James Shore

in 99 words

When mistakes occur, blame your process, not people. Root-cause analysis helps. What allowed the mistake to happen? What will prevent them in the future? Assume people will continue to make mistakes and build fault-tolerance into your improvements.

One approach: ask "why" five times. Use it for every problem you encounter, from the trivial to the significant. You can apply some solutions yourself. Some will require team discussion, and others need coordination with the larger organization.

When mistakes become rare, avoid over-applying root-cause analysis. Balance the risk of error against the cost of more process overhead.

as haiku

a slug eats dessert...
making lattice from lettuce,
she thins the surplus

Commentary

In the Privacy of Your Own Thoughts

Inside This Section

• Root-Cause Analysis
• How to Find the Root Cause
• How to Fix the Root Cause
• When Not to Fix the Root Cause
• Questions
  • Who should participate in root-cause analysis?
  • When should we conduct root-cause analysis?
  • We know what our problems are. Why do we need to bother with root-cause analysis?
  • How do we avoid blaming individuals?
• Results
• Contraindications
• Alternatives