Root Cause Review
The same problem every month is a process wearing a disguise. A short root cause review finds the process, fixes it, and proves the fix.
What's Included
- Impact
- How we got there
- Root cause
- Corrective actions
- Verification plan
Best For
Recurring issues from the Issue & Improvement Log that deserve more than a quick patch.
Target Audience
Small-business teams tired of fixing the same problem every month.
How to Customize
Keep it blame-free and finish within the hour. The verification plan is the part most reviews skip — don't.
When to Use
When an issue in your log keeps coming back despite quick fixes.
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OPERATIONS / REVIEW
Root Cause Review: Friday wholesale delays
A short, blame-free investigation of one recurring problem: what actually happened, why it kept happening, what we are changing, and how we will know the change worked.
What happened | Site | Owner | Date of review |
|---|---|---|---|
Wholesale orders left late three Fridays in a row | Roastery | Dana Kim | September 26, 2026 |
Impact
Two wholesale accounts called about late deliveries. Friday café service absorbed the extra packing work, slowing the counter at peak hours. No accounts were lost, but trust was dented.
How we got there
Why did orders ship late? They were packed after the morning production run instead of during it.
Why were they packed late? Friday wholesale volume was treated as same-day work.
Why was it treated as same-day work? Staging assumed an even Monday-to-Friday flow.
Why did that assumption hold? Nobody wrote the Friday pattern down when wholesale grew.
Why did it stay unwritten? The wholesale procedure never covered staging, only picking and delivery.
Root cause
The wholesale fulfillment SOP describes picking and delivery but not staging. Friday's uneven volume turns a missing staging step into a guaranteed late shipment.
Corrective actions
Add a staging section to the wholesale fulfillment SOP — Dana Kim
Move Friday wholesale staging to Thursday afternoons, effective immediately
Tell the two affected accounts what changed and what to expect
Verification plan
Check three consecutive Fridays of on-time departures before marking the issue verified.
Have whoever runs the staging step confirm the new SOP section matches reality, not the plan.
Record the verification in the Issue & Improvement Log — by hand, at the next operations review.
Stop at the cause you can actually fix. Five whys is a habit, not a rule — if the third why already points at something you can change this week, change it.
Related templates
Issue & Improvement Log
Track operational issues and deliberate improvements side by side — one owner, a severity, a corrective action, and verification for every row.
Standard Operating Procedure
A formal operational procedure template detailing version control, responsibilities, step-by-step instructions, and compliance checklists.
Meeting Notes
A structured meeting record capturing objectives, discussion points, key decisions, and assigned action items with checkboxes.