Process problem or people problem? How to find the root cause of issues

When a problem is brought to my attention, my goal is not just to resolve the immediate issue, but to prevent it from happening again. In some cases, immediate containment is necessary to limit impact. Once the situation is stable, however, the focus must shift from the symptom to the system that produced it.

After clarifying what happened, my first question is always:

What process is involved?

An investigation typically follows a general sequence. The order may vary slightly depending on the situation, but the intent remains the same: to understand whether the process failed, was missing, or was not followed.

• Is the process documented? If not, should it be?
  In some cases, a formal procedure may be unnecessary, and a job aid, checklist, decision tree, or visual control would be more effective at preventing recurrence.

• If the process is documented, where did the problem occur within it?

• Was the process followed?
  If not, why not? This question often leads beyond the process itself and into supporting management processes:

• Is there a clear policy requiring procedures to be followed?

• Is the procedure practical and usable in real conditions?

• Was appropriate training provided?

• Is the importance and value of following the process understood and reinforced?

If the process was followed and the problem still occurred, the focus shifts again:

• How did the problem manifest despite compliance?
  This usually indicates a weakness in the process design itself rather than execution.

• Have we identified the true root cause, or are we addressing a symptom of a bigger problem?

• What change would prevent this from happening again?
  Can the process be simplified? Can controls be moved closer to the point of risk? Can reliance on memory, judgment, or interpretation be reduced?

• Do we need to test or monitor the change to confirm it works?
  And what level of change management is appropriate based on the likelihood and impact of recurrence?

• Can the improvement be implemented quickly?
  If not, is a temporary control needed until the permanent fix is in place?

A crucial part of process management is researching the symptoms that caused an issue and making adjustments. Stock photo by Vecteezy

When the problem appears to be a people issue

Occasionally, a pattern emerges where an individual repeatedly does not follow a clearly defined, well-designed, and well-supported process. Even then, the first responsibility remains with management—not to assign blame, but to examine the management processes that govern how people are hired, trained, and managed.

At that point, the question becomes:

Which management process failed?

Possibilities include:

• The employee selection process (skills, experience, or fit were misjudged)

• The orientation process (expectations around process discipline were not made clear)

• The training process (insufficient, ineffective, or poorly reinforced)

• The discipline or accountability process (inconsistently applied or unclear)

Only after these processes have been examined and corrected does it become reasonable to conclude that an individual may be unwilling or unable to operate within a process-driven environment. Not everyone can (or will) adapt to process thinking, and recognizing that is itself a management responsibility.

Apply process thinking everywhere

An equally important point is that this approach cannot be limited to production or operational processes alone. The same discipline must be applied to administrative, support, and management processes.

Hiring, onboarding, scheduling, approvals, purchasing, audits, corrective actions, and decision-making are all processes. Failures in these areas create just as much risk, cost, and frustration as failures on the production floor.

For a quality-based organization, process thinking must be instilled horizontally and vertically:

• Horizontally across functions and departments

• Vertically from frontline work through management and leadership

When mistakes, failures, or problems emerge, a quality-based organization investigates the process first, not the staff.

Process as a management obligation, not a preference

Managing by process is not a philosophical preference or a “nice-to-have.” It is a management obligation for any organization that wants to reduce mistakes, product errors, rework, delays, and recurring administrative problems.

Organizations that do not manage by process inevitably manage by reaction, by adding rules, approvals, and oversight in response to each failure. Over time, the system becomes more complex, slower, and less effective.

Organizations that do manage by process simplify work, reduce variation, and create systems where the right outcome is the natural outcome.

— GapCross can help find the gaps in your process that are causing issues. Contact us to learn more.