Continuous Improvement “Systemism”

Failure Mode Analysis of Continuous Improvement Systems

Nick Ruhmann

• The Common “Continuous Improvement Programs”

• Failure Modes of These Programs

• Effects of Failure

• Causes of Failure

• Countermeasures for the Causes

Agenda

Taylor’s Scientific Management

Training Within Industry

Job Methods

Crosby’s “Zero Defects”

Deming and TQM

TPS (Lean Manufacturing)

Motorola / GESix Sigma

Shainin's Statistical

Engineering (SE)

Lean Six Sigma

Continuous Improvement “Programs”

Some of this was progress, some

were just new labels

6 Sigma Lean Lean Six Sigma

Most Common Today...

Scott Adams doesn’t just make this stuff up...

• Failure Mode 1:• Copy “tools” only without making work self-

diagnostic• Failure Mode 2:

• Workaround problems even when they are recognized

• Failure Mode 3:• Don’t share systemically what has been

learned locally• Failure Mode 4:

• Don’t develop the capabilities of others to design work, improve work, and institutionalize new knowledge

Why Do We Fail?

1. Relying on technology to solve problems2. Seeking examples to follow rather than developing

solutions (implement the new, cool thing)3. Excuses, such as "our problems are different“4. Relying on quality inspection rather than improving

product quality5. Reliance on quality control departments to solve

problems rather than management, supervisors, and production workers solving problems

6. Placing blame on workforces who are only responsible for 15% of mistakes when the system designed by management is responsible for 85% of them

Effects (Symptoms) Of Failure...

• Failure Mode 1:• Copy “tools” only without making work self-diagnostic

• Causes:• We look only with our eyes...so we only see what is visible

Causes...

"I think that people here expect miracles. American management thinks that they can just copy from Japan—but they don't know what to copy!“

- W. Edwards Demming

• Failure Mode 2:• Workaround problems even when they are recognized

• Causes:• Scientific Problem Solving isn’t taught• Problems aren’t seen as opportunities• Focus on Short Term Goals

• This week

• This Month

• This Quarter

• This Fiscal Year

Causes...

• Failure Mode 3:• Don’t share systemically what has been learned locally

• Causes:• No predefined method of sharing• No way of knowing when sharing has not occurred• Running an organization with functional “Silos”

Causes...

• Failure Mode 4:• Don’t develop the capabilities of others to design work,

improve work, and institutionalize new knowledge

• Causes:• Problem Solving is thought of as a specialist role, rather than

a core capability of every worker to be developed• Problem Solving and the ability to develop problem solving in

others is not a key requirement of managers everywhere• Ignoring the importance of mentor / student ratio’s on the

plant floor.

Causes...

• Forget whatever “Cool” name you’ve given your CI Program – the name matters not

• Stop measuring CI by short term Goals – focus on customer satisfaction, profits will come

• Move away from functional silo’s of disciplinary “experts” – move towards organization built around products

• Give every employee a capable mentor – expect that every employee continue learning

Countermeasures

1. How to Design Work to see problems

• Make All work highly specified as to content, sequence, timing, and outcome

2. Insist on swarming problems• Problems must be immediately

addressed, both to contain their effects from propagating, and to trigger problem solving

Countermeasures (what to teach)

3. Problem Solving Using the Scientific Method

• Any improvement must be made in accordance with the scientific method, under guidance of a teacher, at the lowest possible level within the organization

4. Leaders Must be Teachers• The most senior management

level has to own the capability development process – it must cascade downhill

Countermeasures (what to teach)

15

Capability 1 : Design work to see problems

16

The FOUR Levels of Process Design

1. Defining objectives/outputs for the system

2. Creating pathways by assigning responsibilities

3. Connecting adjacent nodes on the pathway

4. Designing individual work activities

17

Capability 2 : Swarming problems when they occur

And where they occur

Problem Solving is Mostly Simple...

Both Demming and Ishikawa agreed that basic problem solving will solve up to 95% of all problems typical in manufacturing. The problem is one of data collection and rigorous execution of a structured methodology.

Basic PDCA* Problem Solving

Plan• Definition &

Analysis

Do• Try Counter-

measure

Check• Confirm

result

Act• Standardize

or revise

Key Points:

•Constantly repeat the cycle as a problem solving tool & management routine

•Was the Toyota starting point for quality improvement in the 1960’s.

*Originally known as the Shewart Cycle, developed by Walter Shewart in his 1939 book titled “Statistical Methods From the Viewpoint of Quality Improvement” and later popularized by Edward Demming.

Scientific Method in each...

PDCA•Plan•Do•Check•Act

8D Steps•Use Team Approach•Describe the Problem•Containment•Root Causes•Verify Corrective Actions•Implement Permanent Corrective Actions•Prevent Recurrence•Congratulate Your Team

Six Sigma•define •Measure•Analyze•Improve•Control

Pathwise•Problem•Investigate•Compare•Clues•Cause

7 Classic QC Tools

• The 7 Classic QC Tools are essential in gathering data and analyzing problems, they also make relevant information visible.

Check Sheet

C&E Diagram Graphs Pareto

ChartControl Chart Histogram Scatter

Diagram

22

Capability 3 : Sharing knowledge where it is created

23

Capability 3 : Sharing knowledge where it is created

24

Capability 4 : Leaders train, coach, assist, & teach

25

Capability 4 : Leaders train, coach, assist, & teach

Are all your employees afforded a close mentor / teacher?

Problem Solving-is Endless

QUESTIONS?