CI Tools

Gemba Walk, What does “Go see, ask why” mean?

Toyota Chairman Fujio Cho’s words, “Go see, ask why, show respect,” are famous.  They are like a creed for lean practitioners around the world.  Go to gemba, the place where value is created, where the work is done, is one of the core principles of continuous improvement.  Cho’s words are a summary of what going to gemba is.  What do those words mean?

Go See

The purpose of the gemba walk or observation walk is to understand the work and grasp the current situation. A process has three versions, what should happen, what we think happens, and what actually happens.  You will get an understanding of what is happening by observing everything within the area, people, equipment or machine performance, and the work environment.  If you notice any gaps or problems, focus your attention on one at a time.  These are the things you need to see for yourself.

  • What people do, are they following the standards?
  • How people spend their time, how is the work environment?
  • How people move around the work area
  • The workflow, how the product or information flows through.
  • Where the flow stops?  Watch for interruptions and delays.
  • Handoffs between workstations, how the materials, ingredients or information arrives and leaves the station.  

Remember that you are there to understand the situation, not to judge.  All gemba walkers are there to practice observation and active listening.  Focus on the system, quality, cost, and morale.  Look for improvement opportunities. Practice respect while asking questions, let the team shine.

Ask What

Even though Cho’s phrase says, ask why, the first question is what, not why.  What is the purpose of this process, what it intends to achieve?  Only ask why type questions, which are to diagnose, after you understand the process and the current situation.  Ask why there is a gap to the standard, why delays happened, why does rework occur, and others.  Listen to the answers to understand the point of view of the people who do the work, keep learning from them.  The conversation will lead you to a point where you can ask what if.  At this time, you can ask for their ideas, what if you change the method?  

Gemba Walks are a powerful tool to promote the continuous improvement culture or a fast way to kill it!  In a blame-free culture, your associates will be honest, talk freely about their concerns, and share their ideas without problems.  The way you, and your leadership team reacts to comments and concerns, and how diligently you are to facilitate their work and solve their problems will determine how successful these walks are.  As a system, gemba walks supports the scientific method (PDCA) because it is based on actual observation.  

CI Tools

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.