Principle of Flow and Pull

Too often the principle of flow and pull is seen as applicable only in a
manufacturing environment. In fact, the principle can be applied in many
different ways. Experiencing the "Matatu" bus service in Nairobi. It really got
me thinking about the principle of flow and pull.
The system is very different from than in Sydney, which has a very similar
population size to Nairobi. In Sydney, buses are on a fixed timetable, readily
available to look up on various travel apps and published at each bus stop.
Buses are frequent and you can even track your buss real-time location on
your phone. Like most big cities they are more frequent at peak hours, but
despite this, are often full during these hours and relatively empty off peak.
So is this a good example of pull and flow? At one level, buses are pulled
through at peak times to match customer demand based on historical
demand patterns. Flow is dramatically improved through the use of
dedicated bus lanes. Car drivers watch enviously from the queue of their
stationary vehicles as buses shoot down the near empty bus lane.
Occasionally frustration takes over better judgement, and a quick burst down
the bus lane provides the thrill of movement and the often-illusionary
progress as you are forced to wait to be allowed back into your lane a few
hundred meters further on. If you are really lucky you also avoid the fine.
So there is some pull and certainly better flow for the buses than for the
cars. Outside of peak times, the bus system is definitely more push than pull,
with fixed timetables pushing out buses regardless of actual demand.
The system has recently gone cashless, which saves a huge amount of time
in collection and counting of cash, and generally works very well. All you
need to do is make sure you buy an electronic card and keep it charged up
with virtual cash and all is well. That is unless you are a new visitor to the
city and unfamiliar with the bus drivers inability to accept cash. I recently
witnessed an incident with a tourist family trying to board a bus. English was
not their first language, and the driver struggled to explain that just giving
him more and more money would not work.
A couple of passengers tried to help even by offering to use our cards, but
you can only use them once on each journey. So after a lot of shouting and
gesticulating from the driver, they eventually gave up and will hopefully be
able to have a great laugh about the whole experience once they get home
which will hopefully not be by bus. So the electronic payment is intended to
improve flow, and generally does, but it was pushed on to the customers,
many of whom would still prefer to use cash.
Now back to Nairobi. There are no timetables, few marked bus stops out of
the main central boarding points, and you struggle to track your buss
location on your phone. The buses are small and take about 20 people sitting down. I boarded a bus and took a seat. Luckily I knew it was the right
bus because I had a guide. Also there was a very helpful man with a sign who
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stood on the pavement saying where the bus was going and encouraging
passers-by to catch it.
After five minutes, I wondered what time we would set off. My helpful guide
shrugged his shoulders.
"It depends," he said. I decided to practice the five whys and get to the root
cause of why we had been waiting. Well, says my guide, "the bus is not
full."
Eventually my root-cause analysis revealed we would not leave until every
seat was occupied. Now other passengers started to join in and promote the
virtues of the bus by shouting enthusiastically out the windows to anyone
showing the slightest interest. We quickly had every seat full and were off.
A conductor came to collect our fare and asked where we wanted to be
dropped off. We picked a well-known building on the bus route a short walk
from our hotel and paid a fraction of a Sydney bus fare. It was cash only and
calculated based on how far we travelled. The atmosphere on the bus was
fantastic. It was a tight fit, and it was impossible not to get to know your
fellow passengers. Sydney buses tend to be silent with people buried in their
phones and not knowing where to look. We had a great laugh on the Matutu
with everyone sharing a smile and enjoying the experience.
So is the Matatu a push or a pull system? In one respect it's definitely batch
and queue with customers waiting for the full bus or "batch" to be completed
before the journey can start. My initial reaction was that this is not a lean
system but on reflection I realized it has its advantages.
Its top customer value is cost and it certainly delivers on this by only
travelling when full utilization is very high and cost per journey is very
low.
Fewer buses are needed in the fleet, saving on capital and
maintenance costs.
At peak times the wait time is very short as buses fill quickly.
In off-peak times there are fewer buses driving around empty and are
only pulled through based on demand.
So whilst the departure and arrival time may be a little more uncertain than
the Sydney system, overall the Matatu provides a great solution that
minimizes cost and provides customer flow with on-demand pull. "Kenyan
time" has a bit more flexibility than Sydney time, but then it only takes one
accident in Sydney for the whole timetable to get disrupted.
We need to ensure that we design our flow and pull systems to maximize
customer value. Different customers value different things, and we must be
careful not to try to impose one-size-fits-all in our systems design. Both the
Matatu system and Sydney system work well in different contexts and both
have elements of flow and pull.

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When the Cook Spends More Time in the Boardroom than

the Kitchen

Some time ago, a colleague was giving training in operational excellence

to an audience mostly filled with high-level managers. Imagine how excited
he must have been.
Truly giving his best, and pretty confident of getting his message across, he
surely wasnt expecting to stumble upon this mail from one of them the next
morning:

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Thank you for the training given yesterday. Ive noticed youve put a time
slot in my agenda to visit our production plant on Thursday to go & see how
things were progressing.
What was it exactly you were talking about and is it possible to reschedule
our meeting within a month from now? That would better suit the agendas.
Thanks.
Shocked, he wondered:

Was I not clear enough?

Were people sleeping during my training?

Perhaps, he thought, encouraging management to see the reality on the

ground was going to be considered easy and not something to do only when
the time was right.
His story made me think of those cooking shows that seem to be everywhere
on television. I always think its a fun place out there in the kitchen. Thats
where the mealthe valuecomes together. It strikes me that a restaurant
resembles an office space, and a cook seems to have mastered the essence
of creating value for the customer, basically delivering a really fine meal.
Management on the other hand seems to spend time in the boardroom
talking about the added value for the organization. However, are we really
creating value for the customer then, or are we spending too much time on
gathering data, creating numerous reports with over-abundant KPIs,
frustrating our colleagues or discussing results somewhere too far away from
reality?

So my next question would be: Why do we do it?

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Lets perhaps go back to a powerful yet extremely simple approach to

managing organizations. It relies on 1) common sense and is 2) low-cost.
These two phrases always get everyones attention.
Masaaki Imai, a founding father of kaizen, is to be sought after for this.
Kaizen basically means continuous, incremental improvement involving all
managers and workers. He argues that every time you get promoted you get
further away from reality. By the time you are CEO, you are the most clueless
person in your organization.
He continues by saying the more you go up the ladder, the less you might
seem to know about the problems going on. Contradictorily, decisions are
taken on that level where there is little to no knowledge of the real
problems.
As managers we think we can prevent this by relying on numbers, and this is
where the trap lies. Only if we go to the gemba (real place, where it happens)
we are able to accurately interpret the numbers.
Give yourself some time, dont be too busy to go to the kitchen of your
company, observe and ask why as many times as you can to understand
better whats cooking there. It is the place where work gets done and the
only place where value can be added to business processes:

Solve the problem at hand

Prevent it from recurrence

It will result in better quality, delivery and lower costs. Youll be surprised
how much it contributes to the value delivered to the customer.

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Medical Taylorism: An Article that Does a Huge

Disservice to Needed Healthcare Transformation : By Dr.
Patricia Gabow and Ken Snyder
The article, Medical Taylorism,[1][1] by Pamela Hartzband, M.D. and Jerome
Groopman, M.D., in the New England Journal of Medicine, reflects a major
misunderstanding of the principles and practice of the Toyota Production
System, or Lean as it is often called. Specifically, the article appears to
conflate poor implementation with the underlying principles. Several
commentators, including many from the Lean community, have weighed in
on this debate, but more needs to be said given healthcares need for
transformation and the powerful solution that Lean offers in this
transformation.

Principles
Doctors Hartzband and Groopman are feeling pain due to their experiences.
We sympathize with their pain. Too often, whether in healthcare or other
settings, we see poor implementations of Lean. These poor implementations
are almost always due to failure to follow the principles of operational
excellence.
In this discussion about Lean in healthcare, there are some specific principles
that deserve emphasis. In citing these principles, we will adopt the
terminology used in the Shingo Model.[2][2]

Seek Perfection

Respect Every Individual

Control Quality at the Source

Embrace Scientific Thinking

Create Constancy of Purpose

It is unfortunate that many who implement Lean seem to forget these core
principles. It is hard to imagine any set of principles which would more
closely align with the needs of healthcare and commitment to the
populations well-being than these principles.

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Seek Perfection
American healthcare is in dire need for transformation. American healthcare
has significant issues with cost, waste, access/coverage, quality, disparity,
geographic variation, and employee burnout. These issues affect everyone
every American business and their employees. All of us. These problems
cannot be ignored. These problems cannot be fixed by merely wishing for
improvement. Nor will these problems be solved solely by government
actions. Individual healthcare systems must transform the way they deliver
care. This requires a robust and disciplined approach that uses the talents of
the entire workforceexactly what Lean does.
Perfection is an aspiration not likely to be achieved but the pursuit of which
creates a mindset and culture of continuous improvement. The realization of
what is possible is only limited by the paradigms through which we see and
understand the world.[3][3]
Womack, Jones, and Roos first adopted the term Lean to describe
manufacturing systems that are based on the principles employed in the
Toyota Production System. Quoting them, Lean is lean because it uses
less of everything compared with mass production half the human effort in
the factory, half the manufacturing space, half the investment in tools, half
the engineering hours to develop a new product in half the time. Also, it
requires keeping far less than half the inventory on site, results in many
fewer defects, and produces a greater and ever growing variety of
products.[4][4] We use Lean in the meaning that was intended when it was
first coined. Unfortunately, lean[5][5] has subsequently been misused,
abused, and confused, as appears to be the case in Doctors Hartzbands and
Groopmans experience.
Toyota captures the essence of this principle in their slogan used for their
Lexus automobile line The Relentless Pursuit of Perfection a pursuit
worthy of healthcare. Through its Lean transformation, Denver Health made
substantial progress in addressing the problem afflicting American
healthcare. In the most important metric of all, lives saved, Denver Health
estimates that 247 people walked out of the hospital in 2011 that otherwise
may not have survived in other healthcare institutions. This was a reflection
of the fact that in 2011 Denver Health achieved the lowest observed-toexpected mortality rate of all the hospitals in the University Healthsystem
Consortium.[6][6] The pursuit of perfection saves lives.

Respect Every Individual

Respect for everyone is foundational for Lean. For those in healthcare this
respect encompasses the patients, their families, the employees at every
level of the healthcare organization, the suppliers, the communities, and the
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nation. As Toyota states, We build people, before we build cars.[7][7]

Hardly the motto of a stopwatch approach as Hartzband and Groopman see
it.
Many people, even those with only a little exposure to Lean, know that Lean
in healthcare is about removing waste from the patients perspective. Waste
creates useless work, waste impairs quality, waste adds chaos to the work
environment, and waste adds costs. Healthcare is filled with wastes from
waiting, wastes due to defects in the healthcare process, and wastes related
to unused/misused human talent. Waste in providing healthcare is not
beneficial. In the correct application of an improvement process, every
employee from the physician to the housekeeper becomes a problem solver
that removes waste.
What is often not known is that Toyotas philosophy of removing waste is
tightly tied to respect for people. Respect must become something that is
deeply felt for and by every person in an organization. When people feel
respected, they give far more than their handsthey give their minds and
hearts as well.[8][8] The people become the problem solvers.
When Denver Health launched its Lean journey, this relationship of waste
and disrespect was clearly and often articulated. We quoted two sayings of
Toyota leadership on waste, and added two sayings of our own:
Toyota Leadership:

Waste is disrespectful of humanity because it squanders scarce

resources.

Waste is disrespectful of individuals because it asks them to do

work with no value.
Denver Health:

Waste is disrespectful of patients by asking them to endure

processes with no value.

Waste is disrespectful of taxpayers by asking them to use their

money for processes with no value.[1][9]
This key concept of respect for people is also manifested in the Lean tool set
which is robust but simple to understand and use. An example would be a
spaghetti diagram. One does not need a college degree to understand a
spaghetti diagram! Tools such as these enable every employee, from
housekeeper to physician, to be a problem solver. The tools democratize
problem solving. What is more respectful than democratizing work?
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We agree with Doctors Hartzband and Groopman when they write, When it
comes to medicine, man must be first, not the system. However, if the
system is wasteful, every person suffers the consequences and no person is
respected. It is unfortunate that their lean experience appears to have
ignored this foundational principle of respect for every individual.

Control Quality at the Source

Every physician, healthcare worker, or patient wants quality healthcare.
Unfortunately, our current healthcare system cannot guarantee quality. A
recent article dramatically illustrates this by determining there are
approximately 251,000 deaths in American hospitals every year due to
medical errors making it the third leading cause of death.[9][10] Thus, an
approach that fosters quality at the source is critically important.
Perfect quality can only be achieved when every element of work is done
right the first time. If an error should occur, it must be detected and
corrected at the point and time of its creation.[10][11]
The improvement approach taught by Dr. Shigeo Shingo to control quality at
the source is often referred to as pokayoke[11][12] or error-proofing. Truly
controlling quality at the source in healthcare would involve a focus on
preventive care and population health. It certainly would involve more of a
discussion about public health policies. We need to focus both on how to
prevent health issues from occurring and how to treat health issues after
they have occurred.
Application of this principle in the process of caring for someone who is ill is
exemplified in the Lean concept of stopping the line. Healthcare uses this
in many places including time outs for a procedure in which if some part of
the process is not rightwrong patient, wrong procedure, or wrong
equipment the process is stopped. It is also part of a computerized order
entry in which a drug and its dosage are checked by an algorithm and by a
pharmacist stopping the wrong medication or drug dosage from reaching a
patient.
The experience at Denver Health is instructive in a common corollary to this
principle that is, that quality saves money. This corollary emphasizes that
when quality in healthcare is controlled earlier in the process, not only does
healthcare improve, but also tremendous cost savings are realized.
During the Denver Health Lean journey, the system achieved remarkable
quality outcomes in preventive care and management of chronic and acute
disease.[12][13] Approximately 80% of all children were fully immunized,
over 70% of patients with high blood pressure had their blood pressure
controlled, and hospital-observed expected mortality was less than one
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every year.[13][14] These are amazing accomplishments for any healthcare

system, but even more impressive for one that cares for a highly vulnerable
population.
During this same period the system achieved approximately $195 million of
hard financial benefit through reduced costs, increased productivity, and
improved revenue cycle processes.[14][15]

Embrace Scientific Thinking

Innovation and improvement are the consequence of repeated cycles of
experimentation, direct observation and learning. A relentless and
systematic exploration of new ideas, including failures, enables us to
constantly refine our understanding of reality.[15][16]
Doctors Hartzband and Groopman write, We believe that the
standardization integral to Taylorism and the Toyota manufacturing process
cannot be applied to many vital aspects of medicine. Once again, this
statement comes from a misunderstanding of the principles of improvement.
If processes are random, it is not possible to assess what is working and what
is not working. The Toyota Way states, Standardized tasks and processes
are the foundation for kaizen. In a correct improvement process, which
embraces the scientific method, standards are the control. Without
standards, then what can physicians test to make healthcare better?
We praise Doctors Hartzband and Groopman for recognizing some of the
contributions of standards. As they state, To be sure, certain aspects of
medicine have benefited from Taylors principles. Strict adherence to
standardized protocols has reduced hospital-acquired infections, and timely
care of patients with stroke or myocardial infarction has saved lives.
Many people, particularly those who are not directly involved in healthcare,
may think that standardization is present throughout all of healthcare
delivery. This is far from the case. There is variation within an organization,
within a discipline, and across geographies. In the more than 400 rapid
improvement events at Denver Health, the most common insight of the
teams at the end of these week-long events was, We have no standard
work. As physicians, we must not confuse standardizing a process to create
a baseline from which to judge outcome, with the inability to respond to
patient differences or patients choices.
Standards empower the scientific method. Lean exemplifies the scientific
method which demands that experiments be based on a hypothesis that
compares an idea against a control. The Lean tools also embrace the
experimentation part of the scientific method. Anyone who has participated
in a rapid improvement event has seen how critical it is to have rapid
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experiments to test the solutions which move the process from the current
state to the target state. Also Lean communication follows a scientific model.
Any healthcare professional who has submitted an abstract to a scientific
meeting or a scientific journal realizes the abstract mimics perfectly the Lean
tool of A3 in which it articulates the reason for action, the current state, the
target state, the gaps between the two, the solution approach, and the rapid
experiments.[16][17]
One particularly impressive and life-saving example of the power of standard
work in healthcare was a Denver Heath rapid improvement event that
focused on deep venous thrombosis (blood clots in the legs) which is a
potentially life threatening post-operative complication.[17][18] This
complication can be substantially prevented by appropriate anticoagulation.
At Denver Health, the occurrence rate significantly exceeded the national
benchmark. There was no standard approach to post-operative
anticoagulation surgeons, orthopedists, obstetricians all had different
approaches. Many committees failed to solve the problem. A four-day rapid
improvement event involved five physicians, a nurse, and a pharmacist using
Lean tools to tackle this problem. One standard approach emerged and was
implemented. This reduced the rate of post-operative deep venous
thrombosis to at or below the benchmark. In addition, the standardization
prevented misuse of expensive drugs, saving $15,000 per month.
These examples demonstrate that a correct implementation of an
improvement process embraces the scientific method, and leads to
improvements in the care provided.

Create Constancy of Purpose

An unwavering clarity of why the organization exists, where it is going, and
how it will get there enables people to align their actions, as well as to
innovate, adapt, and take risks with greater confidence.[18][19]
Too often, lean methods are applied for the sole purpose of reducing costs.
It is, after all, a process that results in the elimination of waste so, of course,
costs are reduced. However, we suggest that the reduction of costs cannot
be the driving purpose in healthcare. The true north for any healthcare
organization must be a noble and inspiring purpose, important, and a
stretch.
Unfortunately, Doctors Hartzband and Groopman paint a picture where
healthcare is sacrificed for the sake of efficiency. The need felt by Doctors
Hartzband and Groopman to write such an article suggest either no true
north was articulated or communicated throughout the organization; or it
was not noble, important, and a stretch. An appropriate, well-communicated
true north will be embraced by the healthcare workforce, including
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physicians, and will create a constancy of purpose and bring continuous

improvement to the goal.
At Denver Health, the true north cause, which inspired everyone in the Lean
transformation, was to create a mature culture committed to reducing
waste to perfect the patients experience and become a model for the
nation.

Conclusion
We encourage readers to look at the impressive results that a correctly
understood and implemented Lean journey can have on patient care quality,
costs, and employee engagement. There are well-documented examples at
Thedacare,[19][20] Virginia Mason,[20][21] and Denver Health[21][22] to
name a few.
We believe that understanding the Lean principles coupled with an
implementation which utilizes Lean tools offers healthcare an opportunity to
improve quality, lower costs, empower all the workforce, and ultimately
enable better health for all Americans.

About the Authors

Dr. Patricia Gabow, MD, MACP, is an academic nephrologist, physician
administrator, contributor to national health policy, and senior adviser to
Simpler Consulting. During her tenure as CEO of Denver Health, a large
integrated public healthcare system, Denver Health started its Lean
transformation in 2007, and received the Shingo Bronze Medallion in 2012.
Ken Snyder is the Executive Director of the Shingo Institute, Home of the
Shingo Prize, and the Executive Dean of the Jon M. Huntsman School of
Business at Utah State University. Based on the work of Dr. Shigeo Shingo,
one of the key developers of the Toyota Production System, the Shingo Prize
is an internationally recognized standard of operational excellence

KPIs are Dead, Long Live the KBIs!

Project succeeded?
About a year ago, the head of logistics and purchasing asked me to carry out
some observations on the floor. Their new ERP system had been
implemented about two years ago, and he wanted to know where knowledge
was still lacking so he could use the information as input for a training plan.
So off I went to talk to some of the employees. I asked an employee to tell
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me exactly what she did while she was working on something, a bit like TVchef Jeroen Meus. "And now I change this printer to the correct printer ... This
has been wrong in the system for a long time." She felt no regrets to report
the issue and get it solved once and for all, instead she solved the problem
herself on a daily basis. And she was certainly not the only one I noticed
doing this during my observations. The employees certainly knew what the
final output should be, but they were less concerned about how it should be
achieved, or even how efficiently it should be achieved. Is this the behavior
and the consequent results you want to achieve as an organization?

Do you manage your culture or does your culture manage you?

The implementation of a certain tool may bring about on-time and on-budget
performance, but the tool must also be used efficiently once it has been
implemented. It is all very well to have nice tools; however, it is the behavior
of leaders and employees that will determine the final results. An insight
from the Shingo Model explains it beautifully: Only via ideal behavior we
can achieve ideal results. If we want to have a 100% safe environment, we
want to see the staff talk to each other if they see unsafe behavior. Do you
want to achieve a culture of continuous improvement? If you do, you should
look for new items to constantly place on the improvement board, and you
should see tips and tricks shared spontaneously. As leaders, we want to set a
good example; and if a leader sees inefficient behavior among his/her
employees, he/she must speak to them about this in the correct manner. But
how do we get the ideal behavior that we want to see in our organization?
The only thing of real importance that leaders do is to create and
manage culture. If you do not manage culture, it manages you, and you
may not even be aware of the extent to which this is happening.
Professor Edgar Schein of
Management, MIT Leadership Center

the

MIT

Sloan

School

of

Key Behavior Indicators: 5 steps in the right direction

Step 1: The very first question you must ask as a leader is: what culture do
you want in your organization? The desired culture is a collection of all the
desired behaviors you want to see, from the CEO to an operator.

Step 2: Translate the ideal behavior so it is relevant to the entire

organization.
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Co-creation is a success factor: involve managers and employees in the

decision-making process. Communicate about the kind of behavior you
expect within your organization and work with the employees to determine
how this ideal behavior translates into their daily tasks within the
department/team. People can only be expected to display this desired
behavior if they really understand what is expected from them.

Step 3: While measuring results, also measure the ideal behaviour that you
want to see.
Performance is often measured using KPIs, for example, growth in market
share, customer satisfaction, turnover, etc. We find it perfectly logical to
implement the ideal process from a blueprint and to measure the
performance using performance indicators. But do we also find it logical to
do the same for the most basic element of our organization, our culture? Of
course, it is very important to measure results and to monitor KPIs, but is it
also important to monitor how our behavior is evolving in the right direction.
For example, it is possible that zero safety incidents occurred at a particular
production site in the past year; but if no safety inspections have been
carried out, or preventive measures taken to ensure safety (or even increase
safety), this historical figure has no predictive value. It is certainly very
interesting to know the extent of any savings that have been made as a
result of the implementation of improvement ideas, but how many of these
ideas were initiated by employees? Besides the usual KPIs, we should also
have KBIs key behavior indicators. These should be used to see the extent
to which the behavior we want to see in the organization is already present.
An additional advantage of these indicators is that they often have a
leading characterthey are a predictor of future performance.

Step 4: Visualize these measurement points

As a result of our intention to visualize, our success rate increases from 4%
to 40%. Visualizing makes it clear what is important. Hang a white board with
the measurement points on the wall in all departments; take the
measurement points to existing platforms, such as the daily start-up meeting
or weekly/monthly performance meetings. The KBIs are signposts showing
the way to the ideal behavior that will achieve the ideal results. So it is very
important that they belong on your balanced scorecard.

Step 5: Go to the gemba

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A presence on the floor is important, but simply being present is not enough.
Now the ideal behavior is known, a gemba walk no longer has to be an
unstructured walk around. Look and observe whether you perceive the ideal
behavior, and try to find out whether there is a difference between the
current behavior and the desired behavior. Your gemba walk is actually a
manifestation of your belief and subsequent behaviorthat value is created
on the floor and that managers should spend a significant amount of their
time walking around observing, asking questions and appreciating.
Do you know what behavior you want to see in your organization already? Do
your employees already know it? Gandhi said, "Be the change you want to
see in the world." We can start with, "Know the change you want to see in
your organization."

Enabling Employees to Assure Quality

As a child, I remember vividly playing in my grandfathers workshop that was
used to repair and re-tread used, worn and damaged truck and bus tires. As
we ran in and out of the workshop we saw employees working hard on
different processes buffing, loading and unloading, assembling, etc. often
waving and smiling at us as we passed by. My grandfather was a very jovial
person and the complete atmosphere was very happy.
The workshop was very popular in and around the city and known for its
quality and customer service. However, sometimes we would see our
grandfather agitated and upset. This would only happen, as we realized later,
when he received a customer complaint about quality, however minor it
might be. This to him was unacceptable and a very painful experience. I
think his pain was shared by all the employees in the workshop. Quality was
very personal to him. He expected each person to ensure their work was
perfect, as a way of showing pride in their craft and workmanship. Nobody
should be able to find any problem with your work, he would always say.
Pride in the work and ownership of what every employee did was a huge
factor in the success of this small business.
The Shingo Model has embodied this principle as Assure Quality at the
Source. If we want to have an uninterrupted flow of value to our customers,
every element in the process has to take ownership and pride in their work
and ensure that work is perfectly done each time.
We recently saw in a large motorcycle manufacturer how ignoring this
principle led to serious deterioration of quality and other negative
consequences, such as low morale and infighting between employees. The
organizations management team went on a benchmarking study tour to a
strong international plant and came back with ideas to create Quality
Gates as a means of preventing defects from reaching the next process.
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These were inspection stations at the end of the lines to check and provide
feedback to the employees about their quality. Contrary to our advice, these
gates were established and used to check parts and provide feedback. The
accountability of good quality slowly moved away from the operators to
these quality inspectors. The operators stopped taking ownership of their
defects and blamed the quality gates for any issues. The ownership vanished
and defects started to increase. Within a year this practice was abandoned,
but it took a lot more time to re-establish the operators lost pride and
ownership.
Putting people and tools on the line to catch defects created by another
process is a sign of not showing respect in the inherent capability of the
people to do good work. Instead, management has to spend time and energy
in creating processes that are capable and can catch errors and mistakes by
themselves leading to continuous improvement. Dr. Shigeo Shingo preached
these concepts when he talked about zero quality control. According to Dr.
Shingo, we cannot achieve the aim of zero defects until we make each
element of the process capable to produce perfect quality by ensuring the
errors and mistakes are quickly identified and corrected before they lead to
defects. His idea of poka-yoke and source checking are exactly in line with
this principle.
In a nutshell, if we want to create excellent quality and therefore value for
our clients, we have to show respect toward our employees and provide
them with the capability to do quality work and ensure perfection every time.
They should be able to check their own work and catch the mistakes and
errors as they happen.

What Would Happen If...?

Think for a minute:

What would happen if you went to the supermarket but forgot

to pick up the kids from school?

What would happen if you bought a round of drinks in a bar for

all but one of your party?

What would happen if you booked your vacation hotel but did
not book the flight to get there?
Clearly, in each case you might be embarrassed, frustrated and or an
inconvenience to others. You would probably also incur a lot of waste and
excess cost. Indeed, your less than ideal behaviour would be a big problem.
Now lets think about the work situation:
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What would happen if you went on a gemba walk but forgot to
talk to local team members at their workstation or visual management
board?

What would happen if you communicated with the day shift but
not the night shift about an important change in your business?

What would happen if you received a flat order profile from your
customers but passed on a highly variable order pattern to your
suppliers?
Although we may not realise it when we do these things, the outcome is
likely to be pretty much the same as the first three home-based examples.
These less than ideal work behaviours are caused partly through
carelessness, but are probably more likely because we have not been
thinking systemically. Indeed, they almost certainly point to failures to
define, design, implement and sustain effective systems in the organisation,
such as leader standard work, communications and supply chain integration.
So what should we do? Well to start with, we should work to define the key
systems within our organisation and its wider supply chain. Second, we
should review how these work from a technical point of view, but more
importantly from a behavioural point of view. Third, we should prioritise
improvement activity by systems based on the importance of the system and
how far your current practices differ from the ideal. Fourth, we should ensure
we develop a discipline to maintain and further improve these systems.
Sounds easy, but these are some of the hard yards on your enterprise
excellence journey. Oh, and if you succeed, you may even learn how to avoid
the first three home-based problems!

Beliefs and Systems Drive Behavior

The best decisions are made when there is awareness and knowledge of the
different elements of a system, as well as how these elements are
interconnected and what the outputs of the system are.
Systemic thinking is a Shingo Guiding Principle that ties together all other
principles. Thinking systemically improves understanding by learning to see
the system as a whole, including elements sometimes called sub-systems. In
reality, most things are connected to something else in an environment that
is constantly changing.
A clear example of an integrated and complex system is the human body as
it is composed of different sub-systems such as the digestive, circulatory or
nervous systems. Each of these sub-systems performs a function while being
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interconnected with the others, and only its synchronized and balanced
function enables the entire integrated system, the human body, to perform
perfectly.
Likewise in companies, an integrated system is composed of sub-systems
that working together will enable the organization to achieve its best
outcome. Sustainability comes through understanding the interconnections.
Understanding of the relationships and interconnections of elements of a
system makes better decision-making possible and creates visibility to
improvements. Systemic thinking encourages improvements to be made on
the system as a whole, rather than individual components of the system,
which is often where the ideas for change are initiated.
The Shingo Model itself is an example of systemic thinking. Typically
organizations go through a natural progression of learning to understand how
this system works.
1.
Initially, managers understand and use the tools as a way to create
improvements in the business.
2.
Over time, managers discover that tools are not enough and they begin
to see the relationship between the tools and key systems.
3.
Eventually, managers come to understand the principles and systemic
thinking becomes complete when principles, systems and tools are
integrated into a perfect system.
Systemic thinking is closely related to the principle of Focus on the Process.
Similarly, these two principles are closely related to key business systems
such as goal alignment and gemba walks.
The leadership team of the company defines the strategies and goals in a
cyclical and systematic manner. In order to achieve them successfully, it is
necessary to ensure that the whole staff of the organization understands and
are committed. Achieving shared goals requires good data, good analysis
and the discipline to focus on the vital-few.
The related principle of Focus on Process teaches, Good processes make
successful people. A regular and disciplined process of visiting the gemba
provides the breadth of understanding required for leaders and managers to
make good decisions. Seeing firsthand the interactions between related subsystems helps in diagnosing the difference between actual and ideal
behaviors and can reveal whether or not people are using the right data to
manage the business and drive improvements.
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The more deeply you understand the Shingo Guiding Principles the more you
will come to understand their connectedness. You will come to see that a few
critical systems in your business touch all of these principles. This is a great
example of systemic thinking.

Process Problems: Hidden Treasures, Part I

When a company engages its people in problem solving as part of their daily
work, they feel more motivated, they do their jobs better, the organizations
performance improves, and a virtuous cycle starts to turn. Such an approach
can tap enormous potential for the company and its customers.
At one auto-parts manufacturer, each employee generates an average of 15
suggestions for improvement every year. Over a period of 16 years, these
suggestions have helped secure major advances that reached well beyond
productivity and into safety and quality.

Openness to talking about problems

On the face of it, talking about issues or opportunities rather than
problems sounds like a good way to avoid sounding negative or critical. In
practice, though, great problem solving begins with the ability to
acknowledge problems and a willingness to see them without judgment.
When an organization treats problems as bad thingsas mistakes, defects,
or failingsbringing them out into the open will make people uncomfortable.
But problems that stay hidden will not get fixed. And problems that go
unfixed keep the organization from reaching its objectives.
Neither attributing blame nor brushing a problem under the carpet is helpful.
Organizations that embrace continuous improvement take the opposite
approach. They understand that when a problem is properly identified, the
root cause usually turns out to be not a particular group or individual but an
underlying factor that the organization can address, such as a lack of
transparency, poor communication, inadequate training, or misaligned
incentives.
This means that organizations should see problems as something to prize,
not bury. Raising and discussing problems is not just normal but desirable
and critical to success. As one lean leader told us, Problems are gold
nuggets we have to search for. Its when we dont have problems that we
have a problem.

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Willingness to see problems wherever they may be

Before you can acknowledge a problem, you have to be aware of it.
Identifying problems, particularly before they grow into a crisis, is a skill that
can be learned. In lean thinking, all problems can be attributed to some form
of waste, variability, or overburden. Learning how to spot these factors as
they arise is one of the most important skills leaders and their organizations
can develop.
Picture a bank supervisor who takes a call from an irate customer demanding
to know what has happened to the loan she applied for two weeks ago. What
should the manager do? Tell the customer her application is in the system
and she should get her decision soon? Track down the application and quietly
expedite it? Or go and find out what is causing the delay and whether it is
affecting other applications as well? Only the third option will enable the
manager to bring the problems real causes to light and get the team
involved in identifying and fixing it.
Problems are particularly difficult to see when they are hardwired into the
way we do things around here. For instance, some organizations place a lot
of value on certain tasks that their best employees perform in order to work
around uncooperative business partners or cumbersome IT work flows. Yet
under closer examination, many of these tasks turn out to add no value as
far as customers are concerned.
Organizations can often achieve significant improvements simply by
exploring what is preventing them from applying current best practices
consistently across the entire workforce. Once they reach stable performance
at this level, raising the target creates a new gap to be explored.

Understanding that small problems matter

Most large organizations design their processes to manage big, top-down
strategic interventionsreorganizing, migrating to a new IT platform, or
outsourcing a process. They have well-honed routines for handling them:
appoint a manager, set objectives, and check progress at regular intervals. If
the effort fails to move in the right direction or at the right speed, leaders
intervene. Leaders themselves, having grown up in this kind of environment,
believe that implementing these big strategic projects is central to their job
and perhaps their next promotion as well.
However, this view misses an important truth. Businesses dont stand or fall
by big projects alone. Small problems matter too and are often more critical
to great execution. If a project-based approach doesnt work, what will? In
fact, the only way to manage these small, everyday issues is to detect and
solve them as they arise (or even before). That calls for leaders to shift their
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dominant mind-set from that of knowing the answers and directing

employees to learning from and coaching the people who are closest to the
problems.
Solving hundreds of small issues each yearas opposed to managing a
dozen big projectsrequires an organization to develop a more distributed
problem-solving capability. Leaders carry the responsibility for modeling
coaching and analytical problem-solving behavior and ensuring it is adopted
at all levels of the organization. It can take years of practice for this way of
working to become truly ingrained, but when it does, organizations see the
results year after year.

Process Problems: Hidden Treasures, Part II

Most of the leaders we meet pride themselves on their problem-solving
ability. But when we watch how they work, we often see them behaving
instinctively rather than following a rigorous problem-solving approach. All
too often they fail to define the real problem, rely on instinct rather than
facts, and jump to conclusions rather than stepping back and asking
questions. They fall into the trap of confusing decisiveness with problem
solving and rush into action instead of taking time to reflect.
Why does this happen? Following a systematic problem-solving process takes
discipline and patience. There are no shortcuts, even for leaders with a
wealth of experience. An organization that consistently uses a single, simple
problem-solving approach across its entire enterprise can achieve more than
just greater rigor in asking the right questionsit can create a new shared
language that helps people build capabilities more quickly and collaborate
across internal boundaries more effectively. But to do so, it will need to avoid
getting caught up in sophisticated problem-solving techniques until it
captures all that can be learned from the simple ones. The main objective is
to uncover problems, ask the right questions, engage everyone in the
problem-solving effort, and develop the organizations problem-solving
muscles. An effective process for identifying and solving problems involves
five steps:
1.
Define the problem. Clarify what should be happening and what is
happening.
2.
Identify root causes. Learn as much as possible about the problem,
preferably by observing it as it occurs.

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3.
Develop a solution. Crafting a good solution rests on distinguishing
cause from effect.
4.
Test and refine the solution. The solution must be tested to ensure it
has the expected impact. If it solves only part of the problem, further
rounds of the problem-solving process may be needed before the problem
disappears completely.
5.
Adopt new standards. The last step is to incorporate the solution into
standards for work, with training and follow-up to make sure everyone has
adopted the new method.
Recognition that observations are often more valuable than data Most
organizations are good at gathering and analyzing financial and accounting
data for reporting purposes. The average executive is inundated with
management information on revenues, cost of sales, valuations, variances
and volumes. It is of little or no use for identifying operational problems and
uncovering root causes or helping leaders and frontline teams do their jobs
better. Instead, organizations struggle to understand basic questions about
their capacity and level of demand. How many transaction requests did we
receive today? What was our planned capacity? How many transactions did
we complete? What was the quality of the work?
Why dont organizations have this information at their fingertips, as they do
with financial information? Probably because they have never asked these
questions or understood how the answers could help them improve the way
they work. Once they appreciate how useful the information could be, they
tend to assume that some kind of IT solution must be put in place before
they go any further. But the cost and time involved in application
development can be enough to stop the problem-solving effort in its tracks.
There is another way. Taiichi Ohno, the executive often cited as the father
of lean manufacturing, noted that while data is good, facts are more
important. When operational data is not routinely available, teams can often
find what they need not by commissioning new reports but simply by
observing team members as they work and talking to them to find out
exactly what they are doing and why. Observation and questioning provide a
powerful and immediate source of insights into processes, work flows,
capabilities and frustrations with current ways of working. Teams can
typically get the information they need within a week, sometimes sooner.
From problem solving to continuous improvement Executives are often
amazed at the sheer number of problems their organization is able to
identify and fix in the first few months of a lean transformation. Some
wonder whether it can last. But the good news is that in our experience,
problem solving is immune to the law of diminishing returns. Quite the
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opposite: problems never cease to arise. One company we know has been on
a lean journey for 20 years without seeing any letup in the flow of
improvement opportunities. Year after year it surprises itself by managing to
achieve yet another 10 percent increase in productivity and speed.
Building a problem-solving culture that lasts is not about fixing particular
problems but about always striving to do things better. To help create this
kind of environment, leaders must themselves change, respecting the
expertise of the people on their team and finding ways to support them. No
longer pretending to have all the answers, they should focus instead on
defining targets, creating a safe environment for raising problems, ensuring
people have enough time for problem solving, and helping them develop
their skills. Adjusting to this change in role can take time for leaders
accustomed to being the team hero. But by learning how to help others
participate to the full, they can find a new identity and an even more
powerful way to add value to their organization.

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