Worked example · TW-2026-11-11.1

Combined causes

Several contributing factors · Fictional case · Proposed interpretation

Stages reviewed 7 of 7

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.