## Thursday, October 25, 2012

### Henry Kniberg: Cause and Effect & A3 Problem Solving

Cause & Effect Diagrams: www.crisp.se/henrik.kniberg/cause-effect-diagrams.pdf

• Also Ishikawa Fishbone Diagram
• Benefits:
• Creates a common understanding - practical collaboration
• Focuses on most important problems first
• All problems are systemic - don't point fingers - the systems broken to allow this to happen
• Until you find the source of the glitch, most attempts to fix the problem will be
futile or even counterproductive.
• Used as the root cause analysis of A3 problem solving (more below)
• Basic process:
1. Select a problem – anything that’s bothering you - and write it down.
2. Trace “upwards” to figure out the business consequences, the “visible damage” that your problem is causing.
3. Trace “downwards” to find the root cause (or causes).
4. Identify and highlight vicious cycles (circular paths)
5. Iterate the above steps a few times to refine and clarify your diagram
6. Decide which root causes to address and how (i.e. which countermeasures to implement)
• Countermeasures are just experiments - prod the system to see how it will work
• If they don't work, analyse, update diagram, try other countermeasures
• Follow-up is important
• Failure == system trying to tell you something, better listen
• "Only real failure is failure to learn from failure"
• Ask "so what" until get to problem(s) that conflicts with goal
• Analyse consequences of problem:
• Quantify: How much revenue/customers lost?
• How do you know when you've solved problem?
• Ask "why" until dig down towards the root
• Vicious cycles: recurring problems usually involve re-inforcing loops
• Spotting them increases likelihood of solving
• Easy to miss important causes on first pass - go back and ask more "why"s
• Label root causes, propose countermeasures
• Root causes:
• only have arrows going out
• further whys don't feel meaningful
• issues is something we can address with significant positive effect
• It typically takes about 5 whys to get to the root
• In between problems and root causes are symptoms
• E.g. changing the incentive model (reward people for releasing on time or punish people for releasing late)
• How to create
• Alone: powerpoint/Visio
• Small group: whiteboard with post-its, everybody helps
• Large group (>8): split into groups, same problem, compare at end
• Maintaining: Worth keeping in Visio/Powerpoint, replicating on whiteboard for updates, synchronising with soft copy
• Pitfalls:
• Too complex
• Remove redundant boxes
• Focus depth first, write one or two most important problems, dig deeper
• Problem too broad? Limit to narrowly defined problem
• Split diagram into pieces (point to stack of "etc" boxes)
• Too simple
• Never perfect: "all models are wrong but some are useful"

A3 Template: http://www.crisp.se/gratis-material-och-guider/a3-template  PDF, Word
1. Identify the problem or need
2. Understand the current situation/state
3. Develop the goal statement – develop the target state
4. Perform root cause analysis
5. Brainstorm/determine countermeasures
6. Create a countermeasures implementation plan
7. Check results – confirm the effect
8. Update standard work
These steps follow the Deming Plant-Do-Check-Act (PDCA) cycle, with steps 1 through 5 being the ”Plan”, Step 6 being the “Do”, Step 7 being the “Check” and Step 8 being the “Act”.
On the A3 template, the steps are typically laid out like this: