ROOT CAUSE ANALYSIS 4Ps

-commonly used tool in root cause analysis that

helps to identify potential causes of a problem
ROOT CAUSE ANALYSIS  Policies
• Problem solving methodology  Procedures
• Identifying the underlying “root” cause of the  People
problem or event  Plant
Goals: • By analyzing each of the 4Ps, root cause analysis
 Prevention of the problem from recurring can identify potential issues that may contribute
 Address the underlying cause instead just treating to a problem, and determine which of the 4Ps
the symptoms needs to be addressed to prevent the problem
Steps: from recurring.
 Identify the problem or event • For example, in the case of a healthcare facility
 Gather data experiencing a high rate of medication errors, an
 Analyze the data RCA using the 4Ps might identify that the root
 Identify the root cause(s) cause of the problem is a policy that is unclear or
 Develop and implement corrective actions inconsistent, which falls under the "Policies"
 Monitor the effectiveness of the corrective category. The RCA could then recommend
actions changes to the policy, or the development of new
Thus RCA policies, to prevent similar errors in the future
 Identify and address the root cause of problems Ishikawa
 Reduce the likelihood of similar problems Ishikawa, also known as a fishbone diagram or
occurring in the future cause-and-effect diagram, is a tool commonly
 Improve overall performance and efficiency used in root cause analysis to identify the
potential causes of a problem.
4Ms Tool used in RCA - identify causes of the problem Kaoru Ishikawa: a Japanese quality control expert.
 Manpower – knowledge, skills, experience,
The Ishikawa Diagram
training, and workload
a visual representation of all the possible causes
 Machines – condition, maintenance, calibration,
of a problem, organized into categories that
and capacity
resemble the bones of a fish.
 Methods – procedures, instructions, policies, and
The "head" of the fish represents the problem or
standards used
effect, and the "bones" represent the categories
 Materials –inputs or raw materials
of causes. The categories of causes may vary
- Quality, quantity, availability, and
depending on the problem
suitability
By using the Ishikawa diagram, root cause analysis
can identify potential causes of a problem and
By analyzing each of the 4Ms, root cause analysis can:
determine which of these causes needs to be
a) identify potential issues that may contribute to a
addressed to prevent the problem from recurring.
problem, and
The Ishikawa diagram helps to organize and
b) determine which of the 4Ms needs to be addressed to
structure the analysis process, and encourages
prevent the problem from recurring.
collaboration and input from multiple
stakeholders.
For example, in the case of a manufacturing company
Categories of causes:
experiencing an increase in defective products, an RCA
 Manpower
using the 4Ms might identify that the root cause of the
 Machines
problem is a machine that is not functioning properly due
 Methods
to a lack of maintenance, which falls under the
 Materials
"Machines" category.
 Measurement
 Environment
FISHBONE DIAGRAM
 A fishbone diagram, also known as an Ishikawa 5Whys
diagram or cause-and-effect diagram, is a visual  The 5 Whys is a problem-solving technique used
tool used in problem-solving and root cause in management of engineering projects to identify
analysis. the root cause of a problem.
 It involves asking "why" questions repeatedly until
 The diagram is named after its creator, Dr. Kaoru the underlying cause of the problem is
Ishikawa, a Japanese quality control expert discovered. Here are the steps involved in the 5
 The fishbone diagram is designed to help identify Whys technique:
the root causes of a problem by breaking it down
into smaller, more manageable pieces. STEPS:
1.Identify the problem: Clearly state the problem you
 It resembles the shape of a fish skeleton, with the are trying to solve.
head representing the problem, and the bones
2.Ask "why?" five times: Ask "why?" five times to
representing the various factors or causes that
identify the root cause of the problem. For each
contribute to the problem.
answer, ask "why?" again until you get to the root
cause.

3.Verify the root cause: Once you have identified the

root cause, verify that it is the true cause of the
problem by testing or gathering additional
information.

4. Address the root cause: Develop and implement a

plan to address the root cause of the problem
 The fishbone diagram typically includes four main 5. Monitor progress: Monitor progress to ensure that
components: the problem has been effectively addressed.
1.The problem or effect being analyzed, which is
written at the head of the diagram.
2.The major categories of potential causes, which
are typically represented as the "bones" of the
fish. Common categories include "manpower,"
"method," "machine," "material,"
"measurement," and "environment."
3.The subcategories of potential causes, which are
represented as smaller "bones" branching off
from the main categories.
4.The potential causes themselves, which are
listed at the ends of the subcategory branches.

 By using the fishbone diagram, problem solvers

can identify potential causes of a problem and
determine which of these causes needs to be
addressed to prevent the problem from recurring.

 The fishbone diagram helps to organize and

structure the analysis process, and encourages
collaboration and input from multiple
stakeholders.