Effective Root Cause Analysis

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  effective root cause analysis: Effective Root Cause Analysis Giles Johnston, 2019-10-20 Do you want to solve problems in your business once and for all? Some businesses use root cause analysis methods successfully, many do not. These methods have huge potential and using them effectively can deliver amazing results for both you and your business. Being able to use root cause analysis tools effectively can help solve business problems and prevent them from reoccurring in the future. But what if there were a couple of little twists you could use that would make a big difference to your results? This book will share with you some extra tools that can be used to deliver surprisingly powerful results. The methods shared in this book are the same methods Giles Johnston uses with his clients. They are tried, tested and they get results.If you're ready to make root cause analysis deliver some amazing results for your business, then get your copy today!
  effective root cause analysis: Root Cause Analysis Handbook ABS Consulting, Lee N. Vanden Heuvel, Donald K. Lorenzo, Laura O. Jackson, Walter E. Hanson, James J. Rooney, David A. Walker, 2014-10-01 Are you trying to improve performance, but find that the same problems keep getting in the way? Safety, health, environmental quality, reliability, production, and security are at stake. You need the long-term planning that will keep the same issues from recurring. Root Cause Analysis Handbook: A Guide to Effective Incident Investigation is a powerful tool that gives you a detailed step-by-step process for learning from experience. Reach for this handbook any time you need field-tested advice for investigating, categorizing, reporting and trending, and ultimately eliminating the root causes of incidents. It includes step-by-step instructions, checklists, and forms for performing an analysis and enables users to effectively incorporate the methodology and apply it to a variety of situations. Using the structured techniques in the Root Cause Analysis Handbook, you will: Understand why root causes are important. Identify and define inherent problems. Collect data for problem-solving. Analyze data for root causes. Generate practical recommendations. The third edition of this global classic is the most comprehensive, all-in-one package of book, downloadable resources, color-coded RCA map, and licensed access to online resources currently available for Root Cause Analysis (RCA). Called by users the best resource on the subject and in a league of its own. Based on globally successful, proprietary methodology developed by ABS Consulting, an international firm with 50 years' experience in 35 countries. Root Cause Analysis Handbook is widely used in corporate training programs and college courses all over the world. If you are responsible for quality, reliability, safety, and/or risk management, you'll want this comprehensive and practical resource at your fingertips. The book has also been selected by the American Society for Quality (ASQ) and the Risk and Insurance Society (RIMS) as a must have for their members.
  effective root cause analysis: Root Cause Analysis, Second Edition Duke Okes, 2019-02-06 This best-seller can help anyone whose role is to try to find specific causes for failures. It provides detailed steps for solving problems, focusing more heavily on the analytical process involved in finding the actual causes of problems. It does this using figures, diagrams, and tools useful for helping to make our thinking visible. This increases our ability to see what is truly significant and to better identify errors in our thinking. In the sections on finding root causes, this second edition now includes: more examples on the use of multi-vari charts; how thought experiments can help guide data interpretation; how to enhance the value of the data collection process; cautions for analyzing data; and what to do if one can’t find the causes. In its guidance on solution identification, biomimicry and TRIZ have been added as potential solution identification techniques. In addition, the appendices have been revised to include: an expanded breakdown of the 7 M’s, which includes more than 50 specific possible causes; forms for tracking causes and solutions, which can help maintain alignment of actions; techniques for how to enhance the interview process; and example responses to problem situations that the reader can analyze for appropriateness.
  effective root cause analysis: 5 Whys Oliver Roderich, 2021-02-12 In the work environment we need to ask ourselves to know more about what is actually happening in the process. Have you ever wondered why a problem happened? Discover how to identify the root cause with the book 5 why.
  effective root cause analysis: Root Cause Analysis, Second Edition Bjørn Andersen, Tom Fagerhaug, 2006-01-01 This updated and expanded edition discusses many different tools for root cause analysis and presents them in an easy-to-follow structure: a general description of the tool, its purpose and typical applications, the procedure when using it, an example of its use, a checklist to help you make sure if is applied properly, and different forms and templates (that can also be found on an accompanying CD-ROM). The examples used are general enough to apply to any industry or market. The layout of the book has been designed to help speed your learning. Throughout, the authors have split the pages into two halves: the top half presents key concepts using brief language—almost keywords—and the bottom half uses examples to help explain those concepts. A roadmap in the margin of every page simplifies navigating the book and searching for specific topics. The book is suited for employees and managers at any organizational level in any type of industry, including service, manufacturing, and the public sector.
  effective root cause analysis: Root Cause Analysis Matthew A. Barsalou, 2014-12-03 Although there are many books on root cause analysis (RCA), most concentrate on team actions such as brainstorming and using quality tools to discuss the failure under investigation. These may be necessary steps during RCA, but authors often fail to mention the most important member of an RCA team the failed part.Root Cause Analysis: A Step-By-Step
  effective root cause analysis: Root Cause Analysis Denise Robitaille, 2010 Do you have recurring problems that are costing you time and money? Unresolved problems do more than aggravate. They can increase costs, lower quality, and drive customers away. Plus, quality management processes, such as ISO 9001, require organizations to have a corrective and preventive action process in place. Root cause analysis is integral to the success of any corrective action or problem-solving process. Unfortunately, root cause analysis is an often maligned, misunderstood, and misapplied process. Instead of viewing root cause analysis as an opportunity for improvement, many see it only as an admission that things have gone wrong. Root cause analysis should be seen as an opportunity, not a chore. This practical guide offers proven techniques for using root cause analysis in your organization. Inside you’ll find: What root cause analysis is When (and when not) to use root cause analysis Who should participate in the root cause analysis process How to construct a root cause analysis checklist Examples of how a well-run root cause analysis process works And much more!
  effective root cause analysis: Apollo Root Cause Analysis Dean L. Gano, 2008 The purpose of this book is to share what the author has learned about effective problem solving by exposing the ineffectiveness of conventional wisdom and presenting a principle-based alternative called Apollo Root Cause Analysis that is robust, yet familiar and easy to understand. This book will change the way readers understand the world without changing their minds. One of the most common responses the author has received from his students of Apollo Root Cause Analysis is they have always thought this way, but did not know how to express it. Other students have reported a phenomenon where this material fundamentally re-wires their thinking, leading to a deeply profound understanding of our world. At the heart of this book is a new way of communicating that is revolutionizing the way people all around the world think, communicate, and make decisions together. Imagine a next decision-making meeting where everyone is in agreement with the causes of the problem and the effectiveness of the proposed corrective actions with no conflicts, arguments, or power politics! This is the promise of Apollo Root Cause Analysis.
  effective root cause analysis: TapRooT Mark Paradies, Linda Unger, 2000
  effective root cause analysis: The PROACT® Root Cause Analysis Kenneth C. Latino, Mark A. Latino, Robert J. Latino, 2020-09-10 Root Cause Analysis, or RCA, What is it? Everyone uses the term, but everyone does it differently. How can we have any uniformity in our approach, much less accurately compare our results, if we’re applying different definitions? At a high level, we will explain the difference between RCA and Shallow Cause Analysis, because that is the difference between allowing a failure to recur or dramatically reducing the risk of recurrence. In this book, we will get down to basics about RCA, the fundamentals of blocking and tackling, and explain the common steps of any investigative occupation. Common investigation steps include: Preserving evidence (data)/not allowing hearsay to fly as fact Organizing an appropriate team/minimizing potential bias Analyzing the events/reconstructing the incident based on actual evidence Communicating findings and recommendations/ensuring effective recommendations are actually developed and implemented Tracking bottom-line results/ensuring that identified, meaningful metrics were attained We explore, Why don’t things always go as planned? When our actual plans deviate from our intended plans, we usually experience some type of undesirable or unintended outcome. We analyze the anatomy of a failure (undesirable outcome) and provide a step-by-step guide to conducting a comprehensive RCA based on our 3+ decades of applying RCA as we have successfully practiced it in the field. This book is written as a how-to guide to effectively apply the PROACT® RCA methodology to any undesirable outcome, is directed at practitioners who have to do the real work, focuses on the core elements of any investigation, and provides a field-proven case as a model for effective application. This book is for anyone charged with having a thorough understanding of why something went wrong, such as those in EH&S, maintenance, reliability, quality, engineering, and operations to name just a few.
  effective root cause analysis: The ASQ Pocket Guide to Root Cause Analysis Bjørn Andersen, Tom Natland Fagerhaug, 2013-11-06 All organizations experience unintended variation and its consequences. Such problems exist within a broad range of scope, persistence, and severity across different industries. Some problems cause minor nuisances, others leads to loss of customers or money, others yet can be a matter of life and death. The purpose of this pocket guide is to provide you with easily accessible knowledge about the art of problem solving, with a specific focus on identifying and eliminating root causes of problems. Root cause analysis is a skill that absolutely everybody should master, irrespective of which sector you work in, what educational background you have, and which position in the organization you hold. The content in this little pocket guide can contribute to disseminating this skill a little further in the world.
  effective root cause analysis: TapRooT Mark Paradies, Linda Unger, 2008-01-01
  effective root cause analysis: The Art of Application Performance Testing Ian Molyneaux, 2009-01-23 This practical book provides a step-by-step approach to testing mission-critical applications for scalability and performance before they're deployed -- a vital topic to which other books devote one chapter, if that. Businesses today live and die by network applications and web services. Because of the increasing complexity of these programs, and the pressure to deploy them quickly, many professionals don't take the time to ensure that they'll perform well and scale effectively. The Art of Application Performance Testing explains the complete life cycle of the testing process, and demonstrates best practices to help you plan, gain approval for, coordinate, and conduct performance tests on your applications. With this book, you'll learn to: Set realistic performance testing goals Implement an effective application performance testing strategy Interpret performance test results Cope with different application technologies and architectures Use automated performance testing tools Test traditional local applications, web-based applications, and web services (SOAs) Recognize and resolves issues that are often overlooked in performance tests Written by a consultant with 30 years of experience in the IT industry and over 12 years experience with performance testing, this easy-to-read book is illustrated with real-world examples and packed with practical advice. The Art of Application Performance Testing thoroughly explains the pitfalls of an inadequate testing strategy and offers you a robust, structured approach for ensuring that your applications perform well and scale effectively when the need arises. Ian has maintained a vendor-agnostic methodology beautifully in this material. The metrics and graphs, along with background information provided in his case studies, eloquently convey to the reader, 'Methodology above all, tools at your discretion...' Ian's expertise shines through throughout the entire reading experience.-- Matt St. Onge, Enterprise Solution Architect, HCL Technologies America / Teradyne
  effective root cause analysis: Root Cause Analysis (RCA) for the Improvement of Healthcare Systems and Patient Safety David Allison, CPPS, Harold Peters, P.Eng, 2021 The book follows a proven training outline, including real-life examples and exercises, to teach healthcare professionals and students how to lead effective and successful Root Cause Analysis (RCA) to eliminate patient harm. This book discusses the need for RCA in the healthcare sector, providing practical advice for its facilitation. It addresses when to use RCA, how to create effective RCA action plans, and how to prevent common RCA failures. An RCA training curriculum is also included. This book is intended for those leading RCAs of patient harm events, leaders, students, and patient safety advocates who are interested in gaining more knowledge about RCA in healthcare.
  effective root cause analysis: Root Cause Analysis Robert J. Latino, Mark A. Latino, Kenneth Latino, Kenneth C. Latino, 2006-05-05 There is no easy answer to the question, What is RCA? Some will give a general idea of what Root Cause Analysis (RCA) is designed to accomplish, while others will advocate a specific approach. In this third edition of the best-selling Root Cause Analysis: Improving Performance for Bottom-Line Results, acclaimed experts Robert and Ke
  effective root cause analysis: Root Cause Analysis Made Simple Susan Lubell, Ricky Smith, 2015-12-01
  effective root cause analysis: Simplifying Cause Analysis Chester D. Rowe, 2017-11-20 When the challenge is to get to the heart of a problem, you need a simple and efficient cause investigation methodology. And what would make a real difference would be an interactive map to lead you to the answer every time. Chester Rowe’s Simplifying Cause Analysis: A Structured Approach is your instruction book combined with the included downloadable Interactive Cause Analysis Tool you have been looking for. The author intends this book for professionals like you, who have some familiarity with cause analysis projects and are looking for a simple and efficient cause investigation methodology –is a more effective and insightful way of asking “why?” Introducing his multi-function event investigation tool, Chester Rowe says, “There are already many scientific tools to help us understand the physical causes for machine failures; the challenge now is to find a way of investigating human performance failure modes...humans are often a major source of slips, lapses, and mistakes.” Supporting his instructions with diagrams, charts, and real-world examples from companies like yours, the author takes you step-by-step through planning, completing, and documenting your investigation: Chapter 1 gives you a process to determine the level of effort that your investigation should encompass, assess the level of effort needed, and determine the rigor needed. Your investigation needs to be as risk-informed as possible. Chapters 2 through 5 presents a new and innovative structure –rigorous yet intuitively easy to remember – to identify the underlying causes for the event (Cause Road Maps) and conduct the investigation. Chapter 6 introduces conceptual human performance models and tells you how to begin focusing on the human behaviors involved. Chapters 7 and 8 present you with methods, tools, and techniques for carefully interviewing personnel. Chapters 9 through 13 “put the pieces together,” showing you how to analyze and model the event, determine corrective action, and document the investigations and findings. Chester Rowe developed the Cause Road Map over many years to provide a comprehensive taxonomy for every cause investigation. However, fully implementing the Cause Road Map requires the use of other tools to organize, analyze, and present the final results of your investigation. To get you started, Rowe includes his downloadable Interactive Cause Analysis Tool – an easy-to-use tool in familiar spreadsheet format – free with your verified purchase of the book.
  effective root cause analysis: The Great Mental Models, Volume 1 Shane Parrish, Rhiannon Beaubien, 2024-10-15 Discover the essential thinking tools you’ve been missing with The Great Mental Models series by Shane Parrish, New York Times bestselling author and the mind behind the acclaimed Farnam Street blog and “The Knowledge Project” podcast. This first book in the series is your guide to learning the crucial thinking tools nobody ever taught you. Time and time again, great thinkers such as Charlie Munger and Warren Buffett have credited their success to mental models–representations of how something works that can scale onto other fields. Mastering a small number of mental models enables you to rapidly grasp new information, identify patterns others miss, and avoid the common mistakes that hold people back. The Great Mental Models: Volume 1, General Thinking Concepts shows you how making a few tiny changes in the way you think can deliver big results. Drawing on examples from history, business, art, and science, this book details nine of the most versatile, all-purpose mental models you can use right away to improve your decision making and productivity. This book will teach you how to: Avoid blind spots when looking at problems. Find non-obvious solutions. Anticipate and achieve desired outcomes. Play to your strengths, avoid your weaknesses, … and more. The Great Mental Models series demystifies once elusive concepts and illuminates rich knowledge that traditional education overlooks. This series is the most comprehensive and accessible guide on using mental models to better understand our world, solve problems, and gain an advantage.
  effective root cause analysis: Effective Root Cause Analysis Giles Johnston, 2020 Do you want to solve problems in your business once and for all?Some businesses use root cause analysis methods successfully, many do not...These methods have huge potential and using them effectively can deliver amazing results for both you and your business.Being able to use root cause analysis tools effectively can help solve business problems and prevent them from reoccurring in the future.But what if there were a couple of little twists you could use that would make a big difference to your results?This book will share with you some extra tools that can be used to deliver surprisingly powerful results.The methods shared in this book are the same methods Giles Johnston uses with his clients.They are tried, tested and they get results.If you're ready to make root cause analysis deliver some amazing results for your business, then get your copy today!
  effective root cause analysis: Effective FMEAs Carl S. Carlson, 2012-04-11 Outlines the correct procedures for doing FMEAs and how to successfully apply them in design, development, manufacturing, and service applications There are a myriad of quality and reliability tools available to corporations worldwide, but the one that shows up consistently in company after company is Failure Mode and Effects Analysis (FMEA). Effective FMEAs takes the best practices from hundreds of companies and thousands of FMEA applications and presents streamlined procedures for veteran FMEA practitioners, novices, and everyone in between. Written from an applications viewpoint—with many examples, detailed case studies, study problems, and tips included—the book covers the most common types of FMEAs, including System FMEAs, Design FMEAs, Process FMEAs, Maintenance FMEAs, Software FMEAs, and others. It also presents chapters on Fault Tree Analysis, Design Review Based on Failure Mode (DRBFM), Reliability-Centered Maintenance (RCM), Hazard Analysis, and FMECA (which adds criticality analysis to FMEA). With extensive study problems and a companion Solutions Manual, this book is an ideal resource for academic curricula, as well as for applications in industry. In addition, Effective FMEAs covers: The basics of FMEAs and risk assessment How to apply key factors for effective FMEAs and prevent the most common errors What is needed to provide excellent FMEA facilitation Implementing a best practice FMEA process Everyone wants to support the accomplishment of safe and trouble-free products and processes while generating happy and loyal customers. This book will show readers how to use FMEA to anticipate and prevent problems, reduce costs, shorten product development times, and achieve safe and highly reliable products and processes.
  effective root cause analysis: Root Cause Failure Analysis R. Keith Mobley, 1999-06-16 Root Cause Failure Analysis provides the concepts needed to effectively perform industrial troubleshooting investigations. It describes the methodology to perform Root Cause Failure Analysis (RCFA), one of the hottest topics currently in maintenance engineering. It also includes detailed equipment design and troubleshooting guidelines, which are needed to perform RCFA on machinery found in most production facilities. This is the latest book in a new series published by Butterworth-Heinemann in association with PLANT ENGINEERING magazine. PLANT ENGINEERING fills a unique information need for the men and women who operate and maintain industrial plants. It bridges the information gap between engineering education and practical application. As technology advances at increasingly faster rates, this information service is becoming more and more important. Since its first issue in 1947, PLANT ENGINEERING has stood as the leading problem-solving information source for America's industrial plant engineers, and this book series will effectively contribute to that resource and reputation.Provides information essential to industrial troubleshooting investigationsDescribes the methods of root cause failure analysis, a hot topic in maintenance engineeringIncludes detailed equipment-design guidelines
  effective root cause analysis: Knowledge Solutions Olivier Serrat, 2017-05-22 This book is open access under a CC BY-NC 3.0 IGO license. This book comprehensively covers topics in knowledge management and competence in strategy development, management techniques, collaboration mechanisms, knowledge sharing and learning, as well as knowledge capture and storage. Presented in accessible “chunks,” it includes more than 120 topics that are essential to high-performance organizations. The extensive use of quotes by respected experts juxtaposed with relevant research to counterpoint or lend weight to key concepts; “cheat sheets” that simplify access and reference to individual articles; as well as the grouping of many of these topics under recurrent themes make this book unique. In addition, it provides scalable tried-and-tested tools, method and approaches for improved organizational effectiveness. The research included is particularly useful to knowledge workers engaged in executive leadership; research, analysis and advice; and corporate management and administration. It is a valuable resource for those working in the public, private and third sectors, both in industrialized and developing countries.
  effective root cause analysis: What Drives Quality Ben Linders, 2017-09-30 With plenty of ideas, suggestions, and practical cases on software quality, this book will help you to improve the quality of your software and to deliver high-quality products to your users and satisfy the needs of your customers and stakeholders. Many methods for product quality improvement start by investigating the problems, and then work their way back to the point where the problem started. For instance audits and root cause analysis work this way. But what if you could prevent problems from happening, by building an understanding what drives quality, thus enabling to take action before problems actually occur? What Drives Quality explores how quality plays a role in all of the software development activities. It takes a deep dive into quality by listing the relevant factors of development and management activities that drive the quality of software products. It provides a lean approach to quality by analyzing the full development chain from customer requests to delivering products to users. I'm aiming this book at software developers and testers, architects, product owners and managers, agile coaches, Scrum masters, project managers, and operational and senior managers who consider quality to be important. A book on quality should be practical. It should help you, the reader of this book, to improve the quality of your software and deliver better products. It should inspire you and give you energy to persevere on your quality journey. What drives quality tries to do just that, and more. This book is based on my experience as a developer, tester, team leader, project manager, quality manager, process manager, consultant, coach, trainer, and adviser in Agile, Lean, Quality and Continuous Improvement. It takes a deep dive into quality with views from different perspectives and provides ideas, suggestions, practices, and experiences that will help you to improve quality of the products that your organization is delivering. This book views software quality from an engineering, management, and social perspective. It explores the interaction between all involved in delivering high-quality software to users and provides ideas to do it quicker and at lower costs.
  effective root cause analysis: Root Cause Analysis Handbook ABS Group Inc. Risk and Reliability Division, 1999 This book presents a proven system designed for investigating, categorizing, and ultimately eliminating root causes of incidents with safety, health, environmental, quality, reliability, and production-process impacts. Defined as a tool to help investigators describe what happened, to determine how it happened, and to understand why it happened, the Root Cause Analysis System enables businesses to generate specific, concrete recommendations for preventing incident recurrences.
  effective root cause analysis: Root Cause Analysis Paul F. Wilson, Larry D. Dell, Gaylord F. Anderson, 1993
  effective root cause analysis: Medical Device Use Error Michael Wiklund, Andrea Dwyer, Erin Davis, 2016-01-06 Medical Device Use Error: Root Cause Analysis offers practical guidance on how to methodically discover and explain the root cause of a use error-a mistake-that occurs when someone uses a medical device. Covering medical devices used in the home and those used in clinical environments, the book presents informative case studies about the use errors
  effective root cause analysis: 5 Whys Majed F Rajeh, 2020-06-20 This book is intended for anyone who wants to know about the 5 Whys and how to use them.The Five Whys tool is considered as the number one tool in ease of use in recognizing the truth of the problems and revealing its causing secrets, as it is considered a complement to many quality tools and systems. Although, there are few who can explain it well, and some even talk about it as if nothing.If you are a student, worker, manager, nurse, teacher, unemployed or anything else and you encounter problems and want to solve them from their roots in an easy and effective way, then this book will help you put your feet on the route of knowledge.As a help, I added templates to help you sort ideas and find causes.When I wrote this work, I tried to keep away from prolonged unhelpful explanation or the use of theorizing. I relied on my accumulated experience over more than 20 years in the field of quality to summarize this topic in an easy, smooth and possibly new way.In this book, you will learn about: - Definition of the problem.- How to represent the problem as a tree.- Learn about the Five Whys.- Types of the Five Whys: simple, tree, in an organization.- When to use each type or method.- Detailed usage steps.- When to stop asking questions.- How to know that you have reached the root of the problem.- Attributes that the problem-solving persons should have.- How to benefit you as a leader.- How to benefit you in your job.- Rocket and the fly theory in dealing with problems.- Examples, exercises, models, etc
  effective root cause analysis: Step-by-step Guide to Effective Root Cause Analysis Kenneth Alan Hirsch, Dennis T. Wallace, 2001
  effective root cause analysis: Why Startups Fail Tom Eisenmann, 2021-03-30 If you want your startup to succeed, you need to understand why startups fail. “Whether you’re a first-time founder or looking to bring innovation into a corporate environment, Why Startups Fail is essential reading.”—Eric Ries, founder and CEO, LTSE, and New York Times bestselling author of The Lean Startup and The Startup Way Why do startups fail? That question caught Harvard Business School professor Tom Eisenmann by surprise when he realized he couldn’t answer it. So he launched a multiyear research project to find out. In Why Startups Fail, Eisenmann reveals his findings: six distinct patterns that account for the vast majority of startup failures. • Bad Bedfellows. Startup success is thought to rest largely on the founder’s talents and instincts. But the wrong team, investors, or partners can sink a venture just as quickly. • False Starts. In following the oft-cited advice to “fail fast” and to “launch before you’re ready,” founders risk wasting time and capital on the wrong solutions. • False Promises. Success with early adopters can be misleading and give founders unwarranted confidence to expand. • Speed Traps. Despite the pressure to “get big fast,” hypergrowth can spell disaster for even the most promising ventures. • Help Wanted. Rapidly scaling startups need lots of capital and talent, but they can make mistakes that leave them suddenly in short supply of both. • Cascading Miracles. Silicon Valley exhorts entrepreneurs to dream big. But the bigger the vision, the more things that can go wrong. Drawing on fascinating stories of ventures that failed to fulfill their early promise—from a home-furnishings retailer to a concierge dog-walking service, from a dating app to the inventor of a sophisticated social robot, from a fashion brand to a startup deploying a vast network of charging stations for electric vehicles—Eisenmann offers frameworks for detecting when a venture is vulnerable to these patterns, along with a wealth of strategies and tactics for avoiding them. A must-read for founders at any stage of their entrepreneurial journey, Why Startups Fail is not merely a guide to preventing failure but also a roadmap charting the path to startup success.
  effective root cause analysis: How to Organize and Run a Failure Investigation Daniel P. Dennies, 2005 Learning the proper steps for organizing a failure investigation ensures success. Failure investigations cross company functional boundaries and are an integral component of any design or manufacturing business operation. Well-organized and professionally conducted investigations are essential for solving manufacturing problems and assisting in redesigns. This book outlines a proven systematic approach to failure investigation. It explains the relationship between various failure sources (corrosion, for example) and the organization and conduct of the investigation. It provides a learning platform for engineers from all disciplines: materials, design, manufacturing, quality, and management. The examples in this book focus on the definition of and requirements for a professionally performed failure analysis of a physical object or structure. However, many of the concepts have much greater utility than for investigating the failure of physical objects. For example, the book provides guidance in areas such as learning how to define objectives, negotiating the scope of investigation, examining the physical evidence, and applying general problem-solving techniques.
  effective root cause analysis: Thinking, Fast and Slow Daniel Kahneman, 2011-10-25 *Major New York Times Bestseller *More than 2.6 million copies sold *One of The New York Times Book Review's ten best books of the year *Selected by The Wall Street Journal as one of the best nonfiction books of the year *Presidential Medal of Freedom Recipient *Daniel Kahneman's work with Amos Tversky is the subject of Michael Lewis's best-selling The Undoing Project: A Friendship That Changed Our Minds In his mega bestseller, Thinking, Fast and Slow, Daniel Kahneman, world-famous psychologist and winner of the Nobel Prize in Economics, takes us on a groundbreaking tour of the mind and explains the two systems that drive the way we think. System 1 is fast, intuitive, and emotional; System 2 is slower, more deliberative, and more logical. The impact of overconfidence on corporate strategies, the difficulties of predicting what will make us happy in the future, the profound effect of cognitive biases on everything from playing the stock market to planning our next vacation—each of these can be understood only by knowing how the two systems shape our judgments and decisions. Engaging the reader in a lively conversation about how we think, Kahneman reveals where we can and cannot trust our intuitions and how we can tap into the benefits of slow thinking. He offers practical and enlightening insights into how choices are made in both our business and our personal lives—and how we can use different techniques to guard against the mental glitches that often get us into trouble. Topping bestseller lists for almost ten years, Thinking, Fast and Slow is a contemporary classic, an essential book that has changed the lives of millions of readers.
  effective root cause analysis: Communities in Action National Academies of Sciences, Engineering, and Medicine, Health and Medicine Division, Board on Population Health and Public Health Practice, Committee on Community-Based Solutions to Promote Health Equity in the United States, 2017-04-27 In the United States, some populations suffer from far greater disparities in health than others. Those disparities are caused not only by fundamental differences in health status across segments of the population, but also because of inequities in factors that impact health status, so-called determinants of health. Only part of an individual's health status depends on his or her behavior and choice; community-wide problems like poverty, unemployment, poor education, inadequate housing, poor public transportation, interpersonal violence, and decaying neighborhoods also contribute to health inequities, as well as the historic and ongoing interplay of structures, policies, and norms that shape lives. When these factors are not optimal in a community, it does not mean they are intractable: such inequities can be mitigated by social policies that can shape health in powerful ways. Communities in Action: Pathways to Health Equity seeks to delineate the causes of and the solutions to health inequities in the United States. This report focuses on what communities can do to promote health equity, what actions are needed by the many and varied stakeholders that are part of communities or support them, as well as the root causes and structural barriers that need to be overcome.
  effective root cause analysis: TapRoot Root Cause Analysis Implementation Mark Paradies, Linda Unger (Performance improvement consultant), 2017
  effective root cause analysis: The Agile Self-assessment Game Ben Linders, 2019-01-16 The Agile Self-Assessment Game is used by teams and organizations to self-assess their agility. Playing the game enables teams to reflect on their own team interworking, discover how agile they are and decide what they can do to increase their agility to deliver more value to their customers and stakeholders. This is the first book specifically about Agile Self-assessments. In this book, Ben Linders explains what self-assessments are and why you would do them, and explores how to do them using the Agile Self-assessment Game. He's also sharing experience stories from people who played the game. This book is based on his experience as a developer, tester, team leader, project manager, quality manager, process manager, consultant, coach, trainer, and adviser in Agile, Lean, Quality and Continuous Improvement. It takes a deep dive into self-assessments, viewing them from different perspectives and provides ideas, suggestions, practices, and experiences that will help you to do effective agile self-assessments with your teams. The book is aimed at Scrum masters, agile coaches, consultants leading agile transformations, developers and testers, project managers, line managers, and CxOs; basically for anyone who is looking for an effective way to help their agile teams improve and to increase the agility of their organization. With plenty of ideas, suggestions, and practical cases on Agile Self-assessments, this book will help you to apply assessments and help teams to improve. Note: The agile coaching cards needed to play the games described in the book can be downloaded for a nominal fee at benlinders.com/downloads.
  effective root cause analysis: The Memory Jogger 2 GOAL/QPC, Michael Brassard, 2010-01-30 This Second Edition Pocket Guide uses GOAL/QPC's detailed graphics and easy-to-understand text and icons to describe what the tools are, why they're used, and how to use them. Critical tools are explained using real-life examples from all types of organizations with problems similar to yours, making them easy for everyone to understand and apply. The Memory Jogger 2 (Second Edition) contains all the tools found in the first edition of the Memory Jogger II, plus 50 pages of new charts and detailed diagram samples, a new tool, and a case study.
  effective root cause analysis: Making Healthcare Safe Lucian L. Leape, 2021-05-28 This unique and engaging open access title provides a compelling and ground-breaking account of the patient safety movement in the United States, told from the perspective of one of its most prominent leaders, and arguably the movement’s founder, Lucian L. Leape, MD. Covering the growth of the field from the late 1980s to 2015, Dr. Leape details the developments, actors, organizations, research, and policy-making activities that marked the evolution and major advances of patient safety in this time span. In addition, and perhaps most importantly, this book not only comprehensively details how and why human and systems errors too often occur in the process of providing health care, it also promotes an in-depth understanding of the principles and practices of patient safety, including how they were influenced by today’s modern safety sciences and systems theory and design. Indeed, the book emphasizes how the growing awareness of systems-design thinking and the self-education and commitment to improving patient safety, by not only Dr. Leape but a wide range of other clinicians and health executives from both the private and public sectors, all converged to drive forward the patient safety movement in the US. Making Healthcare Safe is divided into four parts: I. In the Beginning describes the research and theory that defined patient safety and the early initiatives to enhance it. II. Institutional Responses tells the stories of the efforts of the major organizations that began to apply the new concepts and make patient safety a reality. Most of these stories have not been previously told, so this account becomes their histories as well. III. Getting to Work provides in-depth analyses of four key issues that cut across disciplinary lines impacting patient safety which required special attention. IV. Creating a Culture of Safety looks to the future, marshalling the best thinking about what it will take to achieve the safe care we all deserve. Captivatingly written with an “insider’s” tone and a major contribution to the clinical literature, this title will be of immense value to health care professionals, to students in a range of academic disciplines, to medical trainees, to health administrators, to policymakers and even to lay readers with an interest in patient safety and in the critical quest to create safe care.
  effective root cause analysis: The Lean Six Sigma Pocket Toolbook: A Quick Reference Guide to Nearly 100 Tools for Improving Quality and Speed Michael L. George, John Maxey, David T. Rowlands, Malcolm Upton, 2004-10-13 Vital tools for implementing Lean Six Sigma--what they are, how they work, and which to use The Lean Six Sigma Pocket Toolbook is today's most complete and results-based reference to the tools and concepts needed to understand, implement, and leverage Lean Six Sigma. The only guide that groups tools by purpose and use, this hands-on reference provides: Analyses of nearly 100 tools and methodologies--from DMAIC and Pull Systems to Control Charts and Pareto Charts Detailed explanations of each tool to help you know how, when, and why to use it for maximum efficacy Sections for each tool explaining how to create it, how to interpret what you find, and expert tips Lean Six Sigma is today's leading technique to maximize production efficiency and maintain control over each step in the managerial process. With The Lean Six Sigma Pocket Toolbook, you'll discover how to propel your organization to new levels of competitive success--one tool at a time.
  effective root cause analysis: Cases on Optimizing the Asset Management Process González-Prida, Vicente, Márquez, Carlos Alberto Parra, Márquez, Adolfo Crespo, 2021-10-15 It is critical to improve the asset management system implementation as well as economics and industrial decision making to ensure that a business may move smoothly internally. Maintenance management should be aligned to the activities of maintenance in accordance with key business strategies, which must be designed under the comprehensive approach of an asset management process. After transforming the priorities of the business into priorities of maintenance, maintenance managers will use their medium-team strategies to tackle potential weaknesses in the maintenance of the equipment in accordance with these objectives. Cases on Optimizing the Asset Management Process explains and summarizes the processes and the reference frame necessary for the implementation of the Maintenance Management Model (MMM). This book acts as an overview of the current state of the art in asset management, providing innovative tools and practices from the fourth industrial revolution. Presenting topics like criticality analysis, physical asset maintenance, and unified modelling language, this text is essential for industrial and manufacturing engineers, plant supervisors, academicians, researchers, advanced-level students, technology developers, and managers who make decisions in this field.
  effective root cause analysis: Resilient Health Care, Volume 3 Jeffrey Braithwaite, Robert L. Wears, Erik Hollnagel, 2016-10-03 This book is the 3rd volume in the Resilient Health Care series. Resilient health care is a product of both the policy and managerial efforts to organize, fund and improve services, and the clinical care which is delivered directly to patients. This volume continues the lines of thought in the first two books. Where the first volume provided the rationale and basic concepts of RHC and the second teased out the everyday clinical activities which adjust and vary to create safe care, this book will look more closely at the connections between the sharp and blunt ends. Doing so will break new ground, since the systematic study in patient safety to date with few exceptions has been limited.
  effective root cause analysis: The Root Cause Analysis Handbook Max Ammerman, 1998 The answer is root cause analysis, a process that allows you to find the cause of single events/problems in the workplace. The Root Cause Analysis Handbook presents a walkthrough example that illustrates the method and shows how to implement it.Because poor initial problem definition can (and often does) undermine the problem-solving process, Ammerman places special emphasis on this area to build a solid foundation for effective analysis. He also provides guidance on preparing the final report.The need for clear documentation on dealing with problems makes this book especially valuable for quality managers, engineers, safety managers, and teams implementing the ISO or QS standards. Written in a simple, user-friendly style, you will grasp the core concepts quickly and begin applying them to your work.
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EFFECTIVE definition and mea…
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