Title page
CIP data
Contents
List of Figures and Tables
Preface to the Second Edition
Preface to the First Edition
Chapter 1_Getting Better Root Cause Analysis
The Problem
The Impact
Approaches to Root Cause Analysis
Existing Problem-Solving Models
A Proposed Model
Chapter 2_Multiple Causes and Types of Action
Initial Problem Response
The Diagnosis
Actions to Prevent Future Problems
The Need for Filters
Chapter 3_Step 1: Define the Problem
Selecting the Right Problem
Scoping the Problem Appropriately
The Problem Statement
Chapter 4_Step 2: Understand the Process Setting Process BoundariesFlowcharting the Process
Why Process is So Important
Additional Values of the Flowchart
Chapter 5_Step 3: Identify Possible Causes
Using the Flowchart for Causes
Using a Logic Tree for Causes
Using Brainstorming and the Cause-and-Effect Diagram for Causes
Using Barrier Analysis for Causes
Using Change Analysis for Causes
Eliminating Possible Causes
Sources for Possible Causes
Chapter 6_Step 4: Collect the Data
A Basic Concept
Types of Data
Using Existing Versus New Data
Where to Collect Data
Special Tests
Sample Size and Time Frame Data Collection Tools for Both Low- and High-Frequency ProblemsAdditional Tools for High-Frequency Problems
Enhancing Data Collection Value
Organizing the Data Collection Process
Chapter 7_Step 5: Analyze the Data
Tools for Low-Frequency Data
Additional Tools for High-Frequency Data
Questioning the Data
Data Analyses Summaries
Analyzing Variation
Cautions on Data Analysis
Where to Go Next?
Can't Find the Cause?
Chapter 8_Identify and Select Solutions
Step 6: Identify Possible Solutions
Step 7: Select Solution(s) to Be Implemented Chapter 9_Implement, Evaluate, and InstitutionalizeStep 8: Implement the Solution(s)
Step 9: Evaluate the Effect(s)
Step 10: Institutionalize the Change
Chapter 10_Organizational Issues
Cognitive Biases
Emotional Barriers
Resistance to Change
Organizational Culture
Project Ownership
Coaching/Facilitation Skills
Other Issues
Chapter 11_Human Error and Incident Analysis
Human Error
Incident Analysis
Chapter 12_Improving Corrective Action
Critical Thinking
Buddhism
Stoic Philosophy
Summary of Root Cause Analysis
Appendix A_Example Projects
A Need for Focus How Would They Know?How Proficient is That?
Getting the Shaft Back
Got it in the Bag!
Appendix B_Root Cause Analysis Process Guides
Generic Process Thinking
SIPOC Analysis Form
Data Collection and Analysis Tools
Do It2 Root Cause Analysis Guide
Do It2 Problem-Solving Worksheet
Checklist for Reviewing the Corrective Action Process
Expanded List of Seven Ms
Forms for Tracking Causes and Solutions
Appendix C_Enhancing the Interview
Basic Interview Problems and Process
Types of Interviews and Questions
Leveraging How Memory Works
The Importance of Time and Reflection