The following is the 2nd installment of the 3 part series focusing on the importance of understanding the current state.  Last week we examined why understanding current state is important for process design.  This week we will focus on why understanding current state if important for problem solving.

Often the unfortunate response to a problem is “rush to solution”.  We are all guilty of it even when we know better.  It’s typically quick and then we can move on to the next problem.  Unfortunately this often doesn’t actually solve the problem and we go through a similar exercise again and again.   So we have learned, that if we expect to really solve a problem, we must get down to the root cause.  Mastering root cause analysis can be difficult and there is even some aura or mystery around doing it well.   We try and master root cause analysis using fishbone diagrams, five why’s or some other well known technique.  However, the first and simply the best way to get to the root cause is to deeply understand the current state.  We have found that one of the most effective PS approaches is “swarming” the problem.   Get the right people (usually cross-level and/or cross-functional) and go immediately to the problem.  Swarming  is the best representation of what truly is the current state.  Not someones’ story or someones’ opinion.  It’s not a technique that can be used for every problem but it’s surprising how often the opportunity will arise.  It’s about treating a problem as crime scene.   Law enforcement doesn’t sit in a room discussing what caused the crime—the 1st thing they do is go to the crime scene.  In fact, it’s best if they can observe the crime while in progress.

  • One of our clients is a lead smelter.  Their employees’ health and safety is the #1 priority of the company so they are frequently checking the blood levels of their employees.  Their goal is not to meet industry or regulatory standards, it’s always to beat the standard and beat it by a mile.  They are tougher on themselves than any regulatory or industry agency could ever be.  Because they are almost myopic in their focus on employee health, any slight increase in a blood level, no matter how insignificant, immediately prompts a response.  Their response — “swarming”.  They go to the employee(s) and observe behaviors.  Is there something different in the hygiene?  Are the respirators being handled and maintained as required?  Any change to the environment?  They can almost immediately find the contributing cause(s) and the issue is resolved.

Taking problem solving one step further is problem detection-finding a problem before there is a negative consequence.  That low fuel level light and beep in your car is detecting a issue before you are stuck on the side of the road.  It’s almost impossible to find a process of any kind that doesn’t have an issue and an opportunity for improvement, even if it’s not creating a negative consequence today (efficiency or effectiveness).   This requires expanding the definition of a problem to “any absence or violation of structure even if is not creating a negative consequence”.  We have been working the last few years with the railroad industry in the UK.  During one of our direct observation exercises we observed a maintenance worker in the process of maintaining a set of track switches.  Switches transfer trains from one track to another and are obviously an integral part of the rail infrastructure.  We observed an employee checking the torque on a set of bolts.  He was interrupted to willingly help another worker.  A good guy simply helping a team member.  Unfortunately, when he went back to checking the bolts he missed a few.  Nothing bad happened.  The bolts were tight.  However, by deeply understanding the current state using direct observation we discovered an opportunity to introduce some structure into the process to assure the bolts aren’t missed in the future.  We’ll never know if this prevented a negative consequence in the future but you often don’t know when you have “pervented” a problem.

Next week the final installment, Innovation.   STAY TUNED