THE 5 WHY’S

A Root Cause Analysis Tool

Nicole Boutet, Primary Care Program Manager

Maine Medical Partners
What It Is

• A method of analyzing cause & effect

• A Lean/Six Sigma tool
• A way to identify the root cause of a problem

Need to know the root cause to fix the problem and

not just address the symptoms.
Quotation
“If you don’t ask the right questions, you don’t get the right
answers. A question asked in the right way often points to
its own answer. Asking questions is the ABC of diagnosis.
Only the inquiring mind solves problems”

Edward Hodnett
Earliest Known Version of 5 Whys
For want of a nail a shoe was lost,
for want of a shoe a horse was lost,
for want of a horse a rider was lost,
for want of a rider an army was lost,
for want of an army a battle was lost,
for want of a battle the war was lost,
for want of the war the kingdom was lost,
and all for the want of a little horseshoe nail.

Confesio Amantis, John Gower, 1390 AD.

Why Use the 5 Whys
• Can be used formally and informally to get to the “real”
problem.
• To investigate each identified primary cause of a problem
and identify if it is a symptom, an influencing factor, or root
cause.
• To continue the search for true root causes, even after
finding a possible cause.
• Allows an individual or group to quickly determine the root
cause of a problem.
• It is a simple and effective tool that works well in groups
and by an individual.
When to Use the 5 Whys
• When problems involve human factors or interactions
• During process improvement work
• In day-to-day business life
How to Complete the 5 Whys
1. Write down the problem you are trying to fix.
2. Learn about the current state; observations, interviews.
3. Ask the team to identify some causes of the problem.
4. For each cause ask the group “Why is this a cause of
the original problem?”
5. If the answer doesn’t provide the root cause of the
problem continue to ask Why until the group feels the
root cause has been identified.
 Example
In Washington, D.C., the inside of the Lincoln
Memorial was deteriorating faster than expected

Problem Why? Why? Why? Why? Why? Why? Why?

The inside of Because Because Because Because Because Because the Because
the Lincoln the there's a the birds the spiders the gnats monument we wish for
memorial is monument large come to are there in are lights come people to
deteriorating gets amount of eat the abundance attracted to on at dusk enjoy the
faster than washed bird spiders. to eat the the lights. and are on monument
expected. frequently. droppings. gnats. for a long when it's
time. dark.
Easier Than It Looks
• May not always be able to answer the “Why” question
without additional information, thought, investigation.
• Avoid classical answers such as “not enough time”, “not
enough money”, or “not enough manpower”.
• Beware of accepting too simple answers or “kneejerk”
answers to questions.
• Need to avoid assumptions and logic traps
Traditional Approach
• The traditional problem-solving approach may jump to a
quick conclusion typically resulting in repeat occurrences
of the same / similar issues

Problem Why?
Cylinders Operator
are being Error! The
damaged operator used
at the his own
assembly installation
operation method and
not the
correct tool.
Corrective Action: Retrain the operator.
 Using the 5-Why Approach:
Digging deeper:

Problem Why? Why? Why? Why? Why?

Cylinders Operator Because the Because the Because the Because the
are being Error! The operator required tool process policy for
damaged operator used didn't realize didn't engineer preparing
at the his own there was appear in didn't work
assembly installation only one the written include the instructions
operation. method and approved work special tool doesn't
not the tool to be instruction. number. require tools
correct tool. used. to be listed.
Corrective Action: Revise the policy for creating work instructions to require
that special tooling be called out. Update the applicable work instruction(s).
Communicate the change(s) to applicable process engineers, supervisors, and
operators. Perform verification audit.

A typical root-cause level will often indicate a broken process

or an alterable behavior.
Challenges of this Approach
• Properly identifying the problem.
• Mind set and lack of knowledge (breadth & depth) of the
participants and/or facilitator could constrain analysis.
• Tendency to stop at symptoms rather than going on to lower-
level root causes.
• Stopping after a single root cause is identified.
• Results are often not repeatable.
• The more complex things get, the more likely it is to lead
down a false trail.
5 Why Verification Criteria
Does the final Why satisfy these criteria?
• It initiates or causes the event we are seeking to explain
• It is directly controllable
• The elimination of that root cause will result in the
elimination or reduction of the problem

Applying these criterion will help you determine

if the underlying root cause has been reached
The Therefore Test
• Challenges the 5 Why rational
• Checks your rationale to verify the cause & effect
relationship; does it make sense?
• Validate assumptions through additional data analysis
• Take action against potential causes to prevent
recurrence of the problem
 Traditional Example
Challenge the 5-why rational using the “Therefore” test

Therefore Therefore Therefore Therefore Therefore Therefore Therefore Issue

The inside of The There's a The birds The spiders The gnats The We wish for
the Lincoln monument large come to are there in are monument people to
memorial is gets amount of eat the abundance attracted to lights come enjoy the
deteriorating washed bird spiders. to eat the the lights. on at dusk monument
faster than frequently. droppings. gnats. and are on when it's
expected. for a long dark.
time.

As a result, the lights

now come on later and
go off earlier than
before.
Fishbone Diagrams
• Using the 5 Whys along with a Cause & Effect diagram
can be very effective.
Worksheet
Template Format
1) Identify the problem
2) For each specific cause identified, ask “Why?” at least 5 times to get to the root cause
3) Use the Therefore test to ensure your rationale
Problem: Your vehicle will not start
Why? Why? Why? Why? Why?

Corrective Action:

Therefore Therefore Therefore Therefore Therefore Issue

Example from a Training Company
Problem: The wrong materials for training courses have been delivered to training
venues on several occasions.
• Why did it happen? The person packing and dispatching them for delivery made some
mistakes. She was packing materials for three different courses at the time, was in a
hurry and didn't notice. (Symptom)
• Why was it overlooked? She's quite new to the job and there hadn't been enough time
for training. (Symptom)
• Why was a new person doing this job without any apparent backup? The person who
used to do that job had left and everyone else was busy too. And there's nothing written
down, such as a checklist of materials to pack, nor any procedure. (Symptom)
• Why is there no procedure/guideline etc? We've just had so many new staff lately
(turnover has been very high) that there's been no time for training or writing
procedures. (Symptom)
• Why is that? Root Causes: There is no effective training system in place. And no
priority or importance has been placed on having some basic documentation in place:
writing down essential information to make sure that things are done consistently,
despite changes of personnel.
Note: It might also be worth while looking at why turnover is so high, and/or whether there is adequate advance planning occurring.
 Scenario 1
Problem: The vehicle will not start.
Facts available:
• When you turn over the car nothing happens
• The car was not properly maintained
• The vehicle is pretty old and parts can be difficult to find
Problem: Your vehicle will not start

Why? Why? Why? Why? Why?

Corrective Action:
 Scenario 1 – Possible Solution
Problem: The vehicle will not start.
Why? Why? Why? Why? Why? Why?

The The The The The vehicle Replacement

battery is alternator is alternator alternator was not parts are not
dead. not belt has belt was well maintained available
functioning. broken. beyond its according to because of
useful the the age of
service life recommended the vehicle.
and not service
replaced. schedule.
A Root Optional
Cause Footnote

Corrective Action(s):
1) Start maintaining the vehicle according to the recommended service schedule.
(possible 5th Why solution)
2) Purchase a different vehicle that is maintainable. (possible 6th Why solution)
 Scenario 1 – Validation
Therefore
Problem: The vehicle will not start.

Therefore Therefore Therefore Therefore Therefore Issue

The The The The The vehicle Replacement

battery is alternator is alternator alternator was not parts are not
dead. not belt has belt was well maintained available
functioning. broken. beyond its according to because of
useful the the age of the
service life recommended vehicle.
and not service
replaced. schedule.
 Scenario 2
Patients in a hospital were not arriving to the diagnostic departments during their
allotted time. Because the patients were late, the diagnostic departments were
getting backed up. Thus the problem to be addressed was: reducing patient
back-ups in the hospital’s diagnostic departments due to late arriving patients.

Facts in place:
• Busy NUS’ responsible for contacting Transport; no standard procedure in place to do this
• Page to Transport includes name, not location; Transport unable to find patient
• Nurse not informed of scheduled procedure; patients often not ready for Transport.

Problem: Back-ups in the diagnostic departments

Why? Why? Why? Why? Why?
Why are
there
backups?

Corrective Action:
Scenario 2 – Analysis
Problem: Backups in the diagnostic departments.
• Why? Patients are arriving late *
• Why? The transporters are not called on time
• Why? NUS’ are busy and often forget
• Why? There is no written request
• Why? There is no protocol for contacting Transport
• Why? Transport is unable to locate patients *
• Why? Page does not include patient location (name only)
• Why? No standard protocol for transport paging
• Why? Patient not ready for transport *
• Why? Nurses unaware of prescribed test
• Why? No mechanism to inform RN of scheduled
procedure
* Multiple primary causes of the problem
Scenario 2 – Possible Solution
• Use the Therefore Test to validate your findings
• The team investigating delayed transport of patients to
diagnostic departments discovered that the root cause was
lack of clear protocol for communicating between the
diagnostic department, RN of the clinical department, and
the transporter.
• Proposed countermeasures:
1. A new protocol where the diagnostic department
pages the charge RN and the transporter at the same
time (thus eliminating the NUS as the intermediary)
2. Specified information content of pages
3. New patient prep procedures involving both the RN
and the transporter
Questions?