I was called to a company to do a program in "Team-Oriented Problem Solving." The request for training in this subject area came about because of a quality error involving hundreds of thousands of parts and tens of thousands in dollars.
The eighteen hour problem solving program spans a nine week period with a two-hour class each week. Part of each class session is devoted to problem solving principles and practices and the other part of the class is devoted to discussion of real-world application problems. We also devoted some time attempting to diagnose the root cause of the quality problem that caused the company to have the program.
As we delved into the problem, failure to follow procedure was found pretty much every step of the way. But human error is a forbidden root cause because it is not a controllable or solvable condition that can be completely eliminated. Problem solvers confronting human error are encouraged to look for root causes in areas such as hiring practices, training, morale, motivation, and so forth.
The company had good people, many of whom had been with the company for years. It was a company that spent a lot of money on training. It was a good place to work and morale was high. There were well written procedures to cover everything. Quality was given high priority. So why did people fail to follow quality procedures virtually every step of the way?
As it turned out, the process had quality checks built in every step of the way with much redundancy including double and even triple checks. Since everyone was supposed to be checking, some people simply assumed that their checking role wasn't necessary, seemed to be redundant, and it wouldn't matter if they didn't check because the person before and after them would. While that may be true in a single instance, it certainly isn't true when it becomes widespread.
My advice was to reduce the number of checkpoints to a minimum, but enforce them to the maximum. People charged with checking needed to know that there wouldn't be others close by in the process to catch what they missed. That meant that mistakes would be costly and people who failed to perform required checks would be held accountable.
Moreover, these minimum checkpoints needed to be placed where work that could impact quality was performed, and the people performing that work had to be charged with responsibility for their quality (Quality at the Source).
Clearly my suggestion for less checking was not particularly well received. Indeed I hesitated to make it because it was unconventional. Yet the problem cause clearly seemed to point in the direction of too much checking.
I suspect the company "solved the problem" by hammering home the need for people to "do their jobs," and "follow procedures" and "pay attention" or else. And I believe that approach will work over the very short term. But I am still convinced that when everyone is made responsible for something (especially something redundant and boring), we ultimately end up with a system where some people leave the responsibility for actually performing the duty to someone else. If enough people do that, the system fails.
About me: Before becoming a full time educator, my career experiences included being vice president of a consulting firm, vice president - finance of a publishing company, vice president - sales support services for a manufacturing company and vice president - operations for a distribution company. As a full time educator working principally in Rhode Island (RI), Connecticut (CT) and Massachusetts (MA). I am pleased to share my experiences and business philosophies with managers at all levels.
Copyright © 2009 Daniel W. Pelley
All rights reserved.
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