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We can use RCA to also modify core process and system issues in a way that prevents future problems. Treating the individual symptoms may feel productive. Solving a large number of problems looks like something is getting done. Instead of a news editor just fixing every single omitted Oxford comma, she will prevent further issues by training her writers to use commas properly in all future assignments. There are a few core principles that guide effective root cause analysis, some of which should already be apparent.

Not only will these help the analysis quality, these will also help the analyst gain trust and buy-in from stakeholders, clients, or patients. In addition to discovering the root cause, we should strive to provide context and information that will result in an action or a decision.

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Remember: good analysis is actionable analysis. There are a large number of techniques and strategies that we can use for root cause analysis, and this is by no means an exhaustive list. One of the more common techniques in performing a root cause analysis is the 5 Whys approach. We may also think of this as the annoying toddler approach.

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Children are surprisingly effective at root cause analysis. Common wisdom suggests that about five WHY questions can lead us to most root causes—but we could need as few as two or as many as 50 WHYs. First, our player will present a problem: Why do I have such a bad headache? This is our first WHY. Second answer: Because I my head hit the ground. Third why: Why did your head hit the ground? Third answer: I got hit tackled to the ground and hit my head hard.


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Fourth why: Why did hitting the ground hurt so much? After these five questions, we discover that the root cause of the concussion was most likely from a lack of available helmets. In the future, we could reduce the risk of this type of concussion by making sure every football player has a helmet. Be safe! The 5 Whys serve as a way to avoid assumptions. By finding detailed responses to incremental questions, answers become clearer and more concise each time. Ideally, the last WHY will lead to a process that failed, one which can then be fixed.

Another useful method of exploring root cause analysis is to carefully analyze the changes leading up to an event. This method is especially handy when there are a large number of potential causes. Instead of looking at the specific day or hour that something went wrong, we look at a longer period of time and gain a historical context. These should be any time a change occurred for better or worse or benign. This is where the bulk of the analysis happens and this is where other techniques like the 5 Whys can be used. Example: Within our analysis we discover that our fancy new Sales slide deck was actually an unrelated factor but the fact it was the end of the quarter was definitely a contributing factor.

However, one factor was identified as the most likely root cause: the Sales Lead for the area moved to a new apartment with a shorter commute, meaning that she started showing up to meetings with clients 10 minutes earlier during the last week of the quarter. Example: While not everyone can move to a new apartment, our organization decides that if Sales reps show up an extra 10 minutes earlier to client meetings in the final week of a quarter, they may be able to replicate this root cause success.

Another common technique is creating a Fishbone diagram, also called an Ishikawa diagram , to visually map cause and effect. This can help identify possible causes for a problem by encouraging us to follow categorical branched paths to potential causes until we end up at the right one. Typically we start with the problem in the middle of the diagram the spine of the fish skeleton , then brainstorm several categories of causes, which are then placed in off-shooting branches from the main line the rib bones of the fish skeleton.

As we dig deeper into potential causes and sub-causes, questioning each branch, we get closer to the sources of the issue. We can use this method eliminate unrelated categories and identify correlated factors and likely root causes. For the sake of simplicity, carefully consider the categories before creating a diagram. Science curriculum has long been criticized as reflecting an impoverished and misleading model of science as a way of knowing e.

Although there are notable exceptions to this pattern, most K-8 curricula would appear to at least exacerbate the epistemological shortcomings with which children enter school. In the words of Reif and Larkin , p. The epistemic cognition literature has documented shortcomings in students at all levels of study, including college and beyond. It is not surprising that shortcomings in the understanding of science as a way of knowing have been identified in K-8 teachers. A small literature of classroom-based design studies indicates that these limitations may be at least to some degree ameliorable by instruction.

With appropriate supports for learning strategies of investigation, children can generate meaningful scientific questions and design and conduct productive scientific investigations e. For example, in the small elementary school in which she was the lone science teacher, Gertrude Hennessey was able to systematically focus the lessons on core ideas built cumulatively across grades She chose to. In another example, students showed improved understanding of the process of modeling after they engaged in the task of designing a model that works like a human elbow Penner et al.

In this study, students in first and second grade in two classrooms participated in a model-building task over three consecutive 1-hour sessions. They began by discussing different types of models they had previously seen or made. They considered the characteristics of those models, and how models are used for understanding phenomena. They were then introduced to the task of designing a model that functions like their elbow.

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After discussing how their own elbows work, children worked in pairs or triads to design and build models that illustrated the functional aspects of the human elbow. After generating an initial model, each group demonstrated and explained their model to the class followed by discussion of the various models. Students were then given an opportunity to modify their models or start over.

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In interviews conducted after the session, students improved in their ability to judge the functional rather than perceptual qualities of models compared with nonmodeling peers. They also demonstrated an understanding of the process of modeling in general that was similar to that of children 3 to 4 years older.

Researchers have also identified important curricular features that support the development of a more sophisticated epistemology. Curricula can facilitate the epistemological development of students when they focus on deep science problems, provide students opportunities to conduct inquiry, and structure explicit discussion of epistemological issues see, e. In order to advance their understanding of epistemology, learners engaged in inquiry need explicit cues to reflect on their experiences and observations and consider the epistemological implications Khishfe and Abd-El-Khalick, Finds a variety of ways in which students can externally represent their thinking about the topic.

Begin to address the necessity of understanding other usually peer positions before they can discuss or comment on those positions. Toward the end of the year, begin to recognize inconsistency in the thoughts of others, but not necessarily in their own thinking. Continues to provide an educational environment in which students can safely express their thoughts, without reproaches from others. Models consistent and inconsistent thinking students can readily point out when teacher is being inconsistent. Explore the idea that thoughts have consequences, and that what one thinks may influence what one chooses to see.

Begin to differentiate understanding what a peer is saying from believing what a peer is saying. Begin to comment on how their current ideas have changed from past ideas and to consider that current ideas may also need to be revised over time. Provides lots of examples from their personal work which is saved from year to year of student ideas.

Continue to articulate criteria for acceptance of ideas i. Begin to employ analogies and metaphors, discuss their explicit use, and differentiate physical models from conceptual models. Provides historical examples of very important people changing their views and explanations over time. Many researchers assume that epistemology is trait-like, although some argue that it is situational—an interaction of cognitive and historical resources with environmental features that cue or elicit those resources. Looking across the various lines of research, most children in grades K-8 do not further develop the rudimentary knowledge and skills that are so evident during the preschool years.

Young children tend to move from one level of understanding to the next slowly, if at all, and by middle school few students reach higher levels of understanding, at which knowledge is viewed as problematic and claims are necessarily subjected to scrutiny for their evidentiary warrants. In large measure, this pervasive pattern probably reflects more about the opportunities to learn that children encounter in their.

Evidence from design studies, discussed in this chapter and to which we return in Chapter 9 , suggests that, under optimal curricular and instructional conditions, children can develop very sophisticated views of knowledge. Yet the contrast is remarkable between the capabilities of preschool children and modal patterns of development in older children and the lack of sophisticated reasoning about knowledge in early adolescents. We argue that in carefully designed, supportive environments, elementary and middle school children are capable of understanding and working with knowledge in sophisticated ways.

Instruction in K-8 science can significantly advance their understanding of the nature and structure of scientific knowledge and the process by which it is constructed. With appropriate supports for learning strategies of investigation, children can engage in designing and conducting investigations that enable them to understand science as a way of knowing Gobert and Pallant, ; Klahr and Li, ; Metz, ; Schwartz and White, ; Smith et al.

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The core elements of this scientific activity involve articulating hypotheses, laws, or models, designing experiments or empirical investigations that test these ideas, collecting data, and using data as evidence to evaluate and revise them. We will discuss this literature in depth in Chapter 9. Rather, there is a tendency to overemphasize methods, often experimental methods, as opposed to presenting science as a process of building theories and models, checking them for internal consistency and coherence, and testing them empirically. This lack of attention to theory, explanation, and models may exacerbate the difficulties children have with understanding how scientific knowledge is constructed.

It may, in fact, strengthen their misconceptions, such as the view that scientific knowledge is unproblematic, relatively simple to obtain, and flows easily from direct observation. The role of teachers and teacher knowledge in science education is taken up in greater detail in Chapter Akerson, V. Journal of Research in Science Teaching, 37 4 , Bell, P. Beliefs about science: How does science instruction contribute? Hofer and P. Pintrich Eds. Burbules, N. Science education and the philosophy of science: Congruence or contradiction? International Journal of Science Education, 3 3 , Carey, S.

International Journal of Science Education, 11 5 , On understanding the nature of scientific knowledge. Educational Psychologist, 28 3 , Chandler, M. Relativism and stations of epistemic doubt. Journal of Experimental Child Psychology, 50 , Competing claims about competing knowledge claims. Davis, E. Unpublished doctoral dissertation, University of California, Berkeley. Driver, R. Buckingham, England: Open University Press.


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Giere, R. New York: Holt Reinhart and Winston. Science without laws. Gobert, J. Making thinking visible: Promoting science learning through modeling and visualizations. Presented at the Gordon Research Conference, Mt. Grosslight, L. Understanding models and their use in science: Conceptions of middle and high school students and experts. Journal of Research in Science Teaching, 28, Hammer, D. Epistemological beliefs in introductory physics. Cognition and Instruction, 12 2 , On the form of a personal epistemology.

Hewson, P. On appropiate conception of teaching science: A view from studies of science learning. Science Education, 72 5 , Khishfe, R. Journal of Research in Science Teaching, 39 , Kitchener, K. Reflective judgment: Concepts of justification and their relationship to age and education.

Journal of Applied and Developmental Psychology, 2 , Klahr, D. Cognitive research and elementary science instruction: From the laboratory, to the classroom, and back. Journal of Science Education and Technology, 14 2 , Kuhn, D. The connection of theory and evidence. The interpretation of divergent evidence. Beilin, D. Kuhn, E. Amsel, and M. Louis, MO: Academic Press.


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    Metz, K. Cognition and Instruction, 22 2 , Osborne, J. A Delphi study of the expert community. Journal of Research in Science Teaching, 40 7 , Penner, D. Building functional models: Designing an elbow. Journal of Research in Science Teaching, 34 2 , Perner, J. Understanding the representational mind. Perry, W. Forms of intellectual and ethical development in the college years: A scheme. New York: Holt Rinehart and Winston. Reif, F. Cognition in scientific and everyday domains: Comparison and learning implications.

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