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.

CI 101

What are the rules to fix problems?

One common mistake for a manager or business owner is trying to “fix” problems looking at reports. Those reports are full of old information. They are good to know what happened, but they don’t tell the whole story.

If you are a basketball coach, you won’t try to call the shots just by looking at your team stats from the office. You will go to the basketball court, where the action is. You will observe how the individual members of the team react to the defense or offense play of the rival team. If you see something wrong, you will ask for a time out to discuss a change in strategy. You are observing every move, focusing on what the team needs to do to improve their game, and win. You can not be effective in doing the same thing looking at the score only.

As a business owner, when problems arise with a specific process, you need to do the same thing. Always go to the area where the action happens first. If it is a problem with customer service, observe how your employees interact with customers. If it is an issue related to the quality of the food, try it yourself. Does it look and taste as it should?

Sometimes it is not obvious what is wrong. In that case, focus your attention on the process tools, equipment, and standard work. On the food quality example, you confirm something is off with the quality but don’t know what. Focus your attention on how close is the execution to the standard work or recipe. Observe if the cooks are using the right ingredients, the right quantity, or following the recipe steps.

As soon as you find out the issue, take a temporary fix on the spot. This temporary fix will not solve the problem. To fix it, you need to find the root cause of the problem. Do not try to guess or assign a cause based on your experience, engage the team on this exercise. Once you know the cause or causes of the problem, you can plan how to fix it. To prevent a recurrence, you need to update the standard work.

To succeed in your continuous improvement journey, follow these simple rules while fixing problems.

  • When a problem arises, go to the place where the action or process happens first
  • Check all the relevant things: equipment, tools, materials, standard work
  • Take temporary solutions on the spot
  • Find the root cause
  • Standardize to prevent a recurrence

To acquire knowledge, one must study; but to acquire wisdom, one must observe. – Marilyn Vos Savant