• Describe the opportunity for improvement (OFI).
• Work through the Five Whys, answering the "Why?" question five times. For example:
  • Why did this OFI happen? Because A.
  • Why A? Because B.
  • Why B? Because C.
  • Why C? Because D.
  • Why D? Because E (root cause).
• How would you categorize your true root cause? (Lack of planning, management style, etc.)