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Root Cause Analysis: Parsing Complex Challenges in Academic Libraries
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Sobel, Karen. “Root Cause Analysis: Parsing Complex Challenges in Academic Libraries.” Accepted for publication by the Journal of Academic Librarianship 16 May 2017. https://doi.org/10.1016/j.acalib.2017.05.003
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Sobel, Karen
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Root cause analysis (RCA) has been used in government, technology, health care, and other sectors for over 60 years. It assists organizations in identifying the original, most authentic cause or causes of an extremely complex problem. Depending on the nature of the problem, the organization can then make plans to mitigate the problem or avoid similar situations in the future. Scholarly library literature does not provide examples of any libraries using RCA. This article aims to present RCA as a strong and relevant addition to academic libraries’ array of problem-solving tools. It outlines three models of RCA so that libraries may choose one that suits their needs. As academic libraries almost invariably exist in complex universes of stakeholders, funding, politics, and other factors, I believe that RCA is a natural fit for approaching their challenges efficiently.
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ROOT CAUSE ANALYSIS: PARSING COMPLEX CHALLENGES IN ACADEMIC LIBRARIES 1 Author: Karen Sobel, Associate Professor, University of Colorado Denver This is a pre print manuscript copy of an article published in the Journal of Academic Librarianship Citation: Academic Accepted for publication by the Journal of Academic Librarianship 16 May 2017 https://doi.org/10.1016/j.acalib.2017.05.003 Root Cause Analysis: Parsing Complex Challenges in Academic Libraries Abstract Root cause analysis (RCA) has been used in government, technology, health care, and other sectors for over 60 years It assists organizations in identifying the original, most authentic cause or causes of an extremely complex problem. Depending on the nature of the problem, the organization can then make plans to mitigate the problem or avoid similar situations in the fu ture. Scholarly library literature does not provide examples of any libraries using RCA This article aims to present RCA as a strong and array of problem solving tools It outlines three models of RCA so that libra ries may choose one that suits their needs As academic libraries almost invariably exist in complex universes of stakeholders, funding, politics, and other factors, I believe that RCA is a natural fit for approaching their challenges efficiently Keywords: root cause analysis, problem solving, academic libraries Six Sigma, efficiency

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ROOT CAUSE ANALYSIS: PARSING COMPLEX CHALLENGES IN ACADEMIC LIBRARIES 2 Introduction Root cause analysis (RCA) has helped numerous government agencies, high tech businesses, health care organizations, and, to a lesser extent, educationa l organizations trace the origins of highly complex problems for over 60 years. is to trace a problem back to its initial causes so that organizations in charge of the process can prevent the event from happening again or mitigate a current sit uation. Organizations typically use RCA to investigate multifaceted problems that occur in environments that involve multiple stakeholders, a variety of needs, countless possible failure points, pressure to succeed for the greater good, and, frequently, complicated financial situations. I wrote that description while reading about prevention of nuclear accidents ( Nelson & Van Scyoc, 2009) ; h owever, all of those descriptors characterize academic libraries just as closely. How can academ ic libraries benefit from adopting processes of RCA ? Simply put, administrators and others making major decisions at academic libraries constantly face problems, financial and otherwise, that stem from incredibly complicated intertwined factors. It is al l too easy to begin to see problems as insurmountable, or to automatically focus on the most common challenges (flat budgets, wavering enrollment statistics, non optimal staffing levels, and so on), rather than taking a detailed, critical look at other potential causes. In addition, most library administrators have progressed through a particular sub specialty of librarianship, for example, moving up the ranks from serving as a science librarian to administering a natura l sciences branch library to system (likely with several additional steps in between). Thus, it is natural that an individual library administrator, no matter how experienced and broadly trained, will have stronger a nd weaker areas in terms of expertise. The processes of RCA help adminis trators from all backgrounds parse problems back to their sources, without necessarily having to have deep knowledge of a given area. Tasks related to deeper analysis, mitigation, or creating solutions can then be distributed to colleagues with applicable expertise.

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ROOT CAUSE ANALYSIS: PARSING COMPLEX CHALLENGES IN ACADEMIC LIBRARIES 3 I strongly librarians and administrators to examine large scale problems of unknown ca use, as well as highly complex problems for which tentative causes have been identified, makes it an important addition to the suite of problem solving tools available to academic libraries. High tech, business, government, and other sectors have spent ove r 50 years developing and perfecting models of RCA with different focuses such as examining finances, tracing complicated customer service issues, or integrating large amounts of data into the investigation process. The types of problems that these RCA mod els trace all align with various challenges that academic libraries face. I believe that academic libraries can and should take advantage of these tools, particularly in order to probe the large, systemic problems that often go uninvestigated or unsolved e ven in libraries that tend to solve smaller problems efficiently. This article aims to present several major models of RCA. It also intends to help librarians and administrators match their own complex workplace challenges with models that can help to pa rse and better understand these problems. The article does not provide sufficient detail to perform complete RCA on a problem. Rather, it will help readers to select a method and guide them to a source or sources that do detail that method in full. Problems that Merit RCA RCA can be used to attempt to trace the original cause (s) of any problem. It is generally used in situations in which prevent a negative situation f rom happening again, or that finding original causes would help to improve the current situation. After reading numerous sources on RCA I identified a number of other characteristics of problems for which administrators frequently use RCA Note that none of these conditions are mandatory for its application.

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ROOT CAUSE ANALYSIS: PARSING COMPLEX CHALLENGES IN ACADEMIC LIBRARIES 4 Complicated causation : In all cases using RCA, the question of why an event or p roblem ha s occurred is difficult to determine using surface Multiple factions involved : Numerous organizations, departments, or individuals with disparate roles and responsibilities are involved with a problem or event. Administrators aim to trace and map factors in the problem or event to specific factions. Exper tise : RCA worthy problems typically require expertise from a variety of individuals or organizations to solve them. Administrators may or may not know who the constituents may be when they begin analysis. However, they sense from the outset that the prob lem is beyond any one reach. Financial concerns : Problems approached using RCA often involve amounts of money that are significant to the organization. Competing interests : In some professions that often employ RCA, competing interests between two or more groups often with different levels of sociopolitical or personal power, are routinely a factor They are frequently locked in a cyclical struggle that leads to an ongoing situation or exacerbates an acute problem (Thwink.org, 2014) Selecting a Model of RCA When planning to use RCA to analyze a specific situation, it is important to find a model that aligns with the situation to be studied When a librarian or administrator uses RCA for the first time, it is ea sy to feel intimidated by two things: (a) the sheer number of models of RCA that are readily available, and (b) the amount of theory and background information covered by books and journals on RCA. One further complicating factor is the fact that some organizations tout the value of proprietary forms of RCA. Proprietary forms may require administration by a trained expert, often for a significant fee. They may not make usable information available for f ree. Of course, investing in an expert with an o utside viewpoint may be worth the time and money. This article, however, will focus on three sources of RCA

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ROOT CAUSE ANALYSIS: PARSING COMPLEX CHALLENGES IN ACADEMIC LIBRARIES 5 that librarians and administrators can access for free (online or through library resources), experiment with, and act upon with in house colleagu e s. United States Department of Energy Root Cause Analysis Guidance Document An unassuming 69 page book available freely online, the United States Department of Energy Root Cause Analysis Guidance Document (1992) is one of the sources that other works on RCA refer back to again and again. The Department of Energy has used RCA heavily for decades and has created clear instructions to help its employees use RCA procedures The streng th of this model is that it appr oaches the problem quickly and focuses on assessing the problem and creating solutions, without a great a mount of extraneous analysis or necessary generation of models and graphics. Situations covered by the Root Cause Analysis Guidance Document typically relate to a single U.S. Department of Energy, 1992, pp. 1 2). However, users very easily modify practices to All problems approached with this mod el will work through the same five basic stages: (a) data collection, ( b ) assessment, ( c ) corrective actions, ( d ) inform, and ( e ) follow up ( U.S. Department of Energy, 1992, pp. 1 2). Prospective users choose from among six potential analysis methods by co mparing several aspects of their situation plus desired outcomes with criteria provided in the document ( U. S. Department of Energy, 1992, pp. 1 1 13 14 ) Forms of analysis covered in the document include: (a) events and causal factor analysis, ( b ) change analysis, ( c ) barrier analysis, ( d ) Management Oversight and Risk Tree (MORT), ( e ) human performance evaluation, and ( f ) Kepner Tregoe problem solving and decision making. The Kepner used when a comprehensive analysis is needed for all p hases of (United States Department of Energy, 1992, p. 14) PROACT RCA Work Process One of the leading figures in the field of RCA is Latino, & L atino 2011, p. xv). Latino, founder of the Reliability Engineering

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ROOT CAUSE ANALYSIS: PARSING COMPLEX CHALLENGES IN ACADEMIC LIBRARIES 6 Department at Allied Chemical Corporation ( which is now Honeywell), developed his form of RCA, later branded as PROACT, through decades of meticulous monitoring of mechanical systems a n d human teams that manufactured nylon (Latino et al. 2011, pp. xv xvi). His children Robert, Kenneth, and Mark Latino have continued his work and now run Reliability Center, Inc. a company which provides consulting, training, and software on RCA. Exp erts on PROACT (Latino et al., 2011, p. 1). PROACT is typically used for problems that arise among an entire team of people who perform a process together; it is not intended to work on problems that can be easily tracked to a single team member (Latino et al., 2011, p. 20). It utilizes the conce (KPI) basically, identifying what types of data indicate a current problem and would change if the status of the problem were improving (Latino et al., 2011, p. 4). Through the PRO ACT model, users identify KPI to follow, create an improvement process, and then track the KPI over time (Latino et al., 2011, pp. 8 9 ). Through an example and discussion, the Latino brothers explain that u sers may not know which indicators are the most important in a realistic, highly complex problem within an organization (Latino et al., 2011, p. 1). PROACT will help them to sort this out for purposes of prioritization and targeting. The PROACT model offers multiple benefits. It is highly flexible in terms of stru cture and procedures. It is decidedly data driven. It guides users to identify, collect, and analyze data relevant to problems in their organizations; to map out and potentially alter workflow processes used in their organization s (Latino et al., 2011, p 11) ; and to acknowledge, examine, and learn from problems identified during RCA. Latino, Latino, and Latino put significant emphasis on reasons why individuals and organizations fail to acknowledge and glean lessons from their failures (Latino et al., 2011, pp. 24 25). PROACT trains users to do just this. Organizations that use the PROACT model will end up with useful byproducts of flowcharts, tables of data and additional dat a visualizations that can be used to

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ROOT CAUSE ANALYSIS: PARSING COMPLEX CHALLENGES IN ACADEMIC LIBRARIES 7 communicate chan ges to employees and, in a higher education setting, to university administrators. Software as well as consultants are available for organizations that wish to invest in PROACT in terms of materials (La tino et al., 2011, p. 20; Reliability Center, Inc., 2017). l. A balanced scorecard helps users follow perspectives, objectives, and measures (Latino et al., 2011, p. 7). Since some educ ational organizations already employ balanced scorecards this may help these processes to The main downside to PROACT is that its flexibility and thoroughness make it considerably more complicated than, for example, the Department of Energy model in details, visualizations, and the options for tracking and analyzing data. Users can teach themselves to perform PROACT process (2011) However, users may find that the process works more smoothly with either the proprietary software or professional guidance, both of which cost money. RCA Model Environmental activism think tank Th w ink.org offers a complex mo del that helps users see their problems in terms of destructive cycles, outdated practices that need to be re envisioned, and more. Users of the Thwink.org model will come away with a strong understanding of smaller components of a large problem and leverage points to attack these problems. It is considerably more conceptual than the other two models, though users come away with tangible solutions, much like the PROACT and Department of Energy models Thwin users create an Ishikawa diagram (al so ). The main problem The Ishikawa diagram has six standard primary categories of equipmen t, process, people, materials, environment, and management (Thwink.org, n.d., p. 8) Thwink.org notes that these primary categories

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ROOT CAUSE ANALYSIS: PARSING COMPLEX CHALLENGES IN ACADEMIC LIBRARIES 8 are so common in quality control situations that they will help to analyze most issues (Thwink.org, n.d., p. 8). However, users are welcome to relabel, add, or remove primary categories of causes (Searching After creating the primary all the things they can think of that are going wrong within each primary category of cause They are encouraged to use their own experiences with the problem for inspiration. Figure 1: Ishikawa diagram The second stage becomes more conceptual. Users consider and write about three common change resistance, proper coupling, and m odel drift (Thwink.org, n.d., p. 9) These sub problems represent problems w ith paradigm and practice that ultimately affect the problem at hand in tangible ways. In short, the sub problems are as follows:

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ROOT CAUSE ANALYSIS: PARSING COMPLEX CHALLENGES IN ACADEMIC LIBRARIES 9 Change resistance : Why do individuals, organizations, or society tend to resist the change that you advocate? Proper coupling : What cycles or processes are fighting against each other and thus adding to the problem? Model drift : Is your organization trying to u se solutions that are outdated? The third stage involves breaking down secondary causes from the first stage into the categories of change resistance, proper coupling, and model drift. Users fit the secondary causes into a template and begin to look for leverage points, potential solutions, and convergence of solutions (Thwink.org, n.d., p. 10). T hwink notes that the third stage should take approximately 80% of the total time (Thwink.org, n.d., p. 10). After completing all of the stages, users should come up with a list of relatively small, actionable changes that they can m ake, which will add up to measurable change on the larger issue. Users who are interested in additional discussion, existing models and Goodstein ( 1994 pp. 46 48 ). model leads to great conceptual understanding of the environment surrounding a problem, as well as to breaking the problem into manageable parts. It is freely available online, along with model implementations. It does not, however, necessarily guide th e user to guide data or to look at problems in their organizations as directly as the other models, although the user may certainly choose candid scrutiny. in an article on change resistance in environmental sustainability scenarios (Harich, 2010) Literature Review Practitioners and analysts who are deeply involved in RCA devote little commentary to the history of RCA. Thus, this paper will focus on aspects of RCA deemed more re levant in the literature, and more practical for the academic library user.

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ROOT CAUSE ANALYSIS: PARSING COMPLEX CHALLENGES IN ACADEMIC LIBRARIES 10 Additional Guides for Using RCA Various RCA specialists have published books on the topic, a number of which are devoted to the use of RCA within a specific professional context. A smaller number of volumes discuss RCA in nonspecific contexts. In addition to the three sources for the models outlined in this document, I recommend Duke His book provides practica l guidance on conducting RCA in a committee or other group setting. It also provides models of data visualization tools that users might wish to employ. provides a workbook style collection of charts, data visualizati on tools, and processes for use during RCA. It can be used on its own or as a complement to other RCA guides. RCA users who intend to perform their own statistical analyses may benefit from consulting Stamatis ( 2012). Six Sigma Six Sigma certified pro fessionals sometimes incorporate RCA into their work. A great deal of scholarly literature discusses methods through which Six Sigma can apply RCA. Publications for Six Sigma professionals or advanced users of total quality management are rich sources of commentary on applications of RCA. The follo wing articles provide a very small sample of categories of Six Sigma RCA literature. Barsalou and Perkin (2015) describe a standard application of Six Sigma oriented RCA. This is a good starting point for tho se already acquainted with Six Sigma In an example of a more tailored approach Sarkar and Mukhopadhyay (2013) discuss ways in which Six Sigma or Lean Six Sigma can help users work with a lengthy list of potential causes identified through RCA and narrow it to a much shorte r list of probable causes Hopen and Rooney (2014) that may occur as groups conduct lengthy data analyses during RCA processes. They emphasize the importance of spending copious tim e on the analysis phase and highlight efficient tools for use during analysis Professional Fields that Employ RCA

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ROOT CAUSE ANALYSIS: PARSING COMPLEX CHALLENGES IN ACADEMIC LIBRARIES 11 Numerous professional fields have experimented with and employed RCA. The fields of medicine and allied healthcare, technology and information technology, and business stand out in terms of producing the greatest amount of scholarly and professional literature on the topic. Educators and social scientists have performed som e work with RCA. The following sources provide a small sample of sources from these fields. Some focus on the design of an RCA process, while others share results discovered using RCA. The literature review finishes with a discussion of library and info rmation science and RCA. Note that other fields have produced additional literature that does not appear in this paper. Medicine medical research, and allied h ealth care Professionals in medicine and closely related fields use RCA to probe the causes of (a) specific, ongoing failures and (b) single adverse events in medicine and reduce the risk to future patients. Sources provide both extremely detailed models with a broad view and focused examples of single or multi site applications. In an example of the former, Abujudeh and Bruno includes a guide users toward using or adapting this model. It also provides excellent examples of how RCA can foster greater safety Radiologists appear to have adopted RCA with enthusiasm; medical literature offers dozens of articles on RCA in radiology. In an example of the latter, Longo, Hewett, Ge, and Schubert compare two distinct applications of RCA as they compare hospital wide patient safety systems in employing RCA i n rural facilities. An unintende d strength of their work is that it demonstrates success of this model in environments that are not rich in assets ( Longo, Hewett, Ge, & Schubert, 2007). Behavioral health specialists have begun to adopt RCA as well. Mills, Huber, Watts, and Bagian (2011) have used RCA on a large scale to work toward identifying root causes of suicidal thoughts and behaviors among vet erans of the Iraq and Afghanistan conflicts. Additional rich examples are available through medical databases. Technology and i nformation technology

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ROOT CAUSE ANALYSIS: PARSING COMPLEX CHALLENGES IN ACADEMIC LIBRARIES 12 Technology and related fields have embraced and developed RCA. Interested users will find that these fields provide some of the ric hest and most varied applications and models. At the time this article was written, the database ScienceDirect offered 1,258 papers on root cause analysis, published since 2014. Silva, Cuhna, and Vieira provi de an interesting, highly detailed exploration of problems encountered while creating software that aids in space exploration ( 2016). Both the fields of softwa re design and space exploration use RCA heavily. Readers who are particularly interested in spa ce science applications of RCA can explore the website of the NASA Root Cause Analysis Tool Software ( https://nsc.nasa.gov/RCAT) Root Cause Analysis for Complex Situations in Large provides an excellent example of RCA being used in a highly complicated environment (Schaaf, Wilke, Mikkola, Bunn, Hela, Wache, & Grivas, 2015) Readers may find its ex ploration of potential realms of cause to be surprisingly applicable to libraries. Tech firms businesses, and scholars of innovation use RCA to pinpoint specific aspects of user behaviors relating to technology. For example, Weidlich, Polyvyanyy, Desa i, Mendling, and Weske (2011) have used RCA as a tool to help companies follow the procedures they have developed for their own operations. Companies can use RCA to help identify problems with the compliance process and decide whether to update procedures Urhuogo, Williams, and Hart (2013) examined technology related behaviors on the individual level. They used RCA with large population groups to explore how ogies in their workplaces Similar processes could easily be adapted for higher education, including academic libraries. Business Various fields within business use RCA widely. Much like health practitioners businesspeople and business faculty are continually developing innovative models of RCA and discussing the results of real applications of RCA. Business literature contains examples from a wide range of specialty areas. A tiny sample of articles provides a window into the highly complex uses of RCA in business. Ami

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ROOT CAUSE ANALYSIS: PARSING COMPLEX CHALLENGES IN ACADEMIC LIBRARIES 13 work probes challenges related to the connections between human thought processes and business processes. Insights gathered through the research will ultimately lead to more effective business strategies (Ayad, 2010). Ali, Wilson, and Mohammed d to help businesses find weak points in processes that are conducted within a department, as well as weak connections between departments (2014). Jenson, Leith, Doyle, West, and Miles work with structural and f unctional theories to explore points of failure of innovations in business (2016). Education Literature for and by educators includes a small but steady number of materials documenting usage of RCA. 2006 book integrates simple RCA along with other techniques for da ta gathering and analysis Lu, Tsai, and Hong (2008) propose equipping new educators with skills in using RCA In this case, RCA would primarily be used to analyze and discuss teaching observations, although teachers might find a ddition al productive uses for it Educator Roni L. Silverstein works to educate school administrators and teachers about RCA through her webinars (Silverstein, 2014; Regional Education Laboratory Mid Atlantic, 2014). Library and information science : A gap in the field A search of two major library and information science databases (Library, Information Science and Technology Abstracts; Library Literature & Information Science) brings up only three articles on RCA published from 1990 through 2017. The third article demonstrates earlier thinking on processes in technological fields ( Summer, 1990). I believe that RCA holds tremendous potential for investigating problems and creating change in the world of library and information science. These fields include notoriously complex webs of stakeholders, funding, and politics. RCA can he lp identify leverage points and lead to real change. Scenario: RCA in a Real Academic Library

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ROOT CAUSE ANALYSIS: PARSING COMPLEX CHALLENGES IN ACADEMIC LIBRARIES 14 The following simple fictional example demonstrates RCA at use in an academic library. In addition to seeing the process in action, I intend for readers to note that pieces that colleagues with relevant expertise can work on. Like many problems faced by academic libraries, this one contains both elements that seem mystifyingly large and difficult to trace, and elements that are complet ely mundane within our setting. I have purposefully kept the problem simple in hopes that academic librarians from many areas of practice will be able to follow the storyline That culture, challenges, and institutional goals. Librarians familiar with similar scenario s will likely come up with additional potential details and steps that could be taken all of which could be approached through the process as well. While this single scenario represents only a tiny fraction of the available options for RCA, I hope that it will impress readers with several strengths: (a) its thorough investigation of a complex situation, successfully identifying root causes and courses of action, (b) its incorporation of quantitative and qualitative analysis, as well as data visualizations, and (c) the creation of a plan with concrete steps, documentation, and action steps for involved individuals. The Problem One afternoon in May th e director of the He says that numerous professors have ap proached him with concerns that their international students have are not incorporating sufficient evidence from academic materials into their assignments. The faculty members generally note that international students are having more difficulty than classmates who speak English as a first language. The director o f public service s promises to investigate. She is particularly concerned and interested most recent strategic plan includes a number of goals related to improving graduation and employment rates for international and other ESL stu dents. Here is a meaningful place for the library to

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ROOT CAUSE ANALYSIS: PARSING COMPLEX CHALLENGES IN ACADEMIC LIBRARIES 1 5 as well. She knows that finding root causes will not be easy in this situation. Countless social, cultural, linguistic, educational and other factors affect performance. She knows that the factors that she uncovers through her investigation may reach beyond the boundaries of the library. Since the problem has unknown origins and may require help from multiple departments, she decides to use RCA to investigate and search for solutions. RCA will help her to identify root causes that the library can affect, a nd perhaps some that it cannot. Her goal will be to identify places where the li brary can make changes, and to communicate additional findings to the support office for ESL students. She ( U.S. Department of Energy 1992) since she appreciates its straightforward approach. Phase I : Data Collection The director of public services begins by making a plan to collect information that will help her understand the situation, as well as the environment in which it exists ( U.S. Department of Energy 1992, p. 7). To do this, she has a mee ting with the instruction librarian in her department who performs the most instruction and one on one research consultations for international students. She asks the instruction librarian to help brainstorm potential causes, based on her experience and h er frequent conversations with international students and their professors. They also come up with a list of questions that they would like to ask some of the faculty members, regarding the nature of the problems their students are experiencing, as well a s the assignments and the courses in which they have occurred. The director of public services works with the director of the international student support office to identify a few faculty members to interview. The instruction librarian sets up appointme nts to interview each of these faculty members the following week. Phase II: Assessment

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ROOT CAUSE ANALYSIS: PARSING COMPLEX CHALLENGES IN ACADEMIC LIBRARIES 16 The instruction librarian examines the six options for assessment in the Root Cause Analysis Guidance Document U.S. situation so that she may discern patterns or commonalities t hat have led to the problem. To do this, she carries out the interviews with faculty (which are technically part of Phase I). She also performs her own assessments, gathering assignments that have been associated with the problem, as well as samples of completed assignments by both international students who are non native En glish speakers and native English speakers. The instruction librarian works with several colleagues to hold a focus group with international as their b ackgrounds relating to information literacy. After finishing the interviews, she spends several weeks working with the interview transcripts and sample assignments. She works to gather data and examples, and to connect these with the problems that both t he faculty and the students menti oned. The report focuses on two root causes : (a) the international students reported more concern with other aspects of the writing process and put less energy into research, and (b) the international students reported les s previous information literacy instruction than the majority of their peers had. While data gathered by reading student papers does not directly support these findings, the instruction librarian sees congruence. She writes a report to share with the dire ctor of public services. Based on information gathered through these conversations, the instruction librarian breaks out several categories of recurring challenges that the ESL students face She takes inspiration from the 1 B 9) The completed worksheets will help her to communicate these major findings to her colleagues, as well as to other campus constituents. She will fill out the chart using response options listed in the key. Readers

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ROOT CAUSE ANALYSIS: PARSING COMPLEX CHALLENGES IN ACADEMIC LIBRARIES 17 should note that the chart shown in Figure 2 represents just one of the many tools for organizing information exemplified in the Root Ca use Analysis Guidance Document Flipping through the Document as well as through articles on RCA, will provide many more options for tools. Figure 2 shows an analysis of one of several complicating factors that the instruction librarian uncovered in conve rsations with ESL students and their professors: Figure 2: Worksheet outlining one complication identified through the research; format inspired by the Root Cause Analysis Guidance Document. After creating several work sheets to chart major categories of causes that students and professors had identified, the instruction librarian makes a The Root Cause Analysis Guidance Document provides clear step by step guidance for making these charts (U.S Department of Energy, 1992, pp. D 2), followed by a highly detailed example (pp. D 3 D 5). Basically,

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ROOT CAUSE ANALYSIS: PARSING COMPLEX CHALLENGES IN ACADEMIC LIBRARIES 18 the chart outlines the problem, with several factors that the user has identified. The user identifies a probable cause for each of these factors. He or she then lists at least two pieces of evidence supporting each of the probable causes. The user then repeats the process several times for each of the chains of factors and causes. He or she stops analyzing each of the chains after arriving at a caus e that it is possible to take action on The user may choose to finish a chain by listing potential solutions. Figure 3 shows a simplified cause and effect chart. In reality, the instruction librarian would likely begin with more than two factors.

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ROOT CAUSE ANALYSIS: PARSING COMPLEX CHALLENGES IN ACADEMIC LIBRARIES 19 Figure 3: Cause and effect chart, inspired by the Root Cause Analysis Guidance Document

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ROOT CAUSE ANALYSIS: PARSING COMPLEX CHALLENGES IN ACADEMIC LIBRARIES 20 Ideally, potential solutions at the ends of chains begin to converge. y may help to mitigate multiple effects Actions that appear several times in an RCA cause and effect chart often indicate the most efficient actions to take to solve or lesson a problem. On a chart with more chains of factors, a user might notice that, f or example, several chains ended with a potential solution of offering semesterly library instruction sessions in several additional languages, and inviting students who speak these as a first language to attend Upon seeing such convergence, the user migh t decide that this was an efficient potential course of action. Phase III: Corrective Actions After reading the report, the director of public services takes several steps. She looks through the cause and effect chart and notices that several courses of action have appeared multiple times. She highlights these as likely next steps. She then reviews the library literature to make sure that these align with best practices for working with ESL students which they do. Based on this information, she decides t o suggest future actions of (a) conducting an information literacy session as part of the orientation for new international students that takes place each semester, and (b) sending an email to each international student every fall semester, introducing the m to the liaison librarian for their department (presented as She meets with the director of the international student support office to discuss a potential pilot program involving these two steps in the coming fall semester. The t wo agree to take these steps, to assess improvement, and collaborate on adjusting offerings in coming semesters. Phase IV: Inform Various involved parties decide upon and distribute responsibility for informing different stakeholders. Their multi step pl an is as follows. (a) The director of public services and the director of the international student support center work together to inform various interested parties of their

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ROOT CAUSE ANALYSIS: PARSING COMPLEX CHALLENGES IN ACADEMIC LIBRARIES 21 plan. They first share findings and plans with the faculty members and stude nts who had taken part in focus groups and interviews. (b) director to create posters and texts of emails that will inform and continue to remind international They create a distribution plan as well. (c) The instruction librarian works with colleagues who will take part in both group instruction and research mentoring to create best practices and outlines for lesson plans which individual instructors may adapt as necessary She makes plans to train them herself. (Offering training, rather than expecting collaborators to plan their own courses of action, is a common component of many models of RCA related change.) (d) The instruction librarian works with the faculty who will run the international student orientation to integrate plans for providing instruction and introducing the concept of research mentors. It is important to note that RCA supports clear but sele ctive communication of findings often including narratives, executive summaries, and data visualizations Individuals and groups are kept informed of the findings most relevant to them. RCA processes do not advocate over communication, for example, cont inual updates to departments, when reports a t selected points would suffice Phase V: Follow Up The director of public services creates a plan for year. (a) She plans to survey a sample of faculty members, an d to request samples of student work from librarian to plan to conduct focus groups similar to those conducted this year. (c) To keep track of the pict discuss whether the library can begin to work with data that the university regularly gathers to track performance of all international students. (d) The director of public services and the director of the international student support center plan to informally keep in touch throughout the year to keep each

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ROOT CAUSE ANALYSIS: PARSING COMPLEX CHALLENGES IN ACADEMIC LIBRARIES 22 other informed of concerns, perceptions, and suggestions. All parties involved look forward to roll ing out the program in the coming fall semester. Another Example Readers who would like to peruse another easy to follow example may wish to read Rooney and 2004 article. The piece analyzes causes of a fictional house fire caused by inatt entive cooking of fried chicken. The piece offers a clear, relatable, and somewhat entertaining scenario that exemplifies one RCA process. Conclusions RCA holds potential for assisting libraries in solving problems set in a complex environment, which frequently go on and on without marked resolution It allows users to identify discrete, manageable components o f a larger problem. As demonstrated in the scenario, those employing RCA can distribute actions among col leagues with relevant expertise. Assessment and careful examination play into the picture throughout. Libraries can choose from among the models of RCA to choose those that get to the root of a problem relatively quickly, those that focus on revision of existing processes, those that generate global or conceptual understandings of the problem, and more. For those using (or considering) RCA for the first time, I suggest flipping through resources that model different processes of RCA perhaps at several points throughout the RCA process Models of RCA can be picked through and Future Work I encourage colleagues to experiment with RCA, and to analyze and document their experiences. Existing models of RCA hold great potential for libraries, which can be shown by data and concrete examples. The academic library community can also work together to identify existing models that

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ROOT CAUSE ANALYSIS: PARSING COMPLEX CHALLENGES IN ACADEMIC LIBRARIES 23 perform best for libraries, and to deve specific needs and processes.

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ROOT CAUSE ANALYSIS: PARSING COMPLEX CHALLENGES IN ACADEMIC LIBRARIES 24 References Abujudeh, H. H., & Bruno, M. A (Eds.). (2012). Quality and safety in radiology New York: Oxford University Press. Ali, N. N. K., Wilson, P., & Mohammad, I. Y. (2014). Symptoms v ersus p roblems f ramework (svp): An i nnovative r oot c ause a nalysis t ool. International Journal of Organizational Innovation 7 66 76. Andersen, B., & Fagerhaug, T. (2006). Root cause analysis: simplified tools and techniques (2 nd ed). Milwaukee, WI : ASQ Quality Press. Ayad, A. (2010). Critical thinking and business process improvement. Journal of Management Development 29 (6), 556 564. https://doi.org/10.1108/02621711011046521 Barsalou, M., & Pe rkin, R. (2015). A s tructured, y et f lexible, a pproach. Six Sigma Forum 14 (4), 22 25. Harich, J. (2010). Change resistance as the crux of the environmental sustainability problem. System Dynamics Review 26 (1), 35 72. https://doi.org/10.1002/sdr.431 Hopen, D., & Rooney, J. J. (2014). Getting to the Root of the Problem. Six Sigma Forum 14 (1), 27 29. Jenson, I., Leith, P., Doyle, R., West, J., & Miles, M. P. (2016). The root cause of innovation system problems: Formative measures and causal configurations. Journal of Business Research 69 (11), 5292 5298. https://doi.org/10.1016/j.jbusres.2016.04.127 Latino, R. J., Latino, K. C., & Latino, M. A. (2011). Root cause analysis: I mproving performance for bottom line results ( 4 th ed ). Boca Raton, FL: CRC Press. Lon go, D. R., Hewett, J. E., Ge, B., & Schubert, S. (2007). Rural h ospital p atient s afety s ystems i mplementation in t wo s tates. Journal of Rural Health 23 (3), 189 197. Lu, C., Tsai, C., & Hong, J. (2008). Use root cause analysis teaching strategy to train pr imary pre service science teachers. U.S. China Education Review 5 Retrieved from https://eric.ed.gov/?id=ED503886

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ROOT CAUSE ANALYSIS: PARSING COMPLEX CHALLENGES IN ACADEMIC LIBRARIES 25 Mills, P. D., Huber, S. J., Watts, B. V., & Bagian, J. P. (2011). Systemic v ulnerabilities to s uicide among v eterans from the Iraq and Afgha nistan c onflicts: Review of c ase r eports from a n ational Veterans Affairs d atabase. Suicide and Life Threatening Behavior 41 (1), 21 32. NASA Root Cause Analysis Tool (RCAT) [Computer Software ] (n.d.). Retrieved March 5, 2017 from https://nsc.nasa.gov/RCAT/ Nelson, W. R., & Van Scyoc, K. (2009). Focus on mission s uccess: Process safety for the a tychiphobist. Journal of Loss Prevention in the Process Industries 22 (6), 764 768. https://doi.org/10.1016/j.jlp.2009.07.014 Rooney, J. J., & Vanden Heuvel, L. N. (2004). Root cause analysis for beginners. Quality Progress 45 53. Okes, D. (2009). Root cause analysis: T he core of problem solving and corrective action Milwaukee, Wis: ASQ Quality Press. Pretzer, W. S., Rogers, G. E., & Bush, J (2007). A m odel t echnology e ducator: Thomas A. Edison. The Technology Teacher 67 (1), 27 31. Rasmussen, J., Pejtersen, A. M., & Goodstein, L. P. (1994). Cognitive systems engineering New York: Wiley. Bulletin of the American Society for Information Science, 16 (5), 14. Regional Educational Laboratory Mid Atlantic. (2014). Root c ause a nalysis w ebinar: Q&A with Roni Silverstein. REL Mid Atlantic Webi nar Retrieved from https://eric.ed.gov/?id=ED560799 Root Cause Analysis Training, PROACT RCA Software, Reliability Consulting. (n.d.). Retrieved March 15, 2017 from http://www.reliability.com/ Sarkar, S. A. Ranjan Mukhopadhyay, A., & Ghosh, S. K. (2013). Root cause analysis, lean Six Sigma and test of hypothesis. The TQM Journal 25 (2), 170 185. https://doi.org/10.1108/17542731311299609

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ROOT CAUSE ANALYSIS: PARSING COMPLEX CHALLENGES IN ACADEMIC LIBRARIES 26 Schaaf, M., Wilke, G., Mikkola, T., Bunn, E., Hela, I., Wache, H., & Grivas, S. G. (2015). Towards a t imely r oot c ause a nalysis for c omplex s ituations in l arge s cale t elecommunications n etworks. Procedia Computer Science 60 160 169. https://doi.org/10.10 16/j.procs.2015.08.115 Silva, N., Cunha, J. C., & Vieira, M. (2017). A field study on root cause analysis of defects in space software. Reliability Engineering & System Safety 158 213 229. https://doi.org/10.1016/j.ress.2016.08.016 Silverstein, R. (2014) Data inquiry for school improvement: Root cause a nalysis. Q&A with Roni Silverstein. REL Mid Atlantic Webinar Regional Educational Laboratory Mid Atlantic. Retrieved from https://eric.ed.gov/?id=ED560600 Stamatis, D. H. (2012). Essential statistical concepts for the quality professional Boca Raton, FL: Taylor & Francis. Thwink.org. (2014). Dueling loops. Retrieved from http://www.thwink.org/sustain/glossary/DuelingLoops.htm Thwink.org. (n.d.). Root cause analysis: How it works at Thwink.org Clarkston, GA: Thwink.org. Retrieved from http://thwink.org/sustain/publications/booklets/04_RCA_At_Thwink/RCA_At_Thwink_Pages.pdf Tienken, C. H. (2012). Poverty m atters. AASA Journal of Scholarship and Practice 9 (1), 3 7. Urhuogo, I., Williams, V., & Har t, D. W. (2013). Root c ause a nalysis: Using t heory of c onstraints a pplication to m easure the i mpact of e mployee d emographics on the a doption of information technology e quipment. Journal of Information & Knowledge Management 12 (1), 1350004 1. https://doi.o rg/10.1142/S0219649213500044 U.S. Department of Energy Office of Nuclear Energy. (1992). Root c ause a nalysis g uidance d ocument (DOE NE STD 1004 92). Retrieved from https://energy.gov/sites/prod/files/2013/07/f2/nst1004.pdf

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ROOT CAUSE ANALYSIS: PARSING COMPLEX CHALLENGES IN ACADEMIC LIBRARIES 27 Weidlich, M., Polyvyanyy, A., Desai, N., Mendling, J., & Weske, M. (2011). Process compliance analysis based on behavioural profiles. Information Systems 36 (7), 1009 1025. https://doi.org/10.1016/ j.is.2011.04.002