- Identity the problem that is the priority
Clarify the Problem
- What should be happening?
- What is actually happening?
- Break the problem into individual problems if necessary
- If necessary user temporary measures to contain the abnormal occurrence until the root cause can be addressed.
- Locate the point of cause of the problem – Do not go into cause investigation (next step) until you find the point of cause.
- Grasp the tendency of the abnormal occurrence at the point of cause
- If necessary, “go and see”
- Identify and confirm the direct cause of the abnormal occurrence
- Conduct a 5-Why investigation to build a chain of cause/effect relationships to root cause
- Stop at the cause that must be addressed to prevent recurrence.
Develop and Test Countermeasure
- Take one specific action to address the root cause
- Try to change only one factor at a time, so you can see correlation
- Monitor and confirm results
- Standardize successful countermeasure
- Reflect. What did we learn during this problem-solving process?
- Share via retrospective/postmortem
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