1. © 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

2. © 2008-2011, Leffingwell, LLC. All rights reserved. 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 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 2

3. © 2008-2011, Leffingwell, LLC. All rights reserved. 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 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 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 We need “kaizen mind” an unending sense of crisis behind the company’s constant drive to improve. ̶ Jeff Sutherland – co-creator of Scrum 3

4. © 2008-2011, Leffingwell, LLC. All rights reserved. Excerpt from a board presentation from a high performing agile program in year 4 of agile adoption Kaizen Mind Example 4

5. © 2008-2011, Leffingwell, LLC. All rights reserved. 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

6. © 2008-2011, Leffingwell, LLC. All rights reserved. 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: ?  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

7. © 2008-2011, Leffingwell, LLC. All rights reserved. Problem Solving Workshop (or) 7

8. © 2008-2011, Leffingwell, LLC. All rights reserved. 1.Root Cause Analysis (Fishbone) Diagram 2.Pareto Chart 3.Corrective Action Plan Problem Solving Tools 8

9. © 2008-2011, Leffingwell, LLC. All rights reserved.  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

10. © 2008-2011, Leffingwell, LLC. All rights reserved. Root Cause Analysis (Fishbone) Diagram Our main “bones” represent typical sources of problems in software 10

11. © 2008-2011, Leffingwell, LLC. All rights reserved.  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

12. © 2008-2011, Leffingwell, LLC. All rights reserved.  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

13. © 2008-2011, Leffingwell, LLC. All rights reserved.  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) 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

14. © 2008-2011, Leffingwell, LLC. All rights reserved. Root Cause Analysis (Fishbone) Diagram Cause 1 Cause of cause 1 Cause of cause of cause 1 Cause of cause of cause of cause 1 14

15. © 2008-2011, Leffingwell, LLC. All rights reserved. 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  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

16. © 2008-2011, Leffingwell, LLC. All rights reserved. 1.Root Cause Analysis (Fishbone) Diagram 2.Pareto Chart 3.Corrective Action Plan Problem Solving Tools 16

17. © 2008-2011, Leffingwell, LLC. All rights reserved.  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

18. © 2008-2011, Leffingwell, LLC. All rights reserved.  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

19. © 2008-2011, Leffingwell, LLC. All rights reserved. Prioritize Root Causes 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

20. © 2008-2011, Leffingwell, LLC. All rights reserved. Pareto Analysis 20

21. © 2008-2011, Leffingwell, LLC. All rights reserved. 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  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 21

22. Group Review of Root Cause Analysis and Pareto Charts Timebox: ?

23. © 2008-2011, Leffingwell, LLC. All rights reserved. 1.Root Cause Analysis (Fishbone) Diagram 2.Pareto Chart 3.Corrective Action Plan Problem Solving Tools 23

24. © 2008-2011, Leffingwell, LLC. All rights reserved. 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

25. © 2008-2011, Leffingwell, LLC. All rights reserved. What is a Corrective Action Plan anyway?  C orrective – A different course of action  A ction – Active steps we can realistically accomplish  P lan – Organized, purposeful, accountable, measurable Corrective Action Plan 25

26. © 2008-2011, Leffingwell, LLC. All rights reserved. 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 26

27. © 2008-2011, Leffingwell, LLC. All rights reserved. 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 27

28. © 2008-2011, Leffingwell, LLC. All rights reserved. 2.Brainstorm a solution – Brainstorm prospective solutions with the team – Cumulative vote on suggested next steps Corrective Action Plan Components How do you eat an elephant? One bite at a time. 28

29. © 2008-2011, Leffingwell, LLC. All rights reserved. 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 Corrective Action Plan Components 29

30. © 2008-2011, Leffingwell, LLC. All rights reserved. 4.Specify measurable results – What measures can we use to track progress? Corrective Action Plan Components 30

31. © 2008-2011, Leffingwell, LLC. All rights reserved. 5.Set achievable deadlines – Not to fast – Not to slow – Not TBD Corrective Action Plan Components Action 1 3/16/20011 Action 2 4/11/2011 Action 3 5/01/2011 31

32. © 2008-2011, Leffingwell, LLC. All rights reserved. 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 Corrective Action Plan Components 32

33. © 2008-2011, Leffingwell, LLC. All rights reserved. 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 33

34. © 2008-2011, Leffingwell, LLC. All rights reserved. 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  Pick the top root cause on your Pareto chart  Build a corrective action plan  Prepare to present your results Timebox: ? minutes 34

35. Group Review of Corrective Action Plans Timebox: ? minutes 1 …… 2 ….. 3 ….. 4 ….. 5 ….. 6 ….. 1 …… 2 ….. 3 ….. 4 ….. 5 ….. 6 …..