of all." Ohno saw a problem not as a negative, but, in fact, as "a kaizen
(continuous improvement) opportunity in disguise." Whenever one cropped up, he
encouraged his staff to explore problems first-hand until the root causes were found.
"Observe the production floor without preconceptions," he would advise. "Ask why' five
times about every matter."

He used the example of a welding robot stopping in the middle of its operation to
demonstrate the usefulness of his method, finally arriving at the root cause of the problem
through persistent enquiry:
1. "Why did the robot stop?"The circuit has overloaded, causing a fuse to blow.

2. "Why is the circuit overloaded?"There was insufficient lubrication on the

bearings, so they locked up.

3. "Why was there insufficient lubrication on the bearings?"The oil pump on the
robot is not circulating sufficient oil.

4. "Why is the pump not circulating sufficient oil?"The pump intake is clogged
with metal shavings.

5. "Why is the intake clogged with metal shavings?"Because there is no filter on

the pump.

Toyota engineers working tirelessly to meet emission regulation standards in

1975

Toyota takes pride in the quality of both its products and its processes, and the ability to
solve problems effectively has always been necessary to ensure this quality. Even if initially
time-consuming, identifying the root cause of a problem is important, because it allows us
to take appropriate countermeasures to prevent recurrence in the long-term. "The root
cause of any problem is the key to a lasting solution," Ohno used to say. He constantly
emphasized the importance of genchi genbutsu, or going to the source, and clarifying the
problem with one's own eyes. "Data is, of course, important in manufacturing," he often
remarked, "but I place greatest emphasis on facts."

These days, the global auto market is in a continual state of flux. For Toyota to respond to
market change, it is essential each associate is aware of problems and works to improve
operations at every possible opportunity. Whenever a problem arises whether it be in the
factory or on the sales floor we should follow Ohno's advice: go directly to the source
and keep asking, "Why?" By never becoming complacent and always seeking to innovate,
Toyota will be ready to overcome any challenges it may face in the future.

Toyota employees ask "why" (five times of course) about issues relating to the BX truck.

Getting over problems: a Toyota employee gets down to kaizen during production of the
gas turbine engine in 1988.

End
Some real-life 5 Whys examples
To take the 5 Whys from theoretical to actual, heres a look at a few moments in Buffers history
that have called for a 5 Whys meeting.

In early 2014, we had a brief systemwide outage. Heres a look at the 5 Whys the team
conducted:

And the corrective actions that resulted:

Heres an example from the customer happiness world. One of our Happiness Heroes wanted to
understand how he might have handled a customers problem better, so he performed a modified
5 Whys as a reflection and shared it with the team.
I have learned so much from viewing these examples and being part of 5 Whys processes. Its
been great to develop a habit of reflecting anytime something unexpected happens and taking
incremental steps so that we change what happens the next time around.

The 5 Whys in daily life

Although the 5 Whys is most widely used for manufacturing/development use, Ive found that it
is also quite applicable to daily life in any situation where one might seek deeper understanding
of a problem, a challenge or even a motivation behind an action.
This quick graphic from Start of Happiness provides a great example:
 Ever since learning about the 5 Whys, I find myself asking why? a lot more often.
What sort of process do you use to get to the root

Root Cause Analysis in Healthcare

Posted by Lou Conheady on Thu, Mar 26, 2015 @ 13:03 PM

inShare0

Author: Gary Tyne CMRP

Following the release of a report by economic consultants Frontier Economics(Oct

2014), it was highlighted that the cost of errors in patient safety, which includes the cost
of extra treatment, bed space and nursing care as well as huge compensation pay-outs,
costs the NHS between 1billion and 2.5billion a year.

In a speech to staff at Birmingham Children's Hospital (Oct 2014), Jeremy Hunt (Health Secretary)
said:

World class care is not just better for patients it reduces costs for the NHS as well. More resources
should be invested in improving patient care rather than wasted on picking up the pieces when
things go wrong.
As far back as 2010 Dame Christine
Beasley, chief nursing officer for England said
using Root Cause Analysis (RCA) tools to
understand adverse events is critical to
improving safety across the NHS.

The National Patient Safety Agency (NPSA)

developed a set of root cause analysis
guidelines and instruction documents which
were taken over by the NHS Commissioning
Board Special Health Authority in 2012.

Although the NPSA did not identify a specific

RCA process to be used the toolkit advocates
the use of the Fish-bone or Ishikawa diagram as a key tool for identifying contributory factors and
root causes. Another method utilized within the NHS is a method called 5 Whys

Whilst both Fishbone and 5 Whys are tools that can be utilized in basic problem solving, both
methods have received criticism from within other industries for being too basic and not complex
enough to analyze root causes to the depth that is needed to ensure that solutions are identified and
the problem is fixed.

There are several reasons for this criticism:

Tendency for investigators to stop at symptoms rather than going on to lower-level root
causes

Inability to go beyond the investigators current knowledge cannot find causes that they do
not already know

Lack of support to help the investigator ask the right why questions

Results are not repeatable different people using Fishbone and 5 Whys come up with
different causes for the same problem

Tendency to isolate a single root cause, whereas each question could elicit many different
rootcauses

Considered a linear method of communication for what is often a non-linear event

Many companies we work with successfully utilize the 5 Why technique or Fishbone for very basic
incidents or failures. By utilizing the correct placement of triggers, organizations can use the 5 Why
or Fishbone for its basic problem solving and then move to a form of Cause and Effect analysis like
the Apollo Root Cause Analysis methodology for more complex problems.

A disciplined problem solving approach should push teams to think outside the box, identifying root
causes and solutions that will prevent reoccurrence of the problem, instead of just treating the
symptoms.
Apollo Root Cause Analysis methodology A New Way of Thinking

The Apollo Root Cause Analysis methodology provides a simple structured approach that can be
applied by anyone, at any time on any given event. One of its most powerful attributes is its ability to
create a common understanding of contributing causes, and provide a platform to explore a range of
creative solutions. Through a simple charting process, everyone involved in an investigation can
contribute which generates enthusiasm for the process, resulting in positive problem solving
outcomes and experiences.

The key factor for successful problem solving is the inclusion of cause and effect as part of the
analytical process.

Root Cause analysis identifies causes, so that solutions are based on controlling those causes,
rather than treating the symptoms.

There are many features of the Apollo Root Cause Analysis methodology which naturally fit within
any Problem Solving Excellence program.

The Apollo Root Cause Analysis methodology was developed in 1987 by Dean Gano and is utilized
across the world in various industries from petrochemical, aerospace, utilities, manufacturing,
healthcare and others.

The Apollo Root Cause Analysis process is a 4-step method for facilitating a thorough incident
investigation. The steps are:

Define the Problem

Analyze Cause and Effect Relationships

Identify Solutions

Implement the Best Solutions

The Apollo Root Cause Analysis methodology is supported by software called RealityCharting
which is available in full version (standalone or enterprise) or as RealityCharting Simplified. The
RealityCharting Simplified can be utilized on smaller issues and allows the user to build a cause and
effect chart that is no greater than 4 causes high and 5 causes deep. This allows the user of a 5
Whys approach the ability to create a chart using the same thought process adopted in the Apollo
Root Cause Analysis methodology. It also demonstrates a non-linear output to what was originally
considered a linear type problem.

Training in the NHS

In the study titled: Training health care professionals in Root Cause Analysis: a cross-sectional
study of post-training experiences, benefits and attitudes by Bowie, Skinner, de Wet. A few
interesting statistics begin to arise when it comes to training of RCA with the respondents.

When asked What type of training did you receive? 81.1% of respondents had said they had
received in-house training compared to 6.6% who had received external training.

When asked How long was the training? 89% of respondents said they had less than one day
training compared to 1.3% who had received more than 2 days.

From industry experience these statistics are quite surprising and can only contribute to poor quality
investigations with low prevention success.

Within industry, Apollo Root Cause Analysis methodology trained facilitators are required to take
minimum two day in-class training course with a follow up exam. This is also supported by a pathway
for accreditation. RCA participants are given awareness training of the Apollo Root Cause
Analysis methodology but only the trained facilitators can lead investigations.

Case Study

A National Health Service Trust hospital was experiencing patient complaints and was exceeding
waiting time targets in the antenatal clinic. Several solutions had previously been implemented to
solve this problem. However, the problem continued and it was therefore decided to run a thorough
investigation utilizing the Apollo Root Cause Analysis methodology.
The root causes of the problem were identified during the investigation along with effective solutions.
The solutions were implemented over a period of time. With the solutions implemented an immediate
improvement was seen and waiting time targets were being met.

We had tried to solve this problem on a number of occasions and stress levels were increasing
within the antenatal team. We had previously only dealt with the symptoms and not the root causes.
Only after applying the Apollo Root Cause Analysis methodology were we able to see the evidence
based causal relationships. I found the tool simple but effective and one that should be utilized in
other areas across the NHS Midwife/Deputy Manager, Antenatal Clinic, NHS Trust Hospital

Conclusion
In the study titled The challenges of undertaking root cause analysis in health care by Nicolini,
Waring, and Mengis, (2011) it was concluded that:

Health services leaders need to provide open endorsement of root cause analysis and of the staff
carrying it out; enhance staff participation within learning activities and new analytic tools; and
develop capabilities in change management

Apollo Root Cause Analysis methodology has been taught to well over 100,000 people worldwide
over the last 22 years. It has become known as the preeminent RCA methodology and is used in
many fortune 500 companies and US government agencies like the Federal Aviation Authority and
NASA.

If you are interested in what the Apollo Root Cause Analysis methodology can do for you and would
like further information on the methodology please visit the
website:http://www.apollorootcause.com