How to Do a Root Cause Analysis

​In today's episode, I'm talking to you about a practice that is common to schools and turnaround or schools who have been told by the state that they need to rethink how their school works and design an intense strategic plan. The root cause analysis is a key practice that is often part of these strategic planning conversations. What I do today in this solo episode is dig into what really makes a good root cause analysis to truly uncover what is at the heart of this system. Not serving all students. How do we get there? We'll talk about that today.
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Hi, I'm Lindsay Lyons and I love helping school communities envision bold possibilities, take brave action to make those dreams a reality and sustain an inclusive anti-racist culture, where all students thrive. I'm a former teacher leader, turned instructional coach, educational consultant and leadership scholar. If you're a leader in the education world, whether you're a principal, superintendent, instructional coach, or a classroom teacher, excited about school-wide change like I was, you are a leader. And if you enjoy nerding out about the latest educational books and podcasts, if you're committed to a lifelong journey of learning and growth, being the best version of yourself, you're going to love the Time for Teachership podcast. Let's dive in.

Today. We are talking about root cause analysis. Root cause analysis is a process for identifying the underlying cause of an identified problem. When schools are in need of change or the school is struggling to implement a change initiative, a root cause analysis can help determine where the problem lies, which informs our proposed action. So in my professional life, I've seen a number of root cause analysis performed. And even as a teacher, I encouraged my students to conduct a root cause analysis of problems, trees of issues that they found, in the world. So teachers, this can be done not just at a school level, but also at a classroom level, to really promote some critical thinking and analysis and your students. But for today, we're going to be talking about it from the perspective of school change and what is also called a school reform.

So these types of analyses are commonplace for schools in turnaround schools that have been given a failing grade by the department of education. And so they need to make big changes to turn around their schools. I have both witnessed and participated in root cause analysis in which the group reached what they thought might be a root cause, but no one was really sure. I would love to see school stakeholders, a variety of school stakeholders coming together, teachers, administrators, students, families, community members. I'd love to see them come together to perform this kind of root cause analysis and actually reach a root cause that they can feel to be true in their bodies. There's a visceral knowing that this is it. And if we address this, we can turn it all around. And so my vision for today, what I'd love to kind of help us think through and think about a little bit more concretely is this idea of root cause analysis and how we transform schools that have been struggling that have not served all students.

And in order to do that, we need to dig deep. We need to identify what's really going on far below the surface level of what may appear to be going on, but we know there's so much more below that. And so I'd love to talk you through some examples of, and the process of how to use a root cause analysis in a way that I find to be more effective than I've seen it used in my professional consulting experience with schools and turnaround. The thing is that you'll know it when you see it approach to root cause analysis is so vague and it's unlikely to be helpful because it is so vague. And this was actually the guidance, this phrase we'll know it. When we see it is often the guidance that I heard from folks in charge of leading these analyses at the department of education level.

And so what I'd like us to do today is to go beyond that, to get a bit more concrete on what we're actually looking for when we conduct these root cause analysis. And we engage in this in-depth conversation about what is actually happening in our school system. So we've spoken before about adaptive challenges on the podcast, adaptive challenges are longstanding challenges that cannot be addressed with a technical fix. So a technical fix is something where the solution is really laid out. It's step-by-step, it's like using a new textbook, purchasing a new textbook or having a one-off staff PD workshop, right? These are things that's like, Oh, you just do this. And the problem is solved. Adaptive challenges cannot be fixed with technical fixes. Adaptive challenges are difficult precisely for that reason, we don't know what the solution will be. It's going to take a lot of people coming together to dig into the problem, identify what's going on, and then collectively form a path forward.

So the adaptive challenge is difficult to address because the path forward is unclear from the start adaptive leadership scholars Heifetz Grashow and Linsky are clear about one thing, though, when it comes to adaptive challenges, they right, quote, adaptive challenges can only be addressed through changes in people's priorities, beliefs, habits, and loyalties. That quote is something that I will repeat again and again, because I just feel like it captures the essence of what we're talking about and the importance of a deep root cause. So to me, something that is a deep root cause, something that lies beneath a lot of that surface level stuff, it's likely going to be an adaptive challenge. The problem as a whole, right? And in the root of that, what Heifetz, Grashow, and Linsky say needs to change in order to address that larger adaptive challenge is that underlying priority belief, habit, or loyalty that people in the system hold onto.

This is very informative, I think, for the work of root cause analysis. So a common tool for conducting root cause analysis is what they call a Five Whys protocol. Basically, you name a cause of the problem. The first one that maybe comes to mind, and then you go down five levels. So you ask, okay, well, why is that cause—that I just named that's causing the problem—why is that happening? And then you keep going for, again, five layers, five whys. And I like this approach, but only if we know what we're actually looking for in that final why. Because I have seen five whys analysis just kind of go off the rails and end up in a totally different, completely irrelevant to my mind. A lot of times we played then where we could have gone. If we had had a bit more focus in really knowing what we were looking for as we continue down that five whys path, here's an actual example.

And I'm paraphrasing a bit because I didn't write this down word for word, but here's an example of the five ways that I watched a school leadership team of a school that was in turnaround actually come up with in the root cause analysis meeting. The problem was that their school was in turnaround more broadly, right? And they got into some more specifics, but here's the first reason that they came up with when they did the five whys, the first reason why their school is failing was because according to them, they had a discipline problem. So their school's failing because they have a discipline problem. Then they said our cause is that we have a discipline problem. Well, why do we have a discipline problem? We have a discipline problem because, (and this is their second why of their five whys) students are not following the rules about no hoods, hats, or earbuds.

So they're getting a little bit more specific here. And they said, well, why are students not following these rules in particular, the no hoods, hats, or earbuds? And they had a conversation and they said, okay, well, to us, it seems like that's happening because students don't understand it's disrespectful. Why number three to them was that students don't understand it's disrespectful. Hence they're violating the dress code rules. Hence we have a discipline problem. That's why our school is failing. Now there are two more levels to go still. So they said, why do students not understand that it's disrespectful? So why is this happening? So layer number four is the students don't understand because the teachers don't tell students that is disrespectful. They said okay, let's go a level deeper. The teachers don't explain to students that it's disrespectful because, and this is layer number five here, teachers don't see hallway, dress code policing as part of their job.

And that's where they ended, that was their fifth why in the five whys activity, and they said, this must be our root cause. Which means if you do the check again, the check for a root cause analysis is if that lowest level, that thing you determined to be your root cause is fixed, will it fix the larger problem? So if we did a check here, we would see that this says, if teachers don't see hallway, dress codes, policing as part of their job, if that's a root cause, that means that if we convince teachers to see hallway dress code policing as an integral part of their job, our school will no longer be in turnaround. We will be effectively serving all students. Our discipline problems will go away and we will be a school that thrives and all students will be served. As you can tell, as we think through this, you know, they did end up with a belief of sorts.

If we kind of use that language of Heifetz, Grashow, and Linsky to think about adaptive challenges in this way and connect it with a root cause analysis process, they did end up with a belief, right? Teachers don't believe it's their job to do policing of the dress codes in the hallways, outside of their classroom. In that sense, you know, that's great that we're, we're digging into a belief. And I think this discussion, if pivoted in a slightly different direction, could have been really fruitful here. What I want to pose now is going back to number one, that first layer that first, why is this happening? The reason our school is failing is because we have a discipline problem. That's what was said. That may or may not be the case, but let's say for the sake of this exercise, that it is. The next why says the biggest discipline issue is students not taking off hats and earbuds and hoods in the hallway.

So right here, I think is the pivotal moment that I wish I could go back and step in and ask, let's check our own beliefs, habits, and loyalties around this statement. And the next one, that next level was that it's disrespectful to wear hoods, hats or earbuds in the hallway. That was kind of assumed within that statement of students don't realize it's disrespectful. It was just kind of assumed that it was disrespectful behavior. So I would love for that self-reflection moment to really be highlighted in this discussion so that it wasn't just let's see where we can pinpoint other people who are not us in this room. And might I add, this was just a room of administrators and teachers, to my knowledge, no one in that room was a family member and there certainly were no students in the room. So just to kind of note that this was a limited stakeholder group of people who were deemed to be leaders on some level in the school building.

But if we could introspectively take a moment to look at that point in the conversation and say, let's check our beliefs that are showing up in this statement right here. The question that we might encourage teachers or leaders to discuss at this moment might actually be: Why do teachers think that it's disrespectful? Why is that the belief there what's going on there? Or another question might be to discuss why is this dress code so important? Why is it seemingly more important than achieving the school's goal of reducing disciplinary incidents? Or why is this a rule in the first place? Why is that rule for no hats, no hoods in existence? Where did that come from? Who created that rule? Because I am willing to bet that students were not a part of that conversation in creating that rule. So here's what maybe another version of this five whys activity for this group of educators might have looked like if we started digging into these other questions and we obviously don't know for sure, because only the school stakeholders themselves would know what actually feels true for their school itself.

So, because number one, might've been the same—again for argument's sake, let's just say that was the same. So our school is failing because we have a discipline problem. Why is that happening? Well, discipline is a problem because students are not following the rules about no hoods, hats, or earbuds. Okay, let's keep that the same. Now. Here's where it shifts. Why is that happening? Why are students not following the rules about no hoods, hats or earbuds? Well, maybe students don't follow these rules because they don't agree with them. And again, here, it would be really helpful to have students stakeholders in this conversation. So we're not just assuming what students are thinking, but let's just for sake of argument, go there for the exercise. So students, maybe aren't following these rules because they don't agree with them. Why is that happening? Why are there even rules that students have to follow that they never agreed to in the first place?

So that next level is there are rules that students don't agree with because students were never asked to help make the rules. Now we're in a different place. Okay, let's go one level deeper. So why is it that students are never asked to help make the rules, layer number five could say maybe adults in the school believe again, we're getting another belief here, adults in the school believe students are incapable of making decisions like that decisions that affect their learning or their learning environment. Now that's probably a bit unsettling. It's a very different root cause than the first one. And this one really hits me in the gut. This one is hard to process as an educator who can connect with that, who doesn't like connecting with that, but who at times in my career have definitely noticed that belief coming up in myself.

It's I think a product of how we are taught in teacher school to be as teachers, right? We know what's best; students obey. That's the, that's the game, right? So this one is really different and it's really uncomfortable. But I think to me, when we're thinking about adaptive challenges and addressing those head on, it requires that belief change. It requires an acknowledgement that there's a problematic belief and that needs to shift. And it requires that critical introspection. So no longer pointing fingers and saying, this is where the problem lies outside of me, but how am I contributing to the system to the problem that is being perpetuated by my underlying beliefs, habits, loyalties? What's going on there with me? When we look at the root cause of the first example, the initial actual example that happens and then this hypothetical example that we went through second, the first root cause, shifting teacher beliefs...

So they see it as their job to police hallway dress. That root cause may result in higher disciplinary referrals because now teachers are hyper policing the hallways and they are perhaps writing students up or sending students to the office or getting in altercations in the hallway with students they may or may not know. And now teachers are feeling stressed about that. I'm sure students are feeling stressed about those interactions and we're increasing disciplinary referrals. We're increasing student and teacher stress. I'm not sure that that solves the larger issue of why the school is not serving all students. If that's the ultimate goal. Not sure that that root cause actually solves many of those things. Now in the second one, again, this is not perfect and it is a hypothetical scenario. So we'd have to really talk to the stakeholders in the school itself to figure out what's true...

That second root cause? Shifting adults' beliefs that students can be a part of policy decisions, like the creation of dress codes may result in students following a dress code they helped create. So there's buy-in when diverse stakeholders are part of the process. If we're looking to change student behavior, are students involved in the creation of the rules that they're expected to follow in the first place? Do we have actual stakeholder engagement? If we expect stakeholder buy-in, I would argue that that is necessary. And I talk a lot about that, with shared leadership and student voice. But I think that's something that was kind of missing here that first, that internal reflection of the stakeholders in the space doing the root cause analysis. And then also just to think about once we hit on that belief, does it also speak to the larger way in which we're trying to lead the school?

Is it one of inclusion and shared decision making or is it one in which we're going to tell you what to do and we expect you to follow it. And then if you don't, there's, there's a problem. I also want to talk about an Ishikawa diagram, which is frequently known as a fishbone diagram. It's often used during root cause analysis, and it helps the folx engaging in the root cause analysis to organize their brainstorming by different categories for each cause. So participants can make their own categories or they can use generic headings. These are usually something like methods, machines, or equipment, people, materials, measurement, and environment. In most analyses, I've been a part of, people have used the predefined categories. And again, the idea here is if we're having trouble getting started with just generating some possibilities for those causes, those categories can sometimes prompt some more nuanced or specific discussions of causes.

And also when we use an Ishikawa diagram, because there are so many categories, we're able to see multiple examples of the five whys. So we might have a whole set of five whys around a particular category. For example, people, or even getting more specific students or teachers is another category of people or families, you know, whatever it is. And those might be very different from one another. They also would be very different, likely from materials and thinking about the root causes of materials or, you know, sometimes they might be the same, which is what's so fun about this. I think comparing, do we see multiple root causes showing up in those separate five whys conducted for each category? And if we do, that's probably something. So this is another example and really just a structure to help us with this conversation about root cause and to engage in the five whys so you can use them overlapping.

So now I'll share another example from another school, a different school leadership team that conducted a root cause analysis. Again, this school was in turnaround, and this time they were really focused on the materials part of the Ishikawa diagram. So the problem that they had determined was that the school is failing because our ELA standardized test scores are really low. And so then the cause of that—right, why are our ELA standardized test scores really low—their response in the materials category of the Ishikawa diagram was our ELA curriculum  doesn't address two key areas that are always on the state tests. And so then digging into that, they said the next layer of the why, why does our curriculum not address those two key areas on the test? Well, teachers don't want to change curriculum again every year. So far teachers have had to change curriculum.

There's this constant change and they don't want to change again. And when asked, you know, why don't the teachers want to change curriculum again, the response was the new curriculum will take time to learn. And we just don't have a lot of time. We're very limited in the time that teachers have. They don't want to devote even more time to learn a curriculum when they already know one that they're familiar with and feel comfortable with. And so if we look at this root cause if we think about our solution to a root cause like that one, it might be a decision that the administration makes like we're going to reserve two days at the start of the year. And we're just going to have some, some PD on this new curriculum and that's going to address the problem. We're going to give you those two PD days.

You're going to learn the new curriculum in those two days and you'll implement it throughout the year. Problem solved. Now let's look at that same problem again, from the people category of the Ishikawa diagram. So again, the problem is the school is failing because our ELA standardized test scores are really low in the people category. We say that the cause for this low standardized test score in ELA is students have repeatedly said they find the curriculum boring. Again. I just want to highlight here that we have different stakeholder perspectives, right? The last one was about teachers. This one is about students. It's going to be really helpful to have students be a part of this conversation, but okay. Our cause is that students find the curriculum boring. That's what they tell us. So why is that happening? Why do they find the curriculum boring? Well, the next level is they don't see themselves or the topics they care about represented in the curriculum.

Okay. So now let's go a layer deeper. Well, why don't they see themselves or the topics they care about in the curriculum? Because teachers have used a curriculum designed by someone who doesn't know their students. So they don't know their students' identities, what their students are interested in. We could probably go a lot deeper. And in particular directions— they're talking about Euro-centric materials and white supremacy in historical, traditionally taught textbooks and things—but let's for now just say, teachers are using curriculum designed by someone who doesn't know their students and we'll leave it at that for this example. Now, why are teachers using a curriculum that's designed by someone else that doesn't know their students? Well, the reason for that is, they say, or maybe they would say—this is a hypothetical rewrite. Teachers have always been given curriculum or told to find curriculum, but they've never been supported to create original curriculum.

They've never walked through the process of what that looks like? Where do you go? How do you find resources? How do you make it manageable? How do you invest in student voice and co-construct curriculum with your students? So in this example, the original materials based example, and then my hypothetical rewrite of the people category example, the habit of finding versus creating curriculum is really long standing. This second piece around the people category, I think hits a little bit deeper. I can connect to that. I can connect to the fact that I had been handed curriculum maps early on in my teaching career and was told, “Do this, make it work, but never really walked through the process of, until I got a coach in my third year.

And I was able to just use that coach’s wisdom moving forward year after year, despite only having that coach for about six months of one year of, of my seven years of teaching. That support in creating my own curriculum was a pivotal moment in me being able to engage students and see academic success that I had never seen before with a standardized curriculum. So it really connects me on some level, that this may be true. Now it may not have been true for this group. I'm just trying to kind of highlight how different categories lead us to, to different places. But administrators and teachers may believe, right? Again, that belief idea is crucial here. If we're using that language of adaptive challenges, there may be an underlying belief here that curriculum developed by professional curriculum, authors or companies is actually better for students.

But here's the thing I think about. If students are not engaged in the curriculum, then it's not going to do much. Even if it is amazingly designed, research-based, all of the things...if students aren't engaged in it, it's not doing much for those students. And so the path forward in this case, maybe doing some action research to see if the data confirms or rejects the claim that store-bought lessons or units are more engaging than teacher designed lessons or units. And by teacher design, I mean, co-constructed with students to some degree, and I've talked about that in other podcasts, but just this continuum of designing with students and advancing student voice in these designs now, of course, technical fixes. So for example, training, removing other tasks from teachers’ plates so they have time to create the new lessons would definitely be part of the plan moving forward.

But technical fixes in and of themselves can not fix adaptive challenges. So there's much more work that needs to be done on an inner level, a mindset shift, belief shift level that are going to be required if we want results. Right? If people still believe, if teachers still believe that standardized curriculum is better, there's not going to be buy-in for any of those training that you may offer or the support that you may provide, or the time that you might give for teachers to create original curriculum. If there's not a belief that that's going to be better for their students, as we think about all this stuff, as we think about root cause analysis and what that means for us as we lead schools, either leading schools through transformation, if you're in a school that has been identified as a turnaround school or a school that is not meeting standards, according to the state or a school that is doing really well, according to the state, but you know, there's more work that you want to do.

We're always growing and learning as communities. There's a lot here to kind of unpack and to think through and a root cause analysis is an incredibly powerful tool that you can use when used, well, I think it can really be used powerfully to identify and then work through some of those underlying beliefs, habits and loyalties that you can kind of dig into as a multi-stakeholder group. Now, in terms of putting this into practice, as you go forth and tackle those adaptive challenges in your school and conduct your root cause analysis, I encourage you to remember that key question that helps you really realize and recognize when you've reached a true root cause, which comes from again, the adaptive leadership scholars, Heifetz, Grashow, and Linsky, what are the habits, beliefs, and loyalties we're holding on to? Do those need to shift? And when I say we're holding onto you, I mean, the people doing this analysis, the stakeholders in the room, right? We don't want to always assume for other folks that we want to make sure everyone who needs to be in the room is in the room for this conversation. And what's so amazing is if we can identify and address those underlying habits, beliefs, and loyalties that need to shift, then the technical fixes, which are also useful, have a chance to finally work their magic.

In the show notes, I'm going to link to a freebie for you, which is an adjusted copy of what I actually created for my students when I was encouraging them to create activist based projects in my class as a teacher. But what I think can also be really helpful for school stakeholders and leadership teams in thinking through these different activities, the five whys, that Ishikawa diagram, the root cause analysis as a whole. And so I'll link to that template with the different activities to help you work through the stuff with your team. Thank you so much for listening to another episode. I am so excited to hear what comes out of this. Please share any root cause analysis stories or root causes that you identify as you do this work together as a leadership team, connecting with multiple stakeholders in your community. I can not wait to hear exactly what you come up with, and if you have any questions along the way, please feel free to reach out. 

Thanks for listening, amazing educators. If you loved this episode, you can share it on social media and tag me at Lindsay Beth Lyons, or leave a review of the show. So leaders like you will be more likely to find it. To continue the conversation you can head over to our Time for Teachership Facebook group and join our community of educational visionaries. Until next time leaders, continue to think big, act brave, and be your best.

Episode Freebie: Root Cause Analysis Worksheet