Introduction to lean six sigma
Upcoming SlideShare
Loading in...5
×
 

Introduction to lean six sigma

on

  • 1,672 views

 

Statistics

Views

Total Views
1,672
Views on SlideShare
1,672
Embed Views
0

Actions

Likes
0
Downloads
59
Comments
0

0 Embeds 0

No embeds

Accessibility

Categories

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment
  • (1) Specify value in the eyes of the customer(2) Identify the value stream and eliminate the waste(3) Make value flow at the pull of the customer(4) Involve and empower employees (there is no better source of insight than the employees who are performing the work)(5) Continuously improve (kaizen) in pursuit of perfectionThe five core concepts of lean are:1. Specify value in the eyes of the customer2. Identify the value stream and eliminate waste3. Make value flow at the pull of the customer4. Involve and empower employees5. Continuously improve in the pursuit of perfection.
  • (1) Specify value in the eyes of the customer(2) Identify the value stream and eliminate the waste(3) Make value flow at the pull of the customer(4) Involve and empower employees (there is no better source of insight than the employees who are performing the work)(5) Continuously improve (kaizen) in pursuit of perfectionThe five core concepts of lean are:1. Specify value in the eyes of the customer2. Identify the value stream and eliminate waste3. Make value flow at the pull of the customer4. Involve and empower employees5. Continuously improve in the pursuit of perfection.
  • Learning Points:1. Waiting for the batch to complete takes longerDiscussion:1.
  • (1) Specify value in the eyes of the customer(2) Identify the value stream and eliminate the waste(3) Make value flow at the pull of the customer(4) Involve and empower employees (there is no better source of insight than the employees who are performing the work)(5) Continuously improve (kaizen) in pursuit of perfectionThe five core concepts of lean are:1. Specify value in the eyes of the customer2. Identify the value stream and eliminate waste3. Make value flow at the pull of the customer4. Involve and empower employees5. Continuously improve in the pursuit of perfection.
  • Art Sundry at MotorolaHoneywell (Allied Signal)
  • http://en.wikipedia.org/wiki/Eight_Disciplines_Problem_SolvingEight Disciplines Problem Solving is a method used to approach and to resolve problems, typically employed by quality engineers or other professionals.D0: The Planning Phase: Plan for solving the problem and determine the prerequisites.D1: Use a Team: Establish a team of people with product/process knowledge.D2: Define and describe the Problem: Specify the problem by identifying in quantifiable terms the who, what, where, when, why, how and how many (5W2H) for the problem.D3: Developing Interim Containment Plan Implement and verify Interim Actions: Define and implement containment actions to isolate the problem from any customer.D4: Determine and Identify and Verify Root Causes and escape points: Identify all potential causes that could explain why the problem occurred. Also identify why the problem has not been noticed at the time it occurred. All causes shall be verified or proved, not determined by fuzzy brainstorming.D5: Choose and verify Permanent Corrective Actions (PCAs) for root cause and Escape point : Through pre-production programs quantitatively confirm that the selected corrective actions will resolve the problem for the customer.D6: Implement and validate PCAs: Define and Implement the best corrective actions.D7: Prevent recurrence: Modify the management systems, operation systems, practices and procedures to prevent recurrence of this and all similar problems.D8: Congratulate your Team: Recognize the collective efforts of the team. The team needs to be formally thanked by the organization.[1][2]8D has become a standard in the Auto, Assembly and other industries that require a thorough structured problem solving process using a team approach.
  • http://images.google.co.uk/imgres?imgurl=http://www.webweaver.nu/clipart/img/nature/plants/tree-branches-and-roots.gif&imgrefurl=http://www.webweaver.nu/clipart/trees2.shtml&usg=__RmOHi-9gBqQ2g1BGucT7yStSUvg=&h=239&w=250&sz=10&hl=en&start=18&sig2=R1gI67Hq81hnLm-xd3baEA&tbnid=9b1KipRyYqhJbM:&tbnh=106&tbnw=111&prev=/images%3Fq%3Droots%26imgtype%3Dclipart%26as_st%3Dy%26gbv%3D2%26hl%3Den%26sa%3DG&ei=uwYBS_wnkZ3hBujXtPgL
  • The CMA-CGM M/V Ville D'Orion drew a lot of lookie-loo attention from folks on nearby John S. Gibson Boulevard when it sailed into the TraPac terminal in Los Angeles on FRi. March 24 with stacks of containers at its stern leaning precariously to one side. The containers apparently pulled loose at sea after one of the bottom containers collapsed. The ship was taken to the adjacent Yang Ming Terminal to offload the damaged cans.Final score, according to the Coast Guard, was 69 containers damaged in the incident, no containers lost overboard, no HazMat problems, and no injuries. A barge crane and crew was brought in from Matson Construction after IWLU longshore workers reportedly refused to unload the containers because of safety concerns. Damage to containers ranged from simple cracks to containers torn completely open. Damage to the ship was minimal.Attorneys & marine surveyors were also on hand to assess damage for the owners of the ship, cargo, & containers. The last of the containers was unloaded on Mar. 27 & the Ville D'Orion sailed on.

Introduction to lean six sigma Introduction to lean six sigma Presentation Transcript

  • Introduction to Lean Six Sigma Steve Carleysmith Reo Process Improvement Ltd www.reoprocessimprovement.eu
  • Customer focus 2
  • Think: Who is the „customer‟? What activities make up the process? How can I do the job smoothly? How can I avoid the Seven Wastes? for each“process” 3
  • • Why does your organisation exist??• Purpose of a company – get customers – make money 4
  • Who is the Customer?• The customer is anyone who uses a product or service.• This means anyone who chooses, pays for and uses orproducts.• The internal customer is whomever you pass your work to. 5
  • Who are customers?• Anything useful that we do - must have a customer• Internal customers, within the organisation – next stage of production; HR; Marketing, Exec Team• External customers, generally outside the company – anyone who chooses, pays for or uses our product – shoppers (choose, pay, use) – service user (choose, pay, use) – shareholders (seek dividends and capital growth) – charity user – doctors (choose) – patients (use) – NHS (pays) 6
  • Why is the Voice of the Customer soimportant? or 7
  • Breakout - Voice of the Customer1. What is your product and/or service and who are your internal and external customers?2. What is the value you deliver to each customer?3. What perception do your customers have of your product and service? 1. How do you know? 2. Are you asking the right questions?Feed key points to rest of the group. 8
  • Customer focus - recap• most dissatisfied customers do not complain• we need to delight the customer• we have internal customers and external customers• measure how you meet the customer requirements• anything we do not adding value for the customer is waste… 9
  • Principles of Lean Thinking 10
  • Lean Principles • Specify value in the eyes of the customer • Identify the value stream and eliminate waste and variation • Make value flow at the pull of the customer • Involve, align and empower employees • Continuously improve knowledge in pursuit of perfection 11
  • Lean Six Sigma Understand our processes Add value, create flow Drive out waste, reduce variation Better cost, quality & delivery Delight the customer Raise job satisfaction reduce waste hit the target 12
  • Non value adding time or 13
  • Value added and non value added :.:granulate and tumble blend compress coat releasedry 0.5h 1h 0.5h 4h 1h 1h Typical process time start-to-end = 5-10 days Value-added time = 7 hours Non-value added but essential = 1 hour Value-added time as % of total ~5% 14
  • How much activity is non value added? Typical real values Physical manufacture 5% value adding 60% non value adding 35% necessary but not VA Information processing 1% value adding 49% non value adding 50% necessary but NVA Value is perceived by the customer… 15
  • Time Value Map Map the process activities on a time line with value- adding above and non-value-adding below value adding activities timebasestart endeg days non-value adding activities This is an essential tool for visualising non-value-added activities and wasted time – part of the value stream map… 16
  • Quick NVA exercise ??• Mention 7 wastes• show consultant‟s timeline 17
  • Value adding processesThe value stream will comprise both value adding and non valueadding processes Value adding = a process that transforms, for the first time, material or information to meet Non value adding = processes the needs of the Customer (big that take time and resources C) but do not add to the Customer‟s requirements (many of these processes will This is a critical definition for appear to be necessary, given LeanSigma thinking the current system of working) Non value adding processes and activities typically account for 95% of the time that a product is in the value stream 18
  • The Seven Wastes 19
  • Listen to the Voice of the Customer• pulling the value or 20
  • Lean targets NVA areas…...use new version ?? Most lean opportunities are in non value added areas Traditional approach (blue 95%) focuses on Value- Adding activitiesThere are three main cost drivers: (“efficiency”). Typically 5% of total costs.1. The hidden factory (or Cost Of Poor Quality)2. Time3. Inventory Lean approach focuses on the 95% non-value adding activities through quality, waste and variation elimination, and employee involvement. 21
  • The Seven Wastes...• waste is anything that does not add value for the customer (internal and external) 22
  • The Seven Wastes - to find NVA activities Defects Anything faulty Overproduction Producing more than is immediately needed Transportation Excessive transport of product (can be information) Waiting Waiting for parts or information Inventory Raw materials, WIP (work in progress) and finished product more than necessary Motion Bad ergonomics – reaching, lifting, stooping Processing OVERprocessing – doing non value adding processing plus the 8th waste of untapped human potential! 23
  • In the office Defects Forms filled in wrongly; Use of wrong codes Overproduction Producing info not used; Reworking data in different ways. Transportation Excessive movement of information between departments and sites Waiting Waiting for data not available; Waiting for other groups to act. Inventory Paperwork held and batched instead of processed as received. Motion Reaching for difficult to get at files . Walking to central photocopier. Processing Excessive numbers of meetings. Reports too detailed and not read. 24
  • In the workshopDefects Fitting wrong parts. Using wrong lubricants.Overproduction Doing stuff not needed. Replacing good parts?Transportation Parts and tools are a long way away.Waiting Waiting for tools. Waiting for parts to be delivered.Inventory Too much stuff stored. Too many tools of same type?Motion Poor ergonomics – too much bending and stretching to do the job.Processing Doing work long before it‟s needed. 25
  • In the laboratoryDefects Incorrect data entries. Contaminated samples; ghost peaks.Overproduction Results of analysis not used; Data put into multiple databases.Transportation Excessive movement of samples between departments and sitesWaiting Waiting for instruments & supplies. Waiting to log in on PCs.Inventory Samples held and batched instead of processed as received. Tested samples held awaiting data review.Motion Walking to distant parts of building and site. Poor ergonomics of bench instruments.Processing Unnecessary peer review. 26
  • HealthcareDefects Medical errors Wrong patientOverproduction Testing or treating early to balance workloadTransportation Moving samples, specimens, patients, equipmentWaiting For bed assignments, lab results Queuing for appointmentsInventory Pharmacy and lab supply stocks Beds occupied unnecessarilyMotion Searching for patients, medication, charts, tools, supplies & paperworkProcessing Multiple bed moves Excessive paperwork 27
  • ExerciseIn groups identify some DOTWIMP examples of waste in your workplace Defects Overproduction Transportation Waiting Inventory Motion Processing 28
  • The Lean Sigma journey.Empower people to...simplify to PDCA slide ?? Understand the customer needs. Map the internal processes (value stream) and eliminate waste and variation Make value flow, pulled by the customer Involve everyone. Go round the cycle again -strive for perfection! 29
  • Lean Six Sigma Principles - recap• Specify value in the eyes of the customer• Identify the value stream and eliminate waste and variation• Make value flow at the pull of the customer• Involve, align and empower employees• Continuously improve knowledge in pursuit of perfection• So how do we understand flow?....... 30
  • Batch size, inventory & flow 31
  • Flow of value to the customer information flow product/service flow customer inputs perceived stream of value-adding operations value 32
  • Batch versus one piece flow Traditional batch processing: Process 1 Process 2 Process 3 Cycle time Cycle time Cycle time 10 minutes for 10 minutes for 10 minutes for 10 parts 10 parts 10 parts Total Batch Processing Time : 30 minutes for 10 parts 33
  • Disk turnover experiment• 20 products to be processed (disks)• five work stations + customer• start timing (customer raises order for 20) – time to get first product – time to receive all products• Station 1 turns 20 disks over.• Passes them to Station 2 to turn over – and so on• Stop timer when customer has 20 disks.• Start again, processing one disk at a time.• Compare times. 34
  • Batch versus one piece flow Small batch (single part) processing: Process 1 Process 2 Process 3 Cycle time Cycle time Cycle time 1 minutes for 1 minutes for 1 minutes for 1 part 1 parts 1 parts Total processing time : 12 minutes for 10 parts Only 3 minutes for 1st part 35
  • What is inventory?• raw materials or information for processing• work in progress (WIP)• finished goods or completed output• any part of the product or output not being worked on – i.e. parts or information in NVA time 36
  • Cycle Time cf. Lead Time IMPROVE ??• Cycle time: the repeat time for a particular production operation i.e. how often things come off the production line – If we process 50 bikes per 400 minutes, cycle time for that process is 8 minutes – If we process 2880 dividend payments in 8 hours continuous operation, cycle time is ?? – Excludes account equipment downtime, set up, changeovers...• Lead time is the total time from starting a series of operations to completion. For example – From order to despatch – From first use of information or materials to finished product to customer – All inventory increases lead time by WIP x cycle time – If 7200 dividend payments await processing and the cycle time for the process operation is 10 seconds, what is the lead time in hours ?? NB These definitions may vary – be explicit for each application. 37
  • Exercise• Where do you have inventory in your processes? – raw materials or unprocessed information – work in progress – finished goods or product – office processes: orders, invoices for processing• How does this affect lead time (start to finish)? 38
  • Push vs Pull• Push - produce as much as possible, builds inventory• “Build for stock”• “Ensure people are busy”• “Keep the machines running”• not at all lean! Process 1 Process 2 Process 3 Inventory Inventory 39
  • Pull• Pull - produces product or do work at the request of the customer or next down stream operation.• Pull reduces WIP and controls production between processes• Pull is lean When does process 3 operator work? Information kanban bin Material Material – one item onlyProcess 1 Process 2 Process 3 Full Full Don‟t work Empty Full Don‟t work Empty Empty Can‟t work Full Empty Work 40
  • Exercise• Where could you use lean thinking (customer focus and removal of wastes) to improve a process? 41
  • Recap on Lean and Six Sigma• Lean thinking is about improving flow to the customer and reducing wastes (non value adding activities).• Six Sigma tools identify and reduce variation (of quality, time, cost)• Common themes are customer focus and process thinking• Work from facts & data collected in the workplace• Root cause analysis is a key tool for lean and Six Sigma 42
  • Process thinking 43
  • Process thinkingInput-process-output (IPO) NB Processes under control must have information feedback feedback Process inputs outputs Process thinking Activities convert inputs to outputs via a process. There is always hierarchy of nested processes. 44
  • Manufacturing Raw Materials & Compo- Manufac- nents turing Packaging Distribution Customer These can be IPOs or SIPOCs linked 45
  • Exercise - flowcharting1. Choose a process with problems(s).2. Using stickies, draw a map of the process.3. Add problems as different coloured stickies on the process map.4. We‟ll return to this in root cause analysis. 46
  • The Value Stream 47
  • The value stream is.... the set of specific activities required to design, order and provide a specific product, from concept to launch, order to delivery, and raw materials into the hands of the customer after Womack & Jones (1996) p311 48
  • The Value Stream information flow product/service flow customer inputs perceived stream of all value-adding and NVA operations valueValue stream is everything that is currently done to supply the customer 49
  • Value stream for cola - steps Mine Ore 500,000 tonnes mountain 4 weeks Smelter Hot Roller Reduction Mill 2 hrs Hot roller 30 mins 1 min Remelter Can Warehouse Can Maker Cold Roller 10 secs Bottler 1 min Tesco Store Drink 5 mins RecycleBottler Warehouse Tesco Warehouse Center Home After: Welcome to Detroit. Frank Hennessey, Chairman, Detroit Regional Chamber, Chairman, EMCO Ltd. After Womack and Jones 50
  • Value stream for cola – lean? Eight firms involved. Fourteen storage points Picked up and put down 30 times. 24 percent of raw material scrapped 319 days to do three hours of value-added work. 51
  • Tesco One Touch Replenishment1 2 3 4 5 6 Cola Tesco RDC RDC1 2 3 Cola Tesco RDC X Dock 30% Lower Logistics Costs 52
  • Tesco One Touch Replenishment 53
  • VALUE STREAMS AT TOYOTA Value Stream Organization Body Interior Chassis Elect. Proto. Eng. John Shook • David Verble May 1, 2001 54
  • The value stream map Kaizen improvements move the process towards the Future State 55
  • Table Assignment• What are the value streams for your businesses?• What added value does the customer see?• How could you reduce the lead time of product order to customer delivery by removing non value added activities? 56
  • The Journey Future State,Current State, target condition, Visionsituation, As Is To Be 57
  • Visioning ExerciseCurrent State (baseline)Future State (achievable)Vision (the perfect process)Exercise Think about a process that you work on. Imagine how the “perfect process” would feel. What would people be doing and feeling? Feed back to the group What is the vision for your organisation? 58
  • The Value Stream - recap• The Value Stream – high level – sub-processes• Value Added activities add value perceived by the customer; NVA activities don‟t.• Value Added Time mapping• Value Stream Mapping• Current State and Future State• Visioning• Align all the organisation and measure progress – hoshin kanri and Balanced Scorecard 59
  • Constraints ?? 60
  • 5S ?? 61
  • History of ?? 62
  • Features of Lean and Six Sigma “......primarily a new approach to management, not a technical program.” ”.....many things......can be seen as: a vision; a philosophy; a symbol; a metric; a goal; a methodology." “........also a creativity program.” “All the technical expertise in the world will fail....unless the working environment is receptive” 63
  • Lean Principles • Specify value in the eyes of the customer • Identify the value stream and eliminate waste and variation • Make value flow at the pull of the customer • Involve, align and empower employees • Continuously improve knowledge in pursuit of perfection From Womack and Jones “Lean Thinking” 64
  • Central theme of Lean is Central theme of Sixflow and the elimination of Sigma is to createwaste. Waste is any processes and productsactivity that does not add Lean which are nearly defectvalue for the customer. and variation free. SixThe approach is typified The approach is typifiedby Toyota Production Sigma by Motorola andSystem (TPS). General Electric.Key measurement for Key measurement forLean is value adding time. Six-Sigma is variation. shorter lead lower times proven costs higher quality benefits ! 65
  • History of lean & Six Sigma• Lean • Six Sigma – 1945 on: Japan: Shigeo Shinko – 1970s “Our quality stinks”: Motorola shows batches cause delay quotation – 1948 on: Deming in Japan – 1986 Motorola Trademark; – 1953 Taiichi Ohno develops “Motorola University” Bill Smith Toyota Production System – 1995 General Electric (Jack Welch) – 1960s-70s: Shigeo Shingo poka + wider application yoke & “stockless production” – 1990s Motorola publish Six Sigma; – 1990 Womack and Jones use DMAIC introduced the term “lean” – 1999 application to finance and – ...and in 1996 publish transactional processes “Lean Thinking” – ~2000 Lean Six Sigma in use Shigeo Shingo Taiichi Ohno Bill Smith Jack Welch 66
  • Benefits: use BW colourful slides 67
  • Tea-making 68
  • Lunch 69
  • Root Cause AnalysisSolving problems and finding solutions 70
  • Why have a structured approach? When confronted with a problem, it‟s tempting to jump to a solution. However, misdiagnosis of the reason for the problem may result in an inappropriate solution that doesn‟t address the problem, or worse, creates new problems.• The Jefferson Memorial (Washington, DC) was deteriorating because of frequent washings.• The washings were needed due to so many bird droppings. WHY were there so many birds?• There was an abundance of birds because hundreds of existing spiders provided a ready food supply.• The spiders were feasting on the thousands of midges that were attracted by the lights the Park Service turned on at dusk to illuminate the monument. The Park Service considered: But by identifying the real root cause, • Eradicating the birds in some came up with a simple, cheap manner solution: • Using pesticides to eliminate the • To delay turning on the spotlights spiders and midges until 1 hr after sunset. • The midge population decreased, breaking the food chain. 71
  • Solution jumping 72
  • Root Cause Analysis General Method 1. A significant event (problem) occurs 2. Define the problem statement – wwwwh, what goals of the organisation are affected? 3. Can the cause and solution be quickly identified using 5 whys? – finish, but care! 4. Understand the process in more detail – flowchart & timeline: sequence of events – use diagrams, drawings and photos – interviews and narrative chronology 5. Use RCA tools to seek root causes – fishbone, logic tree, change analysis, barrier analysis 6. Verify causes are correct – OR go back 2, 4 or 5 7. Find possible solutions 8. Select solutions, analyse risk, implement 73
  • Why is root cause analysis important? “Eighty-five percent of the reasons for failing to meet customer requirements are traceable to issues in the process itself rather than to employees… The responsibility of management is tochange processes rather than exhorting individual employees to do better.” W. Edwards Deming We need to understand the process that the customer depends upon – what works for them, what does not and how we can make a verifiable improvement. 74
  • Quality and Human ErrorsHuman error problem can be viewed in two ways: – the people approach – the system approach.Gives rise to different philosophies of quality or error management http://www.xytheme.com/wp-content/uploads/2009/02/human_error.jpg 75
  • 76
  • People Approach(not good)• The person approach focuses on errors and procedural violations of people• It views these errors as arising from forgetfulness, inattention, poor motivation, carelessness, negligence, and recklessness.• The associated countermeasures are directed mainly at attempting to reduce variability in human behavior: – writing another procedure (or adding to existing ones) – disciplinary measures – threat of litigation – retraining, naming, blaming, and shaming. 77
  • System Approach(good)• Humans are not perfect and errors are to be expected – Errors are seen as consequences rather than causes – Errors happen not by the awkwardness of human nature but because of poor processes• The system approach looks for recurrent error traps in the workplace and the organizational processes that give rise to them. – Solutions change the conditions under which humans work e.g. mistake-proofing (poka yoke) – A central idea is that of system defences or barriers. – All hazardous technologies possess barriers and safeguards. – When an adverse event occurs, the issue is not who blundered, but how and why the defences failed.• Ask “how did the system fail the people?” 78
  • System Approach• We cannot change the human condition, but we can change the conditions under which humans work .Failures are like mosquitoes.They can be swatted one byone, but they still keep coming.The best remedies are to createeffective defences and to controlthem in the swamps in whichthey breed. The swamps, in thiscase, are the ever present latentconditions for failure. 79
  • Discussion• What are your experiences of root cause analysis? – how did you select a problem? – what method did you use? – was it successful or not? – why? http://www.thinkreliability.com/Root-Cause-Analysis-CM-Basics.aspx 80
  • Root Cause Analysis General Method 1. A significant event (problem) occurs 2. Define the problem statement – wwwwh, what goals of the organisation are affected? 3. Can the cause and solution be quickly identified using 5 whys? – Quick fix, but care! 4. Understand the process in more detail – flowchart & timeline: sequence of events – use diagrams, drawings and photos – interviews and narrative chronology 5. Use RCA tools to seek root causes – fishbone, why-why cause tree, change analysis, barrier analysis 6. Verify causes are correct – OR go back 2, 4 or 5 7. Generate possible solutions 8. Select solutions, analyse risk, implement 81
  • The ProblemStatement“A problem wellstated is a problemhalf solved”Charles F Kettering 82
  • Example problem/UDE statements• Not “the widgets are faulty!” but: – The widgets from line xx between dates yy and zz are out of specification on the aa measure.• Not “lots of forms are wrongly filled” but – Over the last 3 months, 1 in 25 application forms for the ZZ Department from USA customers are incorrectly filled in on questions 3 and 5.• No assumptions; no solutions 83
  • Exercise• The production supervisor reports: “One of the feeders which add flour to the mix has stopped. It is seized or jammed and the motor may have burnt out. Production of cupcakes has stopped and the maintenance shift is on another urgent job.”• Make a suitable problem statement: – what company goal is affected? – what are the wwwwh? – what additional information may be needed? – what information is not needed? 84
  • Objectives and success measures• What are your measures of a successful solution? – avoid cost increase – prevent late delivery – prevent defects – improve customer relations – make a permanent fix• Can you make a rough financial assessment – cost of RCA and implementing fix versus benefits from permanent cure 85
  • Example• What is your cost of problems on a product or process? – think direct (tangible) costs and indirect (intangible) costs – reputation, lost business, customer dissatisfaction?• What is the cost of training and teamwork on RCA?• How do these costs compare? 86
  • What is “Root Cause”? 87
  • What is a “root cause”? • “the most basic reason for an undesirable event (or condition)” – the “fundamental cause” • why are we finding the root cause? – we ultimately want a solution! – so find root causes that enable solutions • RCA ultimately enables us to find solutions for problems – solutions are also called Corrective Actions or Corrective and Preventive Actions (CAPAs)Analogy: treat the symptoms of anillness (swine flu: paracetamol anddecongestant), or discover and treat theroot causes to the problem (virus:swine flu jab, antivirals Tamiflu andRelenza) http://www.webweaver.nu/clipart/trees2.shtml 88
  • Root cause – one or many?• There will generally be more than one root cause• Flight Safety International state that the fewest number of links in aviation accidents was 4, with the average being 7.• For industrial applications the number of errors (root causes) can be 10 to 14**.• The RCA method must therefore deal with complexity **http://www.plant-maintenance.com/books/0849307732.shtml 89
  • Multiple root causes 90
  • Exercise• Have you encountered any problems having just one root cause?• What accidents or incidents have you experienced with multiple root causes? 91
  • Why do we need a structured methodfor root cause analysis? For every complex problem there is an answer that is clear, simple – and wrong. H.L. Mencken 1880-1956 92
  • Overview of RCA• Define the problem (in terms of the company goals)• Analyse to find the root causes• Implement solutions (to meet company goals) There is no single method for root cause analysis. We will look at methods and tools that cover nearly all types of problem. 93
  • Methods and tools for RCA• 5 whys• fishbone (Ishikawa, cause and effect diagram)• why-why cause tree (fault tree, cause and effect tree...) – plus process understanding (mapping, data collection…)• others that we will not cover today – change analysis (e.g. Kepner-Tregoe) – barrier analysis – events and causal factors charting 94
  • Root Cause Analysis General Method 1. A significant event (problem) occurs 2. Define the problem statement – wwwwh, what goals of the organisation are affected? 3. Can the cause and solution be quickly identified using 5 whys? – Quick fix, but care! 4. Understand the process in more detail – flowchart & timeline: sequence of events – use diagrams, drawings and photos – interviews and narrative chronology 5. Use RCA tools to seek root causes – fishbone, why-why cause tree, change analysis, barrier analysis 6. Verify causes are correct – OR go back 2, 4 or 5 7. Generate possible solutions 8. Select solutions, analyse risk, implement 95
  • 5 Whys problem statement, undesirable effect or care delivery problem problem Why? Tip: keep asking why until you can see solutions - this is usually between 4 and 6 times Symptom Why? Why? Symptom Symptom Why? Why? Why? Symptom Symptom Symptom Why? Why? Why? Symptom Symptom Symptom Why? Why? Why?ROOT CAUSE ROOT CAUSE ROOT CAUSE 96
  • 5 Whys: late in operating theatre The patient was late in theatre, it caused a delay. Why? There was a long wait for a trolley. Why? A replacement trolley had to be found. Why? The original trolleys safety rail There was no spare trolley was worn and had eventually broken. Why? Why? It had not been regularly Faulty trolleys awaiting checked for wear. repair Why? Why? No routine equipment check. Investigate further. Possible solutions: • Routine checks • Repair all trolleys • ...? Modified from (c) NHS Institute for Innovation and Improvement 2009 97
  • Exercise• Practice 5 Whys• Choose a problem that you have encountered recently• Apply the “5 Whys” to this problem – how effective is it? 98
  • 5 whys and a quick fix• 5 whys can find root cause(s) and a quick solution to get operations running again• BUT beware of leaving the quick fix as the permanent solution• ALWAYS check further on root causes and look for solutions giving sustained improvement• Understand the process… 99
  • The Process Flowchart (Map) There are usually 3 versions of each Process Map What you What you What it Want it to be... Believe it is... Actually is... 100
  • Root Cause Analysis General Method 1. A significant event (problem) occurs 2. Define the problem statement – wwwwh, what goals of the organisation are affected? 3. Can the cause and solution be quickly identified using 5 whys? – Quick fix, but care! 4. Understand the process in more detail – flowchart & timeline: sequence of events – use diagrams, drawings and photos – interviews and narrative chronology 5. Use RCA tools to seek root causes – fishbone, why-why cause tree, change analysis, barrier analysis 6. Verify causes are correct – OR go back 2, 4 or 5 7. Generate possible solutions 8. Select solutions, analyse risk, implement 101
  • Fishbone Diagram / Ishikawa Analysis Cause and effect analysis Causes Manpower Machines Materials Effect Mother Measurements Methods Nature1. Called Fishbone diagrams, Ishikawa diagrams, or „6M‟ analysis.2. Logical organisation of possible causes for a problem or effect.3. Generate possible causes 1) from brainstorm 2) using the headings as a prompt4. For admin applications, can use people, places, procedures, policies. Worked example: poor mpg in a company van 102
  • “Cause and Effect Tree” or “Logic Tree*” for Paint Failing Quality Check Solutions *A Logic Tree may use AND and OR symbols for more complex cases. Root causes Set Service Level Problem Agreement with statement supplier I Tubing is Dents are in standard Order higher quality tubing as industrial tubing Arrow shows “caused by” I = investigate supplied quality. I I I Tubing is Tubular frame Dents are Dents are in the dropped into Use Correx sheets to fails paint Holes are visible appearing metal tubing kanban bins separate partsquality check** during handling causing dents I I I Bumps are Metal particles Metal is braze Manual brazing Train brazers visible under the paint spatter Examples **The actual problem Use guards ofstatement should be more barriers specific (effect on goals and wwwwh) Inspect pre-painting I Autobraze 103
  • SolutionsFinding, Selection & Implementation 104
  • Solution Finding• List the root causes• Gather advice – process experts, facilitators• Review existing information – has this sort of problem happened before? – relevant information in the databases?• Use innovation methods – brainstorming• Select the best solutions, check risks, implement Innovation = creativity + application 105
  • The Challenge of ChangeLeadership and Culture 106
  • “ It is not necessary tochange... Survival isnot mandatory.” W. Edwards Deming 107
  • Your view?• Do you know of change programmes?• Why were they successful or otherwise? 108
  • 109
  • Recap• What are the key ideas of lean?• What is the value of root cause analysis? – What are the key tools?• What are the human issues with process improvement? – How do we promote change? 110
  • Recap of the day• Introduction to lean thinking and Six Sigma – History – Principles – Benefits• Value added and non value added activity• Customer focus• The Seven Wastes + Eighth Waste• Process thinking and the value stream – Process mapping – Batch size, inventory and flow• Root cause analysis• The challenge of change• Back in the workplace 111
  • Implementation• What ideas do you have for – a project using lean principles? – an application of root cause analysis?• What are your next steps in lean and root cause analysis? 112
  • ENDExcellence is a journey, not a destination! 113
  • Cupcakes – example problemstatement• “The production of cupcakes has stopped on line L2 during B Shift at xx hrs because flour is not feeding from machine FF3.”• From company goal affected and wwwwh. 114
  • What is Lean and Six Sigma?• A structured method for improving processes – “Improve” means reduce costs, increase quality, reduce times – “Process” is any series of linked activities for a useful function• Lean and Six Sigma work together Lean: improve flow and reduce waste Six Sigma: minimise variation in processes (statistical; not covered today)• When applied, will – reduce costs – improve quality – shorten process times – improve employee engagement 115
  • Some common terms• “Lean”, “Lean Thinking” and “Six Sigma” are industry- standard terms• “Lean Sigma” or “Lean Six Sigma” is the combination of the two• Lean Six Sigma sometimes called “operational excellence” or “service innovation” 116
  • 117
  • 118
  • 119
  • 120
  • Benefits of lean• Toyota became the largest and most successful car company in the world• Tesco is the dominant UK supermarket• Dell “The „direct model‟ that Dell operates, where customer orders are taken directly by the company and then built to order, uses all the principles laid out by the Toyota Production system but also adds many more.”**• IBM Microelectronics Dublin “Inventory down 72%; Cycle Times down by 66%; Space Requirements reduced by 36%; Productivity increased by 20%” in 3 years**• Less information on transactional processes & service industries. Lean projects in: – National Health Service – insurance – finance (RBS) – Starbucks **http://newsweaver.ie/madeineurope 121
  • What is in and out of Lean and SixSigma? IN SCOPE OUT of SCOPE • reduced lead & cycle times • marketing strategy • waste reduction • pricing policies • reduced variation • business deals • efficiency increases • tax efficiencies • quality improvement • transfer pricing • employee engagement • move to low cost countries • customer engagement • some business process re- • focus on repeating engineering (revolution) processes • continuous improvement (evolution) 122
  • DMAIC & team charter?? SKIP 123