This document discusses continuous improvement programs and why they often fail. It provides an overview of common continuous improvement approaches and their failure modes. The four most common failure modes are: 1) copying tools without making work self-diagnostic, 2) working around problems rather than solving them, 3) not sharing learning across the organization, and 4) not developing problem-solving capabilities in others. The document then discusses effects of these failures, causes of the failures, and countermeasures to address the causes, including teaching scientific problem-solving methods, sharing knowledge locally, and leaders developing problem-solving skills in employees.

1. Continuous Improvement
“Systemism”
Failure Mode Analysis of Continuous Improvement Systems
Nick Ruhmann

2. Agenda
•
The Common “Continuous Improvement Programs”
•
Failure Modes of These Programs
•
Effects of Failure
•
Causes of Failure
•
Countermeasures for the Causes

3. Continuous Improvement “Programs”
Taylor’s
Scientific
Management
Training Within
Industry
Job Methods
Crosby’s
“Zero Defects”
Motorola / GE
Six Sigma
Shainin's
Statistical
Engineering (SE)
TPS (Lean
Manufacturing)
Lean Six Sigma
Deming and TQM
Some of this was
progress, some were
just new labels

4. Most Common Today...
6 Sigma
Lean
Lean Six
Sigma

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

6. Why Do We Fail?
• Failure
•
Copy “tools” only without making work selfdiagnostic
• Failure
•
Mode 3:
Don’t share systemically what has been learned
locally
• Failure
•
Mode 2:
Workaround problems even when they are
recognized
• Failure
•
Mode 1:
Mode 4:
Don’t develop the capabilities of others to
design work, improve work, and institutionalize
new knowledge

7. Effects (Symptoms) Of Failure...
1.
2.
3.
4.
5.
6.
Relying on technology to solve problems
Seeking examples to follow rather than developing
solutions (implement the new, cool thing)
Excuses, such as "our problems are different“
Relying on quality inspection rather than improving product
quality
Reliance on quality control departments to solve problems
rather than management, supervisors, and production
workers solving problems
Placing blame on workforces who are only responsible for
15% of mistakes when the system designed by management
is responsible for 85% of them

8. Causes...
•
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
"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

9. Causes...
•
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

10. 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”

11. 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.

12. Countermeasures
•
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

13. Countermeasures (what to teach)
How to Design Work to see
problems
1.
•
Make All work highly specified as to
content, sequence, timing, and
outcome
Insist on swarming problems
2.
•
Problems must be immediately
addressed, both to contain their
effects from propagating, and to
trigger problem solving

14. Countermeasures (what to teach)
Problem Solving Using the
Scientific Method
3.
•
Any improvement must be made in
accordance with the scientific method,
under guidance of a teacher, at the
lowest possible level within the
organization
Leaders Must be Teachers
4.
•
The most senior management level
has to own the capability development
process – it must cascade downhill

15. Capability 1 : Design work to see
problems
15

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
16

17. Capability 2 : Swarming problems
when they occur
And where
they occur
17

18. 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.

19. Basic PDCA* Problem Solving
Key Points:
Act
Plan
• Standardize
or revise
• Definition &
Analysis
Check
Do
• Confirm
result
• Try Countermeasure
•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.

20. Scientific Method in each...
PDCA
8D Steps
Six Sigma
Pathwise
• Plan
• Do
• Check
• Act
• Use Team Approach
• Describe the Problem
• Containment
• Root Causes
• Verify Corrective
Actions
• Implement
Permanent Corrective
Actions
• Prevent Recurrence
• Congratulate Your
Team
•
•
•
•
•
• Problem
• Investigate
• Compare
• Clues
• Cause
define
Measure
Analyze
Improve
Control

21. 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
Chart
Control
Chart
Histogram
Scatter
Diagram

22. Capability 3 : Sharing knowledge
where it is created
22

23. Capability 3 : Sharing knowledge
where it is created
23

24. Capability 4 : Leaders train, coach,
assist, & teach
24

25. Capability 4 : Leaders train, coach,
assist, & teach
Are all your employees afforded a close mentor / teacher?
25

26. Problem Solving
-is Endless

27. QUESTIONS?