Thanks to recent reports across all media (ex., “Toyota’s Slow Awakening to a Deadly Problem“, 1 Feb 2010), we’re beginning to see the enormous scope of the acceleration error that has prompted the recall of millions of Toyota vehicles.

Toyota, a company long considered a paragon of lean manufacturing virtue (hence, its assuming the mantle of “World’s Largest Car Maker” from GM), appears to have a serious defect in many of its highest-selling products. “Unintended acceleration” has resulted in hundreds of accidents (reported so far) and the loss of untold lives. In the last two weeks, Toyota shut down the production lines of some of its most popular vehicles to address the situation.

Could it be, as some have suggested, that Toyota has been “hoist with (its) own petard”? Or, to put it another way, was Toyota done in by the very system designed to make it efficient and prosperous?

Just today (1 Feb 2010), Toyota “officially” announced it had found a way to correct the problem (one that goes beyond replacing or doctoring floor mats), but many people aren’t satisfied the manufacturing giant has found the real solution. And even if it has, it will be a long, long time before Toyota recovers from the damage it has done to its reputation.

Questions abound, including “Why didn’t Toyota conduct a thorough investigation when it first learned of the problem (back in 2007?)”, “Why did the company stay with the ‘floor mat’ explanation for so long?”, and “Why didn’t safety bodies (like the NHTSA) do more when they realized there was a problem?”

Toyota’s TPS system appears to be in need of a corrective action — the question is, “Where?” Is the problem in manufacturing only? Customer service? Marketing? Design & development? Outsourcing? Or, did Toyota get too big for its own good?

Toyota’s not the only organization incriminated in this scenario. The National Highway Traffic Safety Administration doesn’t come out of this situation unbloodied and unbowed. There are allegations that it could have and should have done more to keep the defect, whatever its root cause, from getting out of control.

In a half-hearted defense of NHTSA, they appear to have been ahead of many of their counterparts around the globe. Recalls in Europe and elsewhere followed the recalls in the US. Furthermore, every government body is hurting. There isn’t anything they don’t need — the authority to inspect and recall, or enforce laws; more people; more training; and a degree of autonomy, so they’re not called on the carpet (truly, no pun intended) for doing their job.

No amount of corrective action, though, can begin to make up for the people who’ve already lost their lives. (Interesting how in a situation like this, we tend to say, “Lives were lost needlessly“, when the opposite is true. Too many times, lives have to be lost — often in numbers — before action is taken.)

Lessons we might take from this at this “early” stage? One: corporate management is increasingly susceptible to hubris as a company grows.   Maybe Toyota was afflicted with the same disease financial services caught — we haven’t seen a problem in so long, they must all be licked. Not that corporate “attitude” is the root cause of Toyota’s problem, or even a proximate cause, but the “floor mat” story should have given us all pause to reflect.

Two: nothing can completely take the place of testing and inspection. We have safety standards, regulations, etc., in place in the aerospace and food businesses. For better or worse, more is on the way. Why not make the automotive world jump similar hurdles (i.e., make safety mandatory)?

Three: the best designed, most rigorous systems eventually come apart when they’re not paid attention. CAPAs, like anything else in your Quality Management System, have to be applied continually in order for your company and your system to improve. Toyota has said it in so many ways: “Satisfactory” isn’t.

So, what happened? Your ideas?

(P.S. - Not like Toyota needed more bad news, but now they have a braking problem on the newest Prius. What do you think of that?)

Much has been made about the lean benefits of “5S” — Sort, Shine, Set in place, Standardize, and Sustain — over the years it has been a part of the quality lexicon.  Very little is said about the drawbacks of implementing a 5S system.  5S is an exceptional lean system, in theory.  Where it often falls short is in the execution.  Now, I’m not saying that for every benefit of 5S, there’s a drawback.  As designed, it’s all good.  But like they say, “There are at least two sides to every story.”

The benefits of implementing a lean 5S system are huge.  They include:

• The employer’s concern for cleanliness and worker safety contributing, sometimes significantly, to morale…people take greater pride in their company when the company takes pride in its plant, offices, & people;
• The efficiencies gained by freeing up space, improving layout, and optimizing work flow are enormous;
• The potential for increases in productivity when things are laid out so as to maximize efficiency and turnaround time;
• Less time and motion are wasted when workstation layout is optimized, even in an office setting; and
• A well-run 5S system can encourage employees to think about, and look for, other incremental improvements, or kaizens (”baby steps”, Dr. Leo Marvin* called them) as they go about their daily business.

Read about the Toyota Production System (TPS) if you haven’t already.  There’s much to learn about the benefits of 5S in the TPS story.

The shortcomings of 5S are not in the system itself, but in how 5S is applied.  Most companies that don’t get 5S fall short on the most crucial element of all — sustaining.  To them, 5S isn’t a system — it’s an event.

What they don’t understand is that 5S isn’t a one-time-does-it cure, like a pill or injection for a serious physical ailment.  5S is a system, a cycle.  It’s a habit the workforce gets into, like exercising three or more times a week to decrease the likelihood of a “serious physical ailment”.  The company that doesn’t get much out of 5S probably isn’t incorporating the 5S philosophy in its daily routine.  Perhaps they don’t understand lean thinking.

Clearing everything off of everyone’s desk once a year is not 5S.  Having a place for everything and everything (back) in its place, every day — that’s 5S!

5S is sometimes applied rigorously — to the letter — by overzealous, micromanaging types.  They mistake discipline for tyranny.  Taken to extremes, 5S stifles individuality and creativity, lowering morale and productivity.  (Believe it or not, people aren’t inspired when they’re told, “It has to be this way…or else!”)

Some managers don’t quite get the “standardize” part of 5S, either.  Standardizing is about processes and procedures, not people.  When you say every workstation has to have a uniform appearance, that doesn’t mean you have to rob individual work areas of personality.  Limiting workers to “one or two personal effects, not to exceed a certain size or character”, has nothing whatsoever to do with 5S.

Granted, a small number of coworkers go overboard, with their Beanie Babies and their Star Wars posters, ad nauseam.  But, if my boss said, “Get rid of the hockey puck paperweight…oh, and no baseball calendar”, I’d be much harder to get along with than I already am.  (Ask my coworkers.)

In the effort to optimize work flow, maximize efficiency, and gain productivity, sometimes we forget to “build” breaks into the day.  We can’t possibly keep working at a steady pace throughout the workday, even though our machines and our computers can.  Actually, machines and computers need maintenance and down time almost as much as we do.  People cannot “multitask”, either. (Trying to multitask leads to irritability, sleeplessness, and a greater risk of illness, contributes to short attention span, etc. — as “Yogi” Berra said, “You can look it up!”)

The moral of the story is, “Understand and follow the spirit of the law, not the letter of the law.”  Use 5S as it’s designed and you’ll have increased success and a satisfied workforce.

* “What About Bob?” (1991)

Delivering Global Value and Excellence through Lean and Six Sigma

The ASQ Lean and Six Sigma Conference will be March 8-9, 2010, at the Pointe Hilton Tapatio Cliffs Resort in Phoenix, Arizona.  The theme of this year’s conference is “Delivering Global Value and Excellence Through Lean and Six Sigma.” Register Now

Preceding the conference (on the evening of March 7), the Six Sigma Forum is hosting a reception, at which attendees can meet the keynote speakers: Roger Hoerl, Ronald Snee, Rob Bryant, and Forrest Breyfogle III.

Leaning Out Your ISO 9001 QMS

Chris Anderson from Bizmanualz will be speaking on how to lean out your ISO 9001 QMS to ensure your ISO 9001 QMS is reducing your cost of poor quality.  At the conference, you’ll learn how to use lean principles to:

• Continually improve the effectiveness of your organization;
• Continually improve the capability of your workforce; and
• Reduce your organization’s reliance on procedure documentation.

See how the minimum requirements of ISO 9001 can be met using lean visual management techniques.

Keep those dates (March 8-9, 2010) open!

Why should you implement a lean kanban system?  How can you beat a simplified production system that costs less, satisfies customers more, and takes the headaches out of management?  A kanban is system of signals used in lean to balance the flow of work, materials, and people to get a job done.  Kanbans are used within agile software development, manufacturing, service deployment, construction, and just about anywhere people are implementing lean systems.

Let’s look at the top ten reasons for implementing a lean kanban system.

1. Visualizes your work

A lean kanban translates your production planning into visual kanban boards, kanban cards, or electronic e-kanban signals. A value stream map is used to understand your kanban needs.  Workers can all see what the current production plan is easily and quickly by reading the visual kanbans.

2. Reduces your Work In Progress (WIP)

A Kanban is built by balancing your individual work cells to the pull of customer demand using kanban signals.  Lean balanced flow reduces WIP created by batch sizes that are larger than customer orders.

3. Moves your work along Steadily

A balanced flow is achieved by understanding the takt time or rhythm of customer demand and then adjusting individual work cell batch sizes to achieve the steady balanced product flow.  Your workers jobs are now even, steady, set to a comfortable frequency that satisfies customers and management.

4. Improves your work flow

A steady balanced lean product flow is a great lean process improvement over traditional chaotic systems made of large batch sizes.  The whole system operates together as a team reducing employee stress levels and adding a calm to the organization.

5. Releases your work on demand

New orders trigger the system to produce the next batch.  A balanced system only produces enough products to fulfill customer demand and hence only releases orders on demand.

6. Simplifies your production planning

Your production planning is reduced to adjusting the kanban size as market conditions change.  A steady balanced manufacturing flow sets the order turnaround time eliminating expedited orders and special rush jobs that are the bane of traditional production planning.  In effect, all orders are expedited when you balance the flow to customer demand.

7. Eases your purchase planning

Purchasing becomes balanced with production kanbans and can be simplified even more using e-kanbans that automatically send purchase orders direct to suppliers.

8. Increases your customer satisfaction

The real goal of a kanban is to understand what all customers demand and then focus your production on that customer demand.  When your customers get what they want, when they want it, they become very satisfied customers.  That is the value of a lean competitive advantage.

9. Eliminates your employee confusion

Simplified production planning, simplified purchase planning, and simplified work cells all lead to a simplified system.  Employees can see the simplification and easily understand the flow.  Confusion is virtually eliminated.

10. Minimizes your overproduction risks

Inventory can become obsolete quickly in today’s fast changing marketplace.  A lean kanban will reduce your exposure to excessive older inventory by focusing your production on customer demand instead of production planning.  If you only make what you need then there is little obsolete inventory risk.

Top Ten Reasons for Using a Lean Kanban

1. Visualizes your work
2. Reduces your Work In Progress (WIP)
3. Moves your work along Steadily
4. Releases your work on demand
5. Improves your work flow
6. Simplifies your production planning
7. Eases your purchase planning
8. Increases your customer satisfaction
9. Eliminates your employee confusion
10. Minimizes your overproduction risks

Many prominent figures have emerged within the quality field, but some have stood out as key figures of quality.  Most have passed away, but their memory still lives on in the ideas, concepts, and methods that permeate our quality thinking today.  In no particular order, they are:

• Dr. Walter Shewhart developed the Plan, Do, Check, Act (PDCA) cycle (known as “Plan-Do-Study-Act” in some circles, as well as theories of process control and the Shewart transformation process.
• Dr. W. Edwards Deming developed his complete philosophy of management, which he encapsulated into his “fourteen points” and the “seven deadly diseases of management”.  He advanced the state of quality, originally based on work done by Shewhart with his explanations of variation, use of control charts, and his theories on knowledge, psychology and variation.  Deming greatly helped to focus the responsibility of quality on management and popularized the PDCA cycle, which led to it being referred to as the “Deming Cycle”.
• Dr. Joseph M. Juran developed the quality trilogy - quality planning, quality improvement, and quality control.  Quality management plans quality improvements that raise the level of performance, which then must be controlled or sustained at that level in order to start the cycle again.
• Armand V. Feigenbaum developed the idea of total quality control based on three steps to quality consisting of quality leadership, modern quality technology, and an organizational commitment to quality.
• Dr. Kaoru Ishikawa developed the Ishikawa diagram and was known for popularizing the seven basic tools of quality and the philosophy of total quality.
• Dr. Genichi Taguchi developed the “Taguchi methodology” of robust design, also known as “designing in quality”, which focused on making the design less sensitive to variation in the manufacturing process instead of trying to control manufacturing variation.
• Shigeo Shingo developed lean concepts such as Single Minute Exchange of Die (SMED) or reduced set-up times instead of increased batch sizes as well as Poka-Yoke (mistake proofing) to eliminate obvious opportunities for mistakes.  He also worked with Taiichi Ohno to refine Just-In-Time (JIT) manufacturing into an integrated manufacturing strategy, which is widely used to define the lean manufacturing used in the Toyota production system (TPS).
• Philip B. Crosby developed the idea of “quality is free” which asserts that implementing quality improvement pays for itself through the savings from the improvement, increased revenue from greater customer satisfaction, and the improved competitive advantage that results. His popularized “zero defects” to define the goal of a quality program as the elimination of all defects and not the reduction of defects to an acceptable quality level.
• Dr. Eliyahu M. Goldratt developed the Theory of Constraints which focuses on a single element in a process chain as having the greatest leverage for improvement (i.e., “1% can have a 99% impact”). This compares to the Pareto principle which states that 20% of the factors have an 80% effect on the process.
• Taiichi Ohno developed the seven wastes (muda), which are used in lean to describe non-value-added activity. He developed various manufacturing improvements with Shigeo Shingo that evolved into the Toyota Production System.

Top Ten Quality Gurus

1. Dr. Walter Shewhart
2. Dr. W. Edwards Deming
3. Dr. Joseph M. Juran
4. Armand V. Feigenbaum
5. Dr. Kaoru Ishikawa
6. Dr. Genichi Taguchi
7. Shigeo Shingo
8. Philip B. Crosby
9. Dr. Eliyahu M. Goldratt
10. Taiichi Ohno

There are seven common Quality Tools you can use to understand and improve processes during a process improvement event.   Each tool helps you identify sources of variation and aids in the analysis, documentation, and organization of the information, which leads to process improvement. 

1. Flowcharts, or Process Maps, visually represent relationships among the activities and tasks that make up a process.   They are typically used at the beginning of a process improvement event; you describe process events, timing, and frequencies at the highest level and work downward.  At high levels, process maps help you understand process complexity.  At lower levels, they help you analyze and improve the process.
2. Ishikawa, Fishbone, or Cause & Effect Diagrams visually represent the causes of a problem - or effect - and help you determine the ultimate source of the problem — the root cause.  (This tool is called a “fishbone” diagram because of its appearance; Ishikawa was its inventor.)   The cause-and-effect diagram is used at the beginning of root cause analysis, to organize the causes of a problem (people, methods, equipment, materials, measurement, and environment) and prioritize them.
3. Data Checklists, check sheets, or recording tables are matrices designed to assist in the tallying, recording, and analysis of test results or event occurrences.  They are utilized in production to count defects and collect process data, which you analyze to identify opportunities for improvement.
4. The Pareto chart is named after Vilfredo Pareto, who came up with the Pareto Principle (or the “80/20 rule”), which says that 20% of the factors account for 80% of potential problems.  The Pareto chart ranks defects, causes, or data from the most significant to the least significant, in descending order.  Pareto charts help you separate the “vital few” from the “trivial many”.  They are typically used during process improvement analysis, to understand where to focus improvement for the greatest impact.
5. Histograms consist of vertical bars, side-by-side, that depict frequency distributions within tables of numbers and can help you understand data relationships over time (e.g., the familiar “bell curve”).  Histograms are generally used during process improvement analysis.
6. Scatter charts display relationships between dependent (predicted) and independent (prediction) variables.  They are used during hypothesis testing, to determine if there is a correlation between two variables and how strong the correlation is.  Less scattering indicates stronger correlation.
7. The control chart is a type of statistical process control tool.  Process performance is plotted over time against upper and lower control limits; this helps you readily identify process variations and enables determination of special cause and common cause variation.  Control charts are used during production, or after process improvement implementations, to ensure that processes are within control limits, or “in control”.

To achieve the best results, start by (1) drawing up a process map, so you understand the process flow.  Next, (2) analyze the process flows for the primary causes of problems and develop your cause-effect diagram.  Then, (3) collect data using check sheets and (4) plot your data using a Pareto chart and/or (5) a histogram.  Next, (6) determine the relationship of various variables in your cause-effect chain using a scatter chart.  Once you have solved your problem, (7) use a control chart to ensure that the process is staying within process control limits — demonstrate process control.

The Seven Quality Tools

To summarize, using these seven quality tools:

1. Flowcharts or Process Maps;
2. Ishikawa, Fishbone, or Cause & Effect Diagrams;
3. Data Checklists, check sheets, or recording tables;
4. Pareto Charts;
5. Histograms;
6. Scatter plots; and
7. Control Charts (SPC)…

…especially in combination, will help you improve your processes and achieve your objectives.

At Bizmanualz, process improvement — internal and external — is one of our main objectives.

Many of us in the USA and elsewhere are aware of the need for significant improvement in many aspects of the health care process — providing and insuring, for example.  In a recent blog post about the US Healthcare Problem, we presented a case for using the ISO 9001 standard to drive health care process improvement.  Now, we’ll look at ”lean” and how it pertains health care.

The concept of “lean” was developed for production environments (see the Toyota Production System) but with a few modifications, it applies to services as well.  In either case, Lean considers the use of resources for goals other than “creating value for the customer” to be waste and such wastes should be eliminated.

From the customer’s perspective, value describes an item or a service they’re willing to pay for.  Lean is sometimes said to be about “creating more value with less work”; in reality, it’s about “maximizing value while minimizing waste”.  And though people can’t seem to agree on much of anything in the health care “debate”, one thing we should all be able to agree on is that there’s plenty of inefficiency throughout the health care system.

Bicheno and Holweg (in their book, “Lean Toolbox”), describe seven service wastes:

1. Delay – customers waiting for a service;
2. Duplication — having to reenter data, repeat details on forms, copy information across, or answer queries from several sources within the same organization;
3. Unnecessary Movement — having to get in line several times, lack of a “one-stop” service encounter, etc.;
4. Unclear Communication – wastes of seeking clarification, confusion over product or service use, wasting time finding a location that may result in misuse or duplication;
5. Incorrect inventory — being out-of-stock, unable to get exactly what was required, substitute products or services, or not having the right provider available;
6. Opportunity lost to retain or win customers – failure to establish rapport, ignoring customers, unfriendliness, and rudeness; and
7. Errors in the service transaction — product defects in the product-service bundle, lost or damaged goods (famously, the airman who was supposed to have his gallbladder removed but had his lower limbs amputated).

As providers and as customers, we’ve seen these wastes…far too many times.  We need to remove as many of these wastes as possible and improve the process.  That’s where Lean can help, and many health care providers are already implementing Lean and other process improvement tools and techniques.

We need to take Lean, ISO 9001, and other tools deeper into the entire process of providing health care — more providers and insurers — if we’re going to make things better and make the improvements last.  The answer is certainly not going to be found in new legislation (see #4, above).

Now, shall we – at long last — begin?

Information Technology Infrastructure Library (ITIL) has been growing in popularity because of its universal suitability as a framework for managing information technology (IT) services, including the infrastructure, development, and operations of an IT department.

In its fullest implementation, ITIL is a perfect complement to - and is perfectly complemented by - Six Sigma and Lean to create more agile and higher quality IT operations.  Using Six Sigma techniques like the DMAIC process introduces a more structured engineering approach to ITIL’s framework.  Lean thinking promotes continuous improvement and waste reduction into ITIL’s best practices.

ITIL itself does not provide methods to identify and target waste, document value streams (as is usually done with Lean), or measure customer satisfaction.  Nor is ITIL itself a transformation method used for change management.  But ITIL does provide the vocabulary and framework we think of as the process approach advocated by Deming, which is where all process improvements start.

Implementing an ITIL framework is an excellent starting point for IT organizations looking to evolve toward a more process-oriented state.  Six Sigma and Lean can be added to the ITIL framework to help your IT organization achieve continuous improvement and organizational agility.

For those who work with processes, we know that variability is the key factor.  The desired state is more consistency and less variability.  When processes have wide variability and inconsistent results, we call the process out of control.  When processes operate within established limits, the process is considered in control.

Typically, we attribute process variability to two causes—common cause and special cause.  Common cause variation is expected.  It is a result of the process design, machinery, and activities.  For example, I walk to the train station every day after work, and it takes six to 10 minutes.  The variation is due to factors like how long I have to wait for the elevator, how many times the elevator stops, and how long I have to wait at crosswalk lights.  These variations occur every day, and they are expected.  They are common cause variations.

Then one day it took 12 minutes to walk to the train station.  It took longer because someone approached me on the sidewalk and asked for directions.  They were lost, so I took a few minutes to explain to them where they are and how to get to where they are going, plus exchange a few pleasantries.  But that doesn’t happen very often.  In fact, it hardly ever happens.  The next day I return to the six to 10 minute window for my walk to the station.  It was a special cause of variation.

When addressing variation in a process, you have to understand if the variation is due to common cause or special cause.  The type of variation determines the activities we need to take to reduce variation.

To reduce common cause variation, it usually takes experimentation and/or statistical analysis to optimize the process.  Experimentation means changing something and measuring the results over time.  Statistical analysis means looking at results in different ways—stratifying and categorizing data in diverse manners and employing varying statistical methods like Pareto charts.

For example, I might experiment and collect data and find that if I leave at 4:45 instead of 5:00, the elevators are much less busy, and variation in the time to reach the station is reduced.

Special cause variation is typically discovered using root cause analysis.  In my example it was easy to identify why it took extra time to reach the station, but frequently the cause of unexpected variation is not so easy to see.  It takes an investigation using quality tools like 5 whys or fishbone charts to understand what happened.  Then, you can take action to prevent the unexpected cause of variation or simply ignore it because you realize that it happens rarely and the consequences are acceptable (as in my example).  I don’t mind missing a train to help someone out.

I will be leaving to speak at and attend the ASQ Lean Six Sigma Conference on Mar 2-3, 2009 in Phoenix, AZ.  If you are in the area then stop by to hear about Setting Goals with Lean Thinking.  You will learn the importance of position goals for lean thinking, finding your lean goals/metrics or what success will look like. Many people wonder about what lean tools are used to determine where to start your lean journey. I will be talking about using Value stream, Visual space, and Material flow analysis to create your lean improvement opportunities plan.  Stop by the Lean Six Sigma conference to learn about Setting Goals with Lean Thinking.