Metode Ilmiah Analisis Akar Masalah
Metode Ilmiah Analisis Akar Masalah
METODE
ANALISIS AKAR MASALAH
(ROOT CAUSE ANALYSIS)
Setiap masalah selalu mempunyai akar masalah. Akar
masalah sangat penting diketahui untuk melakukan tindakan
perbaikan dan pencegahan secara efektif. Untuk mengukur
efektifitas tindakan perbaikan, tips berikut ini mungkin dapat
dipakai sebagai acuan untuk menetapkan kriteria efektif:
tidak berulangnya kasus yang sama
bisa diterapkan
tidak membutuhkan investasi yang sangat tinggi
fleksibel dengan komponen lainnya
mudah dievaluasi
dll
Jika saat ini efektif, mungkinkah bulan depan atau tahun
depan bisa muncul kembali masalah yang sama? sangat
mungkin, karena faktor variasi akan muncul secara alami dari
faktor man, material, method, and machine.
A process improvement and error or defect prevention tool
that examines the individual processes within a system,
identifies the control or decision points, and uses a series of
why? questions to determine the reasons for variations in the
process paths.
Contoh Definisi :
In normal chaotic organizational environments it is
often quite difficult to find candidates for root cause
analysis because the situations which repeat are either
distributed over time so one doesn't realize they are
actually recurring, or the situation happens to different
people so there isn't an awareness of the recurring
nature of the situation (systems-thinking.org).
On receipt of initial notification, the department will
provide the hospital with a sentinel event reference
number to be indicated on the root cause analysis, risk
reduction action plan summary and other
correspondence about the episode (Victorian State
Government Health).
Root cause analysis (RCA) is a methodology for finding
and correcting the most important reasons for
performance problems. It differs from troubleshooting
2
and problem-solving in that these disciplines typically
seek solutions to specific difficulties, whereas RCA is
directed at underlying issues (bill-wilson.nrt).
Root cause analysis (RCA) merupakan metode untuk
menemukan dan mengoreksi alasan-alasan yang paling
penting bagi masalah-masalah kinerja. Metode RCA lebih
diarahkan pada isu-isu berikut ini.
Dalam kaitannya dengan proses bisnis, metode RCA
mencari kendala-kendala yang dianggap tidak perlu
dan control yang tidak memadai.
In safety and risk management, it looks for both
unrecognized hazards and broken or missing barriers.
It helps target CAPA (corrective action and preventive
action) efforts at the points of most leverage.
RCA is an essential ingredient in pointing
organizational change efforts in the right direction.
Finally, it is probably the only way to find the core
issues contributing to your toughest problems.
While it is often used in environments where there is
potential for critical or catastrophic consequences, this
is by no means a requirement. It can be employed in
almost any situation where there is a gap between
actual and desired performance. Furthermore, RCA
provides critical info on what to change and how to
change it, within systems or business processes.
Significant industries using root cause analysis include
manufacturing, construction, healthcare,
transportation, chemical, petroleum, and power
generation. The possible fields of application include
operations, project management, quality control,
health and safety, business process improvement,
change management, and many others.
Your problems may not be as spectacular as the ones
pictured above, but they probably have many
similarities under the surface. This is the point of root
cause analysis -- to dig below the symptoms and find
the fundamental, underlying decisions and
contradictions that led to the undesired consequences.
If you want your problems to go away, your best option
is to kill them at the root.
Teknik analisis akar masalah merupakan teknik analisis yang
bertahap dan terfokus untuk menemukan akar masalah suatu
3
problem, dan bukan hanya melihat gejala-gejala dari suatu
masalah.
Contoh Definisi:
Saat ini Pendekatan Analisis Akar Masalah banyak di
gunakan di lingkungan pelayanan kesehatan / rumah
sakit untuk menyelesaikan masalah akibat Kejadian
Tidak Diharapkan (KTD) dan Sentinel Event untuk
Program Keselamatan Pasien (
Institut Manajeme
http://pojokantikor
4
akar penyebab (Root Cause Analysis). RCA adalah
sebuah metode yang terstruktur yang digunakan
untuk menemukan akar penyebab dari masalah
kerusakan poros (LP UNHAS).
LP Universitas Ha
http://w w w .unha
5
ada aktivitas identifikasi mengenai apa saja checkpoint (poin pemeriksaan) dari tiap peralatan. Tindakan
kita adalah memperkenalkan aktivitas identifikasi check point
untuk tiap peralatan.
Apa yang kita lakukan untuk mendapatkan akar masalah dan
peluang perbaikan sebanyak diatas? Well, hanya bertanya,
simply by asking.
Cara menjalankannya, kumpulkan orang-orang yang relevan
dan punya semangat perbaikan. Anda tentu saja tidak
memerlukan seorang skeptis dan pesimis yang meragukan
setiap action-plan kita. Kedua, lakukan dalam waktu yang
singkat. Jika dibutuhkan waktu sampai 2 jam untuk
menjawab, mungkin diperlukan perangkat (tools) yang lebih
bagus, misalnya diagram tulang ikan (Fishbone diagram).
Diagram Tulang-Ikan
6
Dari contoh gambar berikut terlihat bahwa faktor penyebab
problem antara lain (kemungkinan) terdiri dari :
material/bahan baku, mesin, manusia dan metode/cara.
Semua yang berhubungan dengan material, mesin, manusia,
dan metode yang saat ini dituliskan dan dianalisa faktor
mana yang terindikasi menyimpang dan berpotensi terjadi
problem. Ingat,..ketika sudah ditemukan satu atau beberapa
penyebab jangan puas sampai di situ, karena ada
kemungkinan masih ada akar penyebab di dalamnya yang
tersembunyi. Bahasa gaulnya, jangan hanya melihat yang
gampang dan nampak di luar.
Ishikawa mengajarkan untuk melihat ke dalam dengan
bertanya mengapa?mengapa?dan mengapa?. Hanya
dengan bertanya mengapa beberapa kali seorang peneliti
mampu
menemukan
akar
permasalahan
yang
sesungguhnya. Penyebab sesungguhnya, bukan gejala yang
tampak. Dengan menerapkan diagram Fishbone ini dapat
menolong
peneliti
untuk
dapat
menemukan
akar
penyebab terjadinya masalah khusus khusus yang akan
ditelitinya, karena memang banyak ragam faktor yang
berpotensi menyebabkan munculnya permasalahan. Apabila
masalah dan penyebab sudah diketahui secara pasti,
maka tindakan dan langkah penelitian akan lebih mudah
dilakukan. Dengan diagram ini, semuanya menjadi lebih
jelas dan memungkinkan peneliti untuk dapat melihat
semua kemungkinan penyebab dan mencari akar
permasalahan sebenarnya.
7
Diagram tulang ikan (Sumber:
http://hardipurba.com/2008/09/25/diagram-fishbone-dariishikawa.html)
TANGKAP
DI
No
1
Pelaku
Pemda
Dinas
Perikanan dan
Kelautan
Nelayan
Pengusaha
Pedagang/Bak
ul
Kebutuhan
-Peningkatan pendapatan DaerahPeningkatan Lapangan Kerja-Peningkatan
kesejahteraan nelayan
-Produksi Hasil Tangkapan memenuhi
kebutuhan pasar-Menjaga potensi
sumberdaya perikanan-Peningkatan
sumber informasi perikanan
-Bantuan modal untuk biaya operasiPenambahan unit penangkapan
-Peningkatan jumah alat tangkapTersedianya BBM-Pabrik es
-Bantuan modal-Fasilitas untuk
berdagang-Mutu ikan yang bagus
Formulasi Masalah
8
Formulasi masalah adalah suatu upaya untuk
pendefinisian permasalahan secara spesifik, sehingga
masalah tersebut mencapai suatu individu yang
dimungkinkan dilaksanakannya usaha ke arah
pemecahannya. Formulasi masalah didasarkan pada
penentuan informasi yang terperinci yang dihasilkan selama
identifikasi sistem. Adapun beberapa masalah yang berkaitan
dengan sistem perikanan tangkap di PPN Palabuhanratu,
diantaranya :
1).
Identifikasi Sistem
Identifikasi sistem berhubungan dengan kebutuhankebutuhan yang dibutuhkan oleh pelaku dalam system
perikanan tangkap dengan masalah-masalah yang
dihadapinya. Kebutuhan tersebut ebeliputi input-output yang
terkendali dan input-ouput yang tidak dapat dikendalikan.
Input yang terkendali merupakan faktor yang mempengaruhi
pemasukkan dari suatu sistem yang dapat dikendalikan,
seperti nelayan, kapal, bahan bakar, es, dan pasar. Adapun
input yang tak terkendali yang merupakan faktor yang
mempengaruhi sistem yang tidak dapat dikendalikan, seperti
sumber daya ikan, iklim, dan musim. Sedangkan, output
terkendali merupakan faktor yang mempengaruhi keluaran
dari suatu sistem yang dapat dikendalikan, seperti harga
ikan, upah ABK, retribusi, dan biaya perawatan kapal. Adapun
output yang tak terkendali merupakan faktor yang
mempengaruhi keluaran suatu sistem yang tidak dapat
9
dikendaikan, seperti kenaikkan harga BBM, dan hasil
tangkapan yang didapatkan.
Diagram Lingkar Sebab-Akibat
Diagram lingkar sebab akibat merupakan penjelasan
sederhana dari sistem perikanan yang menjelaskan tentang
hubungan dari sub-sub sistem yang ada. Dari diagram sebab
akibat, sumber daya alam merupakan sub sistem utama yang
sangat berpengaruh terhadap sub-sub sistem yang lain.
10
11
Sumber:
http://menyelamatkandanaulimboto.wordpress.com/pengendalianpencemaran-danau/marganof/3-metode-penelitian/
12
1. Tidak diperhatikannya limbah dari aktivitas KJA yang
ditunjukan dengan tidak adanya pemahaman mengenai
dampak dari limbah KJA terhadap kualitas air.
2. Tidak tersedianya sistem pengolahan limbah penduduk,
menyebabkan buangan limbah dari permukiman akan
langsung mengalir ke perairan danau, sehingga kualitas
perairan danau menjadi turun.
3. Tidak diperhatikannya pemanfaatan tata guna lahan di
kawasan sempadan danau yaitu banyaknya
pengembangan permukiman, hotel, restoran, dan home
stay serta pembukaan lahan pertanian yang tercermin
dari tingginya padatan tersuspensi di perairan danau.
4. Tidak diperhatikannya persepsi masyarakat di sekitar
perairan danau dalam upaya pengendalian pencemaran
yang terjadi di perairan danau.
5. Tidak adanya zonasi (penataan ruang) kawasan danau
yang tercermin dari penyebaran atau letak keramba
jaring apung yang tersebar hampir di seluruh tepian atau
keliling perairan danau.
Identifikasi Sistem
Identifikasi sistem merupakan suatu rantai hubungan
antara pernyataan dari kebutuhan dengan pernyataan
khusus dari masalah yang harus dipecahkan untuk
memenuhi kebutuhan-kebutuhan tersebut. Hal ini sering
digambarkan dalam bentuk diagram lingkar sebab-akibat
(cousal loop diagram) . Diagram tersebut merupakan
pengungkapan interaksi antara komponen di dalam sistem
yang saling berinteraksi dan mempengaruhi dalam kinerja
sistem. Disamping itu, hubungan antara input (masukan) dan
output (keluaran) dalam suatu sistem digambarkan dalam
sebuah diagram inputoutput (masukan-keluaran) seperti
disajikan pada gambar berikut. Diagram lingkar sebab-akibat
merupakan gambaran dari struktur model pengendalian
pencemaran di perairan danau yang dibuat berdasarkan
diagram input-output.
13
14
Diagram masukan-keluaran (input-output diagram)
sistem pengendalian pencemaran perairan danau adalah
berikut ini.
Sumber: http://menyelamatkandanaulimboto.wordpress.com/pengendalianpencemaran-danau/marganof/3-metode-penelitian/
PENGANTAR
ANALYSIS)
METODE
RCA
(ROOT
CAUSE
15
16
7. Tanpa harus menjadi terlalu rinci, periksa kembali
DIAGRAM pohon masalahuntuk melihat apakah
pernyataan SEBAB-AKIBAT atas setiap keadaan
yangditulis pada setiap kartu telah lengkap
8. Sepakati DIAGRAM Pohon Masalah sebagai hasil kerja
bersama.
Contoh Pohon Masalah.
sampahkurangterawat
Pokok
Masalah
Banjir
Ht gundul
Akar
Masalah
Pembalaka
n
Tdk
ada
reboisa
Irigasi
Samp
ah
Tdk
terawat
SISTEMIK MASALAH
Berbeda dengan Pohon Masalah, metode ini melihat bahwa masalah
itu saling bertautan dan saling mempengaruhi. MASALAH POKOK
merupakan masalah yang mempunyai pengaruh terbesar terhadap
MASALAH lainnya.
Tahap-tahap yang harus dilalui adalah:
1. Menuliskan MASALAH-MASALAH masing-masing
pada selembar kartu
2. Menempelkan semua kartu yang bertuliskan
MASALAH pada papan
17
3. Menunjukkan SEBAB AKIBAT antar masalah-masalah
tersebut denganmenggunakan TANDA PANAH
4. Begitu seterusnya sampai dapat diidentifikasi
MASALAH yang mempunyai pengaruh terbanyak
5. Tanpa harus menjadi terlalu rinci, periksa kembali
DIAGRAM SISTEM MASALAHuntuk melihat apakah
pernyataan SEBAB-AKIBAT atas setiap keadaan yang
ditulis pada setiap kartu telah lengkap
6. Menyepakati DIAGRAM SISTEMIK MASALAHsebagai
hasil kerja bersama
Contoh Sistemik Masalah
Sekala Usaha
Kecil
Sekala
Usaha
Sekala
Akses
Kecil
modal
Usaha
lemah
Kecil
Daya
tawar
lemah
Investasi
Kecil
Profit Kecil
18
Analisa akar permasalahan adalah suatu
penyelidikan / pengusutan yang terstruktur yang
bertujuan untuk mengidentifikasi penyebab
sesungguhnya dari suatu masalah, dan tindakantindakan yang dibutuhkan untuk mengeliminasi /
menghilangkan
Walau kedengarannya agak terus-terang, akan dapat dilihat
bahwa analisa akar masalah tidak dilaksanakan dengan
menggunakan satu alat atau strategi tunggal, tetapi dengan
sejumlah alat yang sering dikombinasikan.
Analisa akar masalah adalah suatu istilah yang kolektif yang
digunakan untuk menggambarkan berbagai pendekatan, alat
serta teknik yang digunakan untuk membongkar sebab-sebab
suatu masalah, sebagian pendekatan lebih diarahkan untuk
mengidentifikasikan akar-akar masalah yang sesungguhnya
daripada lain-lainnya.
Ada pendekatan yang lebih berupa teknik-teknik umum untuk
pemecahan masalah, adalagi yang hanya menawarkan
dukungan pada aktivitas inti dari analisa akar masalah. Ada
alat-alat yang bercirikan pendekatan terstruktur, adapula
yang lebih kreatif (dan serampangan / sembrono ).
Hal yang penting adalah bukan mempelajari dan
menggunakan semua alat in, tetapi lebih untuk mengenal
alat-alat analisa akar masalah dan mengaplikasikan teknikteknik atau alat yang sesuai untuk menangani suatu masalah
tertentu.
Alat-alat Analisa Akar Masalah
Beberapa alat analisa akar masalah telah dikelompokkan
sesuai dengan tujuan (dan dititik mana alat itu digunakan).
Untuk alasan-alasan berikut:
1. Ada sedemikian banyak alat sehingga perlu menjaga
kejelasan selama presentasi alat- alat itu.
2. Meraka secara alami akan masuk ke kategori-kategori
alat yang berfungsi untuk tujuan-tujuan yang agak
berbeda.
Kelompok-kelompok alat, sesuai dengan
tujuannya adalah sbb:
PEMAHAMAN MASALAH
1. FLOWCHART : Chart / Grafik yang digunakan untuk
melakukan gambar tentang proses dunia.
19
2. Kejadian yang kritis : Pendekatan yang anggun
digunakan untuk mengeksplorasi / menyelidiki isuisu yang paling kritis dalam suatu situasi.
3. Grafik Laba-laba / Spider Chart : Sebuah grafik
perbandingan untuk menandai sebuah masalahmasalah.
4. Matriks Penampilan : Digunakan untuk membantu
menentukan pentingnya masalah-masalah atau
sebab-sebab.
ASAL TIMBULNYA PENYEBAB DAN PENCAPAIAN
MUFAKAT
1. Brainstorming. Suatu pendekatan resmi yang dapat
digunakan selama analisa akar masalah bila
dibutuhkan banyak ide.
Brainwriting. Sebenarnya merupakan sesi
brainstorming tertulis.
2. Teknik kelompok nominal : Teknik yang digunakan
untuk membantu sebuah kelompok dalam
memprioritaskan berbagai alternatif misalnya,
sebab-sebab masalah.
3. Perbandingan berpasangan : Suatu teknik yang
digunakan untuk mencapai mufakat dengan
memperoleh partisipan atau peserta memilih antara
dua alternatif yang dibandingkan.
PENGUMPULAN DATA PENYEBAB DAN MASALAH
1. Sampling/Contoh : Digunakan untuk mengumpulkan
data disuatu populasi yang besar dengan
mengambil sedikit sample / contoh.
2. Survey : Digunakan untuk mengumpulkan data
tentang pendapat-pendapat dan sikap-sikap dari
pelanggan , pegawai dll.
3. Check sheet : Suatu pendekatan yang secara
sistematis mengumpulkan data berdasarkan pada
sheet (lembaran) yang sudah dibuat dulu yang
digunakan selama periode pengumpulan data.
ANALISA PENYEBAB YANG MUNGKIN
20
1. Histogram : Suatu diagram yang mudah digunakan
yang membantu mengidentifikasi pola-pola atau
anomali / kelainan-kelainan.
2. Pareto Chart : Alat visual lain yang digunakan untuk
memberi ilustrasi penyebab-penyebab dominan
yang menimbulkan efek / pengaruh paling besar.
3. Scatter Chart : Digunakan untuk memberi ilustrasi
hubungan antara dua sebab atau variable-variable
lain dalam situasi bermasalah.
4. Diagram hubungan (Relations Diagram) : Suatu alat
yang digunakan untuk mengidentifikasi hubungan
logis antara berbagai ide atau isu dalam suatu
situasi yang rumit atau membingungkan .
5. Diagram Afinitas (tarik-menarik) : Suatu pendekatan
grafik (chart approach) yang membantu
mengidentifikasi ide-ide, sebab-sebab atau konsepkonsep yang kelihatannya tidak berkaitan sehingga
mereka semua bisa dieksplorasi / ditinjau lebih
lanjut.
Diagram Hubungan
Diagram hubungan antara iklim dan tanaman.
Pengaruh cuaca terhadap tanaman berbeda dengan
pengaruh iklim. Suatu wilayah pusat produksi tanaman
yang telah berlangsung puluhan hingga ratusan tahun,
kondisi iklimnya jelas sesuai bagi kultivar yang
dibudidayakan. Walau demikian sesekali mengalami
cuaca ekstrim selama beberapa hari sehingga gagal
panen. Jadi, keadaan cuaca menentukan kondisi aktual
hasil panen sedangkan kondisi iklim menentukan
kapasitas dan rutinitas panen.
Kondisi iklim /cuaca mikro secara langsung mempengaruhi
proses fisiologi karena berhubungan dengan atmosfer di
lingkungan tanaman sejak perakaran hingga puncak tajuk.
Unsur yang berpengaruh kuat terutama radiasi surya, suhu
udara, suhu tanah, kelembapan, kecepatan angin, presipitasi
dan evapotranspirasi. Mekanisme pengaruh faktor
pengendali dan unsur iklim terhadap tanaman dan
lingkungan dapat dilihat pada gambar berikut.
21
22
DIAGRAM LINGKAR HUBUNGAN SEBAB AKIBAT:
SISTEM AGRIBISNIS
Diagram lingkar sebab akibat selain menggambarkan
hubungan antar elemen, pengaruh hubungan, juga
membantu untuk melakukan identifikasi sistem. Inventarisasi
hubungan dapat dilakukan menggunakan bantuan dafta atau
tabel sebab akibat. Sebagai contoh hubungan sebab akibat
adalah Sumber Daya Alam merupakan penyebab tumbuh
berkembangnya IPTEK yang lebih efisien dan efektif untuk
memanfaatkan Sumber Daya Alam. Ketersediaan, kesesuaian
Sumber Daya Alam juga akan menyebabkan bertambahnya
jumlah Agribisnis, demikian seterusnya.
Sumber: http://taman-agribisnis.blogspot.com/2010_02_01_archive.html
23
DIAGRAM AFINITAS (Affinity Diagram)
Diagram afinitas (affinity diagram) merupakan suatu diagram atau
tabel yang diperoleh sebagai hasil dari suatu tata cara pengumpulan ide,
dimana sejumlah atau sekumpulan ide yang tidak beraturan dikelompokkan
berdasarkan jenisnya. Kumpulan ide tersebut biasanya diperoleh dari
brainstorming. Dengan demikian diagram afinitas adalah suatu alat analisis
manajemen yang diterapkan untuk menjaring ide-ide yang diperoleh dari
aktifitas brainstorming, Namun demikian, kumpulan ide yang akan
dikelompokkan menjadi beberapa group kecil (misalnya 5 group) tidaklah
mesti merupakan kumpulan ide yang diperoleh sebagai keluaran dari suatu
aktifitas brainstroming. Misalkan dari suatu aktifitas brainstroming yang
bertujuan untuk menjaring ide terhadap pertanyaan: Bagaimana
mempertahankan kesuksesan proses yang telah berhasil diterapkan ?, maka
kira-kira akan diperoleh hasil berupa daftar ide seperti yang diperlihatkan
pada tabel berikut.
Apabila dilakukan pengamatan yang saksama terhadap ide-ide tersebut,
maka akan terlihat bahwa diantara ide-ide tersebut terdapat ide-ide yang
mempunyai tema yang sama, misalnya tema tentang training dan
keterampilan, tema tentang manajemen, tema yang menyangkut konsumen
dan sebagainya. Oleh karena itu sekumpulan ide tersebut dapat
dikelompokan menjadi sejumlah kecil kelompok ide yang lebih bermakna.
Diagram afinitas terutama bermanfaat jika digunakan dalam
kondisikondisi seperti:
a). tidak ada kepastian akan fakta dan pemikiran/opini yang
terkumpul sehingga perlu pengorganisasian akan hal tersebut,
b). jika terdapat suatu ide atau paradigma yang dianut sebelumnya
dan perlu untuk diantisipasi,
c). jika terdapat ide-ide yang perlu diklarifikasi dan
d). jika ingin diciptakan keutuhan tim.
Penting untuk diingat bahwa penamaan terhadap kelompok ide (atau tema
dari kelompok) sebaiknya dicantumkan setelah dilakukan proses
pengelompokkan dan bukan sebelumnya. Sehingga dengan demikian tema
kelompok ide akan relevan dengan ide-ide yang terkumpul pada kelompok
tersebut. Sebagai contoh, kumpulan ide hasil brainstorming seperti yang
diperlihatkan pada tabel berikut, setelah dilakukan penyaringan dan
pengelompokan akan tampak seperti yang diperlihatkan pada tabel.
Diagram afinitas merupakan suatu teknik pengambilan keputusan
yang digunakan/diterapkan pada sekelompok orang (grup), yang
didesain sedemikian rupa untuk menyeleksi sejumlah besar ide
(termasuk pula: variabel proses, konsep dan opini) yang saling
berhubungan, sejenis atau memiliki tema yang sama ke dalam
sejumlah kecil grup ide.
24
Tabel kumpulan ide hasil brainstorming
Bagaimana mempertahankan kesuksesan proses yang telah berhasil diterapkan ?
Mengetahui
Menyediakan training
Menerapkan
Mendapatkan
kebutuhan konsumen
pengawasan;
komitmen
pemeriksaan dan
manajemen
pengendalian mutu
Mewawancarai
Mengetahui alat alat
menerapkan tata
melibatkan top
konsumen
pengembangan dan
cara analisa dan
manager dan middle
perbaikan mutu
pengukuran
manager sebagai
steering commitee
Mengidentifikasi
konsumen
Melakukan
investigasi terhadap
usaha usaha tentang
perbaikan mutu
secara terus menerus
Mengembangkan
tata cara koreksi
yang efektif terhadap
penyimpangan
Menerapkan sistem
rewarding yang
konsisten
membuat defenisi
operasional
mengenai pengetian
out-put
Melibatkan karyawan
Menerapkan
pengembangan
berdasarkan project
by project
membuat defenisi
operasional
mengenai pengetian
proses
menyediakan job
security, seperti
freedom to fail
Menghitung process
capability.
membuat program
goals yang jelas
meningkatkan
komunikasi di semua
sektor
menyediakan
waktu bagi middle
manager untuk
berpartisipasi
Membentuk steering
committee dengan
wewenang yang jelas
Menciptakan
keakraban dengan
jalan menghilangkan
penghalang diantara
kariawan
Menyediakan support
staff bagi middle
manager
25
Mengidentifikasi konsumen
membuat
defenisi
operasional
mengenai
pengetian
output
melakukan
investigasi
terhadap
usahausaha
tentang
perbaikan mutu
secara terus
menerus
mengembangka
n tata cara
koreksi yang
efektif terhadap
penyimpangan
menerapkan
system
rewarding yang
konsisten
melibatkan
karyawan
menerapkan
pengembangan
berdasarkan
project by
project
menyediakan
job security,
seperti freedom
to fail
menciptakan
keakraban
dengan jalan
menghilangkan
penghalang
diantara
kariawan
membuat
defenisi
operasional
mengenai
pengetian
proses
menyediakan
support staff
bagi middle
manager
menghitung
process
capability.
Membuat
program goals
yang jelas
Menyediakan
waktu bagi
middle manager
untuk
berpartisipasi
membentuk
steering
committee
dengan
wewenang yang
jelas
26
c. Melakukan klarifikasi terhadap ide-ide yang tidak
jelas, sehingga dengan demikian dapat digolongkan
ke dalam salah satu kelompok.
d.
Jika suatu ide dapat digolongkan ke dalam lebih
dari satu kelompok, buatlah copy atas ide itu dan
tempatkan ke dalam kelompok-kelompok itu
e. Mengitung jumlah ide yang telah digolongkan ke
dalam masing-masing kelompok
f. Mempertimbangkan untuk memasukkan anggota
kelompok kecil ke dalam kelompok yang anggotanya
lebih besar, demikian juga sebaliknya, membagi
suatu kelompok menjadi dua bila ide yang terkumpul
di dalamnya terlalu banyak.
g.
Setelah semua ide habis dan selesai
digolongkan, buatlah judul untuk masing-masing
kelompok.
27
ANALISIS SEBAB-AKIBAT
1. Cause and effect chart (CE diagram). Suatu alat yang
mudah diaplikasikan / digunakan untuk menganalisa
sebab-sebab yang mungkin dari suatu masalah.
2. Matrix Diagram. Suatu teknik visual untuk mengatur
potongan-potongan informasi sesuai dengan aspekaspek tertentu.
3. Five whys (Lima Mengapa). Suatu pendekatan yang
digunakan untuk menyelidiki lebih mendalam tentang
hubungan-hubungan sebab (causal relationships).
Contoh CE-diagram:
Step 1
Write down the effect to be investigated and draw the 'backbone' arrow to it.
In the example shown below the effect is 'Incorrect deliveries'.
Step 2
Identify all the broad areas of enquiry in which the causes of the
effect being investigated may lie. For incorrect deliveries the diagram
may then become:
28
For manufacturing processes, the broad areas of enquiry which are most
often used are Materials (raw materials), Equipment (machines and tools),
Workers (methods of work), and Inspection (measuring method).
Step 3.
This step requires the greatest amount of work and imagination
because it requires you (or you and your team) to write in all the
detailed possible causes in each of the broad areas of enquiry. Each
cause identified should be fully explored for further more specific
causes which, in turn, contribute to them.
29
Sumber:
http://www.hci.com.au/hcisite3/toolkit/causeand.htm
30
31
following description of scientific method from Wikipedia
provides a good summary of my viewpoint:
So, even root cause analysis efforts that delve into issues of
human and organizational performance must be performed
scientifically and be subject to rigorous standards of
evidence. (Of course, this has little bearing on the parts of a
root cause analysis that deal solely with physical/technical
issues.)
32
In summary, the root cause analysis process contains many
elements that are not consistent with the belief that it is an
art. These elements (evidence, reasoning, objective
standards), however, are fully consistent with the
characterization of root cause analysis as a science, or at
least as a process dominated by scientific thinking. While
certain aspects of the process may be subjective in nature,
even these must be performed within an objective, scientific
framework for the process to have any validity. Thus, the
assertion that RCA is "more art than science" is not justified,
and should not be promoted.
33
34
35
Given a set of factors sufficient to drive a change, it would be
instructive to ask what happens if one or more of the factors
were not present. If the factor is not necessary, then it
doesn't matter whether it does or does not exist. However, if
the factor truly is necessary but not present, then the change
cannot happen.
So, in order for a change to be produced, we must have a
sufficient set of factors in which all necessary factors are
present. If any of the necessary factors are not present, the
change does not occur -- each of the necessary factors is a
sort of on/off switch for the given change. In this sense, each
of the necessary factors can be considered a cause of the
effect.
Hubungan
antara
sebab
dan
akibat
yang
ditimbulkannya dapat dilukiskan dalam bentuk
diagram tulang ikan , seperti contoh berikut:
36
Sumber: http://syque.com/quality_tools/toolbook/causeeffect/example.htm
37
these phases Investigation, Analysis, and Decision. Read on
to see why.
Tahap 1: Investigation
The purpose of the investigation phase is to discover facts
that show HOW an incident occurred. During investigation,
we are not concerned with what didn't happen, or what
should have happened -- the only concern is what actually
happened, without any judgement of value. Investigation
deals with facts in a value-neutral manner.
During the investigation phase, if you find yourself using
words
like
"not",
"should",
"error",
"incorrect",
"inappropriate", etc., STOP! You are injecting value
judgements into a practice that requires absolute neutrality.
Facts exist regardless of what we think or feel about them.
Jumping too early into what should have happened will
obscure your vision of what did happen.
There may be times when required facts simply aren't
available -- critical evidence was destroyed in the process, or
there were no witnesses to a critical event. In such cases, you
have some options. Consider secondary sources that may not
be conclusive, but could provide enough circumstantial
evidence to guide further investigation. Attempt to
reconstruct the event using plausible scenarios and then
perform controlled tests to confirm or deny the most likely
explanations.
Regardless of the tools you use, the final product of the
investigation phase should be a factual representation of the
incident. If some facts were not available, and theory (backed
up by testing) had to be used instead, ensure this is clearly
evident in the representation of the incident. This
representation should then be thought of as a complete script
or plan for reproducing the incident in detail. Only after
you've reached this point should you progress to the next
phase, Analysis.
Tahap 2: Analysis
38
The purpose of the analysis phase is to discover reasons that
explain WHY an incident occurred. This is when you take the
purely factual representation of the incident and view it
within the context of the system (or organization) that
created it. The values of the system (purpose, rules, culture,
etc.) can now be used to compare what actually happened
against what should have happened, at any point during the
incident.
During the analysis phase, do not let yourself fall into the trap
of believing that the values of the system are always correct!
You are not just analyzing the incident itself, but also the
system that created it. Mentally place yourself within the
incident, watch events unfold, and then determine if the
system's values were, for example: correct but inadequately
applied, insufficient to prevent the incident, or incorrect such
that the system's values actually created (or contributed to)
the incident.
Don't get too caught up in the mechanics of the analysis tool
being used. Many tools are available to aid the analysis
phase. Each has it's own strengths and weaknesses, and
preferred realms of application. For example, if you're not
getting any insight using barrier analysis, switch over to
change analysis. The point of any analysis tool is to provide
insight, and in some situations, one tool may be vastly
superior to another.
Finally, do not let questions like "how can I fix this? ..." be
considered during the analysis phase. It is all too easy to let
desired corrective actions colour your perceptions of an
incident's causes. However, analysis is about discovering
conditions that exist now or existed in the past. The future
must not enter into the equation. Jumping too early into what
could be risks obscuring your vision of what is.
Regardless of the tools you use, the final product of the
analysis phase should be a finite set of root causes for the
incident that show why it was inevitable. Yes, inevitable -these are fundamental, latent conditions that were just laying
around waiting for some kind of trigger to activate. Only after
you've reached this realization should you progress to the
next phase, Decision.
Tahap 3: Decision
The purpose of the decision phase is to develop
recommendations that identify WHAT should be learned and
WHAT needs to be done. In this phase, we are concerned with
correcting or eliminating the root causes of an incident. This
can only be accomplished if both learning and action occur.
39
Learning without action is mere mental trickery, while action
without learning is simply useless physical exercise. Both are
required for long-term, effective results.
During the decision phase, beware of overly-specific,
conditional corrective action recommendations! It is often
tempting to save effort by cramming one more feature or
condition into an existing mechanism. However, doing so
often just adds complexity to a situation that has already
shown itself to be prone to failure. Do not be afraid to
recommend complete redesign in such situations.
In some situations, there may be several options available to
correct or eliminate a root cause. In such cases, a structured
decision analysis method should be used to gauge competing
recommendations against criteria such as simplicity,
effectiveness, longevity, cost, etc. However, do not forget to
consider potential risks or side-effects of each
recommendation as well. In correcting one set of root causes,
be sure you are not creating another set of latent conditions
or weaknesses that could lead to future (perhaps completely
different) incidents.
Finally, once it is decided which lessons must be learned and
which actions must be taken, make one final check. Evaluate
the recommendations against the original incident. Ask
yourself "if we had known these lessons, and had these
measures in place, would the incident still have occurred?"
Similarly for the root causes, ask "... would these root causes
still exist?" Only when you can honestly answer "NO" to both
of these questions do you have a plan that has a good
chance of being effective.
40
Catatan Penutup
Hopefully, by this point you have begun to understand why
I've identified three different phases of Root Cause Analysis
and why they should be kept separate. I hope this one final
thought will help you understand completely: the three
phases of Root Cause Analysis differ in their balances of
objectivity versus subjectivity. Moving subjectivity too early
into the process ultimately destroys it's integrity.
Investigation must be completely objective, in order to
expose only factual relationships.
Analysis can be subjective, but only to the extent that
different systems or organizations have different
values, some of which may be contradictory or
incorrect.
41
Finally, note that in this whole article, I've not taken us past
the point of deciding what to do. In other words, what about
actually doing? In my opinion, that's a completely different
process, perhaps the subject of a future article. All I will say
at this point is that the Root Cause Analysis philosophy
outlined above fulfills the "Plan" portion of the "Plan-DoCheck-Adjust" cycle (PDCA). Hopefully, what I've written here
will help you Plan better!
42
Counter measures the do phase of the PDCA are
the actions the PDCA group will take to eliminate the root
causes, and ultimately prevent the problem from
recurring. These actions are specific activities that have
a clear function, a beginning and an end. Each counter
measure must tie back to a root cause, and each counter
measure must support achieving the goal statement. A
counter measure must have a begin date and a target
date (or expected date to complete). One member of the
PDCA group is responsible for ensuring the counter
measure is implemented by the target date; that group
member may only assist in doing the actual work or
many not even be involved in the actual work, but he or
she is ultimately responsible to ensure that it happens.
43
counter measure or stepping back and reviewing the
Point of Cause and Root Causes.
Follow-up is often the most ignored step in a PDCA cycle,
and is arguably the most critical.
7. Standardization
Standardization is developing the logistics of the process
so that work is performed the same way across
communities, companies, cities and states.
Standardization includes communication and education.
The group communicates the standard through sharing
the PDCA, creating a Standardized Work Instruction
Sheet (SWIS), creating a Value Stream or Process Map,
updating a manual, among other tools. The group
educates through reviewing a SWIS at a team meeting,
creating a certification program, one-on-one coaching,
and so on.
44
Menindaklanjuti hasil untuk membuat perbaikan yang
diperlukan. Ini berarti juga meninjau seluruh langkah
dan memodifikasi proses untuk memperbaikinya
sebelum implementasi berikutnya.
45
understood. (This is not to say that the tools are perfect,
because they're not.) However, the story is a little different in
the performance improvement area. The theoretical
underpinnings are generally not as well-developed, and while
there are a number of tools available, there is less knowledge
about the usefulness of the various tools.
A recent study by Dr. Anthony Mark Doggett [Ref 1] tries to
improve the state of knowledge regarding three tools used
widely in the performance improvement school of RCA: the
cause-effect diagram (CED), the interrelationship diagram
(ID), and the current reality tree (CRT). The purpose of the
study was to "...compare the perceived differences... with
regard to causality, factor relationships, usability, and
participation." In doing so, Doggett attempts to address the
perception that "...one tool is as good as another tool."
Note: Please have a look at my RCA Tools page if you're
interested in detailed information on other tools.
Hasil-hasil Statistik
A key feature of this study is that it is qualitative, and
measures perceived differences between the tools. The
measurements were obtained by having several groups of
college students actually perform RCAs. They were
introduced to the tools, given opportunities to ask questions,
and then presented with a problem and asked to "...find the
perceived root cause of the problem." Afterwards, the
students' perceptions were captured using question surveys
and analyzed statistically.
Participation: No statistical differences (between the 3
tools) were perceived regarding the ability to spark
constructive discussion in a group setting.
Causality: No statistical differences were perceived
regarding the ability to identify interdependencies
between causes, or to find root causes.
Factors: No statistical differences were perceived
regarding the ability to find factors (causes, effects, or
both), or relationships between them. However, posthoc testing showed that the CED was perceived to be
better at categorizing factors.
Usability: There were significant statistical differences
observed in this area. Generally, the CRT was judged to
be much harder to use than both the CED and the ID.
46
Contoh Analisis Faktor
Dalam kajian-kajian social seringkali peneliti membutuhkan
pengembangan pengukuran untuk bermacam-macam
variabel yang tidak dapat diukur secara langsung, seperti
persepsi, perilaku, pendapat, intelegensi, personality dan
lain-lain. Faktor analisis adalah metode yang dapat
digunakan untuk pengukuran semacam itu. Tujuan dari
analisis faktor adalah untuk menggambarkan hubunganhubungan kovarian antara beberapa variabel yang
mendasari tetapi tidak teramati, kuantitas random yang
disebut faktor. Vektor random teramati X dengann p
komponen, memiliki rata-rata dan matrik kovarian. Model
analisis faktor adalah sebagai berikut :
X 1 1 11 F1 12 F2 .... 1m Fm 1
X p p p1 F1 p 2 F2 .... pm Fm p
Atau dapat ditulis dalam notasi matrik sebagai berikut :
Fj
hi2 2i 1 2i 2 .... 2i m
47
r
i 1 j1
KMO =
r
i 1 j 1
2
ij
2
ij
a ij2
i 1 j 1
rk
1 p
rik
p 1 i 1 , k = 1, 2,...,p
48
2
rik
p ( p 1) i k
( p 1) 2 1 (1 r ) 2
p ( p 2)(1 r ) 2
Dengan :
r k = rata-rata elemen diagonal pada kolom atau baris ke k
dari matrik R (matrik korelasi)
r = rata-rata keseluruhan dari elemen diagonal
Daerah penolakan :
tolak H0 jika
(n 1)
p
2
(
r
r
)
(r k r ) 2 2 ( p 1) ( p 2) / 2;
2 ik
(1 r ) i k
k 1
49
Hasil-hasil Akar-Penyebab (Akar-Masalah)
Beyond the statistical results, the study examined the
ability of the students to identify root causes that were
specific and reasonable. Note that this factor was examined
separately from the usability factor discussed above.
CED: In general, students using the CED were not able
to identify specific root causes, even though they
perceived it to be better at "... facilitating productive
problem-solving activity, being easier to use, and more
readable."
ID: Students using the ID were able to find (i.e., identify
and agree upon) root causes, but they were of mixed
quality as regards specificity and reasonability.
Otherwise, the ID was perceived to be no worse than
the CED, in general.
CRT: The students perceived the CRT as complex and
difficult to use. However, even though most students
using the CRT were uncomfortable doing so, the quality
of their outputs was better. They were able to find root
causes most of the time, and with high integrity in over
half the cases.
50
Diagram CED Degradasi mangrove (Sumber:
http://thesisondisastermanagement.blogspot.com/2011_04_01_archive.htm
l
51
Contoh aplikasi ID :
An Interrelationship Digraph is used to analyze the cause and effect
relationships that exist between ideas so that the key drivers and
outcomes can be determined. An Interrelationship Digraph consists
of circularly positioned ideas with arrows indicating the direction of
influence of one idea upon another. Only the dominant direction of
influence is drawn, therefore arrows pointing in both directions
between ideas are not present in a traditional Interrelationship
Digraph (ID).
The following steps show how a traditional ID is constructed.
1. Define an issue or problem and collect the related ideas
(5 to 25 ideas).
2. Write the ideas on cards in large letters and arrange them
in a large circular pattern on a wall or other surface such
that arrows can be easily drawn between them.
52
CRT pada dasarnya tool untuk mencari akar masalah seperti halnya
fishbone diagram. Bedanya crt digambarkan dari atas ke
bawah.pada top diagram terdapat gejala masalah. Pertanyaan whywhy dapat kita angkat untuk mendapatkan apa penyebabnya.
Penyebabnya diletakkan di bawahnya dengan arah panah menuju
akibat (dalam hal ini gejala masalah). Hal ini terus dilakukan
sehingga kita tidak dapat lagi menemukan jawaban terhadap why.
Dengan demikian tidak ada pengelompokkan masalah seperti 4m /
5m dalam fishbone. Semuanya dibiarkan bebas agar keterkaitannya
dapat dilihat dengan jelas.
Pada prinsipnya sebab yang paling akhir di setiap ujung diagram
akan menjadi akar masalah yang harus dicari solusinya. Mungkin
saja CRT berujung pada satu akar masalah, mungkin juga banyak
akar-masalah. Jika yang belakangan terjadi, dalam terminologinya
ada yang dikenal dengan core problem, yaitu akar yang
menyebabkan dampak terbesar ~ 80%. Walau angka ini bisa
diperdebatkan, kalau bercermin dari konsep pareto, maka kita tidak
perlu ragu menggunakannya.
Pada prakteknya, diagram yang digunakan mirip dengan fault tree
analysis, setiap node dalam cabang masalah ini dikenal dengan
UDE undesireable effect. Solusi atau injection (meminjam istilah
pengobatan) pada akar dapat juga disertai injection pada UDE
karena boleh jadi ada prasyarat agar hasilnya lebih optimal.
Biasanya CRT digunakan untuk menggambarkan kondisi saat ini
(as-is). Oleh karenanya dengan CRT kita dapat mengetahui kondisi
pencemaran lingkungan pada saat ini. Kalau ingin membangun
kondisi yang seharusnya (to-be or should be) maka CRT dapat
dimodifikasi dengan memberikan injection di bagian tertentu plus
wording-nya diubah sesuai dengan kondisi yang diinginkan (kalimat
positif). Diagram baru ini disebut FRT (future reality tree).
53
54
55
56
Transition Tree (TrT) - describes in detail the actions that
will lead to the fulfillment of a plan to implement a certain
outcome, the expected intermediate states and the
assumptions of why one believes the actions will work.
57
Strategy & Tactics Tree (S&T) - a tool to develop
and integrate strategy and tactics to achieve
significant objectives. It uses many of the underlying
logic structures of the thinking process tools to create
synchronized implementation tactics that can be
evaluated and tested.
58
Checklists Akar-Masalah
Visi Akar-Masalah (The Root Cause Vision)
59
8. The fundamental causes can be found through
investigation and analysis.
9. If fundamental causes are modified appropriately, the
conditions necessary for occurrence of the problem will
cease to exist... thereby preventing recurrence of the
problem.
10.The activity by which fundamental causes are found
and corrected is called Root Cause Analysis.
Incident Response
60
5. Can anything else, besides this cause, lead to the
stated effect? (Are there alternative explanations that
fit better? What other risks are there?)
Pertanyaan tentang Human Error
61
2.
3.
4.
5.
62
you've got to have at least one acronym attributed to you.
Therefore, I hereby unleash the BOGUS test upon the world at
large, as defined by these five factors:
Beyond Control
Obvious
Grandiose
Unrelated
Simplistic
Obviously, BOGUS is an acronym. What makes BOGUS better
than most acronyms, however, is that it is easily
pronounceable, is spelled the same as a real English word,
and the meaning of that word is applicable to the concept. In
other words, it is the perfect acronym, and it is all mine! Well,
okay... you can use it too, but you should first read the
explanatory text below.
Beyond Control: Some conditions are beyond our control, like
stupidity, gravity, or the weather. We can't make them go
away, nor can we change their fundamental natures. The
problem is that by identifying such a condition as a cause, we
run the risk of deciding to ignore it because its "beyond our
control." The attribution of cause should instead be made to a
lack of protection against a hazard.
Obvious: At times, the cause of a problem seems completely
obvious -- so obvious that we can't resist naming it. Items
that fall in this category often involve actions by people,
including "operator error" and "lack of procedure
compliance." Stopping at this point is akin to finger-pointing,
though. People do what they do for a reason, good or bad...
dig deeper and find out why.
Grandiose: Sometimes you hear cause statements that make
you wish you knew what the investigator was smoking. "We
did not leverage our core competencies to instill a culture of
knowledge discovery and effect a paradigm shift to agile
performance..." is an example of a grandiose cause
statement. It would be better to say something like "... we
dont learn from our past mistakes, and that is hurting us."
There is virtue in simplicity -- try to distill cause statements
down to their pure essence.
Unrelated: We often have more than one problem to deal
with, and it can be tempting to tie one problem to another in
63
order to save time and effort. However, in doing so we must
ensure that we do not attempt to "force-fit" an unrelated
cause onto a different problem. In trying to kill two birds with
one stone, we might later find that both birds are alive and
well, and happily making new baby birds that can't wait to
grow up and come peck your eyes out.
Simplistic: Earlier I said that there is virtue in simplicity.
However, there is danger in being overly simplistic. We must
recognize that some problems are more complex than others,
and may result from the interaction of several different
causes. If we don't identify all the relevant interactions, we
may miss something truly important.
The best defenses against BOGUS cause determinations are
rigorous application of necessary and sufficient logic during
an investigation, and requiring corroborating evidence for
every causal claim. Then when you're done investigating, use
the BOGUS test as a final check of root cause statements,
prior to developing corrective actions. Think of it as a quality
control check of your root cause analysis.
Alternatively, you might want to use the BOGUS test if you're
responsible for giving final approval for implementation of a
corrective action plan. Please do me a favour, though... if you
do decide to reject a report because of the BOGUS test, don't
tell the report's author about me. I don't need that kind of
attention!
64
Pros
Cons
Definisi-definisi
65
Control: A mechanism intended to prevent undesired effects
to the target. A control is often active, i.e. its protective
nature is brought into being through the actions of an agent.
Countermeasure: A barrier or control intended to cut off a
pathway between hazard and target.
Hazard: An agent that can adversely affect a target.
Pathway: A route or mechanism that provides the means, or
medium, through which a hazard can affect a target.
Target: An object that requires protection, or needs to be
maintained in a particular range or set of conditions.
Diskusi
At the heart of barrier analysis is the concept of the target.
The primary quality of a target is that it exists under a
specified range or set of conditions, and that we require it to
be maintained within that specified range or set of
conditions. This very general quality means that almost
anything can be a target -- a person, a piece of equipment, a
collection of data, etc.
Given the concept of the target, we then move to the means
by which a target is adversely affected. By adverse effect, we
mean that the target is somehow moved outside of it's
required range or set of conditions. Anything that does this is
called a hazard. This is a very general quality -- almost
anything can be a hazard. However, it is possible to uniquely
define hazard/target pairs by the pathways through which
hazards affects targets.
Having identified hazards, targets, and the pathways through
which hazards affect targets, we arrive at the concepts of
barriers and controls. These are used to protect and/or
maintain a target within it's specified range or set of
conditions, despite the presence of hazards. The primary
quality of a barrier or control is that it cuts off a pathway by
which a hazard can affect a target.
Barriers and controls are often designed into systems, or
planned into activities, to protect people, equipment,
66
information, etc. The problem is that design and planning are
rarely perfect. All hazards may not be identified beforehand,
or unrecognized pathways to targets may surface. In both of
these cases, appropriate barriers and controls may not be
present. Even if they are present, they may not be as
effective as originally intended. As a result, targets may lack
adequate protection from change or damage.
The purpose of barrier analysis is thus to identify pathways
that were left unprotected, or barriers and controls that were
present but not effective. All pathways relate to specific
hazard/target pairs, and all barriers and controls relate to
specific pathways. Success in barrier analysis depends on the
complete and thorough identification of all pathways.
Konsep-konsep
Energi dan Perubahan
The concept of energy has historically been used to
characterize the pathways by which hazard affects target.
Very generally, energy is any physical quantity that can
cause harm. There are many types of energy, including
electrical, mechanical, hydraulic, pneumatic, chemical,
thermal, radiation, etc. Note again that these are all physical
quantities, and can only be used to describe physical
hazards. Consequently, the types of barriers and controls that
can be considered are primarily physical in nature, or relate
to physical harm.
More recently, hazard pathways have been characterized by
the concept of change. This concept is based on the
recognition that any change in a target's condition, physical
or otherwise, could be detrimental or undesired. This allows
us to consider hazards and damage mechanisms other than
the purely physical, and can lead us into areas that are more
administrative, knowledge based, or policy based in nature.
Furthermore, the concept of change does not prevent us from
investigating purely physical phenomena.
The pathway characterization (or viewpoint) affects the types
of hazards, targets, and damages that will be seen and
considered during investigation and analysis. Investigation
from a purely energy-based viewpoint will tend to
67
concentrate on physical, energy-based hazards and damage
mechanisms. Alternatively, a change-based viewpoint can be
used to find both physical and non-physical damage
pathways. For this reason, it is recommended that a changebased characterization for hazard/target pathways be
adopted for general usage.
Efektivitas Umpan-balik
68
creation of the hazard. This is rarely (if ever) practical,
however. We are then forced into designing or planning
countermeasures that merely reduce risk. This means that no
single countermeasure can ever be 100% effective.
Reduction of risk to acceptable levels often requires the use
of multiple, diverse countermeasures. Multiple, because
usually no single countermeasure can provide the required
risk reduction. Diverse, because the possibility of commonmode failure itself increases overall risk. Barrier analysis thus
needs to consider all the following:
where countermeasures should have been provided, but were
not;
how existing countermeasures failed to prevent undesired
change;
whether an appropriate mix of multiple and diverse
countermeasures
was
provided;
and
if the overall risk of undesired change was acceptable.
Kelemahannya
The
use
of
barrier
analysis
presupposes
that
countermeasures were considered during the design of a
system, or planning of an activity. The results of a complete
and thorough barrier analysis may identify many
opportunities to create new countermeasures, or to improve
existing countermeasures. However, given the same
consequence to investigate, different investigators might
propose any of the following (or variations and/or
combinations thereof) as root causes:
69
as a root cause analysis tool. It is therefore recommended
that
barrier
analysis
results
always
be
reviewed
independently, and that barrier analysis never be used as the
sole method for determining root causes.
In the opinion of the author, the only statement above that
qualifies as a potentially valid root cause statement is the
first, "preliminary hazard analysis was inadequate." This
statement could then be qualified with supporting evidence
and analysis; in fact, all the other items listed might be
provided to illustrate how the preliminary hazard analysis
failed.
70
Pros
Cons
Definisi
71
DEVIASI: A situation in which actual results or actual
performance differed from what was expected.
Diskusi
As suggested by the name of the technique, change analysis
is based on the concept that change (or difference) can lead
to deviations in performance. This presupposes that a
suitable basis for comparison exists. What is then required is
to fully specify both the deviated and undeviated conditions,
and then compare the two so that changes or differences can
be identified. Any change identified in this process thus
becomes a candidate cause of the overall deviation.
What is a suitable basis for comparison? There are basically
three types of situations that can be used. First, if the
deviation occurred during performance of some task or
operation that has been performed before, then this past
experience can be the basis. Second, if there is some other
task or operation that is similar to the deviated situation,
then that can be used. Finally, a detailed model or simulation
of the task (including controlled event reconstruction) can be
used, if feasible.
Once a suitable basis for comparison is identified, then the
deviation can be specified. Various schemes exist for
performing this specification. Perhaps the most useful
scheme (attributed to Kepner and Tregoe) involves four
dimensions (WHAT, WHERE, WHEN, and EXTENT) and two
aspects (IS and IS NOT). Regardless of the scheme used, the
end result should be a list of characteristics that fully
describe the deviated condition.
Given the full specification of the deviated condition, it
becomes possible to perform a detailed comparison with the
selected undeviated condition. Each difference between the
deviated and undeviated situations is marked for further
investigation. In essence, each individual difference (or some
combination of differences) is a potential cause of the overall
deviation.
After the potential causes are found, each is reviewed to
determine if it could reasonably lead to the deviation, and
under what circumstances. The most likely causes are those
72
that require the fewest additional conditions or assumptions.
In this way, a large list of potential causes can be whittled
down to a short list of likely causes. Finally, given the likely
causes, the actual or true cause(s) must be identified.
Generally speaking, the only way to verify which likely cause
is the true cause is by testing.
The purpose of change analysis is thus to discover likely
causes of a deviation through comparison with a nondeviated condition, and then to verify true causes by testing.
True causes found using change analysis are usually direct
causes of a single deviation; change analysis will not usually
yield root causes. However, change analysis may at times be
the only method that can find important, direct causes that
are obscure or hidden. Success in change analysis depends
ultimately on the precision used to specify a deviation, and in
verification of true cause through testing.
Konsep-konsep
Perubahan (Change)
Change is introduced in all factors of life continuously. Some
sources of change are planned, as in deliberate actions taken
to achieve a purpose. Other sources of change are
unplanned, as in natural, random variation, or as in factors
introduced unintentionally due to outside influences or as the
result of error. Whatever the source, change is often a source
of disruption in the normal, expected, or usual flow of events.
When change is not accounted for or compensated, it can
lead to deviations.
As discussed above, change analysis depends on the
recognition of changes or differences that could have led to a
specific deviation. Sometimes, however, multiple changes
may have occurred over time that combine to cause the
deviation. Therefore, it is important for the investigator to
consider combinations of changes or differences as potential
causes, in addition to individual changes or differences.
73
74
Cons
75
Definisi
76
Diskusi
Tree structures are often used to display information in an
organized, hierarchical fashion: organization charts, work
breakdown structures, genealogical charts, disk directory
listings, etc. The ability of tree structures to incorporate large
amounts of data, while clearly displaying parent-child or
other dependency relationships, also makes the tree a very
good vehicle for incident investigation and analysis.
Combination of the tree structure with cause-effect linking
rules and appropriate stopping criteria yields the causal
factor tree, one of the more popular investigation and
analysis tools in use today.
Typically, a causal factor tree is used to investigate a single
adverse event or consequence, which is usually shown as the
top item in the tree. Factors that were immediate causes of
this effect are then displayed below it, linked to the effect
using branches. Note that the set of immediate causes must
meet certain criteria for necessity, sufficiency, and existence.
More information on what constitutes a necessary and
sufficient cause can be found in this article on the definition
of cause. Proof of existence requires evidence.
Once the immediate causes for the top item in the tree are
shown, then the immediate causes for each of these factors
77
can be added, and so on. Every cause added to the tree must
meet the same requirements for necessity, sufficiency, and
existence. Eventually, the structure begins to resemble a
tree's root system. Chains of cause and effect flow upwards
from the bottom of the tree, ultimately reaching the top level.
In this way, a complete description can be built of the factors
that led to the adverse consequence.
Often, an item in the tree will require explanation, but the
immediate causes are not yet known. The causal factor tree
process will only expose this knowledge gap; it does not
provide any means to resolve it. This is when other methods
such as change analysis or barrier analysis can be used to
provide answers for the unknowns. Once the unknowns
become known, they can then be added to the tree as
immediate causes for the item in question.
Each new cause added to the tree should be evaluated as a
potential endpoint. When can a cause be designated as an
endpoint? This is an object of some debate. Several notable
RCA practitioners use some version of the following criteria:
The cause must be fundamental (i.e. not caused by
something more important), AND
The cause must be correctable by management (or
does not require correction), AND
If the cause is removed or corrected, the adverse
consequence does not occur.
These three criteria, taken together, are basically just a
statement of the most-widely used definition for "root cause".
An alternate set of criteria, preferred by the author, is
presented below. Note that these are all referenced to the
system being analyzed. (An article deriving and explaining
these criteria is forthcoming.)
The cause is a system response to a requirement
imposed from outside the system, or
The cause is a contradiction between requirements
imposed from within the system, or
The cause is a lack of control over system response to
a disturbance, or
The cause is a fundamental limit of the system design.
A causal factor tree will usually have many endpoints. The
set of all endpoints is in fact a fundamental set of causes for
the top consequence in the tree. This fundamental set
includes endpoints that would be considered both beneficial
or detrimental; every one of them had to exist, otherwise
the consequence would have been different. Endpoints that
require corrective action would typically be called root
78
causes, or root and contributing causes if some scheme is
being used to differentiate causes in terms of importance.
Sumber: http://www.oxenrideronsynergy.com/2011/09/creativeroot-cause-analysis-terminology/
79
Root Causes: Factors that fuel (feed) the surface problem
Analysis:
doi:10.1136/bjsm.2008.054700)
The built environment and physical activity agenda provides a
unique opportunity for public health, physical activity and
planning researchers to be front and centre of a movement
aimed at creating healthier and more sustainable environments.
However, in order to optimise environments that encourage
physical activity across the life course, researchers in this field
need to think beyond their square that is, the target group,
setting and physical activity behaviour with which they work.
We suggest that researchers working in this field need a better
understanding of systems theory to appreciate that a change to
one part of a complex system can positively and negatively
influence other parts of the system. An understanding of
systems theory would help minimise unintended negative
consequences to other population subgroups or to other types
of physical activity from the implementation of our research
findings. In this way, a more comprehensive set of research,
practice and programme-related activities may emerge, which
will advance physical activity research and practice, and
improve population health across the life course.
80
In summary, the causal factor tree is an
investigation/analysis tool that is used to display a logical
hierarchy of all the causes leading to a given effect or
consequence. When gaps in knowledge are encountered, the
tree exposes the gap, but does not provide any means to
resolve it; other tools are required. Once the required
knowledge is available, it can be added to the tree. A
completed causal factor tree provides a complete picture of
all the actions and conditions that were required for the
consequence to have occurred. Success in causal factor tree
analysis depends on the rigour used in adding causes to the
tree (i.e., ensuring necessity, sufficiency, and existence),
and in stopping any given cause-effect chain at an
appropriate endpoint.
81
82
Agregasi
83
84
pencemaran
sungai
85
86
3. Adjust the structure wherever necessary and revise
statements;
4. Delete objectives that are not desirable;
5. Check whether rewording will lead to meaningless or
ethically questionable statements; in that case, reformulate
the objective or indicate that this problem cannot be solved
in the given context; and
6. Add new objectives if they appear to be relevant and
necessary in order to achieve the stated objective at the
next higher level.
87
strategy (or strategies) to pursue. The figure below summarizes the
passage from the situation analysis to planning:
88
89
5. ANALYZE - Analyze the why: break down the script
and determine critical points, figure out what should
have happened, find the gaps between actual and
expected, uncover key forcing factors, determine
extent of cause.
6. DESIGN - Design the solution: find the weaknesses,
pick the points of most leverage, develop solution
options, decide on best combination of actions,
validate the plan, get buy-in and funding.
7. EXECUTE - Execute the plan: develop timeline, obtain
materials, marshall resources, initiate action, monitor
performance, verify completion.
8. REVIEW - Review effectiveness: check for recurrence
of original problem, check for instances of related
problems, verify actions taken still relevant, assess
continued risk.
9. ADJUST - Adjust the plan: address deficiencies in
execution, assess effects of changes from outside the
plan, identify new/revised actions needed to ensure
effectiveness.
Stages 4 - 6 above are discussed more thoroughly in Phases
of Root Cause Analysis... however, note that the phase
previously referred to as Decide is now designated Design. I
just thought Design captured the intent better.
90
91
them, we prevent large events as well. However, using this
strategy, do we limit the severity of potential future events?
Suppose we analyze only small events. We'll have a lot of
data on common event initiators and latent conditions. As
we'll have a lot of data, we'll develop a very good
understanding of the events and our corrective actions will be
very good. We'll knock down the frequency of these events
by a significant amount, perhaps even eliminate them
completely.
Again, we have to ask the question, have we limited the
severity of potential future events? If we assume that all
events, large and small, have the same root causes, then the
answer is yes. Is this true though? What makes a small event
different from a large event?
92
done is to lie down on the floor, and hold the grinder above
him to get at the bottom of the piece he's grinding. He has
every intention of being very careful. However, he has just
removed his ability to avoid a kickback if it occurs. The
weight of the grinder is now working against him, as well.
The job starts out fine. Then the grinder catches on
something. It kicks back. The worker can't avoid it. The
mechanics of the event are such that the grinder moves
laterally towards the worker's head. The worker receives an
extremely serious laceration to his face.
This is a "large" event. You would never have expected it to
happen. The circumstances of the event were unusual. The
probability of the event happening again appears to be low.
Should we subject this event to a detailed root cause
analysis?
Of course we should! We should investigate and analyze the
heck out of this event. However, we must not limit ourselves
to the question of "why did the worker use the grinder that
way." We must instead find out "what is it about the way we
do business that: set up this situation, forcing the worker to
make this choice; convinced the worker that he needed to do
the job this way; kept him from taking more time to get a
different tool or to rotate the piece he was working on."
I'm not making this up. It actually happened two years ago.
The worker required extensive reconstructive surgery to one
side of his face. It was pure luck that he didn't lose his nose
or one of his eyes.
In conclusion, my belief is that we must investigate and
analyze the sporadic, large events. So what if the probability
of occurrence is low? Remember that risk is probability times
consequences. If the potential consequences are high, we
must do what we can to prevent those consequences from
occurring -- even if it is a low probability event. Sometimes, a
sample of one is more significant than a sample of thousands.
93
94
applicability? We might very well continue using the model
without realizing that it no longer applied.
What other types of models do we employ in root cause
analysis? In some cases, we may develop engineering models
for physical processes, in order to understand how a failure
occurred. In others, we might model an industrial processes
to show where bottlenecks are constraining throughput.
These types of models are used quite frequently, and
generally require specialized knowledge to use properly.
However, the difficulty of developing and using such models
may actually pale in comparison to the modeling of human
behaviour.
Sumber:
http://www.reallysimplebusinesstools.com/content/simplemodel-human-behavior)
95
Beliefs - Beliefs are determined by an individuals past
experiences - the past positive and negative benefits that
have been recieved - or by the expected future benefit. For
example I believe that I will get a bonus if I work very hard
because I did last time (or the negative I believe I will be
ignored and no one will care if I work hard because that is
what happened last time). There are very strongly held
beliefs (values) and weaker ones. You aren't going to change
someone's core beliefs without momentous effort, so you
should focus on the weaker held beliefs. Hire for the strong
beliefs and coach and guide someone to change the weaker
ones such as the example above.
Behaviors - Behaviors are beliefs in action. These actions
are visible, and can be observed. For example Sue stays late
to get a project done and completed to high quality.
Benefits - Benefits can be either positive or negative. The
more immediate the benefit, the more powerful the impact
on beliefs and future behaviors. It is important to note that
benefits can be intrinsic or extrinsic and that the benefit is
only what the person persieves the benefit to be. So if you
give someone a bonus but this person doesn't value money
as much as praise they won't get the benefit you intended
them to get. Also people can get intrinsic benefits such as
feeling proud for their work.
96
different is the sharp focus on failure propagation. The
underlying assumption tends to be that accidents start as
relatively simple, minor events that eventually spiral out of
control. In fact, most recently developed accident models
tend to be system models that focus attention on complex
interactions between multiple, lower-level failures or
infractions.
97
MODEL: What is an Ecosystem?
An ecosystem is a group of living and non-living components
interacting together on a given physical landscape. The size
of an ecosystem is arbitrary and could be as small as a few
square centimeters if you are looking at a soil microbial
ecosystem; as large as thousands of square kilometers if you
are looking a biome like the Great Plains ecosystem; or a few
hectares if you are looking at a single forest stand ecosystem.
One way to learn more about how a forested
ecosystem works is to build a model.
An ecosystem model is an accurate but simplified
representation of an ecosystem that can be very useful in
thinking about or simulating the actions of a real ecosystem.
Because any ecosystem has many different but interrelated
components, the best way to understand the system is to
break it down into its component parts. To get an introduction
to a very simplified forest model, see our Forest Ecosystem
Gamewhich gives participants and introduction to how a
hardwood forest ecosystem works before and after exotic
earthworms invade.
Step One:
The first step in building a graphical model of a hardwood
forest ecosystem is to identify its major components.
The components of any ecosystem are those physical things
that contain energy and nutrients. In a graphical Forest
Ecosystem, these components are often illustrated using
boxes like in Figure 1 below.
98
Some components of
illustrated using boxes
graphical
forest
ecosystem
99
100
or nutrients are represented. You will see why this is
important a little later.
Now lets add the animals and the people components to our
ecosystem. You can see in Figure 3 below that energy &
nutrients flow from the trees and understory plants to the
animals when they eat the leaves, twigs and buds of trees or
graze on understory plants; and when the animal excrete
waste products or die, energy & nutrients are returned to the
forest floor component. Since people are really just a special
kind of animal, you can see that energy & nutrients flow from
the trees to people when they eat something from a tree, like
maple syrup Read more.
101
Step Three:
Determine the major inputs and outputs of your ecosystem.
As you are building your ecosystem model, one thing to think
about is whether your ecosystems could be opened or closed.
A closed ecosystem is one that has no inputs of energy or
nutrients from outside the ecosystem and no outputs of
energy or nutrients leaving the system. The earth is an
example of a closed ecosystem with respect to nutrients and
an open ecosystem with respect to energy (see figure 4
below). All the nutrients that have ever been on earth are
here and simply continue to cycle, there are no additions or
losses. However, the earth is constantly getting inputs of
energy from the sun and simultaneously radiating energy
back. The earth doesnt heat up too much or cool down too
much because the earths energy balance is in a relatively
stable equilibrium, meaning that the amount of energy being
input and output are about equal.
102
103
Some typical inputs and outputs of nutrients and energy for forested
ecosystems include evapotranspiration, nutrient leaching, sunlight and rain.
Step Four:
Once you have identified the components, processes and
major inputs and outputs in your ecosystem model, then you
can begin to add the actual values to these parts of your
ecosystem by measuring them. For example, you could
measure the amount of litter that falls to the forest floor each
year (a process), what the biomass of trees is in a given
forest (a component), how much light reaches the forest over
a growing season (an input), or how much nitrogen leaches
from the forest (an output). Needless to say, some of these
things are easier to measure than others and for most of
these things it would be very hard to directly measure the
value for a whole forest. For example, it would be hard to
104
catch every single leaf that fell from the trees in a given year
and weigh them all! So, researchers estimate these values
taking samples of the given measurement they want to know.
In the case of leaf litter, you can put out trays in the forest
and after all the leaves have fallen for the year, dry and
weight the leaf liter in your trays. They you can use that
value to calculate an estimate of the total leaf litter for your
forest.
Step Five:
Use your ecosystem model to think about how changes can
cascade through an ecosystem or to ask specific questions
that can be answered with further research. When the major
components, processes and inputs and outputs of an
ecosystem are understood, then you can use the model to
see how changing one part of the ecosystem affects other
parts. For example, if you harvest trees from your forest, that
will decrease the amount of leaf litter reaching the forest
floor each year which may lead to decreases in available
nutrients for understory plants. This is the type of thing forest
ecology researchers often study.
For example, researchers may monitor soil nutrient levels for
many years after trees have been harvested to see how the
real forest behaves compared to what they thought might
happen based on their forest model, their understanding of
how the forest works. If the results in the real forest are very
different than those predicted by their model, then they know
that they dont have full understanding of how their forest
works and they may go back to try to improve their model.
105
106
107
3.
4.
5.
6.
7.
108
Penyebab
ketidakoptimalan
dan
ketidakstabilan
produktivitas tanaman padi tersebut adalah rendahnya
ketersediaan unsur hara, ketersediaan air yang terbatas,
serta gangguan fungsi penunjang mekanik tanah tersebut.
Ketersediaan unsur hara yang rendah dapat disebabkan oleh
erosi, maupun karena rendahnya keragaman mikroorganisme
di dalam tanah tersebut. Penyebab utama erosi ialah
kelerengan yang cukup curam dan terjadinya pencucian hara
akibat runoff. Hal ini disebabkan oleh kurangnya penutup
tanah, baik itu berupa pohon maupun seresah, di permukaan
tanah. Sedangkan rendahnya keragaman mikroorganisme
dalam tanah disebabkan oleh kandungan C-organik dalam
tanah yang rendah pula. Rendahnya kandungan C-organik
tanah dapat disebabkan oleh pencucian hara, kurangnya
bahan organik dalam tanah, serta pengolahan tanah yang
terlampau intensif.
109
Sumber: http://meelaisme.wordpress.com/2011/10/19/analisis-masalahdan-akar-masalah-penanaman-padi-sawah-irigasi-oryza-sativa-pada-tanahseri-tlogorejo/)
110
111
What - Action plan, specifying activities that will lead to
achieving target
When - Time frame, deadline for the activities
How
112
mempercepat, mengoptimalkan setiap perubahan itu sendiri.
Pendidikan mampu mengubah manusia dan manusia itu
sendiri yang mampu mengubah pendidikan. Oleh sebab itu
tidak sedikit kini muncul berbagai paradigma baru dalam
sistem pendidikan sebagai bukti nyata bahwa pendidikan
berubah seiring dengan perubahan manusia. Dan manusia
pun berubah seiring dengan perkembangan sistem
pendidikan itu sendiri.
Manusia senantiasa akan berupaya mengeksplorasi
segala sumber daya yang dimilikinya. Dengan cara
mencurahkan segala daya dan kemampuanya untuk selalu
berinovasi menemukan sesuatu yang baru yang dapat
membantu hidupnya menjadi lebih baik. Jika manusia tidak
menggali segala kemampuanya maka ia akan tertinggal
bahkan tergerus oleh zaman yang selalu berkembang.
Dalam dunia penelitian dan pendidikan, Inovasi
merupakan hal yang mutlak dilakukan karena tanpa inovasi
akan terjadi kemandekan pada dunia pendidikan yang
kemudian berimbas pada pada elemen-elemen kehidupan
yang lain seperti politik, ekonomi, sosial dan lain-lain.
Pertanyaan yang terbentuk kini adalah realisasi prinsip dasar
inovasi untuk pemecahan masalah atau kebermaknaan
inovasi itu sendiri. Hal ini berangkat dari bahwa segala
macam proses berawal dari perencanaan yang matang if
you fail to plan, you plan to fail sehingga konteks analisis
akar masalah lebih kentara pada proses perencanaan inovasi
demi memunculkan solving, perubahan dan memunculkan
inovasi. Meskipun tidak sellu inovasi adalah perubahan,
namun diyakini bahwa perubahan merupakan bagian dari
inovasi.
Implementasi Fishbone Diagram (Kaoru
Ishikawa) dalam Merencanakan Inovasi
Pendidikan.
1. Merencanakan Inovasi Pendidikan
Berdasarkan pada 6 prinsip dasar inovasi pendidikan
maka setidaknya kita tidak akan semena-mena dalam
merencanakan inovasi. Kembali ketitik awal bahwasanya
proses inovasi dapat bermula dari munculnya kesenjangan
(GAP), ketidaksesuaian sehingga diperlukan pembaharuan,
perubahan atau tindakan korektif atau kebijakan baru yang
sifatnya inovatif, meskipun setiap perubahan belum berarti
inovasi namun setiap inovasi meski di dalamnya adalah
perubahan.
113
Singkatnya langkah langkah secara global sebagai berikut di
bawah ini:
1. Dokumentasi gap atau kesenjangan dan
ketidaksesuaian (proses). Baik secara kuantitatif
maupun kualitatif. Hingga terbentuk prosses
flowchart.
2. Identifikasi kebutuhan (demand) pelanggan
dalam hal ini pengguna jasa pendidikan.
3. Menganalisis gap dan kesenjangan dan
ketidaksesuaian (analisa proses) tersebut.
4. Pengembangan tindakan korektif (root causes
analysis)
5. Implementasi inovasi.
6. Validasi.
Tahapan tersebut di atas menunjukkan bahwa root causes
analysis memegang peranan penting dalam menentukan
kebijakan selanjutnya (korektif/pembaharuan/inovasi).
Gejolak, Penomena, Gap, Ketidak sesuian yang terjadi dalam
proses pendidikan atau berbagai permasalahan yang aktual
baik teoritis maupun paraktis, baik dalam tatanan makro
maupun mikro, bahkan skup yang lebih kecil seperti
permasalahan di dalam kelas dijadikan sandaran dalam
berinovasi di dunia pendidikan. Namun untuk kebermaknaan
suatu inovasi tetap harus mengusung prinsip-prinsip inovasi
itu sendiri. Untuk itu salah satunya, masalah yang diungkap
haruslah terlebih dahulu dinalisis (akar masalah) sehingga
inovasi betul-betul berkenaan dan bermakna (mainfull).
Berikut di bawah ini adalah diagram framework dimana
esensi analisis akar masalah demi mewujudkan inovasi
pendidikan yang penuh makna.
114
115
3. Menggambarkan diagram dengan pertanyaan
masalah ditempatkan pada sisi kanan (membentuk
kepala ikan) dan kategori utama seperti: material,
metode, manusia, mesin, pengukuran dan
lingkungan ditempatkan pada cabang-cabang
utama (membentuk tulang-tulang besar dari ikan).
Kategori utama ini bisa diubah sesuai dengan
kebutuhan.
4. Menetapkan setiap penyebab dalam kategori utama
yang sesuai dengan menempatkan pada cabang
yang sesusai.
5. Untuk setiap penyebab yang mungkin, tanyakan
mengapa? untuk menemukan akar penyebab,
kemudian daftarkan akar-akar penyebab masalah
itu pada cabang-cabang yang sesuai dengan
kategori utama (membentuk tulang-tulang kecil
dari ikan). Untuk menemukan akar penyebab, kita
adapat menggunakan teknik bertanya mengapa
lima kali (Five Why).
6. Menginterpretasikan diagram sebab akibat itu
dengan melihat penyebab-penyebab yang muncul
secara berulang, kemudian dapatkan kesepakatan
melalui konsensus tentang penyebab itu.
Selanjutnya fokuskan perhatian pada penyebab
yang dipilih melalui konsensus itu.
7. Menerapkan hasil analisis dengan menggunakan
diagram sebab-akibat itu dengan cara
mengembangkan dan meng-implementasikan
tindakan korektif, serta memonitor hasil-hasil untuk
menjamin bahwa tindakan korektif yang dilakukan
itu efektif karena telah menghilangkan akar
penyebab dari masalah yang dihadapi.
116
117
Bercabang hingga mencapai lima yang menggambarkan sub
tulang ikan itu sendiri. Dimana kategori utama Manusia,
Pengukuran, Metode, Materia, Mesin dan Lingkungan dapat
diganti sesuai kebutuhan misalkan, dalam konteks
permasalahan penurunan kualitas lulusan bisa diganti
dengan: Sarana Belajar, Orang tua, Teman Sekolah,
Kurikulum, Guru, Kepala Sekolah, Lingkungan Belajar, dll.
3. Implementasi Root Cause Analysis menggunakan
Fishbone Diagram dalam Perencanaan Inovasi
Pendidikan
Penerapan atau implementasi Fishbone Diagram dalam
analisis akar masalah dalam berinovasi di bidang pendidikan,
berikut di bawah ini langsung disajikan dalam bentuk contoh
root cause analysis dalam bidang pendidikan.
Contoh 1.
Masalah: Mengapa Kualitas Lulusan SDM Rendah?
Kategori Utama
Sebab 1 (Sb1): Guru/Dosen
Sebab 2 (Sb2): Siswa
Sebab 3 (Sb3): Masyarakat
Sebab 4 (Sb4): Kurikulum
Five Why: Why Sebab 1 Sebab 2 Sebab 3 Sebab 4
1. Why 1. Guru/Dosen kurang kompeten/tidak banyak
belajar. Siswa input (lulusan sekolah sebelumnya)
kurang berkualitas. Masyarakat kurang peduli
kualitas lulusan siswa. Kurikulum kurang tepat atau
salah arah.
2. Why 2. Guru/Dosen mengajar ditempat lain atau
sibuk mencari uang tambahan. Unit pemroses
lembaga pendidikan sebelumnya berkualitas
rendah (guru, fasilitas, dll). Masyarakat sudah
menganggap biasa atau terbiasa dengan KKN Ada
kepentingan tidak etis dalam penyusunannya
3. Why 3. Kesejahteraan kurang. Anggaran APBN
Rendah (BOS tidak normal). Rekruitmen siswa dan
SDM tidak bersih atau transaparan . Tidak ada
akses kontrol untuk masyarakat atau pemerhati
pendidikan
4. Why 4. APBN tidak mencukupi Pajak negara
terserap sedikit. Ada ketidak sesuaian penerapan
118
kebijakan. Sistem demokrasi anomali yang sarat
akan KKN
5. Why 5. Pajak banyak hilang korupsi merajalela
(temuan...). Korupsi dan sadar pendidikan moral
rendah. Korupsi dan sadar pendidikan moral
rendah. Korupsi dan sadar pendidikan moral
rendah.
Atau tampilan deskripsi dapat berupa catatan demikian yang
jika diterapkan dalam fishbone diagram memunculkan
gambaran tulang besar dan tulang kecil ikan. Sebagai
berikut:
Sb1-1:
Guru/Dosen kurang kompeten/tidak
banyak belajar
Sb1-2:
Guru/Dosen mengajar ditempat lain atau
sibuk mencari uang tambahan
Sb1-3:
Kesejahteraan kurang
Sb1-4:
APBN tidak mencukupi
Sb1-5:
Pajak banyak hilang korupsi merajalela
(temuan...)
Sb2-1:
Siswa input (lulusan sekolah sebelumnya)
kurang berkualitas
Sb2-2:
Unit pemroses rendah (guru, fasilitas, dll)
Sb2-3:
Anggaran APBN Rendah (BOS tidak
normal)
Sb2-4:
Pajak negara terserap sedikit
Sb2-5:
Korupsi dan sadar pendidikan moral
rendah
Sb3-1:
Masyarakat kurang peduli kualitas lulusan
siswa
Sb3-2:
Masyarakat sudah menganggap biasa
atau terbiasa dengan KKN
Sb3-3:
Rekruitmen siswa dan SDM tidak bersih
atau transaparan
Sb3-4:
Ada ketidak sesuaian penerapan
kebijakan
Sb3-5:
Korupsi dan sadar pendidikan moral
rendah
Sb4-1:
Kurikulum kurang tepat atau salah arah
Sb4-2:
Ada kepentingan tidak etis dalam
penyusunannya
Sb4-3:
Tidak ada akses kontrol untuk masyarakat
atau pemerhati pendidikan
Sb4-4:
Sistem demokrasi anomali yang sarat
akan KKN
119
Sb4-5:
120
1. Why 1. Guru kurang kompeten. Siswa kuarang
antuasias belajar. Masyarakat kurang peduli kualitas
jasa pendidikan. Membutuhkan banyak praktek dan
referensi. Referensi dan praktek kurang memadai
2. Why 2. Fasilitas pendidikan dan pelatihan kurang.
Teacher center dan pembelajaran sering konvensional.
Masyarakat hanya sekedar berpifikir tentang lulus dan
tidak lulus. Tujuan kurikulum banyak . Buku, Alat dan
bahan kurang memadai
3. Why 3 Tidak ada waktu dana pendukung. Kurangnya
referensi atau buku sumber dan praktek. Terlalu
percaya pada sekolah. Materi yang harus disampaikan
banyak. Keterbatasan Dana
4. Why 4 Pendanaan dari pribadi, pemerintah dan komite
sekolah kurang lancar Kurangnya fasilitas. Membatasi
diri hanya berpikir tentang kelangsungan pendidikan
siswa (ekonomi). Tuntutan kelulusan untuk
melanjutkan kuliah Keterbatasan bantuan dari
pemerintah maupun komite sekolah
5. Why 5 Alokasi dana pemerintah dan siswa terbatas.
Alokasi dana pemerintah dan siswa terbatas. Angapan
ekonomi lebih utama untuk kehidupan dibanding
lainnya. Perbaikan pendidikan untuk perbaikan
ekonomi. Alokasi dana pemerintah dan siswa terbatas
Atau tampilan deskripsi dapat berupa catatan demikian yang
jika diterapkan dalam fishbone diagram memunculkan
gambaran tulang besar dan tulang kecil ikan. Sebagai
berikut:
Sb1-1:
Guru kurang kompeten
Sb1-2:
Fasilitas pendidikan dan pelatihan kurang
Sb1-3:
Tidak ada waktu dan cana dukungan
Sb1-4:
Pendanaan pribadi, pemerintah dan
komite sekolah kurang
Sb1-5:
Alokasi dana pemerintah dan siswa
terbatas
Sb2-1:
Siswa kurang antusias belajar
Sb2-2:
Teacher center
Sb2-3:
Kurangnya referensi atau buku sumber
dan praktek
Sb2-4:
Kurangnya fasilitas
Sb2-5:
Alokasi dana pemerintah dan siswa
terbatas
Sb3-1:
Masyarakat kurang peduli kualitas jasa
pendidikan
121
Sb3-2:
122
Diagram tulang-ikan: Rendahnya IPK mahasiswa (Sumber:
gkm1.blogspot.com)
Akar masalah dari suatu system pendidikan adalah
keterbatasan pendanaan baik dari pemerintah maupun
komite sekolah untuk menunjang proses belajar baik tingkat
profesional/komptensi guru maupun siswa. Sehingga
solusinya adalah penggalangan dana atau
pengalokasian/pendistribusian dana yang diterima sekolah
untuk menutupi kekurangan tersebut. Konteks tersebut di
atas tidak mutlak, artinya hasil analisis akar maasalah
bergantung pada individu/Tim melaksanakan Brainstorming.
Bahkan kajian seperti di atas (kesulitan belajar) bisa
dipersempit skupnya dalam konteks materi, metode
mengajar, media, guru, siswa, dll, bergantung pada sudut
pandang Tim analisis akar masalah.
Analisis akar masalah sangat membantu dalam
merencanakan tindak lanjut atau tindakan pemecahan
masalah. Dimana outcome-nya adalah dapat dalam bentuk
perubahan atau perbaikan bahkan inovasi baik discovery
maupun invention. Setidaknya hal ini membantu mahasiswa
dalam upaya membuat inovasi melalui jalur skripsi atau
thesis, untuk guru membantu dalam memperlancar penilitian
tindakan kelas. Selain itu lembaga pendidikan baik pusat
maupun daerah serta sekolah itu sendiri sebagai wujud
organisasi dimana di dalamnya terjadi proses manajemen
sudah selayaknya berinovasi yang berbasis pada 6 prinsip
inovasi untuk lebih bermakna setidaknya dapat menjauhi
untuk mengeluarkan kebijakan-kebijakan pendidikan yang
tidak bijaksana.
123
124
4. Cost of Living
a. Hand phones, which in fact are becoming more fads and
crazes instead of necessity.
b. Rising cost of healthcare as reflected in medical expenses.
c. Rising cost of education.
d. Hike in transport fare
e. GST hike
f. Rising cost of housing
g. Needs for broadband connection to gain access to the
World Wide Web.
5. Employment
a. Automation displaces human labor.
b. Company mergers and acquisition causing lay offs on
redundant workforce.
c. Underemployment
d. Downsizing of companies
e. Managerial jobs are taken over by intelligent systems.
f. Job losses
g. Retrenchment
6. Behavior (Psychological)
a. Financial phobia where people keep on denying their
indebtedness.
b. Banking on windfall.Compulsive shopping.
125
126
127
DAFTAR PUSTAKA
Danim, Sudarwan. 2010. Manajemen dan Kepemimpinan
Ytransformasional Kekepala Sekolahan. Jakarta: Rineka
Cipta.
Danim, Sudarwan. 2010. Inovasi Pendidikan Dalam Upaya
Peningkatan Profesionalisme Tenaga Kependidikan.
Bandung: Pustaka Setia.
Gaspersz, Vincent. 1997. Manajemen Kualitas Penerapan
Konsep-Konsep Kualitas Dalam Manajemen Bisnis Total.
Jakarta: PT. Gramedia Pustaka Utama.
Harsono, Ari. 2008. Metode Analisis Akar Masalah dan Solusi.
MAKARA, SOSIAL HUMANIORA, VOL. 12, NO. 2,
DESEMBER 2008: 72-81
Kusmana, Suherli. 2010. Manajemen Inovasi Pendidikan,
Ciamis: PascasarjanaUnigal Press.
Mulyasa, E. 2008. Menjadi Guru Profesional Menciptakan
Pembelajaran Kreatif dan Menyenangkan. Bandung:
Rosda.
Suud, Udin Syaefudin. 2010. Inovasi Pendidikan. Bandung:
Alfabeta.