Contact Information

Jennifer L. Metzler, Director


Creighton Business Institute
Heider College of Business
Creighton University
2500 California Plaza
Omaha, NE 68178

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Root Cause Analysis and Mistake Proofing

If your team is having challenges making permanent improvements in your operation and problems seem to recur, this course will help you break through to eliminate problems and energize, standardize and sustain efforts for robust processes where ordinary people achieve extraordinary results.


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Executives, Managers, Supervisors, Process Experts


In this course, participants will learn the definitions of Root Cause Analysis and Mistake Proofing, and learn to leverage visual tools for rapid team collaboration and quick consensus building for sustaining improvements through interactive teamwork.


The concept is simple: identify the reason for the problem, and eliminate the reason to prevent a recurrence of the problem. Learn these techniques to prevent recurring issues within an organization.

This course is designed to provide participants information and practice in applying generally accepted Root Cause Tools and Mistake Proofing skills. When the workshop is over, learners should be able to:
  • Select tools that fit the situation,
  • effectively and ethically lead teams in the process,
  • create rationally determined solutions to mistake proof and eliminate problems with multiple inputs and variables.


Instructor-led course

We are continually addressing complex processes in business operations.  These create variation in output and use resources for control. As humans, we are quick to jump to solutions, but often just put Band-Aids on the problems and create redundancy and waste in our Value Streams.  By finding the root cause and implementing processes that help eliminate variation and problems, we can create operations where ordinary people can produce consistently extraordinary results. 

The purpose of this course is a systematic approach that
                  1) focuses on the causes of problems,
                  2) identifies direct causes
                  3) detect associated or contributing causes
                  4) uses date to determine the root cause
                  5) provides a questioning approach to test potential causes to truly find and eliminate them,
                  6) looks objectively at alternatives and options to decide on solutions,
                  7) use objective criteria to determine reasonable numbers for return on effort and,
                  8) builds trust & involvement for self-empowered teams to use a scientific approach to continuously improve work.  

The workshop is based upon the basic scientific method and tools and techniques that have a foundation in TQM, Lean (Toyota Production Systems- TPS) and Six Sigma.  This basic scientific method has its foundation in the idea of experimentation and the use of data.  The teaching methodology uses a series of exercises and hypothetical problems to highlight the foundational techniques and allows experimentation with a variety of tools. You will have the opportunity to try various tools to see where each addresses different work groups and types of situations.  You will have the opportunity to discuss the differing contexts of mistake proofing, including the human behaviors; as well as experiment with ideas and methods for mistake proofing.  The workshop will help you refine your skills and prepare you to achieve top results to improve work performance in operations.

Finding and Defining Problems

  • Where and why
  • Impact of defects and variation in operations
  • Processes - variety of inputs and conditions
  • Problem solving compared to Root Cause Analysis (RCA)
  • Eliminating fixes that fail
  • Goal is to stop errors before they become defects

Teams and Root Cause Analysis (RCA)

  • The power of teams
  • Teams and visual communication for speed of understanding and consensus
  • Team Roles, Rules and Processes
  • Deciding how to work as a team BEFORE the work begins
  • Trust
  • Being Trustworthy

RCA Process: Visuals and Communication

  • Breaking down the problem
  • Investigation Timeline
  • A3 tool to define and describe problem
  • Tools that support the process - overview

Tools and Testing : Plan, Do, Check, Act - (PDCA)

  • Use of data to understand the current situation
  • Defining the gap and measuring it
  • Data displays for teams – fast and at the work place
  • Dipstick approach where data is absent
  • Isolate the causes or groups of causes to select alternatives

Mistake Proofing Basics

  • Use data to decide
  • Question every detail 
  • Eliminate
  • Combine
  • Rearrange
  • Simplify & (“Safety-fy”)
  • Develop new method & test results
  • Implement and if it works, make it the new standard
  • Objective criteria
  • Trust through authentic communication

Designing Processes for Consistency

  • Selecting level of mistake proofing appropriate for the return on effort for the situation
  • Examples of mistake proofing
  • Case study of application using a team approach

Alternatives and Testing

  • Creativity mining- the THREE alternative rules
  • Decision criteria and rating created before team decides (decide how to decide)
  • Visual tools for the process
  • Summarizing the countermeasures and making the decision transparent with visual communication to the target area
  • Pugh method

Implementations (PDCA) Plan, Do, Check, Act

  • Action lists – plan for implementation
  • Short term planning – within the control of the team
  • Gantt Chart for visual planning of implementation
  • Review of A3 as a tool the process


  • Don’t jump to conclusions (fixes that fail)
  • Use data and let facts speak for themself
  • Objective evaluation of alternatives
  • Take ACTION!

Scheduled Classes

No classes currently scheduled.