Worked example · TW-2026-11-11.1
Combined causes
Several contributing factors · Fictional case · Proposed interpretation
Executive summary
The answers suggest several contributing factors: Management or environment, Skill or knowledge. Their relative importance is unresolved.
Reported evidence and route
Performance gap — Fictional dispatch team at Meridian Works. Expected: At least 98 of every 100 orders pass the first quality check. Observed: In the last sample, 91 of 100 orders passed the first check. Evidence: The fictional dispatch log records nine rework orders in a sample of 100.
Impact — Significant impact
Expectations — Only partly understood
Working conditions — Tools, time and support are adequate
Consequences — Desired performance is penalised
Skill and knowledge — Has demonstrated part of the skill
Remaining obstacles — Several possible factors need investigation
Past practice — Has done it before but rarely uses it
Manager’s observation or concern — The fictional team has mixed experience, a speed incentive and conflicting instructions.
Possible causes supported by the answers
The performance standard is missing or only partly understood.
Workplace consequences may contribute: Desired performance is penalised.
The respondent reports a specific skill gap. Has done it before but rarely uses it.
What remains uncertain
Further investigation is needed before confirming the remaining factors.
Suggested management actions
Agree an observable standard and ask the team to demonstrate its meaning.
Compare what receives recognition with the required standard. Trial one change and measure the effect.
Arrange practice of the specific skill and observe the next attempt.
Manager’s decision
Example choice: verify the possible cause with the team before committing resources.
Proposed improvement plan
30 days — Check the proposed cause and record a baseline against the stated standard.
60 days — Compare results after the agreed trial. Record its effort, cost and effect.
90 days — Compare the same measure with baseline. Keep, change or stop the intervention based on the evidence.
Performance indicator
Reported standard: At least 98 of every 100 orders pass the first quality check. Starting observation: In the last sample, 91 of 100 orders passed the first check. Compare the same measure and the cost of the trial at each review.
Conclusion
Combined causes. Review the proposed findings with the people who do the work.