© 2008-2011, leffingwell, llc. all rights reserved. inspect and adapt workshop toolkit improving...

© 2008-2011, Leffingwell, LLC. All rights reserved.

Inspect and Adapt Workshop Toolkit

Improving Release Outcomes

(or any other problem)

with Root Cause Analysis and

Corrective Action

1


Predictive vs. Empirical Process

If a process is too unpredictable or too complicated for the planned, (predictive) approach, then the empirical approach (measure and adapt) is the method of choice.

Ken Schwaber

Empirical (Adaptive) Process

Proc

ess

Controls

Inpu

ts

Out

puts

Plan – measure – adapt – repeat

2


Kaizen Mind

70% of improvement processes that require change fail, mainly due to a lack of sense of urgency amongst leadership.

John Kotter, Harvard Business School

There is a sense of danger. Koki Konishi, Toyota City Technical Skills Academy

We need “kaizen mind” an unending sense of crisis behind the company’s constant drive to improve.

Jeff Sutherland – co-creator of Scrum

3


Excerpt from a board presentation from a high performing agile program in year 4 of agile adoption

Kaizen Mind Example

4


Continuously solving root problems drives organizational learning

– Go and See for yourself to thoroughly understand the situation

– Make decisions slowly by consensus, thoroughly considering all options; implement decisions rapidly;

– Become a learning organization through relentless reflection

The Toyota Way

Kaizen Mind and Lean Thinking

Image taken from:http://jude-users.com/en/modules/weblog/details.php?blog_id=37

5


Exercise ‒ Gap Analysis

All release objectives were assigned a business value from 1-10

Review and rate your release achievements– How well did you do against your stated objectives,

including a) timeliness, b) content and c) quality?

– Scale: (1-10), max being max total business value

Average these across all objectives and give yourself a percent achievement score

Timebox: ?

6


Problem Solving Workshop

Insufficiently Reliable Release Commitments?

(or)

Any other problem that is inhibiting performance

7


1. Root Cause Analysis (Fishbone) Diagram

2. Pareto Chart

3. Corrective Action Plan

Problem Solving Tools

8


Definition: A graphic tool used to explore and display opinion about sources of variation in a process. – Also called a Cause-and-Effect , Ishikawa Diagram (who first used

the technique in the 1960s.) or Fishbone Diagram.

Purpose: To arrive at a few key sources that contribute most significantly to the problem being examined. – These sources are then targeted for improvement. – Also illustrates the relationships among the wide variety of

possible contributors to the effect.

The name of a basic problem of interest is entered at the right of the diagram at the end of the main "bone".

Root Cause Analysis Diagram

Source: wikipedia

9


Root Cause Analysis (Fishbone) Diagram

People Process

Tools Project Environment

Insufficiently Reliable Release

Commitments

Our main “bones” represent typical sources of problems in software

10


The main possible causes of the problem (the effect) are drawn as bones off of the main backbone.

The starting bones represent all possible influences.

Brainstorming is typically done to add possible causes to the main "bones" and more specific causes to the "bones" on the main "bones".

This subdivision into ever increasing specificity continues as long as the problem areas can be further subdivided.

The practical maximum depth of this tree is usually four or five levels.

When the fishbone is complete, one has a complete picture of all the possibilities about what could be the root cause for the designated problem.

Root Cause Analysis Diagram, contd.

Source: wikipedia

11


The 5 Whys is a question-asking method used to explore the cause/effect relationships underlying a particular problem. Ultimately, the goal of applying the 5 Whys method is to determine a root cause of a defect or problem.

A critical component of problem solving training integral to the Toyota Production System.

The architect of the Toyota Production System, Taiichi Ohno, (Toyota Chairman) described the 5 whys method as "... ... by repeating why five times, the nature of the problem as well as its solution becomes clear.”

The tool has seen widespread use beyond Toyota, and is now used within Kaizen, lean manufacturing, and Six Sigma.

The 5 Why’s

Source: wikipedia

12


Questioning could be taken further to a sixth, seventh, or greater level.

This would be legitimate, as the "five" in 5 Whys is not gospel; rather, it is postulated that five iterations of asking why is generally sufficient to get to a root cause.

The key is to avoid assumptions and logic traps

Instead trace the chain of causality in direct increments from the effect to a root cause that still has some connection to the problem.

Example ‒ The 5 Why’s

My car will not start. (the problem)

Why? – The battery is dead. (first why)

Why? – The alternator is not functioning. (second why)

Why? – The alternator belt has broken. (third why)

Why? – The alternator belt was well beyond its useful service life and has never been replaced. (fourth why)

Why? – I have not been maintaining my car according to the recommended service schedule. (fifth why, root cause)

Source: wikipedia

13


Root Cause Analysis (Fishbone) Diagram

People Process



Commitments

Cause 1

Cause of cause 1

Cause of cause of cause 1

Cause of cause of cause of cause 1

14


Exercise- Root Cause Analysis

Succinctly state the problem you are addressing Create a fishbone diagram for your problem statement Brainstorm potential causes of the problem, and place them

on the chart For each cause identified, use the 5 whys technique to get

to a potential root cause Prepare to present your result

Timebox: ? minutes

15



2. Pareto Chart



16


Pareto analysis is a statistical technique in decision making that is used for selection of a limited number of tasks that produce significant overall effect.

It uses the Pareto principle – 20% of the work can generate 80% of the advantage of doing the entire job.

In terms of quality improvement, a large majority of problems (80%) are produced by a few key causes (20%).

Pareto Analysis

17


Useful where many possible courses of action are competing for your attention.

The problem-solver estimates the benefit delivered by each action, then selects a number of the most effective actions that deliver a total benefit reasonably close to the maximal possible one.

Helps stimulate thinking and organize thoughts.

Pareto Analysis, contd.

Source: wikipedia

18


Prioritize Root Causes

People Process



Commitments

Cause 1

Cause of cause 1

Cause of cause of cause 1

Cause of cause of cause of cause 1

Cause of cause 1

19


Pareto Analysis

Cause 1 Cause 2 Cause 3 Cause 4 Cause 5 Cause 60

1

2

3

4

5

6

7

8

9

10

20


Exercise- Pareto Analysis

Use a cumulative voting technique to do a Pareto analysis of each identified root cause

Each team member gets 10 votes Place your votes on as few or as many (limit 5 votes per

item) root causes as appropriate Refactor, re-aggregate causes as appropriate Use that data to create a big visible histogram chart Prepare to present your result

Timebox: ? minutes

Cause 1 Cause 2 Cause 3 Cause 4 Cause 5 Cause 6

0123456789

10

21

Group Review of Root Cause Analysis and Pareto Charts

Timebox: ?



2. Pareto Chart



23


After we determine we have a problem, what’s next?

a. Ignore it - the problem may go away

b. Blame it on another team

c. Blame it on the business owner

d. Blame it on another program

e. Create a Corrective Action Plan

Answer:

e. Create a Corrective Action Plan

Houston, we have a problem.

Image taken from: www.theage.com.au

24

http://kailash.balnac.com/blog/wp-content/uploads/2009/01/blame.jpg


What is a Corrective Action Plan anyway?

Corrective – A different course of action

Action – Active steps we can realistically accomplish

Plan – Organized, purposeful, accountable, measurable

Corrective Action Plan

No solution without a CAP

25


1. State the new problem (the selected root cause) succinctly

2. Brainstorm a solution. Divide into discrete activities.

3. Establish accountability

4. Specify measurable results

5. Set achievable deadlines

6. Monitor progress

Effective Corrective Action Plans

A journey of a thousand miles begins with a single step.

26


1. State the new problem succinctly– Pick one specific root cause, i.e. the top root causes that you

identified in your analysis– Restate that as the new problem

Corrective Action Plan Components

Root cause of the problem

27


2. Brainstorm a solution– Brainstorm prospective solutions with the team– Cumulative vote on suggested next steps


How do you eat an elephant?

One bite at a time.

28


3. Establish accountability– Identify the stories you’ll need to

effect the solution – Take responsibility for stories – Prepare to put the stories on your

release plan– Escalate those impediments that are

outside of your control


29


4. Specify measurable results– What measures can we use to track

progress?


30


5. Set achievable deadlines– Not to fast– Not to slow– Not TBD


Action 1

3/16/20011

Action 2

4/11/2011

Action 3

5/01/2011

31


6. Monitor Progress– How will we track our action steps?– How will we know when this is no longer the biggest problem?– Define what “done” means for the CAP


32


1. State the problem succinctly

2. Brainstorm a solution. Divide into discrete parts.

3. Establish accountability

4. Specify measurable results

5. Set achievable deadlines

6. Monitor progress

Effective Corrective Action Plans

Houston, We have a plan

33


Exercise- Corrective Action Plans

Pick the top root cause on your Pareto chart

Build a corrective action plan

Prepare to present your results

Timebox: ? minutes

34

Group Review of Corrective Action Plans

Timebox: ? minutes

1 ……

2 …..

3 …..

4 …..

5 …..

6 …..

© 2008-2011, leffingwell, llc. all rights reserved. inspect and adapt workshop toolkit improving...

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