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Is human error an acceptable root cause? Find a better root cause to have a more effective corrective action than employee retraining.

I was called to help this company to investigate the root cause of all the non-compliance observations they got on a recent third-party audit.  It turns out that a couple of those observations were recurrent, and the audit agency wanted to see a corrective action preventive action (CAPA) report for each.  The experience was the perfect opportunity to have department and line leaders learning and practicing how to do root cause analysis.

Soon enough, after we start analyzing the first observation, the group concludes that the root cause was human error.  The corrective action to avoid recurrence was retraining.  I moved on to the next two, obtaining similar results.  I know three points are not enough to say there is a pattern, but in this case, it was enough to prove my point.   

It is common to choose employee retraining as a corrective action, but because human error is not the real root cause, it will not prevent the problem from happening again.  RCA requires persistence to keep asking why until finding the end cause.  If you stop digging before finding the underlying cause, the process fails.  You end up working with a symptom or a proximate cause.  In the example above, human error is the symptom or physical source.  The source of it is the real root of the problem.   

Asking why the person made the mistake will help to identify the real root cause.  Keep asking why to dig deeper into the problem.  Human error is often the product of inadequate processes, lack of resources, using the wrong tools, complicated work instructions, too many interruptions, or noisy environment, between others.  

Do you want to find the real reason for human error?  Engage the team, the people who create value, those who actually do the work, and ask why.  I bet you that they will have lots of ideas to improve the process and minimize or eliminate recurrence.  Humans are not perfect, acknowledge that fact and design robust systems that minimize defects or errors.  Visual management and mistake-proofing devices are good tools to accomplish that.  

Next time you find that the cause of the problem is human error, keep digging!  Why humans erred?  Be as curious as a cat, find the real underlying cause and improve your process.

CI Tools

How to write a work instruction. Easy guide to create your own template.

Standard Work (SW) is a simple written description to perform a task. SW is the safest, highest quality, and most efficient way to execute a particular task. The three components of standard work are the following.

  • Job sequence to complete the job
  • The rate at which products must be produced to meet customer demand (takt time)
  • The standard amount of work in process inventory

Let’s focus today on the first component.  One way to document this component of standard work is by using work instructions.  A work instruction describes in detail the step by step information to do the task.  In general, they combine words, pictures, icons, or sketches, to define each step.  They also contain important tips for things that can make or break the job, safety, and quality.  

The first step to create standard work was to understand the process and break down the job.   If you follow all the steps, then you already have the job sequence to perform the job safely and efficiently while achieving high quality.  All you have to do now is to present the information in a simple and easy to understand format.

Document header

  1. This is an official document and should contain the company or business name, and address. 
  2. Use a clear title that describes the task.
  3. Although is not critical, you should have a standard alphanumerical format to identify the work instructions.  This is helpful if you plan to create instructions for key tasks in different departments.  This number should go next to the work instruction title.
  4. Identify the department and position(s) that will perform this task.
  5. Include the document effective date.
  6. When the job has safety risks or required the use of personal protective equipment, you should identify both.  This information can go either on the heading or the body of the instruction.  You can use words but is better to use icons to represent risks and PPE.

Work Instruction body

  1. List the materials or equipment required to do the job, use bullet points to facilitate reading.
  2. Describe how to perform each step following the appropriate sequence.
  3. For each step, include risks, and tips to do the job easier and/or achieve the desired quality.

Document footer

  1. If you are using the WI as a training tool, the footer should include space for the trainer and trainee names and signatures.

Do the following while writing your work instructions.

  1. A number sequence for the steps.
  2. Limit the numbers of steps, if the task has more than 8-10 steps, subdivide the instruction in different subjects.
  3. Bullets or numbers each time you need to list something.
  4. Highlight important information using a different color, bold or italics.
  5. Use pictures, screen shots or icons every time you can.

Create a document template with the format you chose and a library with the icons to depict risks, actions, personal protective equipment, and others.  Designate who will be responsible for creating the work instructions.  Also, who will manage the documents library, including numbering, and filing.  Consistency and clarity are critical to avoid confusion

CI Tools

How to create standard work? Using PDCA to create the baseline for continuous improvement.

Although PDCA is a problem-solving tool, this methodology is excellent for any improvement activity.  We followed PDCA while walking through the kaizen steps, and today we will use it to create standard work.  In general, the following are the steps to create work standards.  The figure below shows how they translate into the PDCA steps.

  1. Understand the process, break down the job & question every detail
  2. Develop a new method for performing the job
  3. Run the process and observe results
  4. If it is necessary, adapt the process and go back to step 4.
  5. When you find the best method, create the standard

PDCA should be a team exercise, always recruit team members to analyze and create standards.  The most important part of the PDCA cycle, understanding the problem is critical for its success. This statement remains true when we use PDCA to create standard work.  Even if you know the process, ask what it is about, and what is supposed to accomplish.  What is its purpose?    If you can eliminate or combine the process, do it!  If you cannot, then continue to understand the job sequence, breakdown the job, and question each step. Always observe the process and talk with the people who do the work.

The next step is to develop a new method.  Engage the team in a brainstorming session for improvement ideas.  Prioritize and select the best solutions to design a new way to perform the job.   Use those ideas to design the safest, highest quality, and most efficient way to do the work.  Test the new design, observe the process, and measure the results.  All this is part of the step Do, the second of the PDCA cycle.

The third PDCA step is Check, which is what you will do while analyzing the results from your test drive.  Does the new process achieve the objectives?  Is this the best way to do the job?  If it is, start to create the standard, which is the last PDCA step, Act.  If it is not, modify or adapt the process.  

If your test drive proves that you need to improve the new process further to accomplish the goals, modify it, and test it again as part of the PDCA step Act.  You keep changing, testing, and analyzing until you reach the desired condition.  When this happens, it is time to create the standard.

PDCA provides a framework that is easy to follow and repeat.  In the same way that you can use it to standardize Kaizen, you can use it for your standard work creation also.  Standard work is the baseline for future improvements.  You create the standard, let the operation stabilize, and then improve the standard.  

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What is Leader Standard Work?

The fundamental ingredient for a successful lean implementation is creating a continuous improvement culture.  It is impossible to create a culture without the active participation and support of leadership.  Most of the time, leaders at all levels have to learn continuous improvement principles and tools along with their team.  But that is the easy part, the challenging one, is to move away from traditional thinking and adopt a completely different way to behave, think, solve problems, communicate and relate to others.  

In other words, leaders looking to use continuous improvement and lean thinking need to build a new business persona.  This journey will help you to reflect on how you manage or supervise now and build new habits for the future.   Some people say it takes 21 days to build a habit, while others claim it takes up to 66 days.  I don’t know the right answer, but I know that building the habits required to successfully change a culture takes more than a couple of months of practice.

One tool that helps with leadership changes in behavior is Leader Standard Work.  Standard work ensures consistent results and is the baseline upon which improvements are made.  Leader standard work is a description of the safest, highest quality, and most efficient way to drive continuous improvement and Lean thinking throughout the organization.

Leader standard work is usually presented as a form or checklist with daily tasks, as well as space for additional tasks specific for the day.  You can divide the daily tasks by time-specific, like meetings and non-time specific.  A different approach is to divide tasks into sections.  For example, before, during, and at the end of the shift.  Like many other things with continuous improvement, you can select the format that makes more sense for you and your business.

The following are things that you should include in your Leader Standard Work because they support and promote continuous improvement.

  • Daily team meetings
  • Walk the area where value is created
  • Observe out of normal situations
  • Support continuous improvement activities
  • Follow-up performance vs. objectives
  • Set direction, ask and answer questions
  • Reflection
  • Plan the next day

Although many can say that using a form to guide what you have to do through the day is too restrictive and takes away the flexibility to deal with daily problems, it is the contrary.  Remember, you are building a new habit, a new way of doing business.  The form will help you to create that habit and make you focus on those things that will help to identify out of standard situations before they become a problem.  It will take time, but in the end, you will see the benefits of seeing things by yourself and not relying on reports with outdated information.  Lean is about learning, experimenting, and reflection on the results to keep learning and improving.  As a leader, you set the example by doing what you expect your team does.

This is like whey you are trying to build the habit of jogging or have a walk daily. It is hard, but over time you will get the benefits, will get used to it and doing it is almost like breathing.

CI Tools

What are the best practices to create standard work? What are the standard work documents?

Standard work documentation is important to record the right and only way to complete a process.  Although they are not a training tool by itself, it provides clear, simple, accurate, and complete information to support training.  Standard work is the foundation for improvements if they are not documented, that foundation is weak, and it will not drive the desired change.

The following are best practices to create standard work documentation.

  • The people who do the work participates in the process
  • Include all relevant information on one, easy-to-read document
  • Keep it simple and use visualization if possible.
  • Make the documentation accessible
  • Set clear expectations regarding revisions and improvements

There are different types or formats to document standard work.  The best format is the one that works for you, as long as it follows best practices and it contains the three components of standard work.

  • Job sequence
  • Rate at which products must be produced to meet customer demand
  • Standard work-in-process inventory quantity

The following are examples of different templates or forms for standard work documentation.

Standard Work DocumentationDescription
Process capacity sheetDefines the available capacity
Standardized combination tableDefines the work of one operator during the process cycle, it describes what the operator is doing and when it is doing it.
Standardized Work ChartIt is a simple layout of the work area that shows the flow of the worker, information, and materials through it while keeping the production rate to meet customer demand.
Work instructionThere are different formats but in general, they contain step by step information to do the work.  They have a combination of words and pictures or drawings, to describe the step.  They also contain important tips for things that can make or break the job, safety, and quality.  
ChecklistThis simple document can have two different uses, to confirm that everything was done or to check as you carry out the task.
Visual aidSimple instructions using pictures or drawings to show the steps of the process.  They are posted at the point of use.
Memory joggerThese can be a group of laminated cards with general guidelines, settings, or other information that is not used very frequently.  

The first three worksheets on the table above are used in Toyota to facilitate the documentation of standard work.  Their use is fairly common in manufacturing, but not in the service industry.  The other examples listed are common everywhere.  You can use different types of templates to document your processes but be consistent on when you use each type and the format of the documents itself.  You do not want to confuse the employees.  

Standard work documentation is important to record the safest, highest quality, and the most efficient way known to perform a task.  They reduce variation and improve consistency.  This document is the baseline for future improvements.  It is important to emphasize that standards exist to be improved.  After you create a new standard, you wait until the process is stable and improve it again.  

CI Tools

How you can prioritize ideas after a brainstorming session?

If after a brainstorming session, you have a lot of excellent ideas to improve or redesign the process, you have a sweet problem on your hands.  You and your team cannot implement all of them, you would have to go through validation, and prioritization process to choose those that will happen now, later, or maybe never.

To choose the ideas that require less effort and create more impact, you need a prioritization tool.  The prioritization matrix shown below is the one I use.  It shows a graph that measures effort along the x-axis and impact along the y-axis.  Each axis was divided by half, creating four boxes.  Each one represents a different action based on the level of impact on the desired results and the level of effort need it to achieve it.  

The options are the following.

  1. High impact, low effort – These are quick wins, prioritize these ideas.
  2. High impact, high effort – Ideas under this box deserve action, maybe they can’t be completed within a week or required more resources but should be next in priority.
  3. Low impact, low effort – Consider implementing ideas within this box.  You can do them when there is time available.  Some people think about this category as fill-ins.
  4. Low impact, high effort – Ideas that have low to no impact in the desired condition can represent a waste of resources, do not do them.

This is how you prioritize the ideas.

  1. After brainstorming, assign a number to each idea.  
  2. Draw the prioritization matrix in a whiteboard or flipchart.
  3. With the participation of the same team that generate the ideas, classify each one in one of those boxes.  
  4. Select the ideas for short-term implementation.

The next step is to select a leader and team for each initiative.  In no time, you all are going to be ready to have more fun!  

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Here is another example of 5 Why, this time in a restaurant.

Here is another example of how to use the 5 Whys, this time in a service environment.  For example, in a restaurant, the symptom is a customer complaining about the waiting time.  Unfortunately, the way many people would fix this is by apologizing to the customer and make sure that he or she gets the food as fast as possible.  What is the problem?  What is the root cause of the problem?

Remember our friends from Yummy Broth?  They are a small restaurant specialized in soups, but they also served salads and sandwiches.  One day, not one or two, but four customers were complaining about the service.  The truth is that the food was not arriving in a reasonable amount of time, and the front-end supervisor was concerned.  They managed to get food in front of the customers to fix the immediate problem.  The manager does not want this to happen again.  She knows how to use 5 Whys, so next day during their stand-up meeting, she went ahead to analyze the root cause of the situation.

For this problem, probably most people will choose to expedite the food for the complaining customers, a second group would try to find a root-cause and will stop with the third or the fourth why.  Only if you keep digging, will find that the root cause is that there is no standard work.  Even if team members want to help, they could not do the right thing because there is no instruction to do the work.  Without a standard, effective cross-training is not possible.  At least the manager knows better and keeps asking why until the real reason was uncovered.  Now, she should be creating that standard work with the team to organize cross-training.

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What are the kaizen steps?

Previously I mentioned that PDCA is a good tool to standardize the kaizen event.  Today I will show you the general steps to do a kaizen event and how to use PDCA.  The following are the general steps to plan and execute a kaizen event.

  1. Understand the problem
  2. Plan the event
  3. Learn about the current state
  4. Design and test the new process
  5. Validate the results against objectives
  6. Modify the process if necessary
  7. Once we achieved results, standardize, train, and communicate
  8. Make further improvements, start over.

We learn before that the planning step is critical for problem-solving.  It is because, during that step, you are studying the problem to understand in detail what is happening, which includes finding the root cause for the situation.  

It is similar while planning a kaizen event.  You start by understanding the problem or situation.  You need to describe the problem as detailed as possible using the affected KPI’s, the process name, and its description. The charter document is very useful for kaizen planning.  It is important to identify all the key information to make the event a success.  It includes the scope, objectives, expected deliverables, team members with their roles, event dates, location, and basic information regarding the problem to tackle. These two steps are the equivalent to the Plan step of PDCA, the next two are the Do step.

The third step is to establish the current state, to draw a picture of the process as is.  For this, you need to know the process, the first and last step, steps sequence, and standards.  You also need to know the customer needs.  The golden rule to fix problems is to go where the value is created, observe, measure, and ask questions respectfully.  Identify waste, where the flow stops, safety hazards or risks, and quality concerns. The most important part of the PDCA cycle is understanding the problem.  While doing a kaizen, it is critical to understand the process, including the root cause of the problems identified.

Equipped with this information, you are ready to start designing the new process.  For this, start brainstorming possible solutions.  The target is to eliminate waste, improve quality, or reduce the cycle time.  Refine the list and select those ideas that are expected to have a bigger impact, and the team is able to do it during the allotted time frame.  Test the process, simulate the conditions of the new process, and measure the results.  Analyze the results vs. the objectives, validate if the process can achieve them.  Modify the process if you need, test, and measure as many times as it is necessary until the desired condition is reached.  If you noticed, this fourth step is following PDCA by itself, as shown in the figure below.

The kaizen step equivalent to Check is to validate the effectiveness of the new process.  The event is scheduled for one week or less, but sometimes you will have pending items that need to be finished later.  This step includes follow-up on the completion of those items.  It also includes a revision of the results to determine if the kaizen achieved its objectives.  Normally, this follow-up process happens 30 days after the completion of the event.  Similar to what happens in the previous step, if the new process falls short on the objectives, you follow PDCA to modify, measure, and adapt until the desired condition is reached.

The last step in the kaizen event is to evaluate the performance of the process.  Process monitoring should be part of the daily operation as well as discussion of gaps between standards and current results.  Daily kaizen should address problems in quality, safety, or delivery performance.  Remember, once the improved standard is stabilized, it is time to start the improvement process again.

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What is Kaizen? What is a Kaizen Event?

Continuous improvement (CI) or Kaizen is the daily practice of creating small changes using low-cost common-sense solutions.  In my post, Take Baby Steps for Continuous Improvement, there is a little history of how Kaizen was born.  Continuous improvement involves everyone in the organization, improving processes everywhere, every day.   

Since the goal of lean is to deliver to the customer the highest quality, at the shortest lead time, at the lowest possible cost, kaizen focus is quality, cost, and delivery.  Kaizen’s major activities are 5S, standardization, and waste elimination.  Daily execution of these three activities drives incremental improvement that brings dramatic results over time.

Daily CI is important to tackle small problems before they become big ones.  The inspiration for daily kaizen comes from observation of frequent deviations from the standard, or ideas to improve the process.  However, sometimes we have challenges that require a more methodical approach.  When that happens, a Kaizen event comes to the rescue.  Recurrent problems that affect productivity or KPI performance are a good candidate for an event.  

A CI or Kaizen event is focused on one problem or improvement idea at a time.  The goal is to accomplish dramatic improvements in 2-7 days period.  These are rapid events, short, and based on common-sense solutions with very low or no-cost at all.  The understanding of the problem, and kaizen planning are critical for success.  It is also important to standardize the way of performing kaizen, everybody should follow the same steps and document the execution of those steps in the same way.  A good method to ensure the problem-solving activity is standardize is using PDCA.

When it is done correctly, kaizen not only improve quality, cost, and delivery.  It also helps the heart of the lean system, the people.  It does so by eliminating safety hazards, simplifying processes, and teaching people how to identify opportunities, and improve their processes.  In my next post, I will discuss the general steps to perform a kaizen event.

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Do you want to see some examples of Kanban in action?

Continuous improvement creates changes in your business operation using common-sense solutions.  It approaches common problems using good judgment.  For that reason, any given day, you will see examples of lean tools in your daily life or at your workplace.  We saw that before with visual management, which is now the favorite tool to communicate and guide behavior during the COVID-19 pandemic.  

Although it is not as popular as visual management, kanban is no exception.  Here are some examples.