Root Cause AnalysisMI-CSI Representatives:

Lisa Asaro, Macomb ISDGail Hughey, WBRC Area Schools

Christine Todd, Monroe ISD

Learning Targets

1. Root cause analysis is part of the Assess Needs process for continuous improvement.

2. Root cause analysis is a process that teams use to understand the “why” of a specific performance need or asset, resulting in a challenge or an opportunity.

3. Stakeholders who use root cause analysis to understand assets can leverage those assets to address opportunities for growth.

4. Root cause analysis removes the tendency to address symptoms instead of the root cause.

The core of MICIP

The Michigan Integrated Continuous Improvement Process (MICIP) is a pathway for districts to improve student outcomes by assessing whole child needs to develop plans and coordinate funds.

The MICIP Three Big Ideas

The MICIP Mindset

Continuous Improvement

Systems

Whole Child

The Continuous Improvement Cycle operationalizes the Process.

OPERATIONALIZES

Continuous Improvement CycleUnderstanding where Root Cause Analysis Fits

The Assess Needs ProcessIdentify Area(s) of

Inquiry

Data Discovery

Initial Initiative Inventory

Gap Analysis

Data Story Summary

Conduct Root Cause Analysis

Identify Challenge

What are you looking at? What will you explore? How will you explore it?

What do you see? What does the data say?

What are you currently doing to address your data?

How well is that working? How far are you from where you need to be?

What do you know?

Why are things the way they are?

Where is there an opportunity to grow?

Identifying Need

PRESENT STATE

DESIRED STATE

THE GAP is the NEED

We have talked about a NEED…

now let’s talk about an ASSET.

ASSET NEED

OR

Root Cause Analysis

PerformanceSuccess

PerformanceChallenge

A Data Story Summarycan be a…

What is Root Cause Analysis all About?

The Definition

ROOT CAUSE ANALYSIS is used to better

understand the WHY of the identified need

or asset.

Test Hunches

Identify Hunches

Data Story

Summary

Identify Root Cause

Start Here End Here

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Domino’s Pizza

Let’s look at a situation Domino’s was experiencing which created a NEED to better

understand their lack of performance.

Data Story Summary StatementThere were 74

customer complaints about the pizzas delivered to their

homes.

Domino’s Pizza ComplaintsWhat does the data say?

• Received 74 complaints in a 2-month timespan

• Each complaint indicated the pizzas took more than the promised 30 minutes from order to door

• 70% of pizzas were cold and the toppings disheveled

• All pizzas were made in the usual timeframe and ready for delivery according to Domino’s standard

What are your hunches and why?

Domino’s Pizza What HUNCHES might you have about Why?

HunchesWhat is believed to be a possible cause based on personal

experience or knowledge.

Domino Stakeholder HunchesThe time allowed between leaving the store and delivering pizzas to

customers is inadequate.

Managers schedule too many customer deliveries on a single scheduled route, so we are unable to get pizzas to customers warm.

The delivery guidance section of our employee manual doesn’t have a method to collect input for ideas like new topping requests and dough type requested.

The employee enrollment program is weak. Training does not include follow-up and support does not exist, so driver turnover is high.

The people providing training to delivery employees are subpar.

The delivery employees are on their cell phones in-between deliveries and preoccupied with their personal lives.

Hunches are not the end point; instead, they are beginning of the diving deeper process.

TESTINGOne Domino Hunch

The time allowed between leaving the store and delivering pizzas to

customers is inadequate.

This is where Root Cause

Analysis begins.

Root Cause Analysis5 Whys Protocol

Three Types of Statements involved in Root Cause Analysis

Data Story Statement

HunchStatement

Root CauseStatement

Hundreds of customers contacted Domino’s customer service to

complain about dissatisfaction with their pizzas delivered to their

homes.

The time allowed between leaving the store and delivering pizzas to

customers is inadequate.

Currently road conditions include potholes and repair

workers on many road surfaces which caused

timely delays, tire blowouts and disheveled or cold pizzas to be delivered.

Educational ScenarioDelving for Root Cause

Data Summary Statement

50% of the teaching staff indicate that they do not plan with the

interventionist because there is no common planning time.

Cause And Effect Fishbone Diagram

Cause And Effect Fishbone Diagram

Only a part-time

interventionist

Other important

tasks

Uninterrupted 90-minute

reading block

Interventionist is never available

Too many duties interfere

The interventionist is

only in the building part-time

Root Cause

Data Story Statement

No common planning time for the teachers and

the interventionist.

Learning Targets

1. Root cause analysis is part of the Assess Needs process for continuous improvement.

2. Root cause analysis is a process that teams use to understand the “why” of a specific performance need or asset, resulting in a challenge or an opportunity.

3. Stakeholders who use root cause analysis to understand assets can leverage those assets to address opportunities for growth.

4. Root cause analysis removes the tendency to address symptoms instead of the root cause.

A leader takes people where they want to go. A great leader takes

people where they don’t necessarily want to go,

but ought to be.

-Rosalyn Carter

 

 

1/15/20

Welcome to this presentation focused on root cause analysis.  This process is part of the Michigan Integrated Continuous Improvement Process also known as MICIP.  We will highlight where root cause analysis fits into MICIP, the purpose and benefits of root cause analysis and the key components of that process.  Presenting today are Lisa Asaro from Macomb ISD, Gail Hughey from West Branch Rose City Area Schools, and Christine Todd from Monroe ISD, also members of the Michigan Continuous Systems Improvement team, or MI‐CSI.

 

Let’s review our learning targets for this presentation.1. Root cause analysis is part of  the Assess Needs process for continuous 

improvement. 2. Root cause analysis is a process that teams use to understand the “why” of a 

specific performance need or asset, resulting in a challenge or an opportunity. 3. Stakeholders who use root cause analysis to understand assets can leverage those 

assets to address opportunities for growth. 4. Root cause analysis removes the tendency to address symptoms instead of the 

root cause.

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3/2/2020

Let’s begin with  briefly reviewing MICIP.  The Michigan Integrated Continuous Improvement Process, or MICIP, is a pathway for districts to improve student outcomes by assessing whole child needs to develop plans and coordinate funds. Needs, Plans and Funds are at the core of MICIP.

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3/2/2020

When we talk about MICIP, we are referring to a new systemic way of thinking that encompasses the three big ideas of mindset, process, and platform.

As part of the MICIP Mindset, • we will move from an annual to a continuous improvement plan, with smaller cycles of 

improvement within the larger cycle, • we will ensure that systems are in place to support actions, and • we will address and leverage the characteristics of the Whole Child.

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Next let’s look at the MICIP Process.  The Continuous Improvement Cycle operationalizes the process and is the way that we address Needs, Plans, and Funds.  The Cycle is contextualized in the district vision, mission and beliefs and is focused on the Whole Child. 

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When you enter the cycle for the first time, Assess Needs begins the cycle.  Root cause analysis is part of Assess Needs, and the challenge or opportunity statement resulting from root cause analysis is used to develop an Action Plan where you will select evidence or research‐based strategies to implement, monitor, and evaluate.

     

 

 

Let’s briefly look at the Assess Needs process to see how Root Cause Analysis fits; you’ll notice that each part of the process includes one or more key focus questions. • The process begins with the identification of an Area of Inquiry.  What will you explore and 

how will you explore it? • The Data Discovery process helps you identify and analyze the data related to your area of

inquiry. • The Initial Initiative Inventory identifies what you are currently doing to address your data. • The Gap Analysis process helps to analyze the gap between where you are and where you 

wish to be.  You can also identify the level of satisfaction with your progress. • Your Data Story Summary describes the WHAT related to your data. • Our focus today, ROOT CAUSE ANALYSIS, helps us understand the WHY of the data. • The Assess Needs Process concludes with a statement of the Identified Need or Challenge, 

sometimes also referred to as an Opportunity.

The term NEED refers to the gap between the present state (what is) and the desired state (what should be).

The NEED is neither the present nor the future state; it is the gap between them.

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 Another way to move through the Assess Needs process is to explore Assets to gain an understanding of strengths, or what is going well.  The goal of this approach is to learn about the behaviors, processes, procedures and systems that led to successful results so that they can be replicated in an area of need or challenge and/or sustained in the current area.

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 To summarize, root cause analysis begins with a Data Story Summary that results from analyzing the data.  The Data Story Summary identifies either an ASSET or a NEED you may want to better understand.  If the Data Story Summary identifies a Performance Success, this indicates an ASSET.  If the Data Story Summary identifies a Performance Challenge, this indicates a NEED.  You can use root cause analysis to better understand the WHY of either.

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So what happens during root cause analysis?

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 Remember that Root Cause Analysis is used to better understand the WHY of your need or asset. 

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Root Cause Analysis starts with the Data Story Summary. Then you identify your hunches for your Statement.   Hunches are your best guesses for the cause, or the why. Next you test your hunches. Finally, based on your testing, you identify the Root Cause

Let’s look at an illustration of the root cause process. 

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Here is an example from Domino’s Pizza.   As you can see, Domino’s received a number of customer complaints about their pizzas.  

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To help better understand this situation, Domino’s leadership looked at some additional data to better understand the customer dissatisfaction.  Complaints included the fact that the pizza took longer to arrive than the promised 30 minutes from order to delivery and when it did arrive, it frequently was cold or disheveled.  Furthermore, the problem seemed to be in the actual delivery since the preparation time met Domino’s standards.

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Based on this data, the leadership began to surface hunches, or possible causes, about why these might be happening.  If you were Domino’s staff, what might your hunches be?  What might be impacting the delivery time? Let’s see what the Domino’s staff had to say.

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 This slide illustrates the hunches identified by Domino’s staff for their challenge.  Take a few minutes to read through them to yourself.

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Domino’s could have used any of the hunches on the previous slide to begin identifying action steps; however, engaging in root cause analysis will help them to narrow their focus and better understand the why so that they identify appropriate action steps and not waste time or head in directions that might not address the real reason for the challenge.

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This protocol is called the Five Whys; it is one of the tools embedded in MICIP.  It begins with the hunch statement and keeps asking Why about the answer to the previous question.  The intent is that by asking this series of questions you will eventually get to the real reason, or why, of the challenge.  Let’s look at this example.

• The protocol begins with the statement describing the what; in this case, drivers were not able to deliver the pizza in a timely manner. So why was that?

• Since the guideline was established, circumstances had changed, and 30 minutes was no longer a sufficient amount of time.  Why was that?

• The guideline had been established in another location so that the guideline was not necessarily appropriate for all locations and was, therefore, outdated.  Why was that?

• The guideline was outdated because road situations had changed since it was first established.  Why was that?

• Road situations had changed since the population had grown and city had not fixed the potholes or made other road repairs, causing extended timelines and damage to delivery vehicles.

At this point Domino’s stopped the analysis process and decided to address the identified challenge. So, given the Domino’s scenario, what actions steps might address the root cause? Domino’s was obviously not in a position to repair the roads themselves.  They could have lobbied for the city to fix the roads but instead they revised their drivers’ routes to avoid bad road conditions and adjusted driver time allocations to reflect those conditions so customers would receive pizzas at their promised time and standard. This was something they 

could control. 

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So let’s summarize.  This slide helps us look at the 3 types of statements that play a role in Root Cause Analysis.  • Data Story Statements are those that summarize the issue and prompt root cause 

analysis. • Hunch Statements are our best guesses of what we believe to be the causation of a 

data story statement. • Root Cause statements indicate the primary cause, or the why of a data story, and lead 

to identifying the challenge or opportunity that can be addressed in the action plan.  It’s also important that the root cause statement be something on which you can have an impact.

Notice how the Domino’s example illustrates these three types of statements.

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Now let’s apply root cause to an educational scenario.

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This slide shares an educational Data Story Summary statement for one elementary school out of six in the district.   At this school, student achievement in reading showed students underperforming students in the rest of the elementary schools by 35 percentile points.  To address this issue, the school used Title I monies to hire a reading interventionist to assist teachers with their instructional planning for reading.  However, after 4 months from employing the reading interventionist, teachers responded to a survey indicating that 50% of them did not plan with the new interventionist because of no common planning time.  The administrator needed to understand why.

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In this scenario we will illustrate the Root Cause Analysis process using the Fishbone Diagram protocol, also one of the protocols in MICIP.   The Fishbone Diagram is a cause and effect protocol with a fishlike shape. This protocol helps organize the brainstorming process for stakeholders that ultimately leads to the root cause for a data story. 

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The staff chose to identify hunches for their Data Story Statement (CLICK) on the left‐hand side of the fish (CLICK).  As you can imagine everyone thought they knew why; however, using the Fishbone Diagram protocol helped narrow the focus and get to the root cause. Let’s take a look at each hunch they surfaced about possible contributing causes: (CLICK) one, only a part‐time interventionist; (CLICK) two, there are other important tasks; (CLICK) three, the uninterrupted 90 minute reading block; (CLICK) four, interventionist is never available; and (CLICK) five, too many duties interfere. After dialoguing as a team, the red circle (CLICK) illustrates the hunch this school identified as the primary root cause.  Knowing this, the school could then develop an action plan to address the lack of time with the interventionist.

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As we conclude, let’s review our learning targets for this session.  How well did we do? 1. Root cause analysis is part of  the Assess Needs process for continuous 

improvement. 2. Root cause analysis is a process that teams use to understand the “why” of a 

specific performance need or asset, resulting in a challenge or an opportunity. 3. Stakeholders who use root cause analysis to understand assets can leverage those 

assets to address opportunities for growth. 4. Root cause analysis removes the tendency to address symptoms instead of the 

root cause.

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And, finally, Rosalynn Carter helps us understand why great leaders who choose to better understand their assets or challenges are better poised to lead. .