Problem Solving (Esp. During a Code Brown)

Problem Consciousness

  • Identity the problem that is the priority

Clarify the Problem

  • FishbonesWhat 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”

Investigate Causes

  • 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

Follow Up

  • 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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