Metode Ilmiah Analisis Akar Masalah
Metode Ilmiah Analisis Akar Masalah
METODE
ANALISIS AKAR MASALAH
(ROOT CAUSE ANALYSIS)
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
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
Contoh definisi:
Salah satu teknik analisis yang biasa digunakan dalam
menganalisa kegagalan suatu sistem adalah analisis
4
http://74.125.153.
Diagram Tulang-Ikan
No Pelaku Kebutuhan
1 Pemda -Peningkatan pendapatan Daerah-
Peningkatan Lapangan Kerja-Peningkatan
kesejahteraan nelayan
2 Dinas -Produksi Hasil Tangkapan memenuhi
Perikanan dan kebutuhan pasar-Menjaga potensi
Kelautan sumberdaya perikanan-Peningkatan
sumber informasi perikanan
3 Nelayan -Bantuan modal untuk biaya operasi-
Penambahan unit penangkapan
4 Pengusaha -Peningkatan jumah alat tangkap-
Tersedianya BBM-Pabrik es
5 Pedagang/Bak -Bantuan modal-Fasilitas untuk
ul berdagang-Mutu ikan yang bagus
Formulasi Masalah
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Identifikasi Sistem
Identifikasi sistem berhubungan dengan kebutuhan-
kebutuhan 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
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Analisis Kebutuhan
Analisis kebutuhan pada dasarnya merupakan tahap
awal pengkajian dalam pendekatan sistem, dan sangat
menentukan kelaikan sistem yang dibangun. Analisis
kebutuhan juga merupakan kajian terhadap faktor-faktor
yang berkaitan dengan sistem yang dianalisis. Oleh karena
itu, dalam penelitian ini analisis kebtutuhan diarahkan pada
pihak-pihak yang mempunyai kepentingan dan keterkaitan
baik secara langsung maupun tidak langsung terhadap
pengendalian pencemaran perairan danau.
Dalam pengendalian pencemaran perairan danau,
pihak yang mempunyai kepentingan dan terkait secara
langsung adalah
(1) Masyarakat lokal yaitu masyarakat yang tinggal di
sekitar danau yang memanfaatkan perairan danau
untuk berbagai kepentingan,
(2) Dinas instansi terkait yaitu semua dinas instansi
pemerintah daerah yang mempunyai hubungan
keterkaitan dengan perairan danau baik langsung
mapun tidak,
(3) Akademisi (peneliti) yaitu orang yang melakukan
penelitian pada perairan danau,
(4) Lembaga Swadaya Masyarakat (LSM) yaitu lembaga
yang dibentuk masyarakat setempat yang mempunyai
kepedulian terhadap kelestarian perairan danau, dan
(5) Badan usaha milik negara yaitu perusahaan yang
melakukan kegiatan usaha di perairan danau.
11
Sumber:
http://menyelamatkandanaulimboto.wordpress.com/pengendalian-
pencemaran-danau/marganof/3-metode-penelitian/
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
Sumber: http://menyelamatkandanaulimboto.wordpress.com/pengendalian-
pencemaran-danau/marganof/3-metode-penelitian/
Pohon Masalah
Untuk mencari MASALAH POKOK, metode pohon masalah ini
mencobamenelusuri masalah hingga ke AKAR MASALAH.
Harapannya, jika akar masalahtersebut bisa terpecahkan maka
masalah utama akan terpecahkan.Instrumen yang paling umum
digunakan adalah pohon masalah.
1. Tuliskan satu MASALAH POKOK pada selembar kartu
dan tempelkan padapapan tulis atau pinboard
2. Carilah penyebab langsung terjadinya masalah pokok
tersebut denganmenelusuri hubungan SEBAB AKIBAT
3. Telusuri SEBAB AKIBAT sampai ke akar penyebabnya,
sampai POHON MASALAHterbentuk secara lengkap
4. Tulislah satu pernyataan yang dianggap sebagai
penyebab langsung terjadinyaMasalah Pokok
5. Begitu seterusnya sampai tidak ada lagi yang masih
dapat diidentifikasi sebagaipenyebab langsung
terjadinya keadaan
6. Tempelkan semua kartu pada papan tempel dan
tunjukkan hubungan SEBAB-AKIBAT dengan tanda
panah
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sampahkurangterawat
Pokok Banjir
Masalah
Ht gundul Irigasi
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
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Sekala Usaha
Kecil
Sekala Daya
Usaha
Sekala
Akses tawar
Kecil
modal
Usaha lemah
lemah
Kecil
PEMAHAMAN MASALAH
Diagram Hubungan
Diagram hubungan antara iklim dan tanaman.
Sumber: http://taman-agribisnis.blogspot.com/2010_02_01_archive.html
23
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.
meningkatkan menyediakan
komunikasi di semua waktu bagi middle
sektor manager untuk
berpartisipasi
akses yang luas Membentuk steering
terhadap informasi committee dengan
wewenang yang jelas
membuat menyediakan
defenisi support staff
operasional bagi middle
mengenai manager
pengetian
proses
menghitung Membuat
process program goals
capability. yang jelas
Menyediakan
waktu bagi
middle manager
untuk
berpartisipasi
membentuk
steering
committee
dengan
wewenang yang
jelas
ANALISIS SEBAB-AKIBAT
Contoh CE-diagram:
How to draw 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:
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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.
Sumber:
http://www.hci.com.au/hcisite3/toolkit/causeand.htm
30
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
Sumber: http://syque.com/quality_tools/toolbook/cause-
effect/example.htm
Tahap 1: Investigation
Tahap 2: Analysis
38
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
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-Do-
Check-Adjust" cycle (PDCA). Hopefully, what I've written here
will help you Plan better!
1. Problem Statement
The Problem Statement is a clear, concise and
measurable description of waste, rework or deviation
from a standard (the norm). It should explain WHO is
experiencing the problem, WHEN they experienced the
problem, and WHERE they experienced the problem. The
description must be measurable, and should refer to the
standard.
2. Goal Statement
The Goal Statement is the clear, concise, measurable
and attainable objective. It must include a precise target
date to accomplish the goal. The Goal Statement must
mirror the problem statement.
3. Point of Cause
Think Cause and Effect. If the problem is waste or the
deviation from standard, then the point of cause is the
physical time and/or location the deviation is occurring.
Apply the Because Equation to the problem to help
define the Point of Cause (The problem occurs BECAUSE
of the point of cause).
4. Root Causes
The root cause is the underlying reason often hidden or
obscure that is creating the problem. If the PDCA does
not identify and eliminate the true root cause (or causes,
there could be several of them) then the problem will
most likely come back. You get to root causes through 5-
Why Analysis and other PDCA tools.
5. Counter Measures
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6. Follow Up
This is the Check and Adjust phase of the PDCA. When
the group first plans the counter measures to be taken,
they should schedule a time to return to check on their
success. This can be a week into the future, a month, six
months, a year depending on the target date set in the
goal statement. If the counter measures were successful,
standardize. If the problem still exists which happens
then adjust. That may mean simply modifying the
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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.
Plan (Rencanakan)
Meletakkan sasaran dan proses yang dibutuhkan untuk
memberikan hasil yang sesuai dengan spesifikasi.
Do (Kerjakan)
Implementasi proses.
Check (Cek)
Memantau dan mengevaluasi proses dan hasil
terhadap sasaran dan spesifikasi dan melaporkan
hasilnya.
Hasil-hasil Statistik
X 1 1 11 F1 12 F2 .... 1m Fm 1
X p p p1 F1 p 2 F2 .... pm Fm p
Dimana: i rata-rata variabel i ; i
faktor spesifik ke i;
Fj
i j
common faktor ke- j; dan loading dari variabel ke i pada
faktor ke-j
Statistik uji :
p p
r
i 1 j1
2
ij
p p p p
r
i 1 j 1
2
ij a ij2
i 1 j 1
KMO =
i = 1, 2, 3, ..., p dan j = 1, 2, ..., p
rij = Koefisien korelasi antara variabel i dan j
aij = Koefisien korelasi parsial antara variabel i dan j
Statistik Uji :
1 p
rk rik
p 1 i 1 , k = 1, 2,...,p
48
2
r 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 ik
2
T ( r r ) (r k r ) 2 2 ( p 1) ( p 2) / 2;
(1 r ) i k k 1
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).
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 why-
why 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.
Current Reality Tree (CRT, similar to the current state map used
by many organizations) evaluates the network of cause-effect
relations between the undesirable effects (UDE's, also known as
gap elements) and helps to pinpoint the root cause(s) of most of
the undesirable effects.
Checklists Akar-Masalah
One expression of the basis for root cause analysis, from The
Root Cause Way.
Incident Response
* If YES, why did the event proceed beyond this point? If NO,
why not?
Deskripsi
Pros
Cons
Definisi-definisi
Diskusi
Konsep-konsep
Efektivitas Umpan-balik
Kelemahannya
Deskripsi
Pros
Cons
Definisi
Diskusi
Konsep-konsep
Perubahan (Change)
Deskripsi
Pros
Cons
Definisi
Diskusi
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.
Sumber: http://www.oxenrideronsynergy.com/2011/09/creative-
root-cause-analysis-terminology/
Agregasi
How to proceed:
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
Sumber:
http://www.reallysimplebusinesstools.com/content/simple-
model-human-behavior)
95
Step One:
Step Two:
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.
Step Three:
Some typical inputs and outputs of nutrients and energy for forested
ecosystems include evapotranspiration, nutrient leaching, sunlight and rain.
Step Four:
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:
Sumber: http://meelaisme.wordpress.com/2011/10/19/analisis-masalah-
dan-akar-masalah-penanaman-padi-sawah-irigasi-oryza-sativa-pada-tanah-
seri-tlogorejo/)
Berdasarkan analisis akar masalah yang digambarkan
dengan pohon masalah di atas, dapat dilihat bahwa
terdapat tiga akar masalah yang menyebabkan tidak
optimal dan tidak stabilnya produktivitas tanaman padi
sawah bila ditanam di lahan di kawasan Tlogorejo. Ketiga
akar masalah tersebut ialah kelerengan yang cukup
curam, kurangnya penutup lahan, serta tekstur tanah
yang agak kasar.
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2. Fishbone Diagram
Diagram Tulang Ikan atau Fishbone diagram sering pula
disebut Ishikawa diagram sehubungan dengan perangkat
diagram sebab akibat ini pertama kali diperkenalkan oleh
Prof. Kaoru Ishikawa dari Jepang.
Pertanyaan Why?
117
Contoh 1.
Contoh 2.
Masalah: Mengapa Siswa SMA Kesulitan Menyerap Pelajaran
Kimia ?
Kategori Utama
Sebab 1 (Sb1): Guru
Sebab 2 (Sb2): Siswa
Sebab 3 (Sb3): Masyarakat
Sebab 4 (Sb4): Kurikulum
Sebab 5 (Sb5): Sarana
Five Why
120
2. Income
a. Same level of income over the years while loans keep on
going up
b. Limited opportunity to increase personal income
c. People are surviving on disposable income making them
vulnerable to interest rates fluctuations
d. Reduced income specially when a person becomes less
marketable in a competitive labor market
e. Saving too little or none at all.
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.
DAFTAR PUSTAKA