A Quality Story

On a cloudy morning a few years ago I started my truck, turned on the headlights and noticed one of them was not working. While changing a headlight isn’t that big a deal, I needed a state safety inspection anyway, and I really didn’t want to mess around under the hood.

So I called the auto repair and tire place up the road, and arranged to come in.

When I got there, I explained that the right headlight was out. Since I knew from experience that the left one would probably fail in a few weeks, I said “Go ahead and change the left one too, and I need the state safety inspection.”

Unfortunately they only had one headlight in stock, so they couldn’t change both, I said OK and got a soda to wait.

A while later, everything was good-to-go, I drove back to work and went home that evening. The next day was sunny.

The following day, however, was cloudy again. I turned on the headlights in the garage, and the right headlight was still out. Hmmm. I took a quick look and noticed that the LEFT headlight was new. They had changed the wrong one.

When I got back to work, I called the shop, explained the issue, and they said come over and they would make it right. (Meaning they would replace the RIGHT headlight at no charge.) After handing the keys back in, the mechanic who did the work came out and tried to convince me that he had simply followed the instructions, and it wasn’t his fault.

OK — let’s break down this situation from the perspective of quality and delivery.

Starting from the end of the story, why did the mechanic feel obligated to try to convince me that I had responsibility for a mistake that the owner had already agreed to correct? What could possibly be gained by trying to make the customer feel wrong here?

Now let’s go back to the beginning.
Customer reports a headlight is out. What is the very first thing you would do? How would you confirm the problem?

Turn on the headlights and check. This takes about 10 seconds. If there was a confusing communication about the problem, this is the time to discover it.

Once the repair has been completed, how would you confirm that it worked?
Turn on the headlights and check. This would verify that the results were as intended. (What does the customer need here? Two headlights that work.)

The other item that was on the instruction was a state safety inspection. Now I am not an expert on the New York State safety inspection, but I am willing to bet at least a can of soda that it includes the headlights. So as part of that inspection, the mechanic should turn on the headlights and check.

Even if the problem had gone undetected up to this point, it should have been caught here. Obviously the “inspection” was just a paperwork drill in this case.

Of course, as the customer, I also failed to turn on the headlights and check when I picked up the vehicle. Silly me.

What is the point of all of this?

The first step of solving any problem is to understand or verify the current condition and compare it with your expectations or standard. (More about standards and expectations later.)

Once a countermeasure had been developed and put into place, the situation must be re-checked to ensure that the countermeasure worked as intended and the process or system is back to the standard condition.

Any process has some kind of intended result. In this case, the headlight repair process should result in two headlights that work. Yet the results were not verified, and the incorrect product was delivered to the customer.

So what did all of this cost?

It cost me my time.
It cost the repair place

  • Double the mechanic time.
  • A headlight +the time to go get one during business hours (because they had not replaced the one they installed on the left two days earlier).
  • Good will. (Later, when they failed to tighten the filter after an oil change, I stopped doing business there altogether. One mistake I was willing to overlook, but I was starting to see a trend developing. I also later had some extensive maintenance and repairs done on the truck, but I didn’t have them done there because I could not trust them to change a headlight or change the oil.)

By the way, I still have the truck. It is coming up on 200,000 miles and runs great.

Back in China

At the end of the last post I promised to write more when I was over the jet-lag of returning from three weeks in China. Well.. I didn’t, and how I am back over here.

While I was in the USA I took some time off, or at least I did during my “day job.” Since I live near Seattle, it is 5:00 pm there when the people here in China get to work and the Blackberry starts buzzing. Thus I am on and off email until either: Things get quiet long enough for me to just decide to go to sleep or 2:00 am when they end the workday here at 5pm.

For better or worse, my approach here has been to try to establish from the beginning a sense that we don’t wait for an “event” to study a process and look for improvements. Instead, we study and improve every time we do it. I am trying to instill a culture that continuously compares “what is happening” vs. “what should be happening” and acts whenever there is a gap.

Overall, however, I find the main role here is to get the right people equipped with the right skills and tools, and ensure they are working on the right things, then supporting them.

“Working on the right things” means taking responsibility for what is not going to get done right now rather than assigning a dozen “#1 priorities.”

The Chalk Circle – Continued

Yesterday I wrote a little about my own experience with Taiichi Ohno’s “chalk circle” as well as some stories I have gathered from others during the years.

Although the insights I got from Iwata-sensei changed my perspective, it was some years later that a few other things got solidified.

My colleagues and I had been hired as a team of “experts” to help a major household-name company implement “lean manufacturing” into their production and logistics processes.

A couple of years into the effort, it was still a struggle.

Although there were a lot of kaizen events happening, it was a continual battle to sustain the results. We were quickly reaching the point where 100% of our effort would be expended simply re-implementing areas where we had already been. That is the danger point when forward progress stops and the program stalls.

Of course we were busy lamenting about the “lack of management commitment” to support and sustain the great work these teams were doing.

The next week we were around the table trying to figure out a countermeasure.

First we had to understand the problem.

As we talked and shared, we discovered that each of us had one area, a single operation, that was showing better results than the others. Operationally, these areas were actually quite diverse. What did they have in common?

Each of them was the area under our respective responsibility that had the weakest or no internal infrastructure for kaizen events. In fact the most successful implementations were happening in the operations that held the least number of week-long kaizen events.

Needless to say, that realization was interesting. So what else did they have in common?

Because we did not have our internally trained people leading kaizen in those areas, we were coordinating and leading the effort personally. One of us, not someone we had trained, was guiding those areas through their implementation.

Why were our results different than the people we trained? What did we do differently?

As we talked, we found that we all would take the line leaders, the managers, the people responsible, to their shop floors, and teach them how to spot problems and what to do about it.

We would stand with them, observe something happening, and ask “What do you see?” We would continue to ask questions until they saw the things that we did. Then we would begin asking about causes. “Why does this happen?” Our objective was to teach the leaders to be intensely curious about what was going on, to compare what they saw against a picture in their mind of an ideal state, and further be curious about why there was a difference.

We paid attention to progress, focused their attention into areas that needed work, and always, constantly, asked questions.

  • “What is supposed to be happening here?”
  • “What is really happening?”
  • “Is that really what you want?”
  • “Why is there a difference? What is in the way?”
  • “Does the Team Member know what to do? How do you know? How does he learn?”
  • “Is this process on track? How can you tell?”
  • “How many are supposed to be here? Why are there extras?”
  • “Why is no one working here? Where did they go?”

Not because we wanted answers, but we were teaching them the questions.

These are the same questions that Iwata-sensei was asking me years earlier.
It was an insightful and team-building moment when we realized that, in spite of our diverse backgrounds (we had not met prior to working here), we all approached things pretty much the same way. The second insight was that, in spite of our diverse backgrounds, we had all learned pretty much from the same teachers, and those teachers had been taught directly by Ohno.

If a line leader “got” what we were trying to get across, they wouldn’t ever see their operation the same way. They would be constantly comparing what they saw (what is actually happening) against some kind of expectation or standard — explicit or implicit — or against an ideal state (what should be happening).

They would see any gap between what should be happening and what was actually happening as a problem to be addressed and at the minimum, corrected.

They would begin to ask different questions of their people, and manage activities toward identifying these gaps and closing them.

Our question to ourselves was: If this worked so well, what did we have everyone else doing?

When we asked this, Dave stands up and starts through his certification program to teach his kaizen leaders how to

  • Present the various training modules
  • Prepare the various forms and reports
  • Organize kaizen events

Then someone, I don’t remember who, asked “Who is teaching the leaders how to manage the new system?”

A long pause followed.

Then Dave said, “oh shit.”

Maybe Dave said it, but we all thought it.

We had started happily blaming the leaders. Then we realized no one was teaching the leaders. THAT was our fault. We weren’t teaching anyone to teach the leaders. Now the question was “What do we do about it?”

Now we understood the current condition and the gap we needed to close.

The Essence of Jidoka

SME: The Essence of Jidoka – dead link

You can download it here.

This link is to an article I wrote for the SME online “Lean Directions” site back in 2002. I am including it on this site for the sake of completeness. I noticed that the Wikipedia article on the same subject is largely derived from this, which I simply consider flattery.