| |
| |
| Foreword | |
| |
| |
| Acknowledgments | |
| |
| |
| Introduction | |
| |
| |
| |
| Root Cause Basics | |
| |
| |
| Why Root Cause Analysis? | |
| |
| |
| What is "Root Cause"? | |
| |
| |
| Modalities of Root Cause Analysis | |
| |
| |
| Examples of RCA Modalities | |
| |
| |
| An Example of a "Positive Reactive" Modality | |
| |
| |
| An Example of a "Positive Proactive" Modality | |
| |
| |
| An Example of "Negative Proactive" Modality | |
| |
| |
| An Example of a "Negative Reactive" Modality | |
| |
| |
| Levels of Root Cause | |
| |
| |
| The Longitudinal Stream | |
| |
| |
| When is a Cause a Root Cause? | |
| |
| |
| Summary | |
| |
| |
| |
| Key Indicators of Student Success | |
| |
| |
| The Importance of Key Indicators | |
| |
| |
| The Verification Process | |
| |
| |
| Other School Indicators | |
| |
| |
| Using Key Indicators of Student Success | |
| |
| |
| Means vs. Ends--Student Results-Focused Goal Statements | |
| |
| |
| Some Data on Goal Statements | |
| |
| |
| Examples of Complete "Ends-Focused" Goal Statements | |
| |
| |
| Key Indicators and Goal Statements | |
| |
| |
| Terminology | |
| |
| |
| One Final Example: The Moose River CSD | |
| |
| |
| A Key Indicators Discovery Process--Half Day | |
| |
| |
| Facilitator's Comments | |
| |
| |
| Templates | |
| |
| |
| Summary | |
| |
| |
| |
| Root Cause Processes | |
| |
| |
| Observations and Suggested Remedies | |
| |
| |
| Root Cause Processes | |
| |
| |
| The Importance of Facilitation | |
| |
| |
| A Brief Word about Paretoing | |
| |
| |
| The Questioning Data Process | |
| |
| |
| Facilitator Guidelines | |
| |
| |
| |
| Applying the Questioning Data Process to Student Failure Rates | |
| |
| |
| Questions About the Students | |
| |
| |
| Questions About the School and Its Processes | |
| |
| |
| Questions About the School in Comparison to Itself Over Time and to Other Schools | |
| |
| |
| |
| Using the Questioning Data Process to Assess a System | |
| |
| |
| The Diagnostic Tree Process | |
| |
| |
| Facilitator Guidelines | |
| |
| |
| The Creative Root Cause Analysis Process | |
| |
| |
| The Five Whys | |
| |
| |
| Force Field Analysis | |
| |
| |
| Presenting Root Cause Products | |
| |
| |
| Templates | |
| |
| |
| Summary | |
| |
| |
| |
| Using Root Cause Analysis | |
| |
| |
| Where Does Root Cause Analysis Fit? | |
| |
| |
| Two Nonacademic Examples | |
| |
| |
| Two Academic Examples | |
| |
| |
| Systems Planning | |
| |
| |
| RCA and Required Planning Processes | |
| |
| |
| Summary | |
| |
| |
| |
| Considerations | |
| |
| |
| How to Use This Chapter | |
| |
| |
| The Issue of Leadership | |
| |
| |
| Central Leadership | |
| |
| |
| Distributed Leadership | |
| |
| |
| Contexts for RCA | |
| |
| |
| Change, Transformation, and RCA | |
| |
| |
| The Obvious and Not So Obvious | |
| |
| |
| A Timetable for Meetings | |
| |
| |
| Prior to the First Meeting | |
| |
| |
| First Meeting--2 Hours | |
| |
| |
| Between the First and Second Meeting--1 to 3 Weeks | |
| |
| |
| At the Second Meeting--2 Hours | |
| |
| |
| Between the Second and Third Meeting | |
| |
| |
| At the Third Meeting--2 Hours | |
| |
| |
| Between the Third and Fourth Meetings | |
| |
| |
| The Fourth Meeting--2 Hours | |
| |
| |
| Using Gantt Charts | |
| |
| |
| The Team Charter | |
| |
| |
| Why Write a Team Charter? | |
| |
| |
| Foundations--Systems, Data, and Variation | |
| |
| |
| Systems Thinking | |
| |
| |
| Russell Ackoff on Systems | |
| |
| |
| What Is Systems Thinking?--A Summary | |
| |
| |
| Data | |
| |
| |
| What Kinds of Data? | |
| |
| |
| Levels of Data | |
| |
| |
| Transforming Data | |
| |
| |
| Squishy Data Warning | |
| |
| |
| Variation | |
| |
| |
| Summary | |
| |
| |
| |
| Models and Stories | |
| |
| |
| A Multiple Measures Model | |
| |
| |
| Steps to Take | |
| |
| |
| An Assessment Analysis Model | |
| |
| |
| Models of Nontraditional Data Sets | |
| |
| |
| The National Transportation Safety Board--A Model | |
| |
| |
| Root Cause Stories | |
| |
| |
| |
| Proctor High School (Utica, N.Y.) Lifted from Probation | |
| |
| |
| |
| A First-Year Superintendent | |
| |
| |
| |
| The First-Year Principal | |
| |
| |
| |
| The Wreck of the Morning Dew--A Tragedy That Should Have Been Avoided | |
| |
| |
| |
| Follow-Up to the Wreck of the Morning Dew--A Tragedy That Should Have Been Avoided | |
| |
| |
| |
| What Has Happened to the Recruits? | |
| |
| |
| |
| Welcome Freshmen! | |
| |
| |
| |
| Firestone Recalls ATX and ATX II and Wilderness Tires--August 9, 2000 | |
| |
| |
| |
| Ammonia Leak Case Settled | |
| |
| |
| |
| Jury Asked to Determine Blame | |
| |
| |
| Root Cause Stories: A Review | |
| |
| |
| Summary | |
| |
| |
| |
| Resources | |
| |
| |
| Why These Resources Are Essential for Understanding Root Cause Analysis | |
| |
| |
| Glossary | |
| |
| |
| Bibliography | |
| |
| |
| Annotated Listing of Web Sites | |
| |
| |
| Sites of Interest | |
| |
| |
| The Regional Educational Laboratory Network | |
| |
| |
| State Departments of Education | |
| |
| |
| Data Warehousing: Examples and Resources | |