Cause Mapping®: Effective Root Cause Analysis
Step 2: Analysis (Cause Map)
To analyze means to break down into parts. The root cause analysis step in the Cause-Mapping methodology breaks down any issue into specific cause-and-effect relationships.
Here, we start with the overall goals impacted by the incident, as defined in Step 1. The Cause Map locates these goals vertically on the left. These goals give the Cause Map a starting point. It helps concentrate on what is most important to the organization; if an element does not relate to the organization’s overall goals, it has no place on the cause map. It also prevents the Cause Map from having too narrow a focus, bringing up different elements that may have been missed otherwise.
From these goals, the map builds left to right through asking the “why” questions. Note that arrows point left simply because the Cause Map builds backwards through time, starting with the ultimate incident and working back through the causes. We identify causes by asking “what was required to produce this effect” and continuing to move to the right.
The dictionary defines “cause” as the producer of an effect. This, while seemingly simple, is fundamental. It applies to all cause-and-effect relationships. Many see cause-and-effect principle as linear, with a single cause leading to a single effect. Although it does build linearly, it also builds vertically. Like logic trees and fault trees, Cause Maps visually capture this relationship. But unlike other methods, a Cause Map focuses specifically on the principle of cause-and-effect and builds from the overall goals that were affected.
Supporting each cause is the collected evidence, added directly to the Cause Map in an “evidence box.” As the true driving force behind any investigation, evidence proves, validates or substantiates that something did or did not occur. If a cause lacks evidence, uncertainty arises. And so, if a cause cannot be substantiated with proof, then a question mark is placed on the cause, in the evidence box, or both, showing that information is missing and further action is required.
A Cause Map, as the word map implies, is a visual tool for collecting and organizing causes for a given incident. The visual approach can be extremely effective when facilitating a group of people, allowing everyone to see what information has been collected. People involved in the investigation can point to the Cause Map and talk about specific parts, rather than pointing fingers at each other. In investigations where personalities may create arguments or defensiveness, a Cause Map can significantly improve the way the group communicates when analyzing an issue.
A Cause Map can be viewed a various levels. A given investigation can be viewed at a very high level with only a few causes identified, or the same incident may warrant additional investigation needing more detail. The high-level and detailed Cause Maps do not contradict each other; they simple depict issues viewed at different levels. This ability to “zoom in” and “zoom out” on a given investigation also can help improve the way people communicate when analyzing a problem. Many miscommunications in investigations happen because people seem to think they are contradicting each other. In reality, they are not actually saying contradictory things, just different things. Note the subtlety here: Two contradictory answers imply one answer is incorrect; different answers are just that, different answers, and it is possible for two people to give two different—yet still truthful and correct—answers to the same question. And the Cause Map can recognize both of them.
By providing a visual tool that recognize all possible causes—and anchored by an organization’s overall goals—a Cause Map can significantly improve the way people communicate when working through a problem.