Years ago, I worked with the Director of QA/QC and was tasked a Root Cause Failure Analysis (RCFA). When I heard about this particular issue, I cringed thinking about how we were going to identify the cause and then fix it. Together, along with a group of others, we spent about an hour on a white board, drawing charts and implementing the Ishikawa Fish Bone Diagram and asked the 5 Whys, affinity diagram, and multi-voting ideas -- basic Lean Six Sigma stuff.
It was something we’ve done many times before.
Then he sat in front of the whiteboard, silent, staring and thinking.
After five minutes, he got up and looked at all of us and said, “process.”
I asked him what he meant.
He explained that when people don’t follow processes, problems occur.
Stands to reason that outcomes are predictable when a person follows steps that in the past created positive results. Negative results occurs when processes aren’t followed.
I have heard many times from people in successful positions who say that they aren’t the smartest nor intelligent, but their successes were based upon their abilities to follow instructions and processes
It makes sense, but yet due to our need to work outside the box, we decide for what underlying causes (which many cases is ambivalence or just being plain lazy) to do something else. Then when the outcome is less than acceptable, blame is placed, feelings get hurt and nothing gets accomplished.
My basic definition of “process” are sequentially taken steps from start to finish that results to an outcome. It usually contains a beginning, middle and end where steps are controlled in the form of a work instruction or Standard Operating Procedure.
One basic tool in Lean Management is aptly named “standardized work”. Here work falls into categories that is routine and organized for efficiency, a method that if done the same way each and every time, results are probable.
The goal of reducing cycle time and defects are based upon reducing or eliminating constraints, waste and variables or variations. A Lean method that’s used consistently is something called standardized work. This means doing the job the same way day-in, day-out, with no variations. It’s a process that has proven successful not only with the present company but with all others in the world. As decided above after the RCFA, the Director determined the culprit as an individual conducting steps outside processes. Many factors play into the dynamics of a failed event, some slight, others major; or, it could be a series of events. One thing for sure is that had the variation not occurred, it would not have created the costly failure.
This does not mean that people should not continuously improve upon a processes. It is, however, best to strategize the improvement change through an isolated pilot program or beta test. This neutral methodology allows for a segregated assessment while limiting the liability should the results fall below expectations.
As simple as this is, it requires discipline. The preferred method of enforcement is to train and mentor the staff to make this part of their culture. Too many times management instructs or mandates (force-feeds) change. When this occurs we interpret this as an “add on” to our list of many things to do and remember; and, as a result, we are less encouraged and more to just say, “the heck with it.’
Best prevention is to continue what has proven effective and then encourage a culture of operational excellence by enforcing standard processes as a fundamental habit for all employees.