The results of your latest root cause analysis are in. The root cause -- the analyst didn't understand the method. Recommended action - retrain the analyst on the method. Does this sound familiar?
When the results of a root cause investigation points to an individual, you are not really getting to the true root cause. Instead of improving the system, you are laying blame on an individual.
When the root cause is pointing to someone who is not doing the job properly we have a bit more work to do. Why is that analyst doing the testing when they don't fully understand the method, are skipping steps or using the equipment improperly? Here are some areas to consider in your investigation:
- Is the problem in how we train our analysts?
- Is it the process we use for checking proficiency?
- Is supervision the issue?
- Why wasn't the issue caught before there was a problem with test results?
- If all of the above is good, how about our hiring processes and our performance assessment processes?
Remember that a root cause analysis is intended to look at your system and the investigation should provide you with the information you need to improve your system. It should prevent an issue from happening again. In the case of the analyst not understanding the test method, the root cause should reveal the weakness in our quality system and reduce the chance of having other analysts conducting tests when they don't understand the procedure.
Train your staff on how to conduct Root Cause Analysis. For information on the training CALA provides on Root Cause Analysis, click here.