Having worked in the airline business, it’s really a matter of having employees that CARE (most due to their own pride, not by management) We many times had weather and mis-connected passengers to deal with. It only took a few minutes of extra time to send a message to the destination station and let them know what to expect or which passenger was going to be disappointed to not get their bag. Today’s situation is exacerbated by under-staffing, stressed employees, passengers with sometimes unrealistic expectations, checked bag fees, etc it’s ugly and very little relief in sight.

He brings up some really interesting points. In most of the airline industry, like most industry in general, “caring” is thought of as something the people have to do.

“The employees don’t care” or even “management doesn’t care” are pretty common statements.

Let’s turn it around.

How was the original process designed?

Continuing on the theme from the original post, I would speculate that most players in the airline industry see themselves as providing transportation to people and their stuff.

The process design is, logically, going to center on what things have to happen to get people and their stuff from their point of entry into the system through to their point of exit at baggage claim. (the fact that the trip doesn’t actually end at baggage claim is another topic – one which has been discussed by Jim Womack in Lean Thinking, among other places.)

In traditional thinking, improvements in that process will involve making those things happen cheaper, usually by doing less.

What if, though, we start with a different question:

“What experience do we want the customer to have?”

Describe, first and foremost, the things the customer has to do to get herself and her stuff from the point of departure to (sadly) baggage claim. (Bonus points if beyond, but let’s not stretch the fantasy too far.)

Even better, act it out. Simulate it. Try it on. Work out the kinks, from the customer’s perspective.

Next, design the interface between your customer and your process. What does the customer-touching part of your process have to look like to deliver that experience?

(I often wonder if airline executives ever see their own web reservation systems.)

Now, only when you know what the “on stage” part of your process looks like can you design the rest of it – the back stage parts that make it all happen.

Economics come into play at this last stage. This is where you have to get creative. If the solution is too expensive, work on the back-stage part to make it cleaner and more streamlined. The customer facing part of the process is the target condition. Your problem solving works to deliver that experience in continuously better ways.

What does this have to do with “caring?”

Remember, this is from the customer’s perspective. When we say “our employees care” do we not really mean “our customer’s feel cared-about?” Since we started with the customer’s experience, if that is what is desired, it was built into the process specification from the beginning.

Once there is a process that we predict will result in customer’s feeling that people care about them, then your market surveys make sense. You are not soliciting complaints about things to fix, you are validating (or refuting) your design assumptions. Every bit of customer feedback will be a learning experience.

Don’t forget Murphy.

In a complex business like airline travel, sometimes luggage doesn’t get to baggage claim at the same time as the customer. It happens. But this is the time to really apply the above process design. What do you want the customer to experience when things go wrong?

Ironically, in the customer satisfaction world, a spectacular and surprising recovery actually generates more loyalty than flawless delivery of service. This is the moment for your company to shine.

Whatever happens, though, make sure it is something you would do on purpose rather than relying on chance or a random team member’s disposition. Build “caring” into the process itself, and you will embed it into the culture.

Fed from: The Lean Thinker. Copyright © 2012, Mark Rosenthal

The Process of Caring

Link to full story: Networks are smart at the edges.

The factory is having a quality issue. The response is pretty typical:

The project followed the usual process: budget and project sponsor allocated, RFP, third-parties selected, and six months (and $8 million) later they had a fantastic solution — on time, on budget, high quality and everyone in the project had a great time. They solved the problem by using some high-tech precision scales that would sound a bell and flash lights whenever a toothpaste box weighing less than it should. The line would stop, and someone had to walk over and yank the defective box out of it, pressing another button when done.

And a great solution. It stops the line and forces someone to pay attention to the problem. While I would usually add that these instances need to be followed up by problem solving to eliminate the issue, even if I were doing so, I wouldn’t eliminate the final verification check. Even Toyota performs a thorough and rigorous final inspection. But that’s not the point here.

It turns out, the number of defects picked up by the scales was 0 after three weeks of production use. It should’ve been picking up at least a dozen a day, so maybe there was something wrong with the report. He filed a bug against it, and after some investigation, the engineers come back saying the report was actually correct. The scales really weren’t picking up any defects, because all boxes that got to that point in the conveyor belt were good.

Puzzled, the CEO travels down to the factory, and walks up to the part of the line where the precision scales were installed. A few feet before it, there was a $20 desk fan, blowing the empty boxes out of the belt and into a bin.

“Oh, that — one of the guys put it there ’cause he was tired of walking over every time the bell rang”, says one of the workers.

Like the Dilbert cartoon about 25 critical focus areas, this is more funny because the original reaction is totally typical, especially in companies who are comfortable with technology, controls, automation, etc.

Cudos to the CEO who realized, at least, that “No problem is a problem” and went to investigate at the actual gemba.

Once the team had a challenge (in this case provided by the annoying bell) they dealt with what they saw as the issue.

Oh – and this graphic? It is an inside joke for some of my readers. Maybe we should have put some fans on the conveyer.

Thanks to Hal for sending the original link to this article.

Fed from: The Lean Thinker. Copyright © 2012, Mark Rosenthal

Simple Solutions

Mike Rother has put up a compelling presentation that highlights a long-standing misunderstanding about the purpose of “standards.”

Some time ago, a (well-meaning) author or consultant constructed a graphic that shows the PDCA wheel rolling up the incline of improvement. There is a wedge labeled “Standards” shoved as a chock block under the wheel to keep it from rolling back. That graphic has been copied many times over the years, and shows up in nearly every presentation about PDCA or standard work.

The implication – at least as interpreted by most – is that a process is changed for the better, a new standard is created, and people are expected to follow the standard to “hold the gains” while they work on rolling the PDCA wheel up to the next level on the ramp.

Slide 6 (taken from the book Toyota Kata) shows the underlying assumptions that are implied by this approach, especially when it doesn’t work.

There are some interesting assumptions embedded in the “wedge thinking.”

The first one is that “the standard can be ‘held’ by the people doing the work.

That, in turn, means that if when things start to deteriorate, the workers and first line leaders are somehow responsible for the “slippage” or “not supporting the changes.”

With this attitude, we hear things like “Our workers aren’t disciplined enough” or “How do I make them follow the standard?” The logical countermeasures are those associated with compliance – audits focused on compliance, and sometimes even escalating punitive actions.

Back in my early days, I had a shop floor team member call us on it quite well: “How can you expect us to hold some kind of standard work if the parts don’t fit?” (or aren’t here, or the tools don’t work, or jigs are misaligned, or the machine isn’t running right, or someone is absent, or we are being told to hurry and just get stuff out the door?)

This is the approach of control. The standard is fixed until we decide to change it.

Taiichi Ohno didn’t teach it this way.

Neither did Deming or Juran. Neither did Goldratt. Nor does Six Sigma, TQM, TPM.

Indeed, if we want creativity to be focused on improvements, we have to look up the incline, not back.

We are putting “standards” on the wrong side of the wheel. Rother’s presentation gets it right – the “standards” are the target – what we are striving to achieve.

The purpose of standards is to compare what we actually do against what we wanted to do so we know when they are different and so we have some idea what stopped us from getting there.

Then we have to swarm the problem, and remove the barrier. Try it again, and learn what stops us the next time.

The old model shows “standards” as a countermeasure to prevent backsliding, when in reality, standards are a test to see if our true countermeasures are working.

I believe this model of “standards” as something for compliance is a cancer that is holding us back in our quest to establish a new level of understanding around what “continuous improvement” really means.

It is time to actively refute the model.

If you own your corporate training materials, find that slide (it is in there somewhere) and change it.

If you see this model in a presentation, challenge it. Ask what should happen if something gets in the way of meeting this “standard.”

“What, exactly do you expect the team member to do?”  That sparks an interesting conversation which reveals quite a bit.

Fed from: The Lean Thinker. Copyright © 2012, Mark Rosenthal

Mike Rother: Time to Retire the Wedge

The article’s lead does a good job of summing up the issue:

Under laws in more than two dozen states and new Medicare rules that went into effect earlier this year, hospitals are required to report infections — risking their reputations as sterile sanctuaries — or pay a penalty. That’s left hospital administrators weighing the cost of ‘fessing up against the cost of fines.

So, in effect, the administrators are faced with weighing the financial impact of lost Medicare payments vs. the financial impact of telling the truth about their infection rates. This is, in my mind, yet another symptom of the General Motors style of management that is taught by every MBA program in the world.

It also suggests that there is a viable alternative of continuing to maintain the illusion that it is not a problem.

Is it a problem? Hospital infections kill about 90,000 people a year in the USA. Compare that with the 40,000 or so that are killed in traffic accidents, and you get the idea.

Add to that the fact that the patient ends up getting billed (and usually insurance pays the bulk) for the treatment of these infections.

Fundamentally this is about quality, and the problem is certainly not limited to health care. (it is just that lives are at stake)

How does your company respond when there is a known issue that is impacting quality?

If you deliver a defective product or service, do you charge your customers for the rework? This is not a facetious question. Some companies do.

Do you avoid collecting information for fear of revealing the true magnitude of a problem?

Do your workers fear bringing it up when they are directed to carry out inappropriate actions, or actions which violate the company’s written policies and procedures?

Is it OK to improvise outside of your known process in order to get the part out the door?

Back to the hospital – we know how to tackle this problem. It is merely extremely difficult. That doesn’t make it impossible. I am glad it is getting attention. I am disappointed that it takes government generated threats of visibility to get action.

Fed from: The Lean Thinker. Copyright © 2012, Mark Rosenthal

NPR: Hospitals New Face Pressure to Reduce Infection Rates

In a recently aired episode of Showdown: Air Combat the host, a USAF fighter jock, asked about a series of colored stripes painted on a bit of sheet metal attached to the landing gear of a beautifully restored A6M Zero .

The piece of aluminum sheet is attached to the landing gear and fairs in the landing gear bay when retracted. The plane’s pilot/historian explained that they were an indicator for the ground (or deck) crew. As the landing gear’s hydraulic struts compress they align with the different stripes, allowing the crew to instantly see the load condition of the aircraft.

So for the cost of nothing more than a few square inches of paint they had an immediate, reliable, easy to use (from a distance, even), intuitive “mechanism” for the aircraft handlers to obtain critical fuel+ordinance info on the planes at any time.

While weight is always critical on an aircraft, it is even more critical on a WWII era aircraft carrier, before there were catapults. Where I can see this simple visual check becoming really valuable is if the crew spots one that is different than the others.

Here is a question – how can you adopt this principle to make a quick, visual weight check to assure, for example, that everything is in the package before it ships?

Fed from: The Lean Thinker. Copyright © 2012, Mark Rosenthal

WWII Visual Control

It said to please call the 800 number if I wanted to make a reservation.

I called the number.

The nice person on the phone asked if I wanted to make a new reservation or discuss a current one.

I said new reservation.

“Oh, our system is down for maintenance. Can you try again in a few hours?”

It was already midnight, so I really didn’t want to do that.

“That’s OK, I’ll just call Hertz.”
Which I did.

I encountered two problems here.
First was the message that implied that a human could make a reservation while the system was down. The accurate message would have been “Our system is down for maintenance. If you want to make a reservation, please try again in a few hours.”

And, since this is the de-facto process, I have to assume that the company is doing it this way on purpose.

Then again…
Do their executives rent cars through the online system? Do they experience what their customers do? Do they see the “we’re closed, please go away” sign that is part of their normal process every Saturday night?

Another company once put me on hold. The system kicked to a local radio station rather than silence. And so I was waiting for a customer service response while listening to Mick Jagger “I don’t get no… sat is fact ion…”

Fed from: The Lean Thinker. Copyright © 2012, Mark Rosenthal

What Does Your Customer See?

This one, though, shows something a little special.

When I first started working there, the idea of a line stop was unthinkable. The plane moved on time, period. Any unfinished work “traveled” with the plane, along with the associated out-of-sequence tasks and rework involved.

The fact that the 737 is now built on a continuously moving assembly line in Renton is fairly well known.

But what struck me in this PTQ video is that one of the things highlighted in it is a line stop. It happens pretty quickly at about 1:57.

The video is also full of rich visual controls to allow the team to compare the actual flow vs. the intended flow. See many many you can spot.

Fed from: The Lean Thinker. Copyright © 2012, Mark Rosenthal

Boeing Moving Line

We talk about 5S, separating the necessary from the unnecessary, a lot, but usually apply it to things.

What about information?

How is critical information presented?

How easy is it for people to see, quickly, what they must?

This is a huge field of study in aviation safety where people get hyper focused on something in an emergency, and totally miss the bigger picture.

This site has a really interesting example of how subtle changes in the way information is presented can make a huge difference for someone trying to pull out what is important. The context is totally different, so our challenge is to think about what is revealed here, and see if we can see the same things in the clutter of information we are presenting to our people.

The purpose of good visual controls is to tell us, immediately, what we must pay attention to. Too many of them, or too much detail – trying to present everything to everyone – has the opposite effect.

Fed from: The Lean Thinker. Copyright © 2012, Mark Rosenthal

He Should Have Seen It

W. Edwards Deming espouses a “system of profound knowledge” as the way to manage complex systems. The key points are:

1. Appreciation for a system. (Systems thinking)
2. Knowledge about variation. (Knowing the difference between variation inherent in the system and variation with an attributable cause.)
3. Theory of knowledge. (Understanding how the organization learns – summarized as PDCA)
4. Psychology.

This last point – psychology – is the one I want to discuss.

The common view of business and production systems is a technical one. We look at things that can be easily disaggregated and analyzed – production processes, financial models, defect rates. Even when we consider the role of people it is in terms of “heads” and labor hours; absenteeism, payroll, labor costs.

Then we turn around and talk about “corporate culture” as though it is an abstract thing that can be analyzed as well, and that conversation all too often turns into commiseration and a blame game where things would be great “if only they….”

Reality, however, is even messier than that. The culture of a company emerges from how people interact with each other, and with the work environment. The work environment itself is also the product of interactions between people. People also interact with the processes themselves. Every second of every day, it is the people who are sensing, assessing, and deciding how to respond to what they see, hear, feel, perceive, believe.

If we truly want to construct a work environment where people make the best possible decisions, it behooves us to rid ourselves of decades old stereotypes and convenient beliefs about why people decide what they do.

Those stereotypes were largely established in the 1930’s and 1940’s. Since then, however, we have learned a great deal about psychology. Further, we are now (finally) beginning to make the connections between what happens in the mind – how people think, feel, perceive, behave – and what happens in the brain – the neuroscience behind the feelings.

How We Decide is a layman’s overview of those linkages.

As I was reading it, I found many topics that link directly to business and the workplace, and stuffed my book full of sticky notes.

Learning

Deming famously said “Management is prediction.” We also know this in the context of PDCA and the scientific method. We make observations, collect facts, and make a prediction. “Given what I know, if I do x I should see y.” Or “… if I observe x happening then y should follow.” These are predictions. By making them, we set ourselves up to either be proven correct, or confront something that surprises us. In either of those situations, we learn either by reinforcing the prediction for next time, or by examining what was not understood and trying to understand it better.

Well – as much as we like to imagine this is a logical process, it isn’t. This is pure emotion, which in turn is driven by changes in the level of dopamine in the brain as we have these experiences. In fact, our emotions learn to predict a vague situation before our logical brains catch on. “I don’t know why, but this feels right” – except that if you think through it that much, you will likely get it wrong.

Lehrer cites a number of scientific studies, but what they all have in common is immediate positive or negative consequences. Without those consequences, the emotional mind is never engaged, and the people never develop that “gut feel” for the situation.

Now before anyone jumps all over the word “consequences” let me be really clear on this point. This has nothing to do with punishment or “accountability.” Indeed, neither of those is immediate enough for this kind of learning to occur. Rather, it means that there is a situation where the person has immediate feedback and knows whether he made a good or bad choice.

What is more interesting is when these experiments were conducted with people who were neurologically impaired to the point where they could only engage in logical thought – they experienced little or no emotion. They failed, totally, at detecting the subtle patterns of success and failure in the experiments. The dopamine driven emotional part of the brain “gets it” and the logic part follows.

So – if we want a person to learn to correctly carry out a subtle process, and develop a good feel for how it is going:

• They need practice.
• They need immediate feedback.
• They need safe opportunities to get it wrong.
• They need emotional support for continuing to try. (More about that later.)

Now think about this in the context of how your people are trained to perform tasks that require skill or developing a “knack.” How well does your work environment provide a safe place to practice?

Another factor that plays a huge role in learning is reflection. Again, this is something that we all know at a logical level, but do we structure our situations to actually do it… or rely on happenstance? Worse yet, do we try to avoid focusing on things that went less than perfectly in our desire to focus on the positive?

Leher’s next key point is that, except in trivial cases, practice is not simply repetition. It is equally important to be good at it – to know how to practice. Reflection plays a huge role in this. He uses the example of a master game player – chess, poker, backgammon. Bill Robertie plays these radically different games at a world class level.

Leher describes how Robertie learned to play backgammon.

Robertie bought a book on backgammon strategy, memorized a few opening moves, and then started to play. And play. And play. “You’ve got to get obsessed,” he says. […]

After a few years of intense practice, Robertie had turned himself into one of the best backgammon players in the world. “I knew I was getting good when I could just glance at a board and know what I should do…The game started to become..a matter of aesthetics.”

Leher is describing the process of training the dopamine receptors in the brain to give a positive emotional response to thoughts of the right move, and a negative emotional response to thoughts of a bad move. That is what happens in the brain of someone who is playing by instinct.

But, he goes on:

But Robertie didn’t become a world champion just by playing a lot of backgammon. “It’s not the quantity of practice, it’s the quality,” he says. According to Robertie, the most effective way to get better is to focus on your mistakes. In other words you need to consciously consider the errors being internalized by your dopamine neurons. After Robertie plays a chess match, or a poker hand, or a backgammon game, he painstakingly reviews what happened. Every decision is critiqued and analyzed.

Actually this kind of reflection can be found behind pretty much any world-class performance you might see. Professional sports teams review the films. The U.S. Army does “after action reviews” in training. The opposing force commanders and the unit being trained first discuss and reconstruct what really happened, and then drill in on cues that might have revealed missed opportunities. By consciously learning from their mistakes in a practice environment – with blanks and lasers – they make far fewer mistakes when the bullets are real.

What about business? If you are a regular reader (meaning you are interested in this stuff), you likely know that “reflection” is a critical part of policy deployment, otherwise known as hoshin kanri. That reflection is the same process – examining the original intention and prediction, and then seeking to understand why things went differently (better or worse) than anticipated. By understanding the why behind the deltas, the leaders are better able to make better and better plans. That might look like they are leading by instinct, but just like Robertie’s backgammon game, that instinct is honed deliberately by a process of learning.

Likewise, when organizations try to learn “problem solving” and “A3” I see them start with big, complicated problems. But in my experience, it is far better to start off on small ones that are easy to solve. There are a couple of good reasons for this. First, it gets leaders down to the place where the work is done and shows that they actually care. This is all well and good, but it isn’t the primary reason.

The main reason is so they have an opportunity to practice seeing and solving problems in an environment where they can do it a lot, get immediate feedback, and contain the effects of their mistakes. In other words, it is an environment where:

To cut to the chase, in follow-up tests, the group that was initially praised for their intelligence avoided subsequent challenges, gave up on tough puzzles more easily, and sought out opportunities to see that they had done better than others.

The group that was praised for their effort, on the other hand, sought out tougher challenges, worked harder on those tougher puzzles, and sought out opportunities to understand why others had done better than they had. In other words, they were driven to learn.

To be clear, the only difference between the groups was the initial praise. Throughout the remainder of the experiment, each group sought to self-validate the single compliment they had been given – one group by selecting tasks that allowed them to look smart, the other group by selecting tasks that allowed them to work hard.

At the end, they were all given a final set of puzzles. Guess which group had learned more about how to tackle them? In short, the kids who were praised for their efforts got better results because they worked hard to learn how to learn.

Now, this is with little kids. But what we all learn as kids are the things which drive us throughout our lives. Each of us seeks to renew the conditions that got us the most acceptance and praise.

Application

Let’s look at how to apply all of this when we are trying to transform an organizational culture.

First, what are we trying to achieve?

If we are trying to instill a culture of problem solving and kaizen, then we want people to try hard to solve the problems they are confronting, are willing to experiment (and make mistakes), realize they have to discover (rather than already know) the answers, and support others in doing the same.

So what are the best conditions to learn how to do that, and do it well?

• Practice.
• Immediate feedback.
• Safe opportunities to experiment.
• Emotional support for continuing to try.

If I go back and look at the learning environment described in Learning to Lead at Toyota by Steven Spear, I actually see these characteristics being deliberately put into play. And not simply for the benefit of the senior executive who is the main character, but for the team leaders in training as well.

Think about how much more effective this gradually building hands-on practice and experience is than sitting people through a three day classroom based “Lean Overview?” Just like you can’t learn backgammon (or infantry tactics) in a lecture, neither is it possible to really understand what kaizen is about. You have to play, and play, and play. You have to reflect, which means you have to know what you expected, know what actually happened, and study the differences.

No matter what you think people’s motivations should be, let go of your judgments, and look at what we know about how people really learn. Use that information to create the best possible space to do it in.

The next section covers the neurological and psychological aspects of what Deming calls “tampering” – why we are tempted to do it – and the psychology behind relying on hope and luck as a risk management plan. Pretty interesting stuff.

Fed from: The Lean Thinker. Copyright © 2012, Mark Rosenthal

The Human in the Loop

I get a referral. The information on the referral slip is the name of the referring dentist (which I can’t read), no boxes checked, and “#31″ in the comments.

I call the specialist and start getting technical questions about what my dentist wants them to look at / look for, etc.

So the process is to use the patient as a conduit for vaguely expressed (in layman’s terms) technical information between highly trained specialists.

Sadly, I think this happens all of the time in the health care industry. It seems that there is so much focus on optimizing the nodes that nobody really “gets” that the patient’s experience (and ultimately the outcome of the process) is defined more by the interactions and interfaces than it is by the nodes themselves.

I am really not sure how fundamentally different this is from a pilot asking a passenger to find the maintenance supervisor and tell the mechanic about a problem with a plane.

The net effect is, as I am writing this, the specialist’s office is calling the referring dentist and asking them what, exactly, they want done.. a net increase of 100% in the time involved for all parties to communicate.

While the national debate is on how we pay for all of this, we aren’t asking why it costs so much (or kills more people than automobile accidents do).

Fed from: The Lean Thinker. Copyright © 2012, Mark Rosenthal

Information Transfer Fail