MBOE recap: The blame game and the Challenger explosion

Students in Fisher’s Master of Business Operational Excellence cohort are back on campus for their second week together in the year-long program. Senior lecturer Mrinalini Gadkari is on the scene for daily recaps.

The 1986 Challenger disaster killed seven astronauts and consumed more than $5 billion as the shuttle broke apart less than two minutes into flight, sending fragments of the craft hurtling into the ocean and putting the nation’s space program on ice for nearly three years. But what caused it? Was it the O-ring failure or that the NASA operational officials’ ignored the warnings of the engineering experts? Was it the absence of clear goals for launching the shuttle? Or was it a problem in their policies? As COE Executive Director Peg Pennington and Senior Lecturer and Executive-in-Residence Gary Butlertold our MBOE students in their final session this weekend, there were multiple causes to the problem – just as there are with any. 

The 1986 Challenger
The 1986 Challenger explosion, captured in this National Geographic photo, killed seven crew members and launched a massive investigation

In a previous blog, I mentioned the importance of defining what your problem really is, whether it’s an exploded space shuttle or a missing file. In hunting the causes, most of us simply go after that root cause that led to the problem. But there’s never just one cause. Problems occur because of multiple causes that underlie the entire system.

Cause mapping, which you’ve read about here before, is a retrospective tool that helps you find out why something happened. This weekend Gary Butler introduced students to a new one – Failure Mode Effects Analysis, or FMEA – that helps you proactively look for when and how things can go wrong before they go wrong. 

How much time do organizations spend on assessing their processes with an FMEA or other tools? If they install new information systems, do they go beyond the cost-benefit analysis? Do they think about the impact they will have on staff, customers or suppliers?  Many organizations have a very narrow-minded outlook and forget to plan for the catastrophes that could be avoided with detailed analysis.

Discuss: Have an incident to share that led to extensive root-cause analysis? Any FMEA stories of your own?

MBOE recap: The secret sauce of standard work

Students in Fisher’s Master of Business Operational Excellence cohort are back on campus for their second week together in the year-long program. Senior lecturer Mrinalini Gadkari is on the scene for daily recaps.

Short question, long answer: How did Toyota become lean?

As MBOE coach David Hoyte told students in a recent session, the automaker organizes all jobs around human motion and creates an efficient sequence with lowest possible waste. If that’s the philosophy, guess how your employees will start thinking and working? They note time they spend walking around, looking for things, bending or lifting when it isn’t necessary. They take more care in detecting errors and preventing them. They come up with a sequence that makes more sense of the process.

If your organization’s philosophy is cost reduction, you run the risk of employees seeking low-cost suppliers and abandoning quality. Instead of focusing on reducing waste in the process, individual productivity is under the microscope and blame reigns supreme.  

In most organizations people are used to doing work at their own pace with undocumented methods. Some work slowly and others work faster. Some have figured out the fastest method but they hide it from others. This makes the process variable and unpredictable. 

Work Flow
Toyota bases its work flow on a philosophy of waste reduction. Image courtesy MotorTrend.com

Take note of these three elements to achieve standard work:

  • Employees must know the pace at which they are supposed to produce/do work (the Takt time)
  • Employees are trained to follow a standard sequence and method such that everyone follows the same steps and sequence in the process
  • Have only just enough supplies when and where they are needed to produce/do work (work in process)

Quite simply, it’s a better use of employees’ time and talent if they spend it doing more value-added work rather than wasting their time in wandering or waiting.

Discuss: Do you see variation in how your employees do work?   How do you apply standardization to your work processes? What are some of the challenges and wins?

MBOE recap: Mr. Potato Head teaches lean

Students in Fisher’s Master of Business Operational Excellence cohort are back on campus for their second week together in the year-long program. Senior lecturer Mrinalini Gadkari is on the scene for daily recaps.

In my last MBOE recap, I stressed the importance of “shine” in 5S. Yesterday, Senior lecturer and COE Executive Director Peg Pennington demonstrated how 5S and visual management apply to the workplace with a little help from Mr. Potato Head.

Who knew Mr. Potato Head could be so educational? Organizing limbs, mustaches and hats, it got me thinking about how in hospitals it isn’t uncommon for nurses and doctors to hoard supplies so they can have them when they need them and won’t be scrambling at the last moment. If the workplace isn’t organized it’s easy to misplace or even lose things. If you can’t find them, you spend valuable time searching, hoard product or order more. 5S removes that waste, eliminates unnecessary items, creates a safer work area with more space – and, of course, saves you time. 

Mr. Potato Head
“This iconic, bespectacled lecturer led students through a look at workplace visual management.”

Once your workplace is organized and all items have a standard place, what work remains to be done on your processes? Each one of us has ordered something online and gotten the wrong product. Heard of wrong-side surgery? It’s easy to see opportunities for improvement in someone else’s processes. Our MBOE students, for example, took a trip to the Ohio State University Medical Center to view Central Sterile Supply and Nutrition Services. Some students say their “Aha! moment” came by watching technicians and nutrition aides.

In his lecture on training within industry on standardized work, Fisher Executive in Residence Gary Butler drove it home, telling students that a combination of standardized work and visual management stabilizes working condition, flags the abnormal from the normal and keeps staff on task toward reaching daily goals.

Discuss: Do you have an “Aha! moment” for your own organization, on the shop floor or in the service area? How did that lead you to standardize processes?

MBOE recap: The Weakest Link (…goodbye.)

Students in Fisher’s Master of Business Operational Excellence cohort are back on campus for their second week together in the year-long program. Senior lecturer Mrinalini Gadkari is on the scene for daily recaps.

As lean guru Tracey Richardsontaught our MBOE students the problem-solving process at Toyota, the thing that amazed me the most was that she rarely used the word “car” or anything close to it. She spent a major part of her time talking about culture and people instead, asking: “Does your company have values?” More importantly, she said, is whether your people believe in them. That, Richardson said, is the weakest link in a company.  Most organizations boast having values, but do leaders have the discipline to live them and hold people accountable? Have they internalized the values to reflect in their character? That’s where most organizations lag.

Tracey Richardson
Tracey Richardson coaches Fisher’s MBOE cohort

An example of a good leader sticking to values, in this case safety, remains in my mind: This company’s CEO was walking with me down a hallway when he noticed a paper clip on the floor. Without a moment’s hesitation, he bent down to pick it up, threw it away and we kept walking. He didn’t have to say a word. That company’s core value was conveyed through that action. 

Culture begins with leaders. People internalize what they see and hear their leaders doing consistently. The “true north” goal at Toyota can be described in one line: Customer first, the highest quality product, lowest cost, shortest lead time, safest manner, while respecting people. At Toyota, to create the highest quality product, they hire the right people in a systematic manner, train them to continue to have standardized processes, encourage them to highlight and solve problems in a systematic manner and value their inputs. Once a month, Richardson said, the president of Toyota would go to the shop floor and spend two hours working on the line, letting front-line staff help the manager on other processes. What a commitment from the president!

Discuss: How do you see the core values of your organization play out in everyday ways?

5S: More to ‘shine’ than the surface

Regardless of where you are in your lean journey, it’s likely you’ve heard of 5S, the set of five words that serves as a methodology for organizing the workplace. In English, they’re Sort, Set in order, Shine, Standardize and Sustain. That’s derived from the Japanese origin of Seiri, Seiton, Seiso, Seiketsu and Shitsuke.

Detractors might say 5S is simply a “spring cleaning” activity where trash is discarded to make room for more, but it’s a great deal more than that. When you sort, you separate and eventually throw away items that are unneeded. You set in order items according to the frequency and sequence of use. You get rid of dirt, dust and any leakages and shine the workplace. Once you organize the items, you standardize their location and level of use. To sustain that organization, you create paperwork that operators or managers can use to reach that goal. 

If it all works so well, then, why do some still consider shine a dusting and cleaning activity? Some say it’s played a part in saving lives. Ever heard of the controversial “Broken Windows Theory? It posits that simple disorder can increase the tendency for crime in urban areas – if more trash isn’t removed, more will pile up. The New York City Transit Authority in the 1990s applied this to stop an increasing graffiti problem on subways, scrubbing down trains each night before resuming service the next morning. Over time, they got rid of the problem as other initiatives were put in place around the city, contributing to a remarkable decrease in vandalism and the crime rate.

When you ‘shine’ the workplace it has a positive impact on the operators working there. A dirty workplace tends to cause distraction and reduce employee morale and doesn’t convey a positive message about the company. With items in ready-to-use condition, working is safer with dust and dirt gone along with slipping and tripping hazards.

In short, a clean and safe workplace begets a safe and clean workplace.

Show me what you got

I got my first real taste of old-fashioned, machismo-fueled negotiation when I wrecked my car earlier this year. Thankfully, I wasn’t the driver to blame, wasn’t hurt and was driving a 15-year-old parental hand-me-down I secretly wished would suffer that fate. Nonetheless, one totaled vehicle meant finding another with a settlement check from an insurance company in tow – and both of those would put me face-to-face with people who assured me they were giving me the best deal they could but were clearly lying through their teeth.

In both scenarios, I (naturally) feel I came out on top in retrospect. Talking an insurance adjuster into a few hundred extra dollars is no small feat and my performance in the car salesman’s office would make Ryan Gosling jealous.

I thought about both of those negotiations last week, when the Center for Operational Excellence hosted a forum for our member companies’ administrative assistants. The brave souls that trekked through an unusually blustery and snowy Columbus day got a hands-on crash course in negotiation from Maggie Lewis, a lecturer in the Fisher College of Business. Unfortunately, that thinking led me to realize the kind of negotiating I did wasn’t that tricky. I cared nothing for the results or the feelings on the other end of the table, a classic “win-lose scenario.”

Maggie Lewis
Maggie Lewis, presenting at COE’s administrative assistants forum

The kind of negotiating we do in our lives as lean thinkers is much tougher than balking at a sticker price. In a realm where responsibility is shared, blame is avoided at all cost and flow requires buy-in and cooperation from everyone involved, negotiation is a tightrope walk. On one end is the current state, riddled with problems and inefficiencies, and on the other is the future state your pursuit of operational excellence will take you. The last thing you need is a disgruntled colleague with a good pair of garden shears.

Lewis during her presentation made a few comments that struck me for their deep relationship to lean principles, chief among them: “Negotiation is just problem solving.” Any manager could tell you that sentence works in both directions.

What’s your problem?

I recently had to take a friend to an urgent care facility in town after she broke out in hives and itchy skin, likely an allergic reaction to a food item. After making it into the exam room, the medical technician very efficiently completed the vitals and reconciled medication and past illness history. Next in was a physician’s assistant, who performed a quick assessment and confirmed our suspicions about the food allergy.

But what food? We still weren’t sure, even as the hives were quickly spreading and my friend agreed to a Benadryl shot. Within 20 minutes, the itching was gone with the hives almost disappeared. One crisis averted, one very drowsy friend.

I have prescribed and given Benadryl shots to my patients in the past but this was the first time as a non-physician that I noticed how quickly the drug acts and makes the reaction disappear. It got me thinking about how a lot of the countermeasures many organizations implement to solve a problem act like Benadryl. Symptoms disappear but the root cause remains.

Cause Map
Cause map slide courtesy Peg Pennington

Most people, in fact, aren’t sure what problem they’re trying to solve. For example, if sales go down, marketing goes up. But what if your products are defective? What if customers are getting the wrong product or are waiting too long to receive it? What if a competitor is turning out a better, faster alternative?

You will only be treating the symptoms if you don’t know the:

–          actual problem you are trying to solve

–          root cause of the problem

There are many tools available to get to the root cause of the problem such as the 5Whys and Fishbone diagram.  I recently learned from a colleague a new method, causal mapping, which I prefer because it is visual and loose in structures, allowing for a free flow of ideas until you find the root cause.

My friend, by the way, is on her way to an allergist to nail down the real culprit.

Tell me where it hurts

Fair warning: This is one of those articles you read that makes you think twice about checking into an emergency room.

I’m still reeling from a recent New York Times article on a Department of Health and Human Services study that found hospital employees note and report only one in seven errors and other incidents of harm to hospitalized Medicare patients. One in seven: That’s an F in a classroom and includes instances that range from bedsores, acquired infections and other mishaps that could even result in death.

Medical error
This x-ray, courtesy BigHealthReport.com, illustrates a much-feared medical error.

The point here isn’t to encourage you to hit the Advil next time you fall off a roof. Read deeper and the lean alarm bells start sounding. According to the article, federal researchers say it isn’t shame or embarrassment that’s keeping these instances from being reported. Rather, it’s hospital employees not recognizing what constitutes patient harm or realizing a procedure has harmed a patient. In lean-speak, researchers hint the root cause lies deep within the procedures and training that line the backbone of hospitals’ operations.

The most staggering sentence in the article comes later: “In some cases … employees assumed someone else would report the episode, or they thought it was so common that it not need to be reported, or ‘suspected that the events were isolated incidents unlikely to recur.’”

This is a shining example of how a finger-pointing, siloed approach to daily work and problem-solving can infect an organization. On a shop floor, this could mean a malfunctioning widget. In a hospital, this could mean one less vacancy in the basement morgue.

The report is mostly, but not all, bad news. Medicare officials told the Times they’ll develop a list of “reportable events” to clear up confusion, a sure sign of progress. But much work remains to be done – a major problem in the system these days, the report states, is that once problems are recognized they very rarely lead to changes in policy or procedure. It’s a good start, though, to define what a problem is, design processes so they expose problems and then have a process in place to address them.

Reading the article, I’m reminded of a chat I had with lean guru Steven Spear when he visited Fisher to coach our Master of Business Operational Excellence cohort in November. Spear has loudly advocated that health-care providers should focus less on problems in the market and more on reforms in specific processes to effect meaningful change.

“I’m not sure that’s caught on in health care in a broad-based way,” he told me.

Unfortunately, he’s right.

Don’t let the Zen garden fool you

I wish you a very happy 2012 as you make progress in your journey of operational excellence.

I am sure many of you must have traveled during the holiday week. On a recent trip I took to Orlando to attend the Annual Institute for Healthcare Improvement (IHI) conference, a very common occurrence got me thinking. We all know how first-class and business-class members get the preferential treatment of boarding the flight before economy class passengers. In terms of customer service, that makes sense. They pay more and get to board earlier. 

What I find extremely ridiculous is that they get to walk on a small piece of carpet when they board the plane, while economy class passengers are diverted to a separate passage that bypasses the carpet. But only one entrance leads to the plane. As you can see in the picture, the airline managed to create a fake sense of “specialness” for first- and business-class passengers.

We see the same thing in hospital waiting rooms and other service operations. Excellent customer service would be no wait at all but service industries use the band-aid approach for the problem. They build Zen gardens and embellish the walls with beautiful artwork in waiting rooms to distract customers. Instead of improving the processes to reduce redundancies and waste, they focus on the perception of customers regarding wait times. If wait times increase beyond a certain time because of “unavoidable” circumstances, customers are given freebies in the form of free parking passes or gift certificates.

The key is to attack inefficiencies in the processes and give customers what they came for. If you went to a grocery store looking for your favorite box of cereal and had to spend a half-hour hunting, guess where you’d go next time? A competitor.

Customers can’t be fooled by superficial embellishments. Give them what they want. Improve the process, not the ambience. That’s true customer service.