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25
Day Two
26
Last session we covered
Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 1
Lean = giving customers exactly what they want, when they want it as efficiently as possible.
Customer Focus
•  Customers buy benefits – problems solved, a new opportunity, enhanced image
•  Your offerings deliver features – Reliability, Assurance, Tangibles, Empathy,
Responsiveness
Value Streams cross functional silos to deliver customer experience
•  The eight wastes erode productivity and quality
•  Value add analysis helps identify wasteful activities to eliminated or improve
27
Session One Value Add Analysis
Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 2
28
How are we doing?
Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 3
Name Company Expected Class Outcomes
Kyley Bonbite Weed out inefficiencies
Steph & Jocelyn Steph Mantis Design TBD
Trevor Underground Signs Efficiency, particularly for packaging and shipping
Ashley Luxholdups Scaling operations
Corrin Patina Studios Efficient processes
Kyiesha Hip Hop Closet Lower packaging and shipping costs (free service)
Akiko Atsuyo et Akiko Operational changes - Wholesale to Retail
Paul Made by Wood Move from one offs to multiple, smaller products
Owen VOM Carpentry Logistics – transport vs time on site
David & Kelly Stitch NYC Systems for Efficiency
29
Simulation Recap – Round One Metrics
Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 4
30
Thinking about continuous flow…..
Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 5
31
Day Two Topics
Continuous Flow
Theory of Constraints
Cost of Poor Quality
Continuous Improvement / Six Sigma
By the end of this session you will:
•  know how to identify and relieve production
constraints
•  understand the cost of poor quality and the DMAIC
improvement framework
•  have learned facilitation and problem solving skills
32
3. Continuous Flow
move as fast as value can be
added, no waiting.
Little’s Law
Theory of Constraints
Set-up Time Reduction
Takt Time
Kanban
Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 27
33
Measuring the Flow of Processes
with Little’s Law
Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 28
Work in Progress
Output
Work in Progress / Output = Cycle-time
120 gallons / 60 gallons per minute = 2 minutes
34
Continuous Flow
The Theory of Constraints
Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 29
CB BA
•  Constraints produce the fewest outputs per unit of time.
Often they will have a stack of work in front of them
•  Constraints govern the output for the whole process – an
hour lost at the bottleneck is lost for the whole process.
•  Efficiency gains at any other location don’t improve
productivity of the process.
Managing the Constraint
1.  Identify it
2.  Exploit it
3.  Subordinate everything else
4.  Increase output of constraint
5.  Rinse and repeat
35
Set-up Time
Reduction
https://vimeo.com/98796938
36
Set-up Time Reduction
(Single Minute Exchange of Die)
Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 31
1 Separate
Elements
Identify tasks that can be performed
during production and make them
“external” to the change over
2 Parallel
Work
Identify tasks performed
sequentially and, where possible,
complete them simultaneously
3 Convert
Elements
Review remaining internal elements
and ask what it would take to make
them external. Convert as many as
possible
4 Streamline Review all elements for
simplification to shorten both
external and change over time.
37
38
Production Systems
Takt Time Example: Willow Run
Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 33
68
Flow, Takt Time and Cellular Design
1940 – A bomber per hour at Willow Run
34,500 Employees
488,000 Discrete parts
33,000 Components
24 Assemblies
1 B-24 per hour
39
Production Systems
Kanban Overview
Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 34Source: http://logisticsglobal.blogspot.com/2011/10/kanban-system-parts-procurement-toyota.html
40
Production Systems
Kanban Board Example: Hiring Process
Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 35
1.  Define Value Stream
2.  Set Work in Process Limit
3.  Establish the Backlog
4.  Start Pulling Work
Application
Received Phone Screen
Manager
Interview
Interview
Complete Decision
G. Martin
Declined
M. Taylor
Offer
B. Miller
W. Jones
F. Brown
C. Williams
A Johnson
C. Smith
M. Jackson
3
M. Garcia
2 Rodriguez
AndersonJ. Davis
1
A. Thomas
Declined
Hernandez
Declined
T. Moore
Declined
D. Jones
No Go
R. Martinez
Offer
A. Richards
Start 15th
G. Wilson
4
41
Simulation Round 3:
Continuous Flow
•  Owner is responsible for final decisions
•  Changes must be reversible
•  No changes that involve customers
•  No elimination of staff
•  Facilitator has final approval
•  Implement changes and train if necessary
Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 36
Objective: identify and relieve constraints in the process.
42
4. Perfection
produce exactly what the
customer wants…
•  Cost of Poor Quality
•  The Case for Continuous
Improvement
•  Simple Six Sigma
37Copyright © Vox Datum LLC (2016-2017). All Rights Reserved.
43
The Cost of Poor Quality
Estimated Costs for American Companies
Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 38
Non-conformance
“The cost of getting it wrong”
Conformance
“The cost of getting it right”
Internal Failures (20% to 40%) Controls (10% to 50%)
•  Scrap materials
•  Rework – doing work twice
•  Lost production time
•  Inspecting for errors, defects
•  Delays waiting for approval
External Failures (20% to 40%) Prevention (0% to 5%)
•  Fines, Penalties
•  Warranties, Concessions
•  Lost revenue
•  Measurement and tracking
•  Root cause analysis
•  Mitigation
Source: The Quality Engineer Primer by Bill Wortman, 1997
44
45
The Limits of Inspection Controls
(and The Case for Continuous Improvement)
Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 40
“Finished files are the result of years
of scientific study combined with the
functional experience offered by
many Financial Services experts.”
46
Another Different Approach to Cost of Quality:
Continuous Improvement
Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 41
Total Costs
Control / Inspection Costs
Non-conformance Costs
Quality
Cost
Prevention Costs
(Continuous Improvement)
47
Conventional wisdom: “This is good enough.”
Six Sigma:
What is it? When is it useful?
Sigma Defects per Million % Good
6 3 99.99966%
5 233 99.977 %
4 6,210 99.4 %
3 66,807 93.3 %
2 308,537 69.2 %
Condition: 99% Good (4 sigma) 99.99966% Good (6 sigma)
High Risk 4 plane crashes per day 1 accident every 5 years
High Volume 2,800 lost packages per hour Less than 2 lost items per day
High Complexity 4,000 surgical mistakes per year Less than 2 mistakes per year
Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 42
Three conditions when “good enough” isn’t:
48
Continuous Improvement:
Will Six Sigma work for us?
Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 43
“Too Complicated”
“Bureaucratic”
“It’s a Black Box”
49
Continuous Improvement:
Six Sigma works for Dabbawallas
Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 44
“There is a service called FedEx that is
similar to ours but they don’t deliver hot
lunches.”
Dhondu Kondaji Chowdhury
50
Continuous Improvement:
How Dabba Deliveries Work
Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 45
10C
VP
M
Collection Codes
VP Residential Location
(Vile Parle)
C Residential Railway Station
(Cooper Hospital)
Red Dabbawalla teams color
Destination Codes
10 Destination Railway Station
(Nariman Point)
9 Dabbawalla team number
M Building Identification
(Mittal Tower)
12 Floor number
“The unavoidable price of reliability is simplicity.”
C. Hoare
51
Six Sigma
DMAIC Improvement Methodology
Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 46
Process Optimization
(People Driven)
Process Characterization
(Fact Driven)
MEASURE
Record performance in a
measurement system
CONTROL
Ensure sustainability
IMPROVE
Agree and make required
changes
ANALYZE
Find the critical few
factors
DEFINE
Document issue, allocate
resources
52
Define:
Tips for Starting an Improvement Project
Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 47
Define the objective •  Articulate the compelling need for change
•  Define goals tied to business objectives
•  Get buy-in from the critical stakeholders
Build the right team •  Ensure stakeholder representation
•  Keep the team small and co-located where possible
•  Hold frequent, timely, informal communications
Freeze the target •  Set specific, measurable success metric(s)
•  Set stretch targets. When in doubt, 50% improvement
•  Make the metrics visible for all and the target hard to change
Invent offline •  Make the most of existing or proven technology
•  Use technical innovation only when it’s fully tested
Be time driven •  80% of target is a win, celebrate success and move on
•  Iterate often, plan multi-generation releases
•  Use parallel work streams where possible
53
Measure:
Record Performance with Run Charts
Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 48
54
Analyze:
Find Critical Few Factors with Pareto Charts
Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 49
55
Analyze:
Using the Five Whys to Find Root Cause
Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 50
Where the Failure Occurred - Process Gaps
1.  Understand what the customer expects
2.  Design the process to meet customer
expectations.
3.  Follow the process as designed
4.  All communications are consistent with
how the process operates
Why? A solid rocket booster exploded.
Why? Hot gasses escaped from the rocket booster.
Why? O-ring seals failed in at least one of the
booster’s joints.
Why? The shuttle launched when the air temperature
was below design specifications for the O-rings
Why? “…NASA’s structure permitted internal flight
safety problems to bypass key shuttle
managers.”
Rogers Commission Report
On January 28, 1986 the Space Shuttle Challenger disintegrated over the Atlantic Ocean 73
seconds into its flight, leading to the deaths of its seven crew members. What went wrong?
56
Improve:
Better Quality with Error Proofing
Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 51
Risk Priority Number = Severity * Occurrence * Detection
Shut down Lock out Warning
Severity Occurrence Detection
5 Harm a customer or employee
Trigger legal or regulatory action
5 Very High (greater than 10%) 5 No controls
4 Cause significant reputational or
financial risk
4 High (1% to 10%) 4 Low
QC/QA sampling
3 Result in a customer complaint 3 Moderate (1/10,000 to 1%) 3 Moderate
100% manual inspection
2 Minor effect on performance 2 Low (1/10,000 to 1/Million) 2 High
Statistical Process Control
1 Unnoticed by customer
Internal waste or rework
1 Very Low (less than 1/Million) 1 Very High
100% auto inspection
57
Control:
Standard Work for Consistency
Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 52
Elements of Standard Work
1.  Inventory – material types and
quantities required to keep the process
operating smoothly
2.  Work Sequence – order of tasks an
operator must perform within takt time
3.  Takt Time - the rate at which
components must be made to meet
customer demand
Prep. Time 15 min.
58
Control:
Monitoring Key Metric(s) Over Time
Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 53
Trend – Six consecutive data points in
either direction
Shift – Eight consecutive points on
one side of the median
59
Process Optimization
Facilitation for Results
Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 54
The problem is often about the process…
“85% of the reasons for failure to meet customer expectations
are related to deficiencies in systems and process…change
the process rather than badgering individuals to do better.”
Dr. W. Edwards Deming
…solutions are ALWAYS about people
Results = Solution * Acceptance
60
Facilitation for
Results
55Copyright © Vox Datum LLC (2016-2017). All Rights Reserved.
61
Facilitation for Results
Open: Idea Generation
Brain Writing
•  One idea per Post-it note
•  In order, each person
reads an idea and puts it
on a wall
•  Team uses what the hear
to modify or generate new
ideas
•  Keep going until ideas dry
up.
Assumption Busting
•  Identify rules or behaviors
that lead to the current
state
•  Surface assumptions
underlying rules or
behaviors (ask why 5x)
•  Challenge assumptions –
existing exceptions?
Premortem
•  Ask, “How can we ensure
the problem happens ALL
the time?”
•  Run like Brain Writing
Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 56
62
Facilitation for Results
Narrow: Affinity Grouping Adds Clarity
Group
A
Others
Group
B
Group
C
Group
D
•  Go through the ideas to see where they can be
meaningfully grouped
•  Move the ideas that belong in the same group
together
•  Look for duplicate ideas. Get permission from each
idea author to consolidate duplicates so that they
overlap
•  Work with the group to define a title post-it that
succinctly describes each group
•  Place all single ideas under the title “Others”
Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 57
63
Facilitation for Results
Narrow: n/3 to Focuses on Best Ideas
2
Group
A
5
4
31
1
1
Others
Group
B
Group
C
Group
D
2
11
•  Count the total number of ideas or groups
•  Divide this number by three
•  Each person on the team gets this number of votes
•  Each person puts dots on the ideas they think are
best
•  Count the number of votes per idea and rank them in
descending order
Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 58
64
Facilitation for Results
Close: Payoff Matrix Drives Consensus and Actions
•  The group agrees precise definitions for Benefit and
Effort
•  Each person rates each idea on a scale of 1 to 5
against potential benefits and effort to implement
•  Check assumptions for ideas with big variation in
scores
•  Average the scores for each idea
•  Apply Post-its in corresponding location on the grid
•  Confirm groups commitment to the results
•  Agree deliverables, next steps, timing and
responsibilities
1
1
1
5
31
4
2
Effort
Benefit
Low
High
High
2
1
Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 59
65
Simulation Round 4:
Defect Reduction
•  Owner is responsible for final decisions
•  Changes must be reversible
•  No changes that involve customers
•  No elimination of staff
•  Facilitator has final approval
•  Implement changes and train if necessary
Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 60
Objective: identify and mediate root causes of highest impact errors.

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Week 06_Handout day 2

  • 1. 25 Day Two 26 Last session we covered Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 1 Lean = giving customers exactly what they want, when they want it as efficiently as possible. Customer Focus •  Customers buy benefits – problems solved, a new opportunity, enhanced image •  Your offerings deliver features – Reliability, Assurance, Tangibles, Empathy, Responsiveness Value Streams cross functional silos to deliver customer experience •  The eight wastes erode productivity and quality •  Value add analysis helps identify wasteful activities to eliminated or improve 27 Session One Value Add Analysis Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 2
  • 2. 28 How are we doing? Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 3 Name Company Expected Class Outcomes Kyley Bonbite Weed out inefficiencies Steph & Jocelyn Steph Mantis Design TBD Trevor Underground Signs Efficiency, particularly for packaging and shipping Ashley Luxholdups Scaling operations Corrin Patina Studios Efficient processes Kyiesha Hip Hop Closet Lower packaging and shipping costs (free service) Akiko Atsuyo et Akiko Operational changes - Wholesale to Retail Paul Made by Wood Move from one offs to multiple, smaller products Owen VOM Carpentry Logistics – transport vs time on site David & Kelly Stitch NYC Systems for Efficiency 29 Simulation Recap – Round One Metrics Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 4 30 Thinking about continuous flow….. Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 5
  • 3. 31 Day Two Topics Continuous Flow Theory of Constraints Cost of Poor Quality Continuous Improvement / Six Sigma By the end of this session you will: •  know how to identify and relieve production constraints •  understand the cost of poor quality and the DMAIC improvement framework •  have learned facilitation and problem solving skills 32 3. Continuous Flow move as fast as value can be added, no waiting. Little’s Law Theory of Constraints Set-up Time Reduction Takt Time Kanban Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 27 33 Measuring the Flow of Processes with Little’s Law Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 28 Work in Progress Output Work in Progress / Output = Cycle-time 120 gallons / 60 gallons per minute = 2 minutes
  • 4. 34 Continuous Flow The Theory of Constraints Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 29 CB BA •  Constraints produce the fewest outputs per unit of time. Often they will have a stack of work in front of them •  Constraints govern the output for the whole process – an hour lost at the bottleneck is lost for the whole process. •  Efficiency gains at any other location don’t improve productivity of the process. Managing the Constraint 1.  Identify it 2.  Exploit it 3.  Subordinate everything else 4.  Increase output of constraint 5.  Rinse and repeat 35 Set-up Time Reduction https://vimeo.com/98796938 36 Set-up Time Reduction (Single Minute Exchange of Die) Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 31 1 Separate Elements Identify tasks that can be performed during production and make them “external” to the change over 2 Parallel Work Identify tasks performed sequentially and, where possible, complete them simultaneously 3 Convert Elements Review remaining internal elements and ask what it would take to make them external. Convert as many as possible 4 Streamline Review all elements for simplification to shorten both external and change over time.
  • 5. 37 38 Production Systems Takt Time Example: Willow Run Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 33 68 Flow, Takt Time and Cellular Design 1940 – A bomber per hour at Willow Run 34,500 Employees 488,000 Discrete parts 33,000 Components 24 Assemblies 1 B-24 per hour 39 Production Systems Kanban Overview Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 34Source: http://logisticsglobal.blogspot.com/2011/10/kanban-system-parts-procurement-toyota.html
  • 6. 40 Production Systems Kanban Board Example: Hiring Process Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 35 1.  Define Value Stream 2.  Set Work in Process Limit 3.  Establish the Backlog 4.  Start Pulling Work Application Received Phone Screen Manager Interview Interview Complete Decision G. Martin Declined M. Taylor Offer B. Miller W. Jones F. Brown C. Williams A Johnson C. Smith M. Jackson 3 M. Garcia 2 Rodriguez AndersonJ. Davis 1 A. Thomas Declined Hernandez Declined T. Moore Declined D. Jones No Go R. Martinez Offer A. Richards Start 15th G. Wilson 4 41 Simulation Round 3: Continuous Flow •  Owner is responsible for final decisions •  Changes must be reversible •  No changes that involve customers •  No elimination of staff •  Facilitator has final approval •  Implement changes and train if necessary Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 36 Objective: identify and relieve constraints in the process. 42 4. Perfection produce exactly what the customer wants… •  Cost of Poor Quality •  The Case for Continuous Improvement •  Simple Six Sigma 37Copyright © Vox Datum LLC (2016-2017). All Rights Reserved.
  • 7. 43 The Cost of Poor Quality Estimated Costs for American Companies Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 38 Non-conformance “The cost of getting it wrong” Conformance “The cost of getting it right” Internal Failures (20% to 40%) Controls (10% to 50%) •  Scrap materials •  Rework – doing work twice •  Lost production time •  Inspecting for errors, defects •  Delays waiting for approval External Failures (20% to 40%) Prevention (0% to 5%) •  Fines, Penalties •  Warranties, Concessions •  Lost revenue •  Measurement and tracking •  Root cause analysis •  Mitigation Source: The Quality Engineer Primer by Bill Wortman, 1997 44 45 The Limits of Inspection Controls (and The Case for Continuous Improvement) Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 40 “Finished files are the result of years of scientific study combined with the functional experience offered by many Financial Services experts.”
  • 8. 46 Another Different Approach to Cost of Quality: Continuous Improvement Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 41 Total Costs Control / Inspection Costs Non-conformance Costs Quality Cost Prevention Costs (Continuous Improvement) 47 Conventional wisdom: “This is good enough.” Six Sigma: What is it? When is it useful? Sigma Defects per Million % Good 6 3 99.99966% 5 233 99.977 % 4 6,210 99.4 % 3 66,807 93.3 % 2 308,537 69.2 % Condition: 99% Good (4 sigma) 99.99966% Good (6 sigma) High Risk 4 plane crashes per day 1 accident every 5 years High Volume 2,800 lost packages per hour Less than 2 lost items per day High Complexity 4,000 surgical mistakes per year Less than 2 mistakes per year Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 42 Three conditions when “good enough” isn’t: 48 Continuous Improvement: Will Six Sigma work for us? Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 43 “Too Complicated” “Bureaucratic” “It’s a Black Box”
  • 9. 49 Continuous Improvement: Six Sigma works for Dabbawallas Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 44 “There is a service called FedEx that is similar to ours but they don’t deliver hot lunches.” Dhondu Kondaji Chowdhury 50 Continuous Improvement: How Dabba Deliveries Work Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 45 10C VP M Collection Codes VP Residential Location (Vile Parle) C Residential Railway Station (Cooper Hospital) Red Dabbawalla teams color Destination Codes 10 Destination Railway Station (Nariman Point) 9 Dabbawalla team number M Building Identification (Mittal Tower) 12 Floor number “The unavoidable price of reliability is simplicity.” C. Hoare 51 Six Sigma DMAIC Improvement Methodology Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 46 Process Optimization (People Driven) Process Characterization (Fact Driven) MEASURE Record performance in a measurement system CONTROL Ensure sustainability IMPROVE Agree and make required changes ANALYZE Find the critical few factors DEFINE Document issue, allocate resources
  • 10. 52 Define: Tips for Starting an Improvement Project Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 47 Define the objective •  Articulate the compelling need for change •  Define goals tied to business objectives •  Get buy-in from the critical stakeholders Build the right team •  Ensure stakeholder representation •  Keep the team small and co-located where possible •  Hold frequent, timely, informal communications Freeze the target •  Set specific, measurable success metric(s) •  Set stretch targets. When in doubt, 50% improvement •  Make the metrics visible for all and the target hard to change Invent offline •  Make the most of existing or proven technology •  Use technical innovation only when it’s fully tested Be time driven •  80% of target is a win, celebrate success and move on •  Iterate often, plan multi-generation releases •  Use parallel work streams where possible 53 Measure: Record Performance with Run Charts Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 48 54 Analyze: Find Critical Few Factors with Pareto Charts Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 49
  • 11. 55 Analyze: Using the Five Whys to Find Root Cause Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 50 Where the Failure Occurred - Process Gaps 1.  Understand what the customer expects 2.  Design the process to meet customer expectations. 3.  Follow the process as designed 4.  All communications are consistent with how the process operates Why? A solid rocket booster exploded. Why? Hot gasses escaped from the rocket booster. Why? O-ring seals failed in at least one of the booster’s joints. Why? The shuttle launched when the air temperature was below design specifications for the O-rings Why? “…NASA’s structure permitted internal flight safety problems to bypass key shuttle managers.” Rogers Commission Report On January 28, 1986 the Space Shuttle Challenger disintegrated over the Atlantic Ocean 73 seconds into its flight, leading to the deaths of its seven crew members. What went wrong? 56 Improve: Better Quality with Error Proofing Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 51 Risk Priority Number = Severity * Occurrence * Detection Shut down Lock out Warning Severity Occurrence Detection 5 Harm a customer or employee Trigger legal or regulatory action 5 Very High (greater than 10%) 5 No controls 4 Cause significant reputational or financial risk 4 High (1% to 10%) 4 Low QC/QA sampling 3 Result in a customer complaint 3 Moderate (1/10,000 to 1%) 3 Moderate 100% manual inspection 2 Minor effect on performance 2 Low (1/10,000 to 1/Million) 2 High Statistical Process Control 1 Unnoticed by customer Internal waste or rework 1 Very Low (less than 1/Million) 1 Very High 100% auto inspection 57 Control: Standard Work for Consistency Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 52 Elements of Standard Work 1.  Inventory – material types and quantities required to keep the process operating smoothly 2.  Work Sequence – order of tasks an operator must perform within takt time 3.  Takt Time - the rate at which components must be made to meet customer demand Prep. Time 15 min.
  • 12. 58 Control: Monitoring Key Metric(s) Over Time Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 53 Trend – Six consecutive data points in either direction Shift – Eight consecutive points on one side of the median 59 Process Optimization Facilitation for Results Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 54 The problem is often about the process… “85% of the reasons for failure to meet customer expectations are related to deficiencies in systems and process…change the process rather than badgering individuals to do better.” Dr. W. Edwards Deming …solutions are ALWAYS about people Results = Solution * Acceptance 60 Facilitation for Results 55Copyright © Vox Datum LLC (2016-2017). All Rights Reserved.
  • 13. 61 Facilitation for Results Open: Idea Generation Brain Writing •  One idea per Post-it note •  In order, each person reads an idea and puts it on a wall •  Team uses what the hear to modify or generate new ideas •  Keep going until ideas dry up. Assumption Busting •  Identify rules or behaviors that lead to the current state •  Surface assumptions underlying rules or behaviors (ask why 5x) •  Challenge assumptions – existing exceptions? Premortem •  Ask, “How can we ensure the problem happens ALL the time?” •  Run like Brain Writing Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 56 62 Facilitation for Results Narrow: Affinity Grouping Adds Clarity Group A Others Group B Group C Group D •  Go through the ideas to see where they can be meaningfully grouped •  Move the ideas that belong in the same group together •  Look for duplicate ideas. Get permission from each idea author to consolidate duplicates so that they overlap •  Work with the group to define a title post-it that succinctly describes each group •  Place all single ideas under the title “Others” Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 57 63 Facilitation for Results Narrow: n/3 to Focuses on Best Ideas 2 Group A 5 4 31 1 1 Others Group B Group C Group D 2 11 •  Count the total number of ideas or groups •  Divide this number by three •  Each person on the team gets this number of votes •  Each person puts dots on the ideas they think are best •  Count the number of votes per idea and rank them in descending order Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 58
  • 14. 64 Facilitation for Results Close: Payoff Matrix Drives Consensus and Actions •  The group agrees precise definitions for Benefit and Effort •  Each person rates each idea on a scale of 1 to 5 against potential benefits and effort to implement •  Check assumptions for ideas with big variation in scores •  Average the scores for each idea •  Apply Post-its in corresponding location on the grid •  Confirm groups commitment to the results •  Agree deliverables, next steps, timing and responsibilities 1 1 1 5 31 4 2 Effort Benefit Low High High 2 1 Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 59 65 Simulation Round 4: Defect Reduction •  Owner is responsible for final decisions •  Changes must be reversible •  No changes that involve customers •  No elimination of staff •  Facilitator has final approval •  Implement changes and train if necessary Copyright © Vox Datum LLC (2016-2017). All Rights Reserved. 60 Objective: identify and mediate root causes of highest impact errors.