Problem Solving Workshop: Critical Thinking and Root Cause Analysis

Transcription

1 IT Service Management Problem Solving Workshop: Seminar Workbook Version Copyright Protection: No part of these notes may be reproduced in any form electronic or printed without the written consent of B Wyze Solutions Inc 1

2 Acknowledgements Problem Solving Workshop B Wyze Solutions Inc LCS Accredited ITIL Training Provider B Wyze copyright 2011 Author: Graham Furnis ITIL v3 Expert Certified ITIL v3 Intermediate Lifecycle Certified ITIL v2 Manager Certified LCS Accredited ITIL Trainer Works Cited Fishbone Diagram, Ishikawa, Kaoru (1990) Kepner-Tregoe Problem Solving (Kepner & Tregoe, 1958) Copyright Protection: No part of these notes may be reproduced in any form electronic or printed without the written consent of B Wyze Solutions Inc 2

3 TABLE OF CONTENTS ACKNOWLEDGEMENTS... 2 WORKS CITED... 2 TABLE OF CONTENTS... 3 OVERVIEW: WHAT TO EXPECT... 5 Who should attend?... 5 Prerequisites... 5 Learning Objectives... 5 SECTION 1: PROBLEM SOLVING WITHIN IT SERVICE MANAGEMENT... 6 IT Service Management (ITSM)... 6 Key Terms... 6 SECTION 2: PROBLEM SOLVING... 7 What is Problem Solving?... 7 SECTION 3: PROBLEM-SOLVING PERSPECTIVES... 8 Adjust your Thinking and Reasoning... 8 SECTION 4: PROBLEM SOLVING AS A STRUCTURED PROCESS Problem Solving Root Cause Analysis (RCA) Kepner-Tregoe Root Cause Analysis Method The Problem Solving Plan Using Kepner-Tregoe SECTION 5: RCA METHODS AND TECHNIQUES Comparison of Methods and Techniques The Journalism Standard ACTIVITY: CASE STUDY ACTIVITY 1: THE JOURNALISM STANDARD Facts Table: ACTIVITY 2: PROBLEM SOLVING PLAN AND STEPS Pareto Analysis ACTIVITY 3: PARETO ANALYSIS Cause and Effect (Relationship) Analysis ACTIVITY 4: CAUSE & EFFECT - TECHNICAL RELATIONSHIPS Copyright Protection: No part of these notes may be reproduced in any form electronic or printed without the written consent of B Wyze Solutions Inc 3

4 ACTIVITY 5: CAUSE & EFFECT PROCESS AND CHRONOLOGICAL RELATIONSHIPS Ishikawa Diagram (Cause and Effect Diagram) ACTIVITY 6: ISHIKAWA DIAGRAM - CREATIVE LEADS SECTION 6: GETTING TO THE TRUE ROOT CAUSE Hypothesis Testing and Validation ACTIVITY 7: HYPOTHESIS TESTING AND VALIDATION The 5 Whys ACTIVITY 8: BUT ARE WE DONE? THE 5 WHY S SECTION 6: PROBLEM OPTIONS AND SOLUTIONS ACTIVITY 9: PROBLEM OPTIONS AND SOLUTIONS Copyright Protection: No part of these notes may be reproduced in any form electronic or printed without the written consent of B Wyze Solutions Inc 4

5 Overview: What to Expect Who should attend? This course will be of interest to: IT support individuals who would like to strengthen their problem-solving skills IT managers seeking to improve their team skills in problem solving IT process management individuals who are looking to improve their problem process and Root Cause Analysis problem-solving activities Prerequisites No prerequisites are required, but an IT background is highly recommended and an understanding of ITIL (IT Infrastructure Library) may be useful. Learning Objectives The learning objectives of this workshop provide value to participants in the areas of: Understand the basic elements of the Problem Solving Skills Understand the perspectives of Critical Thinking and Creative Thinking Understand a process approach to Problem Solving and Root Cause Analysis Understand how to maintain progress in problem solving by adjusting your approach, methods, and techniques Understand how to get to the true Root Cause of a Problem Understand how to solve the Problem Copyright Protection: No part of these notes may be reproduced in any form electronic or printed without the written consent of B Wyze Solutions Inc 5

6 Section 1: Problem Solving within IT Service Management IT Service Management (ITSM) IT Service Management is a discipline for managing IT systems and technology centered on the identification and delivery of IT Services used by the business. These IT Services are defined in business terms and are the final outcome for IT systems and technology. Within the practice of ITSM, the ITIL (IT Infrastructure Library) framework links Root Cause Analysis to the process of Problem Management. The ITSM discipline and the ITIL framework approach provide a beneficial relationship to successful IT related Problem Solving by IT Service Support professionals. As such, it is useful to consider the following definitions: Key Terms Problem and Problem Management A Problem is the unknown cause of one or more related Incidents. Problem Management manages the investigation into the cause of these related Incidents and ensures an appropriate resolution to the Problem is found. Incident and Incident Management An Incident is an unplanned event that is a deviation from normal (as defined by the Service Level Agreement) that affects an IT Service. This deviation could include: o Disruption to the agreed service o Reduction in the quality of agreed service o Something that could lead to a disruption or reduced quality of agreed service Incident Management manages the quick response and restoration of these incidents, and may further escalate issues to Problem Management for further investigation. Priority, Impact, Urgency Priority is a generic ITSM definition that defines the priority in which issues, such as Incidents and Problems, are dealt with. Priority of an issue is a combination of Impact and Urgency. These are defined as the degree of: Impact - positive or negative business effect of something. Urgency - response time required to address an impact event. Service Level Agreement (SLA) A written or understood agreement between an IT Service Provider and the Business (through identification of the Business Customer) that outlines all arrangements for the use, performance levels, and management of an IT Service. Incident and Problem priority objectives and other details are often documented and agreed in this Agreement. Copyright Protection: No part of these notes may be reproduced in any form electronic or printed without the written consent of B Wyze Solutions Inc 6

7 Section 2: Problem Solving What is Problem Solving? Problem Solving is a basic and key life skill that is often considered to be one of the most complex human intellectual functions. Fortunately, it s also something that can be continually learned, practiced and improved. In its basic sense, Problem Solving is a mental process for thinking and reasoning. It can be refined and improved when broken into the separate, but related, parts of Problem Finding and Problem Shaping. Problem Finding Identifying the Problem is the first step to good Problem Solving. The problem statement becomes the target that is being solved for, and getting this target right or wrong can have serious good or bad consequences. In many cases, identifying the problem is more complex than actually solving the problem. A key to good problem finding involves the use of Creative Thinking. Problem Shaping Problem Shaping follows Problem Finding. Once the Problem has been correctly identified, questions need to be asked that shape the direction and findings of problem investigation. Each question leads to insight into the underlying Problem Cause(s), and thus refines and shapes further questions to be asked. A key to good problem shaping involves the use of Critical Thinking. Copyright Protection: No part of these notes may be reproduced in any form electronic or printed without the written consent of B Wyze Solutions Inc 7

8 Section 3: Problem-Solving Perspectives Adjust your Thinking and Reasoning Problem Solving as a skill requires that the problem solver adjust their approach and perspective to solving the problem. Failure to adjust and taking the wrong perspective from the onset is one of the primary reasons problem solvers fail, or fail to act in a timely manner. This can be accomplished by understanding the differences between: Critical Thinking in Problem Solving can be considered logical thinking. It is a methodical approach that involves the cognitive skills of goal clarification, observation, interpretation, analysis, categorizing, relating, inference making, evaluation of results, assessment, and explanation of conclusions. Creative thinking in Problem Solving can be thought of as finding options and alternatives, or more commonly referred to as thinking outside the box of common and tried solutions. Critical Thinking is associated with deductive reasoning, where it is based on a set of propositions and the subsequent investigation and factual discoveries that bring to light the root cause of a Problem. Tends to be a top-down approach to Problem Solving. It requires detailed knowledge or experience combined with a logical process that confirms each proposition is NOT the source of the Problem. Creative thinking is associated with inductive reasoning, where Inductive Reasoning can be thought of as assumptions or generalized conclusions drawn from a set of observations. These assumptions are not necessarily valid conclusions, but start points to be further investigated and validated. Tends to be a bottom-up approach to Problem-Solving. It is based on both intuition and making guesses based on experience. It must be followed up by verification of these guesses, or assumptions, typically using an experimental approach. Copyright Protection: No part of these notes may be reproduced in any form electronic or printed without the written consent of B Wyze Solutions Inc 8

9 When to Use Critical Thinking and Deductive Reasoning A problem is familiar or of a familiar type A problem solver has sufficient skill and experience When to Use Creative Thinking and Inductive Reasoning A problem is unfamiliar Deductive reasoning has reached a dead end and more alternatives are needed For example: For example: A critical marketing application has several different user error messages across the marketing department. With our programming experience we know that each error message is triggered by application error trapping code. Therefore, we deduce that we should investigate the programming code related to the application modules that produced the error message to confirm the application logic. A critical marketing application has several different user error messages across the marketing department. We have no programming skill, but have observed in our past experience that shared applications are run from a central server. The marketing application is a shared application; and therefore we induce (assume) that the Problem must be based on a server. Our investigations will now take this path. Copyright Protection: No part of these notes may be reproduced in any form electronic or printed without the written consent of B Wyze Solutions Inc 9

10 Section 4: Problem Solving as a Structured Process Problem Solving Problem Solving involves a structured and methodical approach to problem solving. In general, this structure involves: (1) Correctly defining the problem, (2) Finding the root cause(s) of the problem through Root Cause Analysis, (3) Determining the most effective corrective actions to take, and (4) Implementing the solution to successfully manage the problem. Primary Goal: The Problem Solving process seeks to prevent Problems from ever recurring by taking effective corrective actions. Root Cause Analysis (RCA) Root Cause Analysis is a sub-process of the larger Problem Solving process that requires an appropriate application of Problem Solving skills in conjunction with a methodical and systematic approach to identifying the true root cause(s) of Problems. Each Root Cause Analysis approach shares a common aim to avoid focusing on and solving the symptoms of the problem, and to instead drill down to identify and solve the true root cause of the problem. A key assumption to Root Cause Analysis is that there is always one true root cause for any given problem. This leads to a key challenge of having sufficient focus and perseverance to find this one true root cause. Primary Goal Root Cause Analysis endeavors to determine the lowest level root cause of a Problem that supports taking the most effective corrective actions. Primary Objective The objective of Root Cause Analysis is to reveal the correct root cause of the Problem, because without it we cannot determine what effective corrective actions must be taken. Copyright Protection: No part of these notes may be reproduced in any form electronic or printed without the written consent of B Wyze Solutions Inc 10

11 Kepner-Tregoe Root Cause Analysis Method The Kepner-Tregoe method to analyze problems was developed by researchers Dr. Charles Kepner and Dr. Benjamin Tregoe. This method emphasizes a structured approach to problem solving that relies on setting priorities and making use of technician knowledge and experience. The method includes five steps to problem solving. Copyright Protection: No part of these notes may be reproduced in any form electronic or printed without the written consent of B Wyze Solutions Inc 11

12 The Problem Solving Plan Using Kepner-Tregoe It is recommended that a structured problem solving plan should be created when solving any Problem. The plan should follow the problem solving steps, such as those defined by Kepner-Tregoe, and should include the business goals and objectives that need to be achieved. Each step can then be managed at an appropriate level based on priorities, time pressures, and availability of information. The Problem Solving Plan is iterative, where new facts and observations shed new and increasingly accurate light on both the Problem definition as well as the root cause investigation. Sample Problem Solving Plan Goal: Objectives: Constraints: Problem Definition: Problem Solving Steps 1. Define the Problem 2. Assess the Problem 3. Establish Possible Causes 4. Explore Possible and Probable Causes 5. Verify Root Cause(s) Technique(s) to Use Copyright Protection: No part of these notes may be reproduced in any form electronic or printed without the written consent of B Wyze Solutions Inc 12

13 Section 5: RCA Methods and Techniques Comparison of Methods and Techniques There are many Root Cause Analysis related methodologies and techniques. The more common ones along with their primary characteristics are listed in the following table. Each has particular strengths that make it suitable for use in specific situations. These are defined more fully in the subsequent pages. Method / Technique Approach Top Down / Bottom up Journalism Standard Pareto Analysis Problem Finding Problem Shaping Problem Finding Problem Shaping Both Top-down / Bottom-up Requires Complementary Methods / Techniques All methods / techniques ITIL Processes Ishikawa The 5 Whys Cause and Effect Analysis Problem Shaping Top-Down ITIL Processes Configuration Relationships Systems Analysis The 5 Whys Change Analysis Problem Shaping Top-down Systems Analysis Ishikawa Diagram Problem Finding Problem Shaping Both Top-down / Bottom-up The 5 Whys Brainstorming The 5 Whys The 5 Whys Problem Shaping Top-Down All methods / techniques Copyright Protection: No part of these notes may be reproduced in any form electronic or printed without the written consent of B Wyze Solutions Inc 13

14 The Journalism Standard The Journalism Standard is a technique that is focused on factual reporting and analysis, where emotion and assumptions are removed from consideration. It can be thought of as listing and considering just the facts. The Journalism Standard reminds the Problem Solver to research and list the basic facts of the situation first, to seek interviews and independent confirmation, and then to evaluate using a neutral approach. This technique also reminds the Problem Solver to avoid some of the more common Problem Solving mistakes including eliminating or limiting possible causes that includes: Avoid Jumping to Assumptions Avoid eliminating possible causes due to one or more incorrect assumptions. Making assumptions is a necessary part of life. However, when the stakes are high and risks of failre increase, making assumptions can be dangerous! Many times a Problem has escalated or dragged on due to an assumption being made that eliminated a check point. For example: A technician may eliminate checking the application drivers on Server PC knowing that it can t be the Server as no one has updated the Server since it was last working Avoid Tunnel Vision Avoid missing possible causes due to an obsession or narrow focus on one or a small range of assumptions. Jumping to a conclusion may lead you to a quick diagnosis of a Problem, but more often than not it leads to a failure to correctly identify the root cause. In other cases, the narrow focus misses the correct root cause and the Problem escalates as the investigation drags on. For example: A technician may limit investigation to a Server PC concluding that it must be the Server as the application error is generated from the software residing on the Server The 5 w s The 5 w s is a simple and commonly known rule to gather the facts: who was involved what events happened when did the sequence of events happen where did the sequence of events happen how did the sequence of events happen why did the problem happen (initial inductions and deductions) Copyright Protection: No part of these notes may be reproduced in any form electronic or printed without the written consent of B Wyze Solutions Inc 14

15 Activity: Case Study Problem Solving Workshop The Marketing Client Support team of LITI Corporation has reported two related Incidents this week related to their Sales Management Service. While each individual Incident has been restored, the issue has been escalated by Marketing staff to the Marketing Manager, who in turn has raised the issue with Service Level Management (SLM). SLM has agreed that this is a Problem that needs to be solved by IT in order to maintain marketing staff productivity and keep good relations with the Business. The issue has been assigned to the Problem Manager, who in turn has opened a Problem record and assigned you to resolve this issue. Initial investigation of related Incident records has revealed the following descriptions: Bob in Marketing has experienced a series of CRM Application "freezes" where he has tried to save an updated client history. Bob called the Service Desk and was advised to re-boot the application. As a consequence, Bob lost his data updates and had to re-enter the updates. Bob mentioned that several other Sales Representatives have experienced the same issue. Mary in Marketing has experienced extreme slowness and failure to save updates several times in the last month when updating client billing and payment information using the CRM Application. Mary did not contact the Service Desk until the event occurred again this week. Mary was dispatched a Level 2 support technician. The technician was able to confirm local network connectivity, and also confirmed that the CRM Application server was up and running. Desktop memory and disk space were confirmed to be sufficient. The technician resolved the Incident by refreshing the client profiles (and consequently losing current data updates), re-entered 3 of the 20 original client updates, and successfully saved to the server without any Incident occurring. Mary was advised to save more frequent. Copyright Protection: No part of these notes may be reproduced in any form electronic or printed without the written consent of B Wyze Solutions Inc 15

16 Activity 1: The Journalism Standard Facts Table: Who What When Where How Copyright Protection: No part of these notes may be reproduced in any form electronic or printed without the written consent of B Wyze Solutions Inc 16

17 Why Deductions Copyright Protection: No part of these notes may be reproduced in any form electronic or printed without the written consent of B Wyze Solutions Inc 17

18 Activity 2: Problem Solving Plan and Steps Goal: Goal: The Problem root cause is to be found Objectives: Objective: The Problem is to be solved using a structured problem solving approach Constraints: Problem is categorized as Priority 2 Problem Definition: Root cause must be found within one week of assignment One problem solving analyst assigned Problem Solving Steps 1. Define the Problem Tactics, Approach, and Technique(s) to Use 2. Assess the Problem 3. Establish Possible Causes 4. Explore Possible and Probable Causes 5. Verify Root Cause(s) Copyright Protection: No part of these notes may be reproduced in any form electronic or printed without the written consent of B Wyze Solutions Inc 18

19 Pareto Analysis Pareto analysis is based on the Pareto principle, which is often quoted as the 80/20 rule. This principle states that (in general) 80% of the effects of something are a result of 20% of the inputs or causes. In the world of ITSM problem solving, Pareto analysis states that problem causes accounting for 80% of problems should be investigated first. Thus, Pareto analysis becomes a statistical technique that relies upon assembling historical problem records. This technique is both top-down and bottom up; by identifying possible causes that can serve as start points to be investigated further using other techniques and methods (such as Cause and Effect analysis). Some considerations include: Pareto Analysis forces the Problem Solver to avoid the temptation to jump directly to problem investigation without a quick check of known or obvious problems. A history of problems and causes is required to produce the analysis. In a green-field situation, this information may take too long to assemble. In such situations, Pareto analysis may be based on technician experience and recollection of past similar events. It s important to remember that the 80/20 rule suggests the most likely causes, and is not intended to be correct every time. As such, it may result in misdiagnosis by overlooking smaller frequency causes or new causes. Pareto Analysis Steps Step 1: Compile a history of unique causes along with specific problems, or types of problems, components or services affected, and/or users affected. Step 2: Compute the percentage that each unique cause has been the source of a problem. Step 3: Apply the 80/20 rule to determine the most likely causes to investigate. Copyright Protection: No part of these notes may be reproduced in any form electronic or printed without the written consent of B Wyze Solutions Inc 19

20 Activity 3: Pareto Analysis Problem Solving Workshop The following Problem History Report is produced when searching for the Generic Problem of Application Failure to Save Data. Last 80/20 Percentage Frequency Category1 Category2 Cause Resolution Assessment 18 month 1.64% 8 Network Hardware Local area network connectivity issues Workaround - Reboot ago at the local network hub 1 month ago 2 months ago 1 month ago 5 months ago 2.46% 4.11% 5.13% 6.16% 12 Server Hardware Server disk capacity limitations caused by accumulation of data Workaround - Archive data 20 Desktop Software Local PC application code error Workaround Reboot or Re-enter data 25 Desktop Software Local PC network connectivity issues at the user's Desktop PC 30 Desktop Software Local PC memory limitations caused by too many open applications Workaround - Reboot Workaround - Close Applications 8 months ago 24.64% 120 Server Hardware Server memory limitations causes by application processing routines overload Workaround - Reboot 2 months ago 27.10% 132 Desktop Hardware Local PC disk capacity limitations caused by accumulation of data Workaround - Archive data 3 weeks ago 28.75% 140 Desktop Hardware Local PC invalid data types entered as record field data Workaround translate data to acceptable type Deductions (what should we investigate first, second, etc.?): Copyright Protection: No part of these notes may be reproduced in any form electronic or printed without the written consent of B Wyze Solutions Inc 20

21 Research Information: Contact the Server Support Group The Server Support group assures you that the Server PC supporting the CRM Application is fully monitored and showed no processing overload according to Server log files, and currently has 50% available disk capacity after a data clean up last month. Contact Bob and Mary Bob and Mary both respond that there s nothing unusual or incorrect with their data as they re-entered and attached the same data after re-booting and successfully saved. While they are on the phone, you also find out: o The Problem first appeared (but was not reported) 4 to 5 weeks ago. The first occurrence was several weeks after a CRM release introducing a Billing module, but just before the Billing bug fix. o The others were almost all other Sales Reps, and they believe the frequency of these failed saves is increasing. o Sales Reps and the Marketing Manager believe that the application is used more heavily and stores more information as time goes on. It must be a failure to save the quantity of data. They demand this failure be addressed to allow them to store the critical information required. Copyright Protection: No part of these notes may be reproduced in any form electronic or printed without the written consent of B Wyze Solutions Inc 21

22 Cause and Effect (Relationship) Analysis Cause and affect analysis is a deductive, top-down problem solving method that requires the problem solver to conduct proper research and information gathering in order to make use of critical thinking and deductive reasoning skills. Cause and Effect Analysis can also be thought of as Relationship Analysis as it first requires identifying relationships between components (including people, process, and technology) and then to determine a cause and effect path. The cause and effect tree or diagram is a visual description of the relationship between two events, where the first event is the cause (the trigger) and the second event is the effect (the consequence). This is a description of causality. Understanding Causality Conditions Causality can better be understood by classifying causes as one of three types of conditions: Necessary Conditions: If event B is always caused by A, then the presence of B implies A must have happened. Sufficient Conditions: If event B is sometimes caused by A, then the presence of B implies A may have happened. This leaves open the possibility of another event resulting in B. Contributory Conditions: If event B is caused by A and other factors (ie: A is not sufficient by iteself to cause B ), then the presence of B implies A and other factors may have happened. Neither necessary nor sufficient but it must be contributory. This requires other events to be searched for and found. Common Cause and Effect Analysis Methods Technical Relationships through the formal or informal Configuration Management Database (CMDB) o Fault Relationships through Fault Tree Analysis (FTA). Fault Tree Analysis is used to analyze a single fault event. It makes use of a cause and effect tree structure that analyzes the relationships of complex system faults (Technical Faults) using logic diagrams displaying the states of each part of a system. IT Process Relationships through the Configuration Management System (CMS) and related process activity records of the Service Management System (SMS), such as Incident, Problem, and Change records. End-User Interaction Relationships through formal or informal observation of IT Service modules of functionality. Chronological Event Relationships (chain of events) through sequencing all known events for people, process, or technology relationships. Copyright Protection: No part of these notes may be reproduced in any form electronic or printed without the written consent of B Wyze Solutions Inc 22

23 Activity 4: Cause & Effect - Technical Relationships The Service Management System (support ticketing system) contains information that relates IT components as well as Incident and Change records. 1. What Configuration Items (CIs) - based on the Service Configuration Model - should be investigated? 2. If the Cause exists within the components identified, how would you rate the Conditions? Configuration Item Cause-Effect Necessary Condition Sufficient Condition Contributory Condition Server PC CRM Server Application Network Router CRM Desktop Application Desktop PCs MS Windows MS Office Failure leads to Problem Failure leads to Problem Failure leads to Problem Failure leads to Problem Failure leads to Problem Failure leads to Problem Failure leads to Problem Deductions: Copyright Protection: No part of these notes may be reproduced in any form electronic or printed without the written consent of B Wyze Solutions Inc 23

24 Problem Solving & Critical Thinking Workshop Activity 5: Cause & Effect Process and Chronological Relationships The following report is produced for all Incident and Changes for the last 2 months for all Configuration Items identified above: Record Occurrences Last Time Component Description Incident 2 1 day ago CRM Desktop CRM Desktop application failure to save Incident 3 2 weeks ago Desktop PC Desktop network cable disconnected, desk-side reconnect Maintenance 2 2 weeks ago Server PC Server shut down and restart standard Sunday maintenance window Incident 5 3 weeks ago Desktop PC Desktop PC performance degradation, close applications or reboot required CRM Desktop CRM Desktop application performance degradation, close applications and reboot required Incident 3 3 weeks ago Incident 1 1 month ago Server PC Server PC disk space alarm, historic data archived Change 1 1 month ago CRM Server Application Release Bug Fix Updates Maintenance 4 1 month ago Server PC Server disk clean up and tuning standard Sunday maintenance window Change 1 2 months ago CRM Desktop Update Desktop CRM Application Drivers Change 1 2 months ago CRM Desktop Application Release functionality Update to Client Billing module Deductions: Copyright Protection: No part of these notes may be reproduced in any form electronic or printed without the written consent of B Wyze Solutions Inc 24

25 Research Information: Problem Solving Workshop Contact the CRM Application Development and Support Group The Application Support group indicates the bug fix was released in response to an undersized data size field limit in the new Client Billing module. Since the bug fix there have been no further related Incidents. The Application Support group believes it must be a User data entry error as the Application has been fully tested. The Application further explains that when data is updated by a User, it is held in memory on the User s PC. When the User saves this data, each record is written to the record on the Server PC Application database. There are no errors recorded in the database error log. Copyright Protection: No part of these notes may be reproduced in any form electronic or printed without the written consent of B Wyze Solutions Inc 25

26 Ishikawa Diagram (Cause and Effect Diagram) Kaoru Ishikawa was a pioneer of quality management processes in the 1960s. His Ishikawa diagram, or fishbone diagram, is a founding tool for modern management and is considered one of the seven basic tools of quality control. The tool forces a problem solver to think creatively across several different categories, the most common of which are shown. Additional value is gained when causal factors are considered in relation to other categories of the fishbone diagram. Causes and Effects The tool, or diagram, is divided into two problem components: Effect The Problem effect can be thought of as part of Problem Finding. The symptoms need to be identified and the problem properly defined. Causes Problem Causes can be thought of as part of Problem Shaping. The detail work of the Ishikawa diagram is performed here, where all possible causes are identified and broken down to sub-causes. Copyright Protection: No part of these notes may be reproduced in any form electronic or printed without the written consent of B Wyze Solutions Inc 26

27 Problem Causes and Categories The numbers and types of main causal bones that are included in the Ishikawa diagram can be quite varied. These can be considered as causal categories that can then be broken down further. Some of the more common categories are: The Basic Ishikawa Factors People (individuals, teams, skills and experience) Process (process and procedure) Technology (hardware and software) Materials (raw materials, consumables, and/or information) Environment (social culture and physical building) Management (decision makers) The 4 Ss (used in the service industry) Surroundings Suppliers Systems Skills Considerations when using the Ishikawa Technique The following considerations are useful when using the Ishikawa diagram technique: The cause-and-effect diagram reveals key relationships between variables and possible causes that are useful in a complex systems environment. This method is both a bottom-up and top-down approach that can benefit from integration with other problem solving methods, such as deriving all possible causes through brainstorming and then investigating using the 5 Whys technique. A general rule to this diagram is to break down each possible cause to the secondary level of granularity (Primary Cause and Secondary Cause) A key to successfully using Ishikawa diagrams is to rate each condition on the fishbone as Necessary or Sufficient. This will help guide the root cause investigation and the assessment of causal combinations that may have occurred. o A necessary condition is one where the event can never occur without it o A sufficient condition is one where the event must occur with it Copyright Protection: No part of these notes may be reproduced in any form electronic or printed without the written consent of B Wyze Solutions Inc 27

28 Activity 6: Ishikawa Diagram - Creative Leads PEOPLE MANAGEMENT PROCESS ENVIRONMENT EQUIPMENT MATERIALS Copyright Protection: No part of these notes may be reproduced in any form electronic or printed without the written consent of B Wyze Solutions Inc 28

29 Research Information: Problem Solving Workshop Contact the Marketing Manager and Sales Reps The Marketing Manager insists the CRM application is not used for any new business activity; nor is it used by any other department as only the Marketing Manager can approve new users. As the software is developed internally, there are no user limits. Also, no environmental factors that have changed (i.e.: no office moves, etc). The Marketing Manager further state that the CRM Application is better managed and used since starting a new quality review initiative where the Manager reviews and updates poorly documented or incomplete Client records. It s critical to the Marketing Manager that these records are accurate as they drive the weekly Sales reports to upper management. This quality effort has been in place now for more than a month. Sales Reps insist that they are following Marketing procedures when updating records. There are no shortcuts taken. Only the Sale Reps have access to these records, and Sales Reps do not have the admin rights to share and update other Sales Reps client records. Sales Reps do not think updates happen at the same time. Client calls are too random. However, there are often multiple records left open for periods of time when multiple Client calls are taken in succession. This practice is the norm, and Sales Reps will complete the Client Updates when call volumes lower and time permits. Copyright Protection: No part of these notes may be reproduced in any form electronic or printed without the written consent of B Wyze Solutions Inc 29

30 Section 6: Getting to the True Root Cause Hypothesis Testing and Validation A hypothesis is a proposed Cause for the Problem and is then tested. There are many ways to test and validate, but these tend to fall into two categories: a controlled experiment or an operational observation. Within the context of IT Service Management (ITSM), a range of testing options should be proposed and each option assessed with a Risk Assessment to manage both time pressures and risk of worsening the Problem. Involvement of affected stakeholders should always be considered and involved when making Testing choices. The following table is a simple and structured way to assess testing options: Testing Option Components Involved Stakeholders Experiment or Observation Risk Assessment Change Analysis (Comparative Analysis) Change Analysis is a form of testing and validation through comparative analysis. This technique is based on comparing all factors contributing to the situation where a problem does not exist, to the situation where the problem does exist. This technique is a top-down approach requiring full knowledge of the correct functional parameters (or design constraints) of a system, as well as the skills and experience of the problem solver. This technique may involve re-enactment and observation, where a technician changes one factor at a time in an attempt to re-create the Problem. The Root Cause of the Problem may be found through a process of elimination of validating key operating parameters. Copyright Protection: No part of these notes may be reproduced in any form electronic or printed without the written consent of B Wyze Solutions Inc 30

31 Activity 7: Hypothesis Testing and Validation You have made a decision that the three previous deductions are most likely and that the only way to confirm your hypothesis is that you test these user scenarios. Complete the following table using previous case study material and propose your choice testing scenario (assume there is no separate testing environment): Testing Option Components Involved Stakeholders Experiment / Observation Risk Assessment Using Sunday maintenance window, apply test cases to operational data. Revert data to original values. Using Sunday maintenance window, create test records and apply test cases to test data. Remove test records. Engage the Marketing Manager and staff to participate in a limited update test of a single client update being shared. Involve participation and cooperation from the Marketing staff. On next occurrence, list all open client records that failed to save and check with staff and management to determine if the record was being shared. CRM data CRM App CRM Server CRM data CRM App CRM Server CRM data CRM App CRM data CRM App What is/are your recommended choices? Marketing Mgr Sales Reps App group Server Group Problem Mgr Marketing Mgr Sales Reps App group Server Group Problem Mgr Marketing Mgr Sales Reps Problem Mgr Marketing Mgr Sales Reps Problem Mgr Copyright Protection: No part of these notes may be reproduced in any form electronic or printed without the written consent of B Wyze Solutions Inc 31

32 Testing Results: Testing has been arranged within the production CRM Application over the maintenance weekend for the creation of 5 test clients and 2 Desktop PCs. The following is observed: When a single client record is updated but not saved, and then the same record is opened and updated in a second PC, the second PC fails to save the record and appears to be frozen. The resolution is to refresh the Client record or close the CRM Application. o This same test for multiple records opened and just one record updated will also fail to save the block of records. o This appears to have duplicated the Problem and identified the Cause. However, it is prudent to test the two other possible contributing scenarios for their effect. On creating batch record updates and saving, there were no application errors. This same scenario was repeated for opening the records in multiple desktop PCs, but only making updates and saving on one specific PC. No save errors resulted. o This same test was duplicated with large PDF file attachments to records. Again, no file save errors resulted. Copyright Protection: No part of these notes may be reproduced in any form electronic or printed without the written consent of B Wyze Solutions Inc 32

33 The 5 Whys The 5 Whys is a method for perseverance in Problem Shaping to find the true root cause, and not to stop at a superficial symptoms and assumptions. This basic cause and effect method is simple in concept: to investigate the possible cause of a problem, ask the question why did this happen in five successions. This technique was originally used within Toyota Motor Corporation and is a critical component of problem solving now also used within Kaizen, lean manufacturing, and Six Sigma. The 5 Whys is a questions-asking method that pushes the problem solver to dig deeper. By no means is the method limited to 5 degrees of detail, but it has been generally accepted that 5 five iterations of asking why is generally sufficient to get to a root cause. Use the 5 Whys technique for simple problems or for use in conjunction with other problem solving techniques. This technique depends on a technician s knowledge and experience that allows them to ask the right why questions. This may result in some causes being overlooked in a complex situation, as well as allowing that varying experience will result in different cause theories/explanations. Success with this method can be increased when combined with the following factors: Verify each why question before proceeding to the next to avoid straying off-track. Focus on making the final why a process questions. Based on the assumption that most problems occur due in some way to a lack of adherence to, failure within, or lack of existence of a process. Copyright Protection: No part of these notes may be reproduced in any form electronic or printed without the written consent of B Wyze Solutions Inc 33

34 Activity 8: But are we Done? The 5 Why s Using the 5 Whys Technique, determine if there is a further root cause: 1. Why did the save error occur? Due to a record concurrency lock 2. Why did the concurrency issue get into production? 3. Why? 4. Why? 5. Why? Root Cause Conclusions: The true Root Cause Copyright Protection: No part of these notes may be reproduced in any form electronic or printed without the written consent of B Wyze Solutions Inc 34

35 Section 6: Problem Options and Solutions The final step of the Problem Solving process is to determine an effective range of solution options to address the root cause(s) of the Problem. Each option should be assessed from a business justified perspective, should consider an assessment of risk, and should be implemented according to an appropriate project plan (based on the complexity and scope of the solution). This step is made more effective when the Problem Solver also considers effective workarounds, or temporary techniques, to deal with the Problem should it recur. The following table is a simplified approach to listing and assessing solution options: Solution Option Business Justification Risk Assessment Priority Approved Copyright Protection: No part of these notes may be reproduced in any form electronic or printed without the written consent of B Wyze Solutions Inc 35

36 Activity 9: Problem Options and Solutions The following table outlines the Problem Options and Solutions. Rank the priority of the options presented, their business justification, and risk assessment. Solution Options Priority (1-4) Business Justified Cost (High/Med/Low) Risk Assessment (High/Med/Low) Approved Standards for considering and implement Application concurrency Procedure ensuring Developed / Purchased Applications meet concurrency standards Testing of all current Applications for meeting concurrency standards CRM Application reprogrammed according to new concurrency standards Temporary Workaround A: Communicate the Problem Cause to Marketing and ensure care is taken NOT to open shared records. In addition, encourage Marketing Staff to save frequently. Temporary Workaround B: The CRM Application is reprogrammed with a warning message to the User should a shared record be opened. What is/are your recommended choices? Copyright Protection: No part of these notes may be reproduced in any form electronic or printed without the written consent of B Wyze Solutions Inc 36