"Team Tool Box" Module TPS Participant's Guide

Cause & Effect Essentials

Key Success Behaviors Clearly state the problem Ask Why? several times Look for recent changes as likely causes

Cause & Effect 2

Page 5

"Team Tool Box" Module TPS Participant's Guide

Steps at a Glance: Cause & Effect

Start
Agree on the problem statement Process Classification Use Dispersion Analysis or Process Classification Format? Dispersion Analysis

Define major process steps

Define major cause categories

Draw in the bones of the fish

Brainstorm causes or use data from Check Sheet

No

Reached the appropriate level of detail?

Yes Interpret fishbone

No

Agreement on root causes?

Yes

Act to correct the causes

Cause & Effect 3

Page 6

"Team Tool Box" Module TPS Participant's Guide

Step-by-Step Construction
Step 3a - Construct the Diagram: Write Problem Statement Causes
Bones (Major cause categories)

Effect
Late pizza deliveries on Fridays and Saturdays

Cause & Effect 4

Page 7

"Team Tool Box" Module TPS Participant's Guide

Step-by-Step Construction
Step 3b - Construct the Diagram: Draw Major Cause Categories
Machinery/ Equipment People Late pizza deliveries on Fridays and Saturdays Methods Materials

Illustration Note: In a Process Classification Type format, replace the major bone categories with: Order Taking, Preparation, Cooking, and Delivery.

Cause & Effect 5

Page 8

"Team Tool Box" Module TPS Participant's Guide

Step-by-Step Construction
Step 3c - Construct the Diagram: Place Causes in Correct Category
Machinery/ Equipment People
Unreliable cars Ovens too small Drivers get lost People dont show up

Late pizza deliveries on Fridays and Saturdays

Run out of ingredients

Poor handling of large orders

Poor dispatching

Methods

Materials
Cause & Effect 6
Page 9

"Team Tool Box" Module TPS Participant's Guide

Step-by-Step Construction
Step 3d - Construct the Diagram: Question Why? for Each Cause
Machinery/Equipment People
Unreliable cars No teamwork Low pay No training No money for repairs Don't know town People don't show up No capacity for Kids own junks Low pay peak periods High turnover High turnover Ovens too small Drivers get lost Poor High turnover Rushed training Poor use Late Poor training Get wrong information of space

Poor handling of large orders High turnover Lack of experience

Run out of ingredients High turnover Don't know Poor use town of space Inaccurate High turnover ordering Lack of Poor training dispatching

pizza deliveries on Fridays and Saturdays

Many new streets

Methods
Page 10

Materials

Cause & Effect 7

"Team Tool Box" Module TPS Participant's Guide

Cause & Effect Example

Bed Assignment Delay
Resources
Nursing shortage Unit clerk staffing Patient arrives too early Unit clerk training Transfer too early from another hospital Call housekeeping when clean

Timing

Wait for MD

Machine (PCIS)
System incorrect Not entered Functions not useful Not used Need more training No trust Not used pending discharge

Discharged patient did not leave Wait for ride Wait for lunch Wait for results Call housekeeping too late Call housekeeping too early Think it will take more time

Patient waits for bed

Double rooms Physician did not write order Medicine admit quota Many transfers Specialty beds Cardiac monitors Admitting unaware bed is clean Delayed entry Too busy Sandbag Physician misuse inpatient Inappropriate ER admittance Unit switch bed Reservation unaware Not entered Unit clerk unaware of discharge or transfer Shift change Not told On break

MD procedures

Hospital procedures

Communication
Cause & Effect 8

Information provided courtesy of Rush-Presbyterian-St. Lukes Medical Center

Page 11

"Team Tool Box" Module TPS Participant's Guide

Cause & Effect Example

Causes for Bent Pins (Plug-In Side)
People
004 prep VA No Fixture Shows pins on bench Carelessness Attitude Lack of attention On-the-job training

Methods
Mylar tape

Handling
Storage In/Out of Boxes
General handling T est Repair Backplane mounting Heavy/Awkward Mount to frame Gauging Storage Damaged connector Improper insertion Bent pins

Scribe slips Placement on edges Assembly difficulty Complex design Retainer Large part # insertion No/Don't Like Fixtures

Placement pins on bench

plug-in side

Not designed for manufacturing 2 backplanes Large part # Assembly difficulty

Casting ties/pliers No Stiffener Plates Bad panel alignment bare Lack of fixtures

Using wrong tools Bits Not enough Improper sizes New tools - long lead time Gauges Screws come loose Damaged connectors Test fixtures Storage

Designer not on site Not Enough Universal Designer can't react to problems

Design

Tools

Damaged connectors

Information provided courtesy of AT&T

Cause & Effect 9

Page 12

"Team Tool Box" Module TPS Participant's Guide

Cause & Effect Example

Process Classification Method
Concept Development
People dont think it through at onset People offer new input at last minute Market research reveals a previously unforeseen customer need Lack of skills Lack of training Inappropriate hiring No project management Delays in mailing process Address errors Authors delay in responding to editorial changes/ questions Lack of experience developing a concept Other projects get in the way Poor time management skills Budget constraints

Authoring
Poor communication between author and publisher Publisher has too many other projects Lack of two-way negotiation in the setting of the deadline Authors see that other authors are late too Work is on royalty, no up-front compensation Lack of training Lack of incentive to meet deadline High incidence of missed deadlines in book publishing process Last minute changes to text or graphics Forgot to send Author traveling and didnt get mail Authors receive text and graphics too late to review on time Hardware breakdown Poor fit of skills to demands of project Lack of training Staf f with more appropriate skills not available

Bad quarter Lack of direction fiscally from supervisor

Authors doing other things Original writing not submitted on time Short on staff Competing demands on desktop publishers time

Competing demands on desktop publishers time Poor planning

Editing

Copy Layout
Cause & Effect 10

Page 13