Chapter 10
Step 8: Conduct Root Cause Analysis to Redesign Workflows and Processes
Do not look where you fell, but where you slipped.
—African proverb
This African proverb, according to Sommer (2003), literally means “Don’t look at your mistakes, look at what caused you to make the mistakes.” This philosophy about root cause analysis helps one dig deep and stay focused on finding the underlying reason for rather than just the symptoms of a problem. Unfortunately, many root cause analyses go astray. C. Robert Nelms (2003) has observed that
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