The document discusses root cause analysis including defining what it is, tools and techniques used, and providing a step-by-step process for conducting a root cause analysis. It outlines forming a team, gathering data, determining the sequence of events, developing cause and effect diagrams, ranking causes, and developing a corrective action plan to address the root causes identified.
The document introduces project management and key concepts including the Project Management Institute (PMI), the Project Management Body of Knowledge (PMBOK) Guide, the five process groups of project management (initiating, planning, executing, monitoring and controlling, closing), and the nine knowledge areas that describe competencies for project managers including scope, time, cost, quality, human resources, communications, risk, procurement, and stakeholder management.
The document discusses project management approaches for elearning development, comparing traditional and agile methods. It introduces scrum and kanban, two popular agile frameworks, outlining their key principles, roles, and processes. Scrum uses timeboxed sprints and prescribed meetings while kanban focuses on visualizing and limiting workflow. Both aim to deliver value continuously through collaboration, adaptation, and incremental improvements. The document advocates adopting agile practices to enable faster time to market, better quality, and greater alignment with changing needs.
The document provides guidance on closing a project by outlining key tasks and processes. It discusses checking that all products have been delivered and approved, documenting lessons learned and follow-on actions, evaluating the project's performance against plans, and recommending official project closure. Visual diagrams illustrate the relationships between initiating, managing, and closing a project. Checklists are also included to help users review their project closure procedures.
1) Risk management is an important practice for any ERP implementation project to help manage risks and increase the chances of success.
2) When estimating projects, risks are assumed but rarely communicated or managed during the project.
3) Implementing a structured risk management process provides visibility of project risks, defines risk ownership, and provides action plans to avoid or mitigate risks.
Sanjiv Augustine
Sanjiv Augustine is an industry-leading agile and lean expert, author, speaker, management consultant and trainer. He is the President of LitheSpeed, an agile consulting, training and product development company. For over 12 years, Sanjiv has assisted leading clients adopt Agile including: HCA Healthcare, General Dynamics, The Capital Group, Nationwide Insurance, Comcast, Capital One, CNBC, and the Motley Fool. He is the author of the book Managing Agile Projects (Prentice Hall 2005) and several publications including Transitioning to Agile Project Management: A Roadmap for the Perplexed, The Lean-Agile PMO: Using Lean Thinking to Accelerate Agile Project Delivery; and the founder and moderator of the Yahoo! Agile Project Management discussion group. Sanjiv was also a founder and advisory board member of the Agile Leadership Network (ALN), and an organizing member of the PMI’s Agile Community of Practice. As an in-the-trenches practitioner, he has personally managed agile projects varying in size from five to over one hundred people, trained thousands of agile practitioners via workshops and conference presentations, and coached numerous project teams.
The document discusses root cause analysis conducted by the PARCA office in the Department of Defense. It provides an overview of PARCA's functions, analytical framework, and operations. Recent root cause analyses have identified unrealistic cost/schedule estimates and quantity changes as common problems. Areas of ongoing development include analytical methodologies, relationships with subject matter experts, and policies/procedures to guide root cause analyses. The goal is to independently identify the predominant causes of problems in a transparent, fact-based manner to prevent repeating mistakes.
Here are the key steps to review and tailor your project as required:
1. Review the project definition, approach, product description, and core team appointments with the Project Board to ensure agreement and buy-in.
2. Present the outline Business Case and projected benefits to the Project Board for review and approval.
3. Obtain Project Board approval of the Initiation Stage Plan, including development of Project Initiation Documentation, committed resources, reporting/control mechanisms, tolerances, logistical support, and understanding of initiation stage risks.
4. Confirm with the Project Board that the initiation stage work defined in the plan is authorized to start.
5. Inform corporate or programme management that the project has been initiated.
The document introduces project management and key concepts including the Project Management Institute (PMI), the Project Management Body of Knowledge (PMBOK) Guide, the five process groups of project management (initiating, planning, executing, monitoring and controlling, closing), and the nine knowledge areas that describe competencies for project managers including scope, time, cost, quality, human resources, communications, risk, procurement, and stakeholder management.
The document discusses project management approaches for elearning development, comparing traditional and agile methods. It introduces scrum and kanban, two popular agile frameworks, outlining their key principles, roles, and processes. Scrum uses timeboxed sprints and prescribed meetings while kanban focuses on visualizing and limiting workflow. Both aim to deliver value continuously through collaboration, adaptation, and incremental improvements. The document advocates adopting agile practices to enable faster time to market, better quality, and greater alignment with changing needs.
The document provides guidance on closing a project by outlining key tasks and processes. It discusses checking that all products have been delivered and approved, documenting lessons learned and follow-on actions, evaluating the project's performance against plans, and recommending official project closure. Visual diagrams illustrate the relationships between initiating, managing, and closing a project. Checklists are also included to help users review their project closure procedures.
1) Risk management is an important practice for any ERP implementation project to help manage risks and increase the chances of success.
2) When estimating projects, risks are assumed but rarely communicated or managed during the project.
3) Implementing a structured risk management process provides visibility of project risks, defines risk ownership, and provides action plans to avoid or mitigate risks.
Sanjiv Augustine
Sanjiv Augustine is an industry-leading agile and lean expert, author, speaker, management consultant and trainer. He is the President of LitheSpeed, an agile consulting, training and product development company. For over 12 years, Sanjiv has assisted leading clients adopt Agile including: HCA Healthcare, General Dynamics, The Capital Group, Nationwide Insurance, Comcast, Capital One, CNBC, and the Motley Fool. He is the author of the book Managing Agile Projects (Prentice Hall 2005) and several publications including Transitioning to Agile Project Management: A Roadmap for the Perplexed, The Lean-Agile PMO: Using Lean Thinking to Accelerate Agile Project Delivery; and the founder and moderator of the Yahoo! Agile Project Management discussion group. Sanjiv was also a founder and advisory board member of the Agile Leadership Network (ALN), and an organizing member of the PMI’s Agile Community of Practice. As an in-the-trenches practitioner, he has personally managed agile projects varying in size from five to over one hundred people, trained thousands of agile practitioners via workshops and conference presentations, and coached numerous project teams.
The document discusses root cause analysis conducted by the PARCA office in the Department of Defense. It provides an overview of PARCA's functions, analytical framework, and operations. Recent root cause analyses have identified unrealistic cost/schedule estimates and quantity changes as common problems. Areas of ongoing development include analytical methodologies, relationships with subject matter experts, and policies/procedures to guide root cause analyses. The goal is to independently identify the predominant causes of problems in a transparent, fact-based manner to prevent repeating mistakes.
Here are the key steps to review and tailor your project as required:
1. Review the project definition, approach, product description, and core team appointments with the Project Board to ensure agreement and buy-in.
2. Present the outline Business Case and projected benefits to the Project Board for review and approval.
3. Obtain Project Board approval of the Initiation Stage Plan, including development of Project Initiation Documentation, committed resources, reporting/control mechanisms, tolerances, logistical support, and understanding of initiation stage risks.
4. Confirm with the Project Board that the initiation stage work defined in the plan is authorized to start.
5. Inform corporate or programme management that the project has been initiated.
1. The document describes several success stories of companies across different industries that implemented Critical Chain Project Management (CCPM) to successfully complete projects faster and with higher quality.
2. Common problems faced before implementing CCPM included unclear timelines and responsibilities, long unproductive meetings, and lack of visibility into project status.
3. After implementing CCPM, companies experienced benefits like reduced project duration, clear accountability and tracking of critical tasks, focused meetings with action items, and improved visibility for management.
Kanban Overview And Experience Report ExportValtech UK
Kanban began in one BBC product team in 2008 and spread to other teams, including application support, product teams, design, and operations. Key principles include starting with current processes and modifying slightly to implement pull systems with work-in-process limits. Metrics allow continuous improvement, and bottlenecks are identified through leading rather than trailing indicators. Planning and other processes can be decoupled, with a focus on quality and reducing variability to improve efficiency. The experience report details improvements in lead time, development time, defects, and other areas through applying Kanban principles.
The document discusses the seven principles, themes, and processes of PRINCE2. The seven principles are continuing business justification, tailoring to individual projects, focusing on products, managing by exception, defining roles and responsibilities, learning from experience, and engaging in progressive elaboration. The seven themes are business case, organization, quality, plans, risk, change, and progress. The seven processes are starting up a project, initiating a project, directing a project, managing a stage, managing product delivery, controlling a stage, and closing a project.
This document outlines a process model for directing a project. It shows the key activities, including authorizing initiation of the project and stages, appointing project managers, reviewing plans and reports, and providing advice and direction to the project board. The process begins with authorizing initiation and ends with authorizing project closure once final reports are approved.
Here are three examples of areas that could benefit from systematic arrangement:
1. Tool storage areas - Arranging tools in an organized way based on type and frequency of use can help tradespeople like carpenters or mechanics find what they need quickly.
2. Office supply storage - Having a defined place for items like paper, pens, binders etc. and labeling storage areas clearly can help staff be more efficient.
3. Kitchen pantry - Organizing canned and boxed foods by category (veggies, soups etc) and using accessible containers makes it easier to find ingredients when cooking.
Slide 31
isc4 Here are some potential areas that could benefit from systematic arrangement based on the presentation:
This document outlines NASA's 7-step project management process presented by the NASA Safety Center. The 7 steps are: 1) establish a vision, 2) develop project success criteria, 3) apply backward planning, 4) use forward action planning, 5) identify metrics, 6) rely on the project team, and 7) communicate frequently. Each step is described in 1-2 sentences with an emphasis on establishing a clear vision and success criteria early, planning backwards and forwards, using metrics to track progress, relying on team members, and ensuring open communication. Real NASA projects are provided as examples to illustrate applying the 7 steps.
The document provides an overview of root cause analysis (RCA) tools and processes. It defines RCA as a systematic process for identifying the root causes of problems in order to prevent recurrence. The document outlines the key concepts, types of causes, common tools like fishbone diagrams and 5 whys, and a 5-step DMAIC process for conducting RCA including defining the problem, measuring its scope, analyzing root causes, implementing solutions, and controlling effectiveness. The goal of RCA is to develop sustainable solutions by understanding underlying causes rather than just addressing symptoms.
A Power Point package designed to allow organisations to run internal lean and continuous improvement training. The package is comprehensive containing 157 slides detailing continuous improvement strategy and tools. Topics include; introduction, change management, team development, facilitation, voice of the customer, the seven wastes, strategy deployment, data collection, metrics, flow, levelling, cell layout, quick changeover, just in time, root cause analysis, 5s, autonomation, error proofing, visual management, standard work, value stream mapping, A3 thinking, PDCA, kaizen, office TPM, and sustainment. Unlike other lean introductory courses, this is not solely aimed at the factory floor.
Terms are defined in English and if Japanese, Romaji and Kanji are also included.
Operating Excellence is built on Corrective & Preventive ActionsAtanu Dhar
This document provides an overview of Corrective Action Preventive Action (CAPA) and how to implement an effective CAPA process. It defines CAPA and explains the difference between corrective and preventative actions. It outlines the benefits of a mature CAPA system, including increased quality, reduced costs from problems, and improved customer satisfaction. The document then discusses various tools that can be used in the CAPA process, including root cause analysis techniques like 5 Whys, fishbone diagrams, and Pareto charts to identify causes and prioritize actions. Examples are provided for how to apply these tools to analyze specific business processes.
This document outlines the objectives and procedures for accident and incident prevention and investigation. It discusses determining the causes of accidents, identifying investigation methods, and prevention. The key points covered include defining accidents and incidents, investigating to establish facts and causal factors using a systematic approach, interviewing witnesses, documenting findings, determining effects, and identifying prevention methods. The overall goal is to conduct thorough investigations to prevent future occurrences.
NIOSH Heavy Equipment Blind Spots and Internal Traffic ControlJustin Tolpa, CSP
This document summarizes NIOSH research on blind spots around heavy construction equipment and internal traffic control plans. It reports that over 900 worker deaths from 1992-2000 were vehicle-related in work zones. Studies evaluated proximity warning systems, measured blind areas, and developed GPS and video methods. Guidelines for internal traffic control plans aim to limit worker exposure to vehicles by coordinating equipment movement and establishing pedestrian-free zones. Case studies investigated fatalities to identify interventions like redesigning traffic patterns.
This document discusses corrective action and root cause analysis processes. It provides an overview of nonconformances, the corrective action process which involves 4 steps - problem identification, short term remedy, root cause analysis, and implementation of corrective actions. Root cause analysis tools like fishbone diagrams, 5 whys, and flowcharts are presented. The importance of determining and addressing the underlying root cause is emphasized to prevent future nonconformances.
Brian Maynard Presentation Comedy Safety Unsafe Actsgitjiggy
I do not make claim to all these photos. These are photos that have been emailed to me over the past few years. I hope you enjoy the presentation. It is great for a safety meeting or class.
The document outlines Millennium Products' new Near Miss Program. It defines a near miss as an unplanned event that could have caused injury or damage but did not. The objectives of the program are to identify risks, prevent accidents, and improve safety culture. Employees are encouraged to report near misses so their causes can be analyzed and corrective actions implemented to prevent future incidents. Examples of near misses at Millennium Products are provided to demonstrate how the program will work.
This document discusses operating heavy equipment safely around ground personnel. It identifies many types of heavy equipment that require safe operation near workers on foot. The goal is to prevent accidents between moving equipment and ground workers by ensuring operators can see workers and workers can be seen. Common causes of accidents are discussed, such as runovers from dump trucks backing up. The document provides guidance on management commitment, employee involvement, hazard controls, training, and operator responsibilities to help achieve a safe worksite where the risk of being struck by equipment is minimized.
The document discusses different levels of project complexity and their alignment with agile project management approaches. It uses the analogy of piloting different types of aircraft to represent different levels of projects, from simple solo projects to highly complex projects critical to national security. The levels progress from having full autonomy to operating within strict rules and oversight, where mistakes are not tolerated due to high stakes and consequences. Agile approaches are best suited for self-contained teams with flexibility and autonomy, while larger, more complex projects require more formal processes and governance.
This document discusses near miss reporting and examples of unsafe acts and conditions. It provides a non-exhaustive list of unsafe acts like operating equipment without permission, defeating safety devices, or not using protective equipment. Unsafe conditions include lack of guarding, inadequate lighting, or faulty equipment. Contributing factors are also examined, like lack of skills/knowledge from inadequate training, job factors like poor equipment maintenance, and personal factors such as distractions. Complacency is highlighted as a major threat. The document advocates for measures to improve skills/knowledge through training, supervision, and setting examples. It also stresses the importance of considering attitudes like behaviors, values, standards, and judgments.
Problem solving road map to guide anybody who must improve a process that is slow, defective, inflexible, unresponsive, costly and risky.
Do you have any like that in your organization?
Of special use for teams following Lean Six Sigma methods (green belt and black belt projects).
Follows DMAIC structure integrated with Lean thinking and tools.
ASSOCIATED KEYWORDS:
Shewhart, Deming, Ohno, Ishikawa, lean, toyota, tps, toyota kata, lean six sigma, project management, six sigma, green belt, black belt, champion, coach, master black belt, deliverables, road map, project management, project plan, DMAIC, LSS, Define, Measure, Analyze, Improve, Control, Sustain, project charter, business case, team, problem solving, milestone, tollgate, baseline, process map, SIPOC, gemba, 7 wastes, 8 wastes, gemba walk, waste walk, spaghetti chart, flow chart, RACI, swimlane, VSM, value stream map, quick wins, operational definition, gage r&r, basic quality tools, check sheet, run chart, histogram, data statification, first time yield, FTY, rolled throughput yield, RTY, COPQ, hidden factory, rework, SPC, Western Electric rules, pareto, prioritization, input, process, output, box plot, scatter plot, correlation, causation, system, 5 whys, cause effect, fishbone, FMEA, hypothesis testing, root causes, quick win, drive out fear, respect for worker, kaizen, 5S, poka yoke, brainstorm, TRIZ, roles, responsibilities, PDCA, PDSA, pilot, roll out, implementation, status, implementation plan, business process management, BPM, KPI, target, performance, response plan, control plan, SOP, inverted pyramid, organization, sustain, plan, budget, communication, training, change, management, adoption, business, capability, prosperity, value, realization, results, replicate, integrate
This document provides an overview of root cause analysis (RCA) and common RCA tools. It discusses the CPAR/SCPAR process for documenting problems, determining root causes, and implementing corrective actions. Three common RCA tools are described: 5 Why's analysis involves repeatedly asking why to drill down to the root cause; affinity diagrams group related causes to identify major causes; and fishbone diagrams illustrate the relationship between causes and effects. The document encourages using the appropriate tool based on the problem complexity and provides examples of applying each tool.
Recorded webinar: http://slidesha.re/1tGIZaH
Subscribe: http://www.ksmartin.com/subscribe
Purchase the book: http://bit.ly/TOObk
Effective problem solving is not an innate skill that most people are born with.
Even for those few few lucky ones who are born with natural problem-solving talent, it is often drummed out of them by parents, teachers, and bosses. And those whose academic preparation would lead you to believe that they're highly skilled in this area (such as engineers and physicians) regularly fall prey to sloppy problem solving.
The good news is that effective problem solving is a skill that can be developed. Everyone can learn to solve problems effectively given the will and ample practice with a skilled coach/teacher.
This webinar focuses on the P (plan) phase of the PDSA/PDCA cycle (plan-do-study-adjust), which is the most difficult phase of scientific problem solving for people to master. Topics include:
• Setting a target condition
• Problem clarification
• Scoping and qualifying the problem
• Root cause analysis
Watch this lively discussion and learn the important first steps for closing the gap between where you are and where you'd like or need to be.
As preparation for the webinar, you may want to read the Discipline chapter in Karen's Shingo Award-winning book, The Outstanding Organization. www.ksmartin.com/TOO
1. The document describes several success stories of companies across different industries that implemented Critical Chain Project Management (CCPM) to successfully complete projects faster and with higher quality.
2. Common problems faced before implementing CCPM included unclear timelines and responsibilities, long unproductive meetings, and lack of visibility into project status.
3. After implementing CCPM, companies experienced benefits like reduced project duration, clear accountability and tracking of critical tasks, focused meetings with action items, and improved visibility for management.
Kanban Overview And Experience Report ExportValtech UK
Kanban began in one BBC product team in 2008 and spread to other teams, including application support, product teams, design, and operations. Key principles include starting with current processes and modifying slightly to implement pull systems with work-in-process limits. Metrics allow continuous improvement, and bottlenecks are identified through leading rather than trailing indicators. Planning and other processes can be decoupled, with a focus on quality and reducing variability to improve efficiency. The experience report details improvements in lead time, development time, defects, and other areas through applying Kanban principles.
The document discusses the seven principles, themes, and processes of PRINCE2. The seven principles are continuing business justification, tailoring to individual projects, focusing on products, managing by exception, defining roles and responsibilities, learning from experience, and engaging in progressive elaboration. The seven themes are business case, organization, quality, plans, risk, change, and progress. The seven processes are starting up a project, initiating a project, directing a project, managing a stage, managing product delivery, controlling a stage, and closing a project.
This document outlines a process model for directing a project. It shows the key activities, including authorizing initiation of the project and stages, appointing project managers, reviewing plans and reports, and providing advice and direction to the project board. The process begins with authorizing initiation and ends with authorizing project closure once final reports are approved.
Here are three examples of areas that could benefit from systematic arrangement:
1. Tool storage areas - Arranging tools in an organized way based on type and frequency of use can help tradespeople like carpenters or mechanics find what they need quickly.
2. Office supply storage - Having a defined place for items like paper, pens, binders etc. and labeling storage areas clearly can help staff be more efficient.
3. Kitchen pantry - Organizing canned and boxed foods by category (veggies, soups etc) and using accessible containers makes it easier to find ingredients when cooking.
Slide 31
isc4 Here are some potential areas that could benefit from systematic arrangement based on the presentation:
This document outlines NASA's 7-step project management process presented by the NASA Safety Center. The 7 steps are: 1) establish a vision, 2) develop project success criteria, 3) apply backward planning, 4) use forward action planning, 5) identify metrics, 6) rely on the project team, and 7) communicate frequently. Each step is described in 1-2 sentences with an emphasis on establishing a clear vision and success criteria early, planning backwards and forwards, using metrics to track progress, relying on team members, and ensuring open communication. Real NASA projects are provided as examples to illustrate applying the 7 steps.
The document provides an overview of root cause analysis (RCA) tools and processes. It defines RCA as a systematic process for identifying the root causes of problems in order to prevent recurrence. The document outlines the key concepts, types of causes, common tools like fishbone diagrams and 5 whys, and a 5-step DMAIC process for conducting RCA including defining the problem, measuring its scope, analyzing root causes, implementing solutions, and controlling effectiveness. The goal of RCA is to develop sustainable solutions by understanding underlying causes rather than just addressing symptoms.
A Power Point package designed to allow organisations to run internal lean and continuous improvement training. The package is comprehensive containing 157 slides detailing continuous improvement strategy and tools. Topics include; introduction, change management, team development, facilitation, voice of the customer, the seven wastes, strategy deployment, data collection, metrics, flow, levelling, cell layout, quick changeover, just in time, root cause analysis, 5s, autonomation, error proofing, visual management, standard work, value stream mapping, A3 thinking, PDCA, kaizen, office TPM, and sustainment. Unlike other lean introductory courses, this is not solely aimed at the factory floor.
Terms are defined in English and if Japanese, Romaji and Kanji are also included.
Operating Excellence is built on Corrective & Preventive ActionsAtanu Dhar
This document provides an overview of Corrective Action Preventive Action (CAPA) and how to implement an effective CAPA process. It defines CAPA and explains the difference between corrective and preventative actions. It outlines the benefits of a mature CAPA system, including increased quality, reduced costs from problems, and improved customer satisfaction. The document then discusses various tools that can be used in the CAPA process, including root cause analysis techniques like 5 Whys, fishbone diagrams, and Pareto charts to identify causes and prioritize actions. Examples are provided for how to apply these tools to analyze specific business processes.
This document outlines the objectives and procedures for accident and incident prevention and investigation. It discusses determining the causes of accidents, identifying investigation methods, and prevention. The key points covered include defining accidents and incidents, investigating to establish facts and causal factors using a systematic approach, interviewing witnesses, documenting findings, determining effects, and identifying prevention methods. The overall goal is to conduct thorough investigations to prevent future occurrences.
NIOSH Heavy Equipment Blind Spots and Internal Traffic ControlJustin Tolpa, CSP
This document summarizes NIOSH research on blind spots around heavy construction equipment and internal traffic control plans. It reports that over 900 worker deaths from 1992-2000 were vehicle-related in work zones. Studies evaluated proximity warning systems, measured blind areas, and developed GPS and video methods. Guidelines for internal traffic control plans aim to limit worker exposure to vehicles by coordinating equipment movement and establishing pedestrian-free zones. Case studies investigated fatalities to identify interventions like redesigning traffic patterns.
This document discusses corrective action and root cause analysis processes. It provides an overview of nonconformances, the corrective action process which involves 4 steps - problem identification, short term remedy, root cause analysis, and implementation of corrective actions. Root cause analysis tools like fishbone diagrams, 5 whys, and flowcharts are presented. The importance of determining and addressing the underlying root cause is emphasized to prevent future nonconformances.
Brian Maynard Presentation Comedy Safety Unsafe Actsgitjiggy
I do not make claim to all these photos. These are photos that have been emailed to me over the past few years. I hope you enjoy the presentation. It is great for a safety meeting or class.
The document outlines Millennium Products' new Near Miss Program. It defines a near miss as an unplanned event that could have caused injury or damage but did not. The objectives of the program are to identify risks, prevent accidents, and improve safety culture. Employees are encouraged to report near misses so their causes can be analyzed and corrective actions implemented to prevent future incidents. Examples of near misses at Millennium Products are provided to demonstrate how the program will work.
This document discusses operating heavy equipment safely around ground personnel. It identifies many types of heavy equipment that require safe operation near workers on foot. The goal is to prevent accidents between moving equipment and ground workers by ensuring operators can see workers and workers can be seen. Common causes of accidents are discussed, such as runovers from dump trucks backing up. The document provides guidance on management commitment, employee involvement, hazard controls, training, and operator responsibilities to help achieve a safe worksite where the risk of being struck by equipment is minimized.
The document discusses different levels of project complexity and their alignment with agile project management approaches. It uses the analogy of piloting different types of aircraft to represent different levels of projects, from simple solo projects to highly complex projects critical to national security. The levels progress from having full autonomy to operating within strict rules and oversight, where mistakes are not tolerated due to high stakes and consequences. Agile approaches are best suited for self-contained teams with flexibility and autonomy, while larger, more complex projects require more formal processes and governance.
This document discusses near miss reporting and examples of unsafe acts and conditions. It provides a non-exhaustive list of unsafe acts like operating equipment without permission, defeating safety devices, or not using protective equipment. Unsafe conditions include lack of guarding, inadequate lighting, or faulty equipment. Contributing factors are also examined, like lack of skills/knowledge from inadequate training, job factors like poor equipment maintenance, and personal factors such as distractions. Complacency is highlighted as a major threat. The document advocates for measures to improve skills/knowledge through training, supervision, and setting examples. It also stresses the importance of considering attitudes like behaviors, values, standards, and judgments.
Problem solving road map to guide anybody who must improve a process that is slow, defective, inflexible, unresponsive, costly and risky.
Do you have any like that in your organization?
Of special use for teams following Lean Six Sigma methods (green belt and black belt projects).
Follows DMAIC structure integrated with Lean thinking and tools.
ASSOCIATED KEYWORDS:
Shewhart, Deming, Ohno, Ishikawa, lean, toyota, tps, toyota kata, lean six sigma, project management, six sigma, green belt, black belt, champion, coach, master black belt, deliverables, road map, project management, project plan, DMAIC, LSS, Define, Measure, Analyze, Improve, Control, Sustain, project charter, business case, team, problem solving, milestone, tollgate, baseline, process map, SIPOC, gemba, 7 wastes, 8 wastes, gemba walk, waste walk, spaghetti chart, flow chart, RACI, swimlane, VSM, value stream map, quick wins, operational definition, gage r&r, basic quality tools, check sheet, run chart, histogram, data statification, first time yield, FTY, rolled throughput yield, RTY, COPQ, hidden factory, rework, SPC, Western Electric rules, pareto, prioritization, input, process, output, box plot, scatter plot, correlation, causation, system, 5 whys, cause effect, fishbone, FMEA, hypothesis testing, root causes, quick win, drive out fear, respect for worker, kaizen, 5S, poka yoke, brainstorm, TRIZ, roles, responsibilities, PDCA, PDSA, pilot, roll out, implementation, status, implementation plan, business process management, BPM, KPI, target, performance, response plan, control plan, SOP, inverted pyramid, organization, sustain, plan, budget, communication, training, change, management, adoption, business, capability, prosperity, value, realization, results, replicate, integrate
This document provides an overview of root cause analysis (RCA) and common RCA tools. It discusses the CPAR/SCPAR process for documenting problems, determining root causes, and implementing corrective actions. Three common RCA tools are described: 5 Why's analysis involves repeatedly asking why to drill down to the root cause; affinity diagrams group related causes to identify major causes; and fishbone diagrams illustrate the relationship between causes and effects. The document encourages using the appropriate tool based on the problem complexity and provides examples of applying each tool.
Recorded webinar: http://slidesha.re/1tGIZaH
Subscribe: http://www.ksmartin.com/subscribe
Purchase the book: http://bit.ly/TOObk
Effective problem solving is not an innate skill that most people are born with.
Even for those few few lucky ones who are born with natural problem-solving talent, it is often drummed out of them by parents, teachers, and bosses. And those whose academic preparation would lead you to believe that they're highly skilled in this area (such as engineers and physicians) regularly fall prey to sloppy problem solving.
The good news is that effective problem solving is a skill that can be developed. Everyone can learn to solve problems effectively given the will and ample practice with a skilled coach/teacher.
This webinar focuses on the P (plan) phase of the PDSA/PDCA cycle (plan-do-study-adjust), which is the most difficult phase of scientific problem solving for people to master. Topics include:
• Setting a target condition
• Problem clarification
• Scoping and qualifying the problem
• Root cause analysis
Watch this lively discussion and learn the important first steps for closing the gap between where you are and where you'd like or need to be.
As preparation for the webinar, you may want to read the Discipline chapter in Karen's Shingo Award-winning book, The Outstanding Organization. www.ksmartin.com/TOO
Root Cause Analysis is the method of problem solving that identifies the root causes of failures or problems. A root cause is the source of a problem and its resulting symptom, that once removed, corrects or prevents an undesirable outcome from recurring.
The document discusses the differences between chronic and sporadic problems and the appropriate approaches to address each type. It defines chronic problems as existing for some time and requiring improvement projects to attain breakthroughs. Sporadic problems are deviations that require troubleshooting to restore normal performance. The document outlines the sequence for breakthrough analysis including diagnosis to find root causes and developing remedies. It also summarizes the key steps in troubleshooting sporadic problems and the link between root cause analysis and the management by fact approach.
How to Become a Thought Leader in Your NicheLeslie Samuel
Are bloggers thought leaders? Here are some tips on how you can become one. Provide great value, put awesome content out there on a regular basis, and help others.
The document discusses Agile methodology, an iterative approach to software development that emphasizes continuous improvement and adaptation to change over rigidly following a plan. It outlines the core principles and processes of Agile development, including short sprints, daily stand-up meetings, prioritizing tasks based on product owner feedback, and evaluating progress at the end of each sprint through demonstrations and retrospectives. The document argues that Agile is better suited than traditional waterfall models for software projects where requirements are uncertain and likely to change during development.
Operational Planning: The Key to Building a Culture of Implementation and Focus4Good.org
Ever wonder why organizations lose focus as their strategic plans gather dust on the shelf?
Ever wonder how to keep everyone on the same page during implementation, and preserve the energy and excitement generated during the strategic planning process?
Want to build a culture of focus that can knit together key organizational processes (planning, communications, evaluation and organizational learning) for sustainable high performance?
Tired of that "flying by the seat of our pants feeling?"
Successful organizations make the shift from "what" (visioning) to "how" (implementation) by building the infrastructure of implementation.
Join me in a practical discussion of what you can do create a focused, effective organization.
This document introduces the return on investment (ROI) methodology for measuring the value of project management. It discusses why measuring value is important, as most projects are over budget and behind schedule. The ROI methodology provides a 10-step process for conducting an evaluation, including planning objectives, collecting data during and after implementation, analyzing data, calculating costs and benefits, and reporting results. Implementing ROI can help justify budgets, improve processes, and show how project management contributes to business goals.
The document discusses NASA's independent review process for programs and projects. It aims to ensure the highest probability of mission success. Key points:
1. Independent reviews are conducted by Standing Review Boards at each project life-cycle milestone to objectively assess technical approach, schedule, resources, risk, and management approach.
2. Reviews provide independent validation of projects' readiness to proceed and reassure stakeholders that commitments can be delivered. Preparing for reviews allows holistic project examination.
3. Reviews follow NASA governance involving senior management, technical authorities, and decision authorities. Standing Review Boards comprised of independent experts conduct the actual reviews.
4. The process helps ensure projects receive independent assurance they are on
Scrum is an agile project management framework that uses iterative sprints, daily stand-ups, and regular planning and review meetings. The key aspects of scrum include sprint planning meetings to select work, daily scrums to track progress, a sprint review to demonstrate completed work, and a retrospective to improve processes. Scrum focuses on empirical process control, self-organizing teams, and iterative delivery of working software.
The document discusses AT&T's agile implementation across its Tel Aviv Center of Excellence, including that it has over 450 employees across 54 scrum teams and 25 discovery teams working on 20 projects, and that AT&T took a "sandwich" approach to implementation from both top-down management and bottom-up team levels while optimizing the entire process. It also provides details on the products, technologies, reasons for choosing agile, and implementation approach used at AT&T.
This document discusses rapid improvement events (RIEs) and quick improvement methods for processes. It describes:
1) RIEs as a facilitated event lasting 3-5 days where a cross-functional team makes rapid improvements to an identified process problem. Documentation is completed during the event.
2) Quick improvements called "Just Do Its" that can bypass analysis and implement low-risk, fast changes identified early in a project using basic tools.
3) The criteria for "Just Do Its" as having minimal costs, low risk, quick implementation within 1-2 weeks, and authority to make the changes. Control plans must still be implemented after quick improvements.
The document describes a Lean Administration & Fast Closing project methodology to improve financial processes. The methodology involves 4 steps: 1) Project Initiation to define scope and goals. 2) "As Is" Analysis to map current processes and identify opportunities. 3) Design a roadmap to prioritize and validate improvements. 4) Implementation of changes, monitoring progress, and identifying additional opportunities. The goal is to enhance efficiency, quality, and value of financial activities like forecasting, closing, and reporting.
The document discusses agile methodology and Scrum in particular. It outlines some key disadvantages of traditional SDLC approaches, including delayed deployment, inability to incorporate new requirements, and lack of early customer feedback. It then introduces agile principles like iterative development, collaboration, and responding to change. Scrum is presented as an agile methodology consisting of roles like Product Owner and Scrum Master, ceremonies like sprint planning and daily standups, and artifacts like product backlogs. Benefits of Scrum include continuous improvement, delivering working software frequently to gather early customer feedback, and higher return on investment.
Holistic Business Life Cycle addresses the need for businesses to continuously change and improve through innovation. It presents a 7-layer Standard Business Framework (SBF) to manage this process. The SBF layers include requirements, implementation, optimization, and monitoring & control. It emphasizes that change, risk, impact, and learning are ongoing and integral to business maturity and growth over time. Key aspects of the framework include stakeholder engagement, requirements analysis, cost/benefit analysis, implementation validation, and continuous improvement through data analysis and decision-making.
In today’s economic environment, all companies strive to control expenses and manage resources efficiently. Most feel this goal is achieved through deploying technology. That is not always the case.
In this session, learn how Amylin Pharmaceutical’s top continuous improvement project surpassed tough targets in procurement and accounts payable, without introducing technology. Discover how to:
- Use Kaizen methodologies with a cross-functional team
- Find solutions without adding software or capital expenditures
- Save money and redirect staff to perform value-added tasks
This document outlines the 8-step process and tollgate requirements for the Control phase of a National Guard Black Belt training module on continuous process improvement. The 8-step process includes validating problems, identifying performance gaps, setting improvement targets, determining root causes, developing countermeasures, seeing results through key performance indicators, confirming results, and standardizing successful processes. Tollgate requirements for the Control phase mandate updating benefits, standardizing processes, establishing process owner accountability, achieving results, implementing control plans, and creating a storyboard summary.
This document discusses how traditional project management approaches can fall short for complex work, and introduces Agile product development using Scrum as a framework. It explains that Scrum focuses on maximizing business value through collaborative customer engagement and empirical process improvement over comprehensive planning. Scrum is presented as a practical method for complex work where needs may change, using short development cycles called sprints to iteratively deliver working software or products.
This document provides information about standardized work processes. It begins with an overview of the 8-step CPI roadmap for process improvement. It then discusses standardized work techniques and tools that can be used to analyze and improve processes. The rest of the document uses an exercise where participants standardize the process of drawing a pig picture to demonstrate how to create a standardized work instruction document. It provides examples of standardized work forms like standard operation sheets that document the best way to complete a task or job through detailed steps and timing. The goal is to achieve consistency in processes to improve safety, quality, productivity and performance.
This document discusses sustaining process improvements through project closeout and transitioning to process owners. It outlines the timeline for project closeout, including transitioning to the final process owner at a commissioning meeting and subsequent review meetings. Maintaining improvements requires executing process management, with elements like process maps, monitoring, and response plans. Process owners must institutionalize changes through cultural shifts and updated systems to drive permanent behavior changes.
NG BB 53 Process Control [Compatibility Mode]Leanleaders.org
This document provides an overview of process control concepts and tools. It discusses an 8-step process for process improvement that includes control. Control plans are important to ensure improved processes remain stable. Measurement systems should be analyzed and process capability recalculated during control. Cultural issues can impact control and force field analysis can identify drivers and restraints. Standard operating procedures, control charts, and mistake proofing are discussed as control mechanisms.
1603960041059_20 Six Sigma Good Tools.pptxMimmaafrin1
The document provides an overview of various Six Sigma tools and methodologies including:
1) Voice of the Customer (VOC) which captures customer requirements and feedback through historical data analysis and direct customer interaction.
2) Critical to Quality (CTQ) which identifies specific measurable characteristics that fulfill customer requirements.
3) Cause and effect diagrams, 5 whys, process mapping and other tools for analyzing processes and identifying sources of variation.
4) Continuous improvement methodologies like Kaizen, PDCA cycles, and standard operating procedures.
5) Total Productive Maintenance (TPM) which aims to eliminate equipment breakdowns through proactive maintenance.
6) Other tools for improving processes like single
This document outlines the define phase of an 8-step continuous process improvement (CPI) roadmap. The define phase includes activities like identifying problems, validating the problem statement, establishing strategic alignment, gathering customer input, and creating a goal statement. It also lists required deliverables for the define tollgate, such as a problem statement, goal statement, project scope, timeline, and high-level process map. The document provides an overview of the key elements and documentation needed to properly define a CPI project.
The document discusses achieving success through the review process. It has two main aims: to provide an understanding of the review process and to introduce the SMART approach to objective setting. The review process benefits both individuals and the university by clarifying expectations, improving communication, and celebrating successes. It also discusses different levels of objectives, the annual review cycle, roles and responsibilities, examples of SMART objectives, receiving feedback, and types of development.
The document discusses creating a balanced scorecard framework for measuring an IT group's performance using Agile methods. It includes creating a strategy map with objectives in the areas of finance, customer value, internal processes, and learning & growth. Key performance indicators are identified for each objective as leading or lagging measures. The framework aims to measure knowledge, skills, abilities, efficiencies in delivering services to clients, and enable periodic reporting with both types of performance indicators based on IT goals.
1. Continuous Improvement
Learning Organization
ROOT CAUSE
SYSTEMS
PROCESSES
SYSTEMS
PROCESSES
ANALYSIS
and
Continuous
Improvement
1
2. Topics to be discussed
• What is Root Cause
Analysis?
• Tools and
Techniques
• Step-by-Step Root
Cause Analysis
• Corrective Action
Planning
2
3. Process Improvement Control System
Forecast
Forecast Monthly
Monthly
Action
Action Action
Action
Review
Review
Log
Log Log
Log
Meeting
Meeting
Process
Process
Master
Master
Schedule
Schedule
Daily
Daily Weekly
Weekly Weekly
Weekly Review
Review
Operating
Operating Meeting
Weekly Report Meeting
Report
Planning
Meeting
ACTION
1 2 3
Action
Daily
Daily Action
Weekly Short
Short Review Log
Weekly Interval Log
Process
Process Interval Meeting
Plan Control
Control
Plan
3
4. Action Log
Review at the beginning and end of every meeting Copy and distribute
to all attendees
before they leave
GKN Sinter Metals ACTION LOG
Meeting: Date: Sheet 1 of ___
Action Log completed by: Meeting attendees: Distribution: Attendees +:
Listed below are the issues discussed and actions agreed at the above meeting. The actions
assigned were committed to by the responsible parties. Relevant material presented or
reviewed is attached or referenced in the text.
# Issue Action Required / Status Responsible Date due Completed?
NEVER ASSIGN RESPONSIBILITY
TO SOMEONE WHO IS NOT AT THE
MEETING
4
6. Interruptions in Process Flow
Emergency
Unforeseen and unplanned or
uncontrolled quality defect or
stoppage of the process that will
adversely impact the delivery of
value to the customer. Requires
immediate, unscheduled response.
Waste and Improvement
Deterioration in process performance.
Responses can be planned and scheduled.
6
7. Achieving Breakthrough Results
SPORADIC
departure from
historic level
HISTORIC LEVEL
L
o The difference between the HISTORIC
s and OPTIMUM level represents a
tremendous cost savings
s
OPTIMUM LEVEL
time
7
8. What is “Failure”?
It no longer achieves a desired standard of
performance.
We fail to achieve our plan.
We fail to deliver value to
our customer.
8
9. If it’s not adding value it is...
is anything other than the minimum amount of
equipment, materials, parts, space and employee’s time which are
absolutely essential to add value to the product or service.
9
10. What is RCA?
Root Cause Analysis is a process of analyzing the
cause-effect relationships between events.
DATA
ACTION ANALYSIS
DECISION
It aims to identify and separate symptoms from the true cause of a
problem, and to identify the actions necessary
to ELIMINATE it.
10
11. Step-by-Step Root Cause Analysis
1. FORM / CONVENE THE TEAM
2. GATHER EXPERTS
3. INVESTIGATE AND GATHER DATA
4. DETERMINE SEQUENCE OF EVENTS
5. AGREE ON THE EFFECTS
6. SEVERITY-OCCURRENCE-DETECTION RANKING
7. CAUSE AND EFFECT DIAGRAM (Fishbone, Mind map)
8. DEVELOP CORRECTIVE ACTION PLAN AND TIMETABLE.
ASSIGN RESPONSIBILITY
9. FOLLOW UP FOR COMPLETION OF ACTIONS
10. EVALUATE EFFECTIVENESS OF ACTIONS
11
12. 1. Form the Team
• Appoint an RCA facilitator and Team
Leader. Facilitator has been trained on
leading an RCA. Team leader has the
content expertise pertaining to the event.
• Team Leader and Facilitator meet and
identify data to be gathered and who
should be on the team for this particular
analysis.
• Select meeting date, time and place and
inform members.
• Ask team members to bring data and a
draft of the sequence of events.
12
13. 2. Gather Experts
• Decide who should help determine the root
cause in addition to the standing team.
• Operators, supervisors, anyone who has
knowledge of the specific event.
• Experts who may not have “been there” but
who have relevant experience are valuable
resources, including manufacturers reps and
contractors.
13
14. 3. Investigate and Gather Data
•As soon as possible after the event, collect
information, including control charts,
operator notes, gage readings, data forms.
Try to get data before, during and after the
event.
• Interview operators, supervisors and
anyone who may have information about
what happened. Ask questions about what
they saw and heard.
• WHO, WHAT, WHERE, AND WHEN
14
15. THE SEVEN QC
TOOLS
RUN CHART HISTOGRAM CONTROL
CHARTS SCATTER DIAGRAM
10 10 UCL •
• • •
5 X VARIABLE •
5 2 •
• •
LCL • • •
0 0
TIME X VARIABLE
•
1
CAUSE AND
EFFECT FLOWCHART PARETO CHART
DIAGRAM
MACHINE MEASUREMENT 10
METHOD 5
MATERIALS MAN 0
TYPE
16. Pareto Chart
3.1 Line, 331 Work order data
Source: PMC work order data 10/09/00
Machine parts/subsystems with more than 1 work order Cumm %
10.9%
Machine part/subsystem No. WO's Machine part/subsystem No. WO's % of Ttl 21.2%
Load nest 3 Probe 17 10.9% 28.2%
Prox 16 Prox 16 10.3% 34.0%
Infeed gear box 1 Hydraulic 11 7.1% 39.7%
Elec 3 Bushing 9 5.8% 44.9%
Pivot stop 1 Clamps 9 5.8% 49.4%
Sealtite connector 1 Swing clamp 8 5.1% 53.2%
Program 3 Sideclamp 7 4.5% 57.1%
Cylinders 1 Switch 6 3.8% 60.3%
Hydraulic 11 Hardstop 6 3.8% 62.8%
Valve 3 Split nuts 5 3.2% 64.7%
66.7%
68.6%
3.1 Line-Work Order Pareto 70.5%
% of total Work
12.0%
72.4%
74.4%
10.0% 76.3%
Orders
8.0% 78.2%
80.1%
6.0%
4.0%
2.0%
0.0%
m
p
p
ic
e
ps
e
ve
or
m
ls
ec
to
le
ey
lin
ul
ob
ril
m
ot
la
ob
al
ds
ra
El
K
D
be
M
Pr
la
ec
V
yd
pr
ar
C
Lu
id
H
H
o
S
N
Subsystem/Machine Part
16
17. 4. Determine The Sequence of Events
1. • Develop a clear picture of what happened first,
second, third, etc.
2. • Don’t try to determine root cause at this stage,
just get the sequence of events right.
3. • Don’t “Rush to Judgement”. The obvious may
not be the right answer.
17
18. 5. Agree On The Effects
Use the results of the investigation and
sequence of events
• Brainstorm any other possibilities
• Rank the effects using
• Severity
• Occurrence
• Detection
18
19. 7. Cause and Effect Diagram
AKA: Ishikawa or Fishbone Diagrams
CAUSES EFFECT
Manpower
Method
Last Minute
rush to build
Material Machinery
19
20. WHAT IS A CAUSE & EFFECT DIAGRAM ?
• Also known as a “Fishbone” (Ishikawa diagram) or Mind Map
• Shows the relationship between the Effect / Problem & possible
causes.
• Helps to differentiate between symptoms and primary causes
• A problem / effect can have several causes. These can be
identified and categorized.
• Often emerges out of a Brainstorming session
• A primary tool for Root Cause Determination
20
21. FISHBONE DIAGRAM
THE EFFECT
• Represented by the HEAD of the skeleton
• The Effect should be stated in simple terms.
• General Effects should be broken down into more specific Effects.
THE CAUSES
• Represented by the RIBS of the skeleton.
• Use the “4M’s” / “4P’s” or others to
categorize the causes.
• Add the causes to the rib.
• Add further riblets to show relationships between causes.
21
22. CAUSE & EFFECT DIAGRAM reminders
The 4 ‘s The 4 ‘s
anpower ersonnel
achinery lant
aterials olicies
ethods rocedures
22
23. Cause & Effect Diagrams
HOW TO CONSTRUCT A CAUSE & EFFECT DIAGRAM
• STEP 1: Agree on one statement that
describes the selected problem
• STEP 2: Generate the causes needed to build
up the problem
• STEP 3: Construct the diagram
• STEP 4: Interpretation
23
24. Cause & Effect Diagrams
FISHBONE DIAGRAM
CAUSES EFFECT
Manpower
Method
Build on
Rush To
Complete
Material Machinery
24
25. FISHBONE DIAGRAM - DAILY EXAMPLE
METHODS MACHINERY
No record
Use wrong gears tire pressure
Drive Fuel mix too
too rich Under-inflated tires
fast Poor hearing
Mech. doesn’t
Radio too loud have specs Poor design
Always
late
POOR
Can’t hear engine Carburetor Difficult air valve GAS
Impatience adjustment stems MILEAGE
Poor training Wrong gas No oil change
Poor type
maintenance
$
No owner’s
$ “When in Rome” manual
Improper
No awareness lubrication
Don’t know Don’t know right oil
recommended
Poor driving petrol type Wrong oil
No owner’s manual
habits
MANPOWER MATERIALS
25
26. Mind-mapping
What is it?
What value does it
have?
Where can it be used?
26
27. Mind Mapping
An unstructured / creative tool
Is an advanced form of Cause and Effect
METHOD MANPOWER
Rules of Mind Mapping
No Operator
Wrong start
g
procedure
nin
al
u
lan
an
Lost
rm
p
Use a brainstorming base
or
Mowe
•
Op
Po
No es
r
fil
No
Lazy
won’t
start
• Centralize the theme Pull rope broken
Gas tank empty
Di
Fouled spark plugs
pe
dn
g
ro
’t
nin
ive
Don’t question or judge
ch
•
lea
ec
ct
fe
k
rc
De
la
gu
MATERIAL MACHINERY
re
• Revisit the tool
No
• As many input sources as possible
27
28. 6. Ranking the Causes
MIND MAP
Process Name_______________________________
Severity
Cause
• Occurrence
Ca
us • Detection
e
Risk Priority No. =
Effect
(Severity) X
(Occurrence) X
(Detection)
Subsystem / Part Severity Occurrence Detection RPN
28
29. SEVERITY EVALUATION CRITERIA
5 Very High Process Problem affects Quality of the Output
4 High Process Problem will likely impact the Quality of
the Output
3 Moderate Process Problem may impact the Quality of the Output
2 Low Subsystem partially fails with a slight impact on quality
performance
1 Minor Potential failure mode has no real affect on quality
performance
29
30. OCCURRENCE EVALUATION CRITERIA
Probability Frequency
5 Very High Failure is certain 1 Daily or every
unit
4 High Failure is highly likely 1 Weekly
3 Moderate Occasional failure 1 Monthly
2 Low Failure not likely 1 Quarterly
1 Remote No failures recorded 1 Annual
30
31. Process Control Detection Criteria
5 Can not detect will not detect that the failure is occurring or will occur
4 Low have a poor chance of detecting the failure
3 Moderate may detect the failure
2 High have a good chance of detecting the failure
1 Very High will almost certainly detect the failure
Risk Priority Number = Severity X Occurrence X Detection
31
32. GUIDELINES-Fish bones and Mind Maps
1. Make sure that everyone agrees completely on the problem
statement
2. Construct carefully to achieve the best result
3. Do not be afraid to spread the diagram out.
4. Avoid using too many ideas under one main cause
5. If the problem is too complex, draw more than one diagram
6. Keep it simple
7. Ranking using Severity-Occurrence-Detection
8. Keep asking....WHY ?…5 times!!!!!
?
32
34. CAUSE AND EFFECT DIAGRAM
METHOD MANPOWER
CAUSES EFFECT
No Operator
Wrong start procedure
Manpower
ng
l
Method
ua
ni
Lost
an
an
pl
rm
or
PO5 STOPS
No
Op
Po
Solenoid valve Mower
file
Lazy
No
gone won’t
s
start
Gas tank empty
Material Pull rope broken
Machinery
Di
Fouled spark plugs
dn
pe
’t
ro
ch
g
nin
ive
ec
k
ct
lea
fe
rc
De
la
gu
MATERIAL MACHINERY
re
No
KEEPING RECORDS
Keep copies of the Cause & Effect diagrams.
They can be used if a similar problem arises in the future.
34
35. 8. DEVELOP CORRECTIVE ACTION PLAN
Recommended Corrective Action-Operations Who? When?
Root Cause Analysis (RCA) Log
Prepared By Date
Maint Supv
RCA No.
ANALYSIS Recommended Corrective Action-Maintenance Who? When?
Problem Description:
What events lead to the above stated problem?
Recommended Corrective Action-Engineering Who? When?
Long term Analysis Assignment Who? When?
Ask Why 5 Times!
Why:
Why:
SIGNOFF:
Why:
Why:
Maintenance Supv. Production Engineer Production Superintendent
Why:
35
36. 9. Follow up on Completion
CORRECTIVE ACTION LOG
RCA No. Date:
Corrective Action Date
No. Date Location Equip/ Resp Due Detailed Description Compltd?
36
37. Human Error
“Errors must be accepted as System
flaws,not character flaws.” L. Leape
The Root Cause of many failures may involve
human error:
• Poor training
• Fatigue
Don’t be afraid to identify Human error as a root cause.
Errors can be addressed positively.
Enter corrective actions involving Human Error in the Corrective
Action Log and complete them with the same urgency as other
“mechanical” corrective actions.
37
38. Evaluate Effectiveness Of Corrective Actions
•After corrective actions
are in place, evaluate
failure history again. Look
at the data!
• Recalculate S.O.D. and
compare with original
number
• Implement additional
corrective actions as
necessary
38
39. WHIDTMSIWNHA
What It
Will
Have
Never
I Happen
Done Again
To
Make
Sure
39
40. Processes, Systems and the Tools Will Empower
the Organization to Make It All Happen
Corrective Action Log CORRECTIVE ACTION LOG
RCA No. Date:
Corrective Action Date
No. Date Location Equip/ Resp Due Detailed Description Compltd?
DATA
Control
the
S
ACTION
whole...
E MANALYSIS
S T
S Y ...by
controlling
the parts
DECISION
40
Editor's Notes
SYSTEMS and PROCESS are the pillars of continuous improvement. SYSTEMS drive all improvement. PROCESS everything can be mapped as a process flow (HR, Customer Service) To be effective a process flow must reflect the “real life flow” of what happens. By identifying what actually is being done improvement can be made. Only those who are involved know what actually happens on a day to day basis. Can’t really problem solve until the process flow is defined. In a LEARNING ORGANIZATION there is degree of empowerment - so that people doing the work - the experts - are the ones from whom information is sought.. The old Boss/subordinate system is replaced with with a new system that solicits everyone's input.
AGENDA Recommended reading: Systems Thinking Peter Synge SPC for the Rest of Us - Root Cause Analysis - Quality Planning and Analysis - Juran & Gryna
Based on Demings’ PDCA 1. The Daily Plan Establish standards for process without waste. Determine how long before the process can run to this standard before it is out of control Determine what the process is suppose to be and compare this to what it actually is. Use examples from your own experiences When you talk about the process real time it is CONTROL - afterward it is an EXCUSE. 2. REVIEW MEETING - What do we do to make sure this never happens again? 3. ACTION LOG - What action has been taken? What still needs to be done. Who is going to do it?
Record both ACTION and ISSUES. Issues may not be resolved by the action taken.
This is a good opportunity to discuss the LEAN philosophy to control waste.
This is another good opportunity to draw on your personal experiences and relate EMERGENCY back to your audience. Use product or processes that they are familiar with.
This is a good chart to help people visualize the difference - the way they usually do things and how they could be doing them. Describe that determining the ROOT CAUSE of why is the catalyst to improvement. This chart can be use to create a dialogue between you and your audience about their particular functions. This can be a hunt to identify the frustrated and angry. They can lead you to more problems to solve.
The above definition of waste has become widely accepted as a main driver of the change process and LEAN Manufacturing. It states that the MINIMUM amount of resources should be used for each and every task throughout the company. Waste is everywhere and its elimination brings massive cost benefits. To create a dialogue with your audience ask for some examples of waste in their areas.
This is another example of Demings’ PDCA in action. Discuss that many time in an improvement process only certain elements are used resulting in continuous fire fighting rather than continuous improvement. Collecting DATA and Analyzing it without making a DECISION or taking ACTION does not improve the process. Collecting DATA, ANANLYZING that Data, making a DECISION,taking ACTION on the DECISION - then starting over again is the way to make incremental corrections to continually improve the way things are done at Sunrise Medical.
Everyone one on the team is a problem solver. The Facilitator and Team leader may be the same person - but whoever is appointed should be somewhat removed form the situation to maintain perspective. The main objective of the LEAD is to keep the team focused on the problem. The LEAD and FACILITATOR decide who should be on the team and what experts are required to solve problems. Publish an AGENDA ahead of time. Establish an environment to achieve the greatest discretionary effort from each individual.
It is KEY to identify the experts that should be on the team. Groups tend not to bring in experts and want to solve problems themselves. As a rule nobody does anything wrong because they want to do something wrong…it is generally the process
This is another good time for you to bring in examples from your experience where a SPORADIC EVENT caused a major quality problem and tie you experiences in with how you investigated and gathered data.
1. Put things in a logical order - from start to finish - assure the order. This process is critical to ROOT CAUSE or you are dealing with symptoms. Don’t rush to judgement. Going through the process will provide valuable insights.
Separate cause from effect and get it all on paper.
The tendency is to grab hold of too large a problem - when that happens divide the problem. One suggestion is to start each session with a little training session to describe the intentions of the meeting and the expected outcomes. This assures that people know what to do and how to do it in each problem solving session. Be comfortable with silence. Learn to wait through the silence as people process information. The tendency is to start fixing. Remember in this situation there is no waste in process.
It is critical to agree and get consensus on STEP 1.
Get down every possible cause for the problem. Record jokes also…even if the finger is pointed at the Supervisor or another person. Things said in jest are often subconscious causes of the problem. Feelings are magical in that they identify things the brain hasn’t integrated.
When people have had allot of exposure to brainstorming - mind mapping can be another alternative to approach creative solutions to problems.
There is always the tendency not to establish the Risk priority. Ranking is very important to identify biggest problems. Ranking systems occurs on the following page.
Is the occurrence SPORADIC or CHRONIC? Walk your class through this ranking to identify frequency.
Use this formula for every problem identified on the FISHBONE to establish priority.
Give an example from your experience of how this has helped.
Keep your information - don’t throw it away - odds are you will not solve all of your problems the first time you use the CAUSE & EFFECT DIAGRAM.
S.O.D. Severity of Occurrence Detection
Without systems in place the process will drift away!