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Corrective Action Program Best Practice 14 – Establish Time Limits for Causal Analyses

March 17, 2015/in Corrective Action Program, Premium/by Nathan Ives

Determining the amount of time required for performing causal analyses is a balancing act. The depth of issue investigation should align with its significance. Consequently, more significant events require additional time to perform the more detailed causal analysis assigned to them. Countering this is the urgency to understand and correct the underlying causes of more significant events as well as to put into place those barriers that will prevent their recurrence. Thus, it is important to establish time limits for causal analysis performance that effectively balance these two opposing needs.[wcm_restrict plans=”48918, 25542, 25653″]

Causal Analysis Time Limits

There does not exist a mathematical formula for universally defining causal analysis timeframes such that depth and timeliness of investigation are appropriately balanced. Instead, appropriate time limits evolve over time based on management experience dealing with an array of events of varying significance.

Having worked with numerous organizations, StrategyDriven observed common causal analysis timeframes established among the most effective corrective action programs. Below are three causal analysis types and the common timeframes balancing investigation depth with issue resolution urgency:

Root Cause Analysis – formal investigation method used to determine the fundamental underlying cause(s) of an event or adverse trend. Root cause analysis methods logically derive the primary and contributing causes of an event; determining what happened, how it happened, and why it happened.
Common Time Limit: 1 month
Apparent Cause Evaluation – limited investigation method used to identify readily apparent causes and the extent of condition of an event or problem. An apparent cause evaluation identifies corrective actions to minimize the recurrence frequency and impact of the associated event.
Common Time Limit: 2 weeks
Direct Cause Evaluation – Direct cause evaluation (DCE) is a corrective action identification method used to address simple, ‘broke-fix’ issues. A direct cause evaluation identifies the obvious corrective actions to resolve the identified failure.
Common Time Limit: 1 – 2 days

Monitoring the Timeliness of Causal Analyses

Ensuring the timeliness of causal analysis performance requires management oversight. In addition to day-to-day status updates and engagement with the corrective action program, several performance measures are often used to ensure the timeliness of causal analysis performance and to identify those needing additional management attention:

Average Time to Perform RCAs/ACEs/DCEs – Average time to perform the RCAs/ACEs/DCEs completed within the past month calculated monthly.
Number of Open RCAs/ACEs/DCEs Greater Than 30 Days Old – Number of RCAs/ACEs/DCEs open on the last day of the month that are greater than 30 days old calculated monthly.
Percent of Open RCAs/ACEs/DCEs Less Than 30 Days Old – Percent of RCAs/ACEs/DCEs less than 30 days old as of the last day of the month calculated monthly.

Note that each of the above performance indicators represents three separate metrics, one for each causal analysis type. Additionally, each measure is commonly assigned to a business unit or location and cascaded to all of the subordinate divisions and departments.[/wcm_restrict][wcm_nonmember plans=”48918, 25542, 25653″]

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About the Author

Nathan Ives is a StrategyDriven Principal and Host of the StrategyDriven Podcast. For over twenty years, he has served as trusted advisor to executives and managers at dozens of Fortune 500 and smaller companies in the areas of management effectiveness, organizational development, and process improvement. To read Nathan’s complete biography, click here.

Corrective Action Program Best Practice 2 – Causal Analyses

December 16, 2014/in Corrective Action Program, Premium/by Nathan Ives

Organizations experience incidents of every sort, some with almost imperceptible impacts and others inflicting catastrophic consequences. While impractical to mitigate all adverse events, it is imperative to prevent recurrence of the most significant incidents, important to limit the frequency and impact of moderate happenings, and necessary to only correct low impact deficiencies. Such a grade approach to corrective action implementation optimally applies the organization’s resources based on the value of event recurrence mitigation.[wcm_restrict plans=”48830, 25542, 25653″]

Condition reports documenting adverse events are prioritized across a continuum relative to the incident’s impact. (See StrategyDriven Corrective Action Program article, Condition Report Prioritization) These priorities provide the basis for a graded approach to the performance of causal analysis identifying the corrective actions necessary to prevent or mitigate event recurrence.

Types of Causal Analyses

Three common causal analyses provide a spectrum of investigation methods and depths. Each analysis type is described below:

Root Cause Analysis

Root cause analysis (RCA) is a formal investigation method used to determine the fundamental underlying cause(s) of an event or adverse trend. Root cause analysis methods logically derive the primary and contributing causes of an event; determining what happened, how it happened, and why it happened. These analyses identify the extent of the adverse condition and corrective actions to prevent event recurrence (CAPRs).

A root cause analysis is typically performed by a multidiscipline team and may take up to a month to complete.

Apparent Cause Evaluation

Apparent cause evaluation (ACE) is a limited investigation method used to identify readily apparent causes and the extent of condition of an event or problem. An apparent cause evaluation identifies corrective actions to minimize the recurrence frequency and impact of the associated event.

An apparent cause evaluation is typically performed by a knowledgeable individual or small team and may take up to a few weeks to complete.

Direct Cause Evaluation

Direct cause evaluation (DCE) is a corrective action identification method used to address simple, ‘broke-fix’ issues. A direct cause evaluation identifies the obvious corrective actions to resolve the identified failure. In worst case scenarios, troubleshooting is required to identify the necessary corrective actions.

A direct cause evaluation is typically performed by the responsible department’s Corrective Action Program Coordinator or a knowledgeable staff member and is often completed at the time of condition report processing.

Relationship between Causal Analyses and Condition Report Significance Level

Each causal analysis type requires a different amount of resources related to the depth of investigation performed. Consequently, a condition report’s significance should dictate the type of analysis performed so that the organization realizes an appropriate return on this investment.

Significance Level 1 Condition Reports

Significance Level 1 condition reports represent an issue or event resulting in a significant impact. A root cause analysis is almost always performed for Significance Level 1 issues.

Significance Level 2 Condition Reports

Significance Level 2 condition reports represent an issue or event resulting in a moderate impact. A root cause analysis is performed for more serious Significance Level 2 issues or collection of related Significance Level 2 issues. An apparent cause evaluation is performed for most Significance Level 2 issues.

Significance Level 3 Condition Reports

Significance Level 3 condition reports represent an issue or event resulting in a minor impact. An apparent cause evaluation is performed for more serious Significance Level 3 issues or collection of related Significance Level 3 issues. A direct cause evaluation is performed for most Significance Level 3 issues.

Significance Level 4 and 5 Condition Reports

Significance Level 4 condition reports represent a low-level problem, typically closed to immediate actions taken or other readily identifiable follow-up corrective actions that requires trending. Significance level 5 condition reports represent an enhancement, opportunity for improvement, or commendable behavior that does not require trending. A direct cause evaluation is performed for Significance Level 4 issues not resolved by the performance of immediate actions. No causal analysis is performed for Significance Level 5 items.

Note that collections or trends of Significance Level 4 issues are commonly captured within a rollup Significance Level 3 condition report and the appropriate causal analysis performed.[/wcm_restrict][wcm_nonmember plans=”48830, 25542, 25653″]