What tool do you use for systemic issues?


If a quality issue is caused by a single or multiple root causes, you use 5-Why, Fishbone, or a combination thereof to find the root cause and set up corrective actions.

What if there are multiple interrelated systemic/management root causes behind the issue? (for ex. insufficient training, machine maintenance, etc.)?
Issues, that, even if you correct the technical root cause, will create another failure soon.
How do you systematize and prioritize such systemic root causes?

The only similar thing that I could find was the Fig2 on page 6 of the article [1], but it doesn't tell me how you decide which cause is the most important one.

Is there any formal tool or a useful approach?

Thank you for any ideas.


[1] Jens Rasmussen 1997 - Risk Management in a Dynamic Society: A Modelling Problem (googleable)

Bev D

Heretical Statistician
Super Moderator
the theory of constraints provides the best thought process for mapping the systems effect on each other and identifying the constraint to go after first. HOWEVER, it is also necessary to put the whole story together: inter-related systemic causes live within a SYSTEM. a system of people. you must motivate the people (managers) to take action. COPQ is a great motivator but you must also provide real tangible solutions which will have their own resistance emotions. by the way the things that need improvement are the things that are in every QMS standard out there. not the "document everything six ways from sunday" but the true intent things: change assessment, V&V, statistical techniques (SPC, DoE), data analysis, corrective action, continual improvement, product realization, training...

YOU must do the hard work to put the story together and influence management. This isn't easy and simple logic won't do it. you must appeal to them on a visceral level...and sometimes get lucky with the right event that opens their eyes...

let me provide an example: several years ago, I had a director who thought SPC was a waste of time. He couldn't get his head around 'prevention' as being valuable. we had a series of very difficult quality excursions, expensive, time consuming, very negative for our customers. Through hands on involvement in the problem solving process and post crisis "lessons learned" sessions with the problem solving teams he came to see the value of supplier quality management, measurement systems analysis, specification development, FMEA and robust V&V. And becuase we had test data, I was able to show him that if we had SPC we could have seen all of the failures coming months before the crashes. He is now our biggest supporter of 'quality' processes. I had to make it personal for him, I had to get him directly involved (out of his office and into the GEMBA). I had to show him how the systems effect the output. not easy and it took two years.

so the tools in my experience are:
Lessons Learned
Make it personal; make it real; give him the path to success.

Mike S.

Happy to be Alive
Trusted Information Resource
One tool that might help is a hammer?..sometimes that it what it takes to get Management?s attention. (Only kidding. Mostly.)

IMO, there is no one tool or method that will always work best to solve common cause problems that usually need direct Management involvement to fix.

What exactly is it that you are trying to accomplish or prioritize? Some additional details may help you get a better answer.
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