This document provides an overview of basic problem solving and root cause analysis techniques. It discusses the importance of fully grasping the situation in order to define the problem. Key aspects of the problem solving process covered include using tools like check sheets, brainstorming, cause-and-effect diagrams, the 5 whys technique, and developing and testing countermeasures. The document emphasizes sustaining solutions by standardizing and documenting countermeasures and regularly checking for effectiveness and opportunities for adjustment.
A3 THINKING FOR SOLVING COMPLEX PROBLEMS AND EVOLUTIONARY CHANGE (ALEXEI ZHEG...Lean Kanban Central Europe
A3 reports are known as a way to capture problem-solving activities following the PDCA (Plan-Do-Check-Act) cycle and also to focus problem-solvers’ thinking, helping them understand the problem deeply and uncover hidden root causes leading to effective countermeasures. This session demonstrates the potential of A3 Thinking as an evolutionary improvement method in organizations that can complement existing process and improvement methodologies, such as Agile, Kanban or ITIL.
The session contains a story of a “data centre crisis” in a software company, when multiple departments, each using different processes and improvement methods, came to work together to learn deeply about their common problem, address its root causes, drastically reduce the downtime and lock in lasting improvements. The story is used to reinforce several key aspects of A3 Thinking, to demonstrate its evolutionary nature, and to explore its relations to organizational complexity. The story also has a number of stopping points, highlighting several key coaching behaviours important to Lean/Kanban change agents, including: the non-judgmental attitude, avoiding resistance to change, working with the existing culture, validated learning, and the ability to lead improvements with safe-to-fail experimentation.
A3 THINKING FOR SOLVING COMPLEX PROBLEMS AND EVOLUTIONARY CHANGE (ALEXEI ZHEG...Lean Kanban Central Europe
A3 reports are known as a way to capture problem-solving activities following the PDCA (Plan-Do-Check-Act) cycle and also to focus problem-solvers’ thinking, helping them understand the problem deeply and uncover hidden root causes leading to effective countermeasures. This session demonstrates the potential of A3 Thinking as an evolutionary improvement method in organizations that can complement existing process and improvement methodologies, such as Agile, Kanban or ITIL.
The session contains a story of a “data centre crisis” in a software company, when multiple departments, each using different processes and improvement methods, came to work together to learn deeply about their common problem, address its root causes, drastically reduce the downtime and lock in lasting improvements. The story is used to reinforce several key aspects of A3 Thinking, to demonstrate its evolutionary nature, and to explore its relations to organizational complexity. The story also has a number of stopping points, highlighting several key coaching behaviours important to Lean/Kanban change agents, including: the non-judgmental attitude, avoiding resistance to change, working with the existing culture, validated learning, and the ability to lead improvements with safe-to-fail experimentation.
This handy guide is for anyone involved in problem solving and improvement activities. It contains guidelines on the use of many of the tools and techniques which can be used as part of a Continuous Improvement process.
Basic Qulaity Tools/Techniques Workshop for process improvementMouad Hourani
This material includes the easiest and most applicable quality tools that could be utilized by staff nurses at the level of direct care givers. some links cant be activated as it is PDF file.
CAPA management, corrective and preventive action, Rootcause analysis, RCA, Problem mapping, FMEA, Failure Mode effect and Analysis, Fault Tree analysis, Fishbone : ISHIKAWA, CTQ Tree (Critical to Quality Tree), AFFINITY DIAGRAM, 5 Why’s, Human errors,
When confronted with a problem, have you ever stopped and asked "why" five times? The Five Whys technique is a simple but powerful way to troubleshoot problems by exploring cause-and-effect relationships.
Cause and Effect Analysis is a technique for identifying all the possible causes (inputs) associated with a particular problem / effect (output) before narrowing down to the small number of main, root causes which need to be addressed.
8D Problem Solving WorksheetGroup NumberGroup Member Nam.docxransayo
8D: Problem Solving Worksheet
Group Number:
Group Member Names:
Date:
8-D is a quality management tool and is a vehicle for a team to articulate thoughts and provides scientific determination to details of problems and provide solutions. Organizations can benefit from the 8-D approach by applying it to all areas in the company. The 8-D provides excellent guidelines allowing us to get to the root of a problem and ways to check that the solution actually works. Rather than healing the symptom, the illness is cured, thus, the same problem is unlikely to recur.
Step
0
1
2
3
4
5
6
7
8
Action
The Planning Stage
Establishing the Team
Problem Definition / Statement & Description
Developing Interim Containment Action
Identifying & Verifying Root Cause
Identifying Permanent Corrective Actions (PCA)
Implementing & Validating PCA
Preventing Recurrence
Recognizing Team Efforts
0
The Planning Stage:
The 8-D method of problem solving is appropriate in "cause unknown" situations and is not the right tool if concerns center solely on decision-making or problem prevention. 8-D is especially useful as it results in not just a problem-solving process, but also a standard and a reporting format. Does this problem warrant/require an 8D? If so comment why and proceed.
Is an Emergency Response Action Needed?
(If needed document actions in Action Item Table)
1
Establishing the Team: (Your group is the team)
Establish a small group of people with the process/ product
knowledge, allocated time, authority and skill in the required technical disciplines to solve the problem and implement corrective actions.
Team Goals:
Team Objectives:
First and Last Name (put an asterisk * after the name of the team leader)
Current Job Position
Skills (related to the problem)Years of Hospitality Work Experience
2A
Problem Definition
Provides the starting point for solving the problem. Need to have “correct” problem description to identify causes. Need to use terms that are understood by all.
Sketch / Photo of Problem
Product(s):
Customer(s):
List all of the data and documents that might help you to define the problem more exactly?
Action Plan to collect additional information:
Prepare Process Flow Diagram for problem
use a separate sheet if needed
2B
IS
IS NOT
Who
Who is affected by the problem?
Who first observed the problem?
To whom was the problem reported?
Who is not affected by the problem?
Who did not find the problem?
What
What type of problem is it?
What has the problem (food, service, etc)?
What is happening with the process & with containment?
Do we have physical evidence of the problem?
What does not have the problem?
What could be happening but is not?
What could be the problem but is not?
Why
Why is this a problem (degraded performance)?
Is the process stable?
Why is it not a problem?
Where
Where was the problem observed?
Where does the problem occur?
Where could the problem be located but is not?
Where else could .
This handy guide is for anyone involved in problem solving and improvement activities. It contains guidelines on the use of many of the tools and techniques which can be used as part of a Continuous Improvement process.
Basic Qulaity Tools/Techniques Workshop for process improvementMouad Hourani
This material includes the easiest and most applicable quality tools that could be utilized by staff nurses at the level of direct care givers. some links cant be activated as it is PDF file.
CAPA management, corrective and preventive action, Rootcause analysis, RCA, Problem mapping, FMEA, Failure Mode effect and Analysis, Fault Tree analysis, Fishbone : ISHIKAWA, CTQ Tree (Critical to Quality Tree), AFFINITY DIAGRAM, 5 Why’s, Human errors,
When confronted with a problem, have you ever stopped and asked "why" five times? The Five Whys technique is a simple but powerful way to troubleshoot problems by exploring cause-and-effect relationships.
Cause and Effect Analysis is a technique for identifying all the possible causes (inputs) associated with a particular problem / effect (output) before narrowing down to the small number of main, root causes which need to be addressed.
8D Problem Solving WorksheetGroup NumberGroup Member Nam.docxransayo
8D: Problem Solving Worksheet
Group Number:
Group Member Names:
Date:
8-D is a quality management tool and is a vehicle for a team to articulate thoughts and provides scientific determination to details of problems and provide solutions. Organizations can benefit from the 8-D approach by applying it to all areas in the company. The 8-D provides excellent guidelines allowing us to get to the root of a problem and ways to check that the solution actually works. Rather than healing the symptom, the illness is cured, thus, the same problem is unlikely to recur.
Step
0
1
2
3
4
5
6
7
8
Action
The Planning Stage
Establishing the Team
Problem Definition / Statement & Description
Developing Interim Containment Action
Identifying & Verifying Root Cause
Identifying Permanent Corrective Actions (PCA)
Implementing & Validating PCA
Preventing Recurrence
Recognizing Team Efforts
0
The Planning Stage:
The 8-D method of problem solving is appropriate in "cause unknown" situations and is not the right tool if concerns center solely on decision-making or problem prevention. 8-D is especially useful as it results in not just a problem-solving process, but also a standard and a reporting format. Does this problem warrant/require an 8D? If so comment why and proceed.
Is an Emergency Response Action Needed?
(If needed document actions in Action Item Table)
1
Establishing the Team: (Your group is the team)
Establish a small group of people with the process/ product
knowledge, allocated time, authority and skill in the required technical disciplines to solve the problem and implement corrective actions.
Team Goals:
Team Objectives:
First and Last Name (put an asterisk * after the name of the team leader)
Current Job Position
Skills (related to the problem)Years of Hospitality Work Experience
2A
Problem Definition
Provides the starting point for solving the problem. Need to have “correct” problem description to identify causes. Need to use terms that are understood by all.
Sketch / Photo of Problem
Product(s):
Customer(s):
List all of the data and documents that might help you to define the problem more exactly?
Action Plan to collect additional information:
Prepare Process Flow Diagram for problem
use a separate sheet if needed
2B
IS
IS NOT
Who
Who is affected by the problem?
Who first observed the problem?
To whom was the problem reported?
Who is not affected by the problem?
Who did not find the problem?
What
What type of problem is it?
What has the problem (food, service, etc)?
What is happening with the process & with containment?
Do we have physical evidence of the problem?
What does not have the problem?
What could be happening but is not?
What could be the problem but is not?
Why
Why is this a problem (degraded performance)?
Is the process stable?
Why is it not a problem?
Where
Where was the problem observed?
Where does the problem occur?
Where could the problem be located but is not?
Where else could .
A3 Problem Solving Template v1.2 (April 2015) by Henrik Knibe.docxSALU18
A3 Problem Solving Template v1.2 (April 2015) by Henrik Kniberg and Tom Poppendieck
License: Creative Commons Attribute 4.0 International
Original link: http://www.crisp.se/lean/a3-template
Background PLAN
Current condition PLAN
Goal / Target Condition PLAN
Root Cause Analysis PLAN
Countermeasures (experiments) DO
Confirmation (results) CHECK
Follow up (actions) ACT
Owner:
Mentor:
Date:
A3: <problem statement>
http://www.crisp.se/henrik.kniberg/
http://www.poppendieck.com/people.htm
http://creativecommons.org/licenses/by/4.0/
http://www.crisp.se/lean/a3-template
A3 Problem Solving Template v1.2 (April 2015) by Henrik Kniberg and Tom Poppendieck
License: Creative Commons Attribute 4.0 International
Original link: http://www.crisp.se/lean/a3-template
Background PLAN
● Why is this important?
● Why should the reader care about this situation and be motivated to participate in
improving?
Assessment Questions
1. Is there a clear theme for the problem report that reflects the contents?
2. Is the topic relevant to the organization’s objectives?
3. Is there any other reason for working on this topic (e.g. learning purposes)?
Current condition PLAN
● How do things work today?
● What is the problem?
● Baseline Metrics?
Assessment Questions
1. Is the current condition clear and logically depicted in a visual manner?
2. How could the current condition be made clearer for the audience?
3. Is the current condition depiction framing a problem or a situation to be resolved?
4. What is the actual problem in the current condition?
5. Are the facts of the situation clear, or are there just observations and opinions?
6. Is the problem quantified in some manner or is it too qualitative?
Goal / Target Condition PLAN
● What outcomes are expected for what reasons?
● What changes in metrics can be plausibly expected?
Assessment Questions
1. Is there a clear goal or target?
2. What, specifically, is to be accomplished?
3. How will this goal be measured or evaluated?
4. What will improve, by how much, and when?
Root Cause Analysis PLAN
● What is the root cause(s) of the problem?
● Use a simple problem analysis tool (e.g. 5 why’s, fishbone diagram, cause/effect diagram) to
show cause-and-effect relationships.
Assessment Questions
1. Is the analysis comprehensive at a broad level?
2. Is the analysis detailed enough and did it probe deeply enough on the right issues?
3. Is there evidence of proper five-whys thinking about the true cause?
4. Has cause and effect been demonstrated or linked in some manner?
5. Are all the relevant factors considered (human, machine, material, method, environment,
measurement, and so on?)
6. Do all those who will need to collaborate in implementing the countermeasures agree on the
cause/effect reasoning?
Countermeasures (experiments) DO
● Proposed countermeasure(s) to address each candidate root cause (this should be a series
of quick experiment to validate causal model analysis)
● Predicted result for e.
Learning Objective: Increase professional effectiveness, data management, and analytical skills
With evolving technology, many people are overloaded and overwhelmed with information and data. Businesses now have access to large amounts of feedback from internal and external sources. How do we make sense of the all of the information? Is the data reliable? How can we manage and utilize the data in order to impact business goals, visions, mission? This seminar with help you turn your information overload into powerful and reliable data that you can use to meet organizational goals.
At the end of this seminar, participants will be able to:
a. Assess and categorize data and information.
b. Identify tools and techniques to organize and interpret data.
c. Explore productivity tools and techniques.
d. Examine common data management challenges and solutions.
Explanation of the seven basic tools used to solve a variety of quality-related issues. They are suitable for people with little formal training in statistics.
Problem Solving Skill merupakan sebuah teknik untuk memecahkan masalah secara terstruktur, kompleks, dan utuh sehingga dapat ditemukan pilihan kebijakan atau kebijaksanaan yang memiliki efektifitas dan efisiensi tinggi serta minim resiko.
Fusion14 session 202 problem management - making it work for your organizationKepner-Tregoe
The Value of Problem Management. In a presentation at Fusion 14, John Custy, Service Management Practitioner with the JPC Group offers a great overview of problem management concepts, frameworks as such as Kepner-Tregoe Problem Management, as well as the value problem management practitioners derive from this practice.
2. Grasp The Situation
Grasping the Situation is Key to Effective Problem SolvingGrasping the Situation is Key to Effective Problem Solving
Problems Are
Treasures
It all starts with a big vague concern
How do I know I have a problem?
What is the standard?
Observe the process?
What should be happening?
What is actually happening?
Is there a problem?
What is the gap?
Investigate the Concern
Break down the problem
Determine focus area
2
Tech Services
QA – Complaints
RG – Functions
R&D – D/E
MFG – Process
Supply Chain
3. P-D-C-A
Check – Observing and
Assessing Results Against
Defined Targets
Adjust – Reflecting on the
Results Confirming the
Hypothesis or Identifying
Needed Adjustments
Plan – The Hypothesis
Expressed as Goals, Metrics
and Actions
Do – An Experiment,
Entails Deployment of
Goals and Activities
The Scientific Method
3
4. P-D-C-A Up Close
Deploy
Observe Work
ID Limitation or Waste
“TRYSTORM”
Develop Countermeasures
Success?
Yes
No
GRASP THE SITUATION
•Is there a problem?
•What is the standard?
•What should be happening?
•What is actually happening?
•Is there a gap? PLANPLAN
Based on what you Observe:
1.Challenge assumptions
2.Ask why its done that way
3.Confirm Cause and Effect
Look to “ROOT CAUSES” – take
time to understand the real
problem and the root causes!
PLANPLAN
•Think of ways to mistake proof -
get rid of “pain points” or waste
DODO
Test the idea NOW, not
in days or weeks
4
5. Deploy
Observe Work
ID Limitation or Waste
“TRYSTORM”
Develop Countermeasures
Success?
Yes
No
CHECKCHECK
Did it work?
Have I confirmed
Countermeasures?
Validate with data!
ADJUSTADJUST
Keep trying improvements
until the problem is
reduced or gone
DON’T STOP
HERE!!
Put the fix in place
across the
organization!
Nail it in place….put it in a
procedure or make it a
requirement!
P-D-C-A Up Close
5
6. Problem Solving A3
Tells a clear, concise story on one page
Used as worksheets to ID problems, root causes, countermeasures
Used to report improvement opportunities to management
Used as tools to track and close rapid improvements
Escalated to management for future project consideration
6
7. Background:
•The current sewing process draws the material on an angle, which has caused
defects in the past (Rework 20% of time due to non-straight sewn lines)
•Worker currently has to keep inventory of supplies at work location in middle of
floor
•Inventory at location becomes Safety/Tripping issue (2 falls this month)
Target/Goal:
•Lines on sewn straight (defect free) on product >98% of the time
•Zero Injuries due to inventory storage
•Zero unnecessary inventory
Causal Analysis:
•Observed and documented the sewing process
•Conduct a Fishbone and Five Why’s on controllable items
•Findings:
1. Angled product feed to sewing machine
causes non-straight lines (defects)
2. Angled product feed designed originally
to keep inventory close
Countermeasures:
•Using idea of toilet paper roll, designed hanger that would fit the roll of material
and provide direct (straight) feed into sewing machine
•Developed ledge on end of hanger that would prevent spinning material roll from
rolling off and causing additional defects
•Removed storage of inventory in walkway that caused excessive motion for worker
who had to replace
•Designed material storage cabinet next to worker for quick access to material rolls
necessary for one shift of work
Action Plan:
•Update material handling process to ensure material is delivered per shift needs
•Standardize solution and deploy across the sewing tasks
Follow-up :
•Standardize solution prototype and create standard feed tool for other sewing machines
•Update job instructions to reflect improved process
Author: Version & Date:
Current State:
Worker
aligns
material to
machine
Worker
begins
sewing
Worker
assesses
straight feed
Worker sews
until roll empty
A3 Example Midmark Investigation Worksheet
Defec
t?
Replaces from
local inventory
7
8. Background:
Target/Goal:
Causal Analysis:
Countermeasures:
Action Plan
(Milestone Chart) :
Follow-up :
Author: Version & Date:
Do I know the cause?
Through the
completion of this plan . . .
Have I confirmed
countermeasures?
Current State:
Do I have a problem?
Through this plan . . .
Have I confirmed cause & effect?
Problem Solving A3 Midmark Investigation
Worksheet
8
9. Problem Definition Exercise
Begin developing a Problem Solving A3 (ONLY first 3
sections of A3) to determine if you have a problem with one
of the frustrations below:
Grocery bill too high
Utility bill too high
Can’t find tools in work area
Can’t find needed work files on PC
Choose Items to Fix That Are Within Your Sphere of ControlChoose Items to Fix That Are Within Your Sphere of Control
9
10. Solving Problems
1. You Grasped the Situation
2. You’ve started filling out a Problem Solving A3
3. You Observed or Documented the process
4. You’re pretty sure you have a problem now
What Do You Do Next?What Do You Do Next?
10
11. Check Sheet for Gathering Data
Check Sheet
1st Shift 2nd Shift 3rd Shift
Item TotalJuly 6, 2000
T
y
p
e
o
f
E
r
r
o
r
s
A
B
C
D
IIII
II
IIII II
III
17
III
IIII I
I
IIII II
17
II
IIII III
IIII
14
8
10
16
14
48
Collected By: JEC
Department: Collections
Date: July 6, 2000
Source: Log Sheets
Definition: A list of check-
off items that quickly
gathers data by type and
over time
Purpose: Collect data by
providing a standardized
format that lends itself to
quantitative analysis.
Three types of Check
Sheets
Counted
Measured
Location
11
12. Brainstorming
Definition: a method for a team
to creatively generate a high
volume of ideas on any topic
Non-judgmental process
May be used to identify
problems, causes or solutions
Assists in ensuring input from
all members
Promotes buy-in
12
13. Brainstorming Rules
Each idea should be recorded as stated
The scribe should write the idea exactly as spoken, not in
his or her words
Get buy-in from the originator of the idea that you have
recorded the idea properly
Don’t criticize -- a brainstorming session is used to
encourage innovative, off the wall ideas
Build on other people’s ideas
No premature decisions or evaluations
Don’t sit on ideas – express them
Brainstorming sessions should result in many ideas, which may lead
to new directions and solutions!
13
14. Brainstorming Types
Unstructured: Ideas are
generated at random,
any time within the
brainstorming process
Structured: A process in
which each team
member gives ideas in a
round robin format
14
15. Unstructured Brainstorming
Write brainstorming question/topic where all can see it
Team calls out ideas
No discussion (positive or negative)
No questions
Rapid generation is the aim
Can be done in “Round Robin” format
Record ideas in exact words
30 second rule → Relaxation technique
Review list for clarity, combine duplicates
Free-form
15
16. Structured Brainstorming
Write down question/topic
Each team member writes 3 ideas on a sheet
Every 5 minutes pass to next person, add 3 ideas to list (new or
expansions)
Repeat until everyone has had each sheet at least once
Harvest ideas Idea 1 Idea 2 Idea 3
Idea 1 Idea 2 Idea 3
Idea 1 Idea 2 Idea 3
Idea 1 Idea 2 Idea 3
Idea 1 Idea 2 Idea 3
Idea 1 Idea 2 Idea 3
Brain-writing
16
17. Write down question/topic
In turn, team members give ideas
May pass and get back in
Record in exact words
Continue until everyone passes
Review for clarity and combine duplicates
Round-robin Brainstorming
Structured Brainstorming
17
18. Nominal Group Technique
Structured brainstorming
that focuses on equal
participation
Allows for quicker
consensus on important
issues
Builds commitment from
the team
Structured Brainstorming
18
19. NGT < Generating Ideas
Scribe the issue that needs to be resolved
Each person should spend a few minutes writing down their
ideas related to the issue
Each team member then prioritizes their ideas into the top 2 or
3 per individual
The team leader should go around the table, soliciting each
member’s top 2-3 ideas
As ideas are given, those with duplicate ideas should cross them
off their finalized list
19
20. Why Look at Root Causes?
What factors are
causing our key pain
points?
What factors are
causing our key pain
points?
VS.
Treating Symptoms
Treating Causes
20
21. Do I know the cause?
I observed the process, asked questions, got the facts
I know how the process flows
I know how long the process takes
Now I need to understand the root cause of the problem!
The 3 types of causes
Point of cause: Where was the physical location of the problem?
Direct cause: What factors contributed to the problem?
Ask 5 Whys to get to the . . .
Root cause: What are the factors that if corrected, would prevent recurrence
of the incident
Three types of root cause
Inadequate standard
Inadequate adherence to a standard
Inadequate system
21
22. Traditional Fishbone Cause Categories
Four Ps for
Service/Transactional
Plant/technology
Policies
Procedures
People
Six Ms for
Manufacturing
Materials
Measurement
Manpower
Machinery
Methodology
Mother Nature
(Environment)
Customize Categories to Fit Your Specific RequirementsCustomize Categories to Fit Your Specific Requirements
22
23. Cause & Effect Diagram (Fishbone)
A structured visual brainstorming tool used to isolate ONE
specific defect, problem, or undesirable condition and
determine the potential causes
Advantages
Predefined categories stimulate thinking
Classifies variables as Controllable or Noise
________
________
Problem or
Effect
Methodology
Materials
Machinery
ManpowerMeasurement
Environment
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
23
24. Cause and Effect Step by Step
1. Choose Categories
2. Brainstorm Causes
3. Classify as “C” or “N”
4. Choose ‘top’ Causes using data
24
25. Exercise
Complete a Cause and Effect Diagram on one of the
following problems:
Car will not start
Poor course grade
Unable to qualify for marathon race
Poor gas mileage
Your choice – instructor approval required
Customize Categories to Fit Your Specific RequirementsCustomize Categories to Fit Your Specific Requirements
25
26. 5 Whys
Useful for less complex problems
Used to generate causes for use in other RCA methods
Advantages
Easy to use
Identifies more than one cause
Identifies causal relationships
Why?Why? Why?
Why?Why?
Why?Why? Why?
Why?Why?
Asking Why 5 Times Often Brings You To The “Real” Root Cause(s)
. . .One You May Have Never Noticed
Asking Why 5 Times Often Brings You To The “Real” Root Cause(s)
. . .One You May Have Never Noticed
26
27. 5 Whys
How to use it
Asking Why simply involves repeatedly asking ‘why’ until the
answer is ‘because that’s the way it is’!
At this point, it is likely that you have identified a root cause of the
problem
If tackled and removed, the observed symptoms of the problem should also
disappear
Although called ‘Asking Why Five Times,’ or ‘the 5 Whys’, five is a
rule of thumb….there may be fewer or more questions depending
on the particular situation.
It is important to beware of channelling your analysis down one
avenue and completely ignoring other contributing root causes of
the same problem
27
28. Developing Countermeasures
Countermeasures Defined
An action aimed at root cause of problem so as to prevent
recurrence
Goal of Countermeasures
Using wisdom and ingenuity to create devices and methods that
allow you to do your job 100% defect free 100% of the time –
mistake proof your countermeasures!
What are the two kinds of countermeasures?
Temporary (short-term)
Permanent (long term)
Aim for Solutions that Make the Right Way Easy
and the Wrong Way Hard!
Aim for Solutions that Make the Right Way Easy
and the Wrong Way Hard!
28
29. Countermeasure Criteria
You should be able to answer yes to all of these
items
Involves the right people?
Prevents recurrence?
Inexpensive?
Made with wisdom and ingenuity?
Simple to use?
Easy to implement?
Durable?
Easy to maintain?
Does not hinder operator?
Reliable?
29
30. Everyday Countermeasures
Choose one of the items below and list all the mistake
proofed devices you have seen:
Gas Station
Lawn Mower
Family Car
30
31. Have I confirmed Cause and Effect?
If I remove or block a cause, what happens to the problem?
Prototype your solution and try it
Make a change and test it
Conduct experiments based on data
If you have more than one cause, do one experiment at a
time
Do my solutions prevent recurrence?
31
32. ….What’s Next?
CHECK To See If It Worked
ADJUST If It Did
Standardize the solution
Document the solution
Share the solution
Check solution sustainment regularly
ADJUST If It Didn’t
I still have the problem or a new problem pops up in 6 months
Develop another countermeasure
Trystorm Again!
Sustain the Solution – Make it Stick!Sustain the Solution – Make it Stick!
32
33. Wrap Up – Expectations…..
Your role……
Start “observing” – use the Check Sheet – and measure…
Understand the REAL PROBLEM and ROOT CAUSES
Develop countermeasure and TRYSTORM
Deploy (with procedure) if successful, otherwise, develop alternate
fix….
Complex problems – contact your area Green Belt or Black Belt for
help
Report improvements / improvement opportunities to management
on the Problem Solving A3
Fix the Problem if You Can. Ask for Help if You Can’t!Fix the Problem if You Can. Ask for Help if You Can’t!
33
Editor's Notes
Instructor points to discuss:
Does XYZ Company consider problems treasures? (most attendees will say No)
How do companies like Motorola, GE, and Toyota benefit from seeing problems as treasures?
Seeing Problems as Treasures is the basis of Grasping the Situation (GTS)
The activity of GTS means observing and documenting the process so that we can clearly see if we have a problem
Do our standards = our current state process? If no, we have a problem
To effectively GTS, we do NOT do that from our desks. 3 Actuals. We go to the Actual place where the Actual work is done by the Actual employees…..we observe and document.
Plan-Do-Check-Adjust – Our Foundation
The Plan-Do-Check-Adjust (PDCA) cycle is W. Edwards Deming’s gift to the world. PDCA is an expression of the scientific method and is the foundation of strategy deployment. PDCA is also the basis for all process improvement in the world (i.e. Six Sigma DMAIC (Define, Measure, Analyze, Improve, Control)
GRASP THE SITUATION
Key to the PDCA cycle is Grasp The Situation. GTS means thoroughly understand 1) what the process should produce, determined by Standards such as Time to Complete Work, First Pass Yield, etc.; and 2) what is the process actually producing today.
PLAN (1) Clearly define the problem and establish a precise problem statement (2) Identify the processes that impact the problem (3) List the steps in the process as it currently exists (4) Map the Process (5) Identify potential cause of the problem (6) Collect and analyze data related to the problem (7) Verify or revise the original problem statement (8) Identify root causes of the problem
DO (1)Establish criteria for selecting a solution (2) Generate potential solutions that will address the root causes of the problem (3) Select a solution (4) Plan the solution (5) “Test” the change (6) Implement the chosen solution on a trial or pilot basis
CHECK (1) Gather data on the solution (2) Analyze the data on the solution (3) Review the action, analyze the results and identify what lessons learned (4) Use the measure or metrics to determine (5) Planned Vs. Actual
ADJUST (1)Take action based on what you learned in the Check step - If the change did not work, go through the cycle again with a different plan. If you were successful, standardize (2)Use what you learned to plan new improvements, beginning the cycle again (3) Adopt the solution (4) Plan ongoing monitoring of the solution (5) Continue to look for incremental improvements to refine the solution.
The cycle is repeated on an annual basis.
Instructor Key Points
Observe the Work
Go to where the Actual work takes place and document what you see. Some keys when Observing: 1) be thorough….how long does it take for a worker to complete a task; how many times do they do this-or-that; how far does the worker have to walk to get the tools and supplies he/she needs to complete the task; etc. Capture as much data while Observing the Work as you can.
As a problem solver, you’ll be looking to improve your own process. So be thorough when documenting the work you do.
Develop Countermeasures
The Key with Countermeasures is that we want to use Ingenuity and Creativity instead of $$$$Dollars
TRYSTORM
Part of developing the countermeasures is actually creating a prototype. Use cardboard, rope, tape, scrap material to create a prototype that you think will enhance the process, fix the problem, and/or make the process more efficient.
The Trystorm step means actually trying the prototype in the work area. Assessing to see if the prototype solved the problem.
Instructor Key Points
Success?
Did the prototype work? Did it solve the problem? Will it prevent recurrence of the problem?
NO:
Develop additional countermeasures, another iteration of your solution, a new solution, whatever it will take, and TRY it again!
YES: Deploy
If the prototype solved the problem, let’s make it permanent, standardize it, share with leadership and teammates.
Keys to the Deploy step are:
Share your solution with others who do similar work and can benefit from your improvement
Do we need to make changes to Work Instructions? Planning? Because of your solution?
Instructor Key Points:
Ask the students if anyone knows what A3 is?
A3 stands for nothing more than the paper size on the printer (roughly 11x17)
The originators of the document did not want the Title of the document to be important. What is important is the content and message being shared.
The A3 is the Roadmap to ensure you are following the PDCA process improvement methodology
It is used to ensure that we hit all the important steps associated with process improvement and a good form to capture our findings and improvements so that the final solutions can be shared with leadership and others
If the issue you are trying to fix goes beyond your Sphere of Control, the A3 becomes a perfect handoff document for you to share with your others who can take up the issue and drive it to a solution
Instructor Key Points:
Walk through how the A3 was completed.
Highlight the key points:
Plenty of data to understand the background (specifics include metrics and percentages)
Current state show WASTE activity (red) and Value activity (green)
Target shows the assessment …. I have a problem
Not just words in the boxes. Graphs and photos that enhance your ability to clearly tell the story.
Through the root cause analysis of the issues, it was determined that all can be eliminated with countermeasures
Problem
Why are you talking about it? Go to the Actual place where the work takes place; Observe the Actual process on the Actual parts; Talk to the Actual people
Current State:
Where do things stand today?
Show visually using Charts, Graphs, Drawings, Maps, etc.
What is the problem?
Ask Questions – (1) What Is the Problem? (2) Where did it occur? (Point of Cause) (3)What could have caused it?
Target:
What specific outcomes are required?
Causal Analysis:
What is the Root Cause(s) of the problem? - Choose the simplest problem-analysis tool that clearly shows the cause and effect relationship
Countermeasures:
What is your proposal to reach the future state, the target condition?
How will your recommended countermeasures affect the Root Cause to achieve the target?
Action Plan:
What activities will be required for implementation and who will be responsible for What and When?
What are the indicators of performance or progress? - Incorporate a Gantt Chart or similar diagram that shows actions/outcomes, timeline, and responsibilities. May include details on specific means of implementation.
Follow-Up:
What issues can be anticipated? (1) Ensure ongoing PDCA (2) Capture and share learning
Exercise Instructions
Teams must complete ONLY the first three sections on the A3
Divide participants into groups of 4-6 and assign each group a different scenario.
Have each group outbrief and discuss their findings.
The check sheet is used to record measurements and observations, usually over a specific time period. Information may be recorded in many ways, ranging from the use of shop floor data systems to a piece of paper with tick marks.
Show the 3 different types of check sheets are as follows:
-- A counted check sheet is used to answer the questions “when” and “how many.” The counted check sheet could show the types of defects observed, how many were observed, and when.
--A measured check sheet is used to answer the questions “when” and “how much.” A measurement is recorded at the time it is made.
--A location check sheet is used to answer the question(s) “where” and “how many.” It focuses on a work area, machine, or process.
Brainstorming is a tools used to identify problems, causes or solutions.
The tool is effective in encouraging open involvement by all team members. It promotes innovative thinking, and, when used properly, has ideas that build on each other.
Review the rules of brainstorming with participants.
Ask if they can think of any other rules that would be appropriate.
Depending on the situation, brainstorming can be done in a structured or unstructured format.
In the structured format, ideas are given one at a time. Remember, this is brainstorming --no idea is to be criticized! All ideas given should be recorded -- team members are encouraged to give ideas that build on one another.
Unstructured brainstorming results in ideas given by anyone at anytime. All ideas should be captured as they occur. A strong code of conduct is important here as participants should not interrupt or talk over others.
Most commonly used form of brainstorming.
As with any brainstorming technique this one starts by writing down the question/topic
Each person starts out with a blank sheet of paper.
Round 1, each person puts three ideas on their sheet of paper. When everyone is done, pass it to the next person
Next person puts three additional ideas on the paper. These can be new ideas or expansions of ideas already on the paper, as long as they don’t duplicate an idea. When all are finished, pass to next person. Repeat until everyone has had each sheet at least once
Can use a number of techniques to harvest ideas.
Give team break and facilitator transfers contents of all sheets onto flip-chart paper
Have team members call out ideas from sheets to transfer to flip-chart paper
Have each person call out best ideas to transfer to flip-chart paper
Limited or unlimited number
Limited to sheet they hold or not
Have team members transfer ideas to post-it notes for affinitization and/or PICK charting
All or some ideas
Limited or unlimited number
From own sheet or any sheet
Other ideas from instructors experience or solicit ideas from students
Used when large numbers or deep expression of ideas is desired
Essentially the same as free-form but team members take turns instead of throwing ideas out in a free-for-all
Go around room giving each participant the opportunity to add one idea to list
Person may pass if they do not have an idea or do not wish to add an idea at that time
If you return to that person, they may add an idea later (i. e. pass is not final)
Continue until every member passes consecutively
Continue as for free-form brainstorming
Nominal Group Technique is a form of brainstorming used to ensure that all team members have a chance to actively participate in the process.
NGT involves generating a list of problems, ideas, or solutions in a structured, written format that allows for equal participation from all team members. It also helps a group narrow down the list of possible answers.
The next slide describes the process for generating ideas. The second slide describes the process for selecting the best ideas
Review the steps in using NGT in detail:
Tell participants that variations of NGT can be used in a given situation. For example, if a team is ready to do a root cause analysis of a problem, using NGT as a starting point may allow participants time to rationally think about the problem, and come closer to root causes quickly (rather than just saying the first thing that comes to mind).
Finding the root cause is the catalyst for the corrective action process. It is important to understand the difference between symptoms and causes.
Symptoms display characteristic signs or indications of the existence of something else that is not working.
A Cause is the producer of an effect, result, or consequence.
A symptom may appear to be a cause until it is further investigated.
It is important to understand the types of causes for the “broken” or “malfunctioning” process being analyzed.
Location (Point of Cause) of the problem should be identified early on as it could be a major factor in determining corrective action.
Contributing factors (5 Whys) will and corrective action are all part of causal analysis.
Traditional Fishbone Cause Categories are broken down into Service/Transactional “header” categories or Manufacturing Categories.
Predefined categories stimulate thinking.
Each category is then populated with pertinent information based on the problem or effect.
The topic of this Cause and Effect “Fishbone” diagram is Customer Dissatisfaction. Instead of using the four Ps for service/transactional causes or the six Ms for Manufacturing causes, this example uses the categories of “Appointment”, “Hospital Staff”, “Lab/X-Ray”, “Doctor”, “Pharmacy” and “General”.
Under the heading “Appointment,” the issues of “ability to get through”, “Appointment availability”, Attitude of phone receptionist” and Holding time for main operator” are brainstormed.
These causes are then further classified as “C” for “controllable” or “N” for “noise”. The noise issues are then eliminated from further analysis.
The 5 Whys is a great Six Sigma tool that doesn&apos;t involve data segmentation, hypothesis testing, regression or other advanced statistical tools, and in many cases can be completed without a data collection plan.
When Is 5 Whys Most Useful?
When problems involve human factors or interactions.
In day-to-day business life;
How To Complete The 5 Whys1. Write down the specific problem. Writing the issue helps you formalize the problem and describe it completely. It also helps a team focus on the same problem.2. Ask Why the problem happens and write the answer down below the problem.3. If the answer you just provided doesn&apos;t identify the root cause of the problem that you wrote down in step 1, ask Why again and write that answer down.4. Loop back to step 3 until the team is in agreement that the problem&apos;s root cause is identified. Again, this may take fewer or more times than five Whys.
Why can’t we do
____________?, or, what
stopped us from doing
_____________? Solve
the stopping point
Test the countermeasure in
minutes or hours – not days or
months
The guidelines on this slide can be followed when creating a Mistake Proofing device.
You should be able to answer “yes” to all of these questions to ensure that you have an effective Mistake Proofing device.
Document your countermeasure criteria by answering “who, what, when, where, or how” to each of the questions.
It’s ideal if your device has all these features, but, if you are unable to obtain this level, it may still be acceptable (something is better than nothing).
Use the “nasty test” in the design stage or as soon as possible, use the device with an intent to make it fail. If it is impossible to fail - then you truly have a Mistake Proof device.
We EXPECT Mistake Proofing in our daily lives as consumers. Should we not expect to Mistake Proof our own processes to produce defect free products and services as producers?
Fueling area of car has three mistake-proofing devices:
1. Filling pipe insert keeps larger, leaded-fuel nozzle from being inserted
2. Gas cap tether does not allow the motorist to drive off without the cap
3. Gas cap is fitted with ratchet to signal proper tightness and prevent over-tightening.
4. Cover opens so that driving off will not cause it to tear off
5. Warning labels
New lawn mowers are required to have a safety bar on the handle that must be pulled back in order to start the engine. If you let go of the safety bar, the mower blade stops in 3 seconds or less. This is an adaptation of the &quot;dead man switch&quot; from railroad locomotives.
Started because a couple of guys lifted up their lawnmower from the bottom to trim their hedges and successfully sued the manufacturing for not warning them they could hurt themselves.
Parking garages have low clearance. To ensure that cars entering the garage will fit, garages are fitted with a go/no-go gauge at the entrance. Hitting the swinging sign or pipe will not damage the vehicle as much as driving into a concrete beam.
You can’t just stop when you have reached a solution! Even a good solution has post work – standardization, documentation, sharing the solution and periodic sustainment checking.
If the solution doesn’t work, try, try, try again! Go back over the fishbone and the “Five Whys” to see if another avenue can be taken. Look at the current countermeasure(s) and develop new ones. Implement these changes (P-D-C-A) until you have an effective, sustainable solution.
Now that you have completed Problem Solving training - you are ready to perform Root Cause Analysis, develop countermeasures and Trystorm on your particular improvement in your sphere of control.
Remember that solving most problems is a team effort and help is available for you.
