Archive for the ‘Human error prevented’ Category

Is quality the cheapest option?

November 1, 2013

Some of us instinctively think quality products should cost more. But by removing the costs of nonconformity, quality products actually cost less to produce. Nonconformity, by the way, is a failure to meet the requirements including the requirements of customers. Some managers pay the price of nonconformity instead of making quality a reality for employees and customers.

At the normal 2 or 3 sigma, the price of nonconformity is 40% of turnover. Many times the level of profit for most organizations. Leaders may not need to measure these avoidable costs to eliminate the causes of failures to meet requirements from their systems. They may even help their suppliers to remove these avoidable costs too.

But more product verification will not help because it is too late. Inspection or testing merely sorts bad product from good product. Therefore, verification of the product is part of the price paid for failing to design capable processes. Capable processes are validated to result in products that need no inspection or testing.

Accordingly, we work to make sure our organizational management systems help employees and suppliers to add value for each customer. Adding value faster while preventing loss sooner. Having prevented nonconformity in our goods, we should also design the service part of our products so we avoid paying the price of service nonconformity too.

Leaders, who choose to avoid paying the price of nonconformity, invest in their process-based organizational management systems so more work is right the first time. They discover that buying and delivering quality costs a lot less than the alternatives. What’s more, in markets, where quality rarely is delivered, customers may be willing to pay a little more to have their requirements fulfilled exactly.

Even so, “quality is free” because it is cheaper to buy and deliver quality than not. Here we see the cost of quality at its lowest when the product exactly meets the requirements of the customer:

Earlier versions of these cost of quality curves mistakenly showed costs tending to infinity with perfection. The old curves showed perfection is not quality. Thankfully, in 1999, these curves were corrected to accord with reality and Crosby’s 1979 definition of quality. Of course, by then Taguchi had also showed that any deviation from the requirement increases costs to society.

In summary, managers of quality prevent nonconforming products to assure quality and satisfy customers. They govern their organizational management systems for creating more successful customers by making and keeping more competitive promises. Tomorrow’s managers of quality will also be focused on sustainability for all by creating more successful stakeholders.

As we can see, designing and producing quality remains the cheapest sustainable option.

What level of human error is acceptable?

September 17, 2013

Even competent humans make mistakes. Mistakes may not result in failures to meet requirements. Some systems evolve to become tolerant of mistakes or some organizations employ their management systems to prevent nonconformity.

The only bad nonconformity it the one we do not know about.

Understanding this fact is the key for leaders and their managers being careful not to create a culture that hides nonconformity.

Even so it is common for managers to demand no mistakes and to react badly to errors.

Leading organizations provide employees with management systems that help them to understand and fulfill the requirements. And servant leaders provide a management system to help their employees to eliminate the causes of nonconformity. They do this gradually, according to the 80:20 (or 50:4) rule, so they always start with the vital few nonconformities that cost the most.

Zero Defects (zero nonconformity actually) has to come with humble managers who take responsibility for their management system causing the nonconformity. Care and respect remain to most powerful parts of such management systems. It should not require courage for employees to talk about problems in doing the right work right.

These organizations welcome nonconformity reports to show where the management system needs further improvement to prevent failures to fulfill requirements. They know the only bad nonconformity is the one that remains hidden.

The primacy of process

November 3, 2012

Many people confuse processes with procedures. Processes are the work of cross-functional teams. Procedures are the specified way of doing the work. Procedures can be mind-numbing for competent workers especially when they specify unnecessary detail or are used instead of training.

A process may or may not add value. A procedure may or may not be effective and may or may not be documented.

Processes are the counterculture where the culture is for functions to congregate in departments to politick for promotion. Such departmental thinking has to change for the functions to coordinate their work to form a joined-up process to create more successful customers.

Indeed, processes refocus workers from keeping old-style departmental bosses happy to collaborate in satisfying customers. Processes that add value to inputs are the lifeblood of organizations that want to create more successful customers. This makes the new-style process bosses very happy.

Processes usually bring resources and controls so the work of humans can add value to a wide variety of inputs. Resources include skills, knowledge, facilities and equipment. Controls include care, coordination, methods and decisions. Get the inputs, resources and controls right and the output will be free from defects and other failures to fulfill requirements

Middle managers add value by coordinating, monitoring and improving the performance of cross-functional process teams to make sure everyone has what they need to keep their work in balance with customer demand. When customer demand reduces, middle managers or coaches help process teams improve their skills, facilities, equipment, methods or remove kinks from their processes. Or, as a last resort, they may be redeployed to under-resourced processes.

Leaders add value by establishing and living the values that impart care for customers and the requirements of other stakeholders. They ensure their organizations work effectively as systems to direct, nurture, support, redesign and remove processes as necessary to fulfill the organization’s mission. Small companies grow and become successful by providing value and continually improving their management systems, processes and products.

Process Management within well-designed systems are necessary for our work to pay our way in this world as we create more successful customers.

Justifiably Confident Leaders

July 27, 2012

Quality, it can be said, is about making and keeping competitive promises that result in more successful stakeholders. Indeed, this is the basis for quality coming from individuals, processes and organizations that meet requirements.

Never question the commitment of senior managers; only their ability to show their commitment to requirements by what they say and do. Recognize that they can feel uncertain, embarrassed or powerless talking about quality leading to actions that may send the opposite message to that intended.

Leaders tend to avoid talking about quality, or showing their commitment to requirements, unless:

A. They agree on what exactly quality means to them and those who rely on them;
B. They have the means to manage quality proactively with their process-based organizational management system; and
C. They know how their organization works as a system to deliver quality.

Once you have A, B and C in place then run an awareness leaders workshop for them. Do not proceed with the workshop unless all three aspects are in place. For example, take action to deliver B if the management system attempts to deliver quality by overreliance on product inspection.

This workshop enables the leaders to develop their message and prepare to explain how their management system brings obligations and benefits as it helps employees and suppliers to determine and meet requirements.

Once suitably equipped and prepared as recommended above, the leaders should feel confident enough to visibly demonstrate their commitment to quality and remove causes of doubt and fear every day of the week.

Before this the leaders will remain unsure about quality and their organization’s ability to keep its promises.

A bad system will defeat a good person every time

March 17, 2012

How can the organizational management system help its users to manage quality while reducing costs to provide long term employment by creating more successful customers?

Realizing quality goods and services is the result of quality processes. Quality is not the result of inspecting the products of badly designed processes. Quality is meeting all customer requirements. Customer requirements include timeliness, affordability and sustainability. Customers need to feel good about what they buy. And a customer is anyone receiving the results of the organization’s work. Quality means more customers are more successful.

Beyond the obvious, customers have many requirements that are hidden. Designers have to elicit and anticipate customer requirements. Designers of products (goods and services) convert customer needs into product requirements as specifications. Designers of production processes enable work to add value faster and prevent loss while fulfilling the requirements for the product. Investors or donors are attracted to organizations that do this well. They invest in the organization’s ability to anticipate and meet customer requirements without undue waste.

Knowing this is not enough. As Dr Deming famously said “A bad system will defeat a good person every time.” Management system professionals help everyone to understand their organization as a system. They help organizations develop the attitudes and processes necessary to assure the quality of their performance by preventing nonconformity.

Blame culture

January 19, 2012

Are we still blaming each other for the poor performance of the systems in which we work?

Recognizing and fulfilling the needs of customers. Doing this as efficiently as possible should be common sense.

Here are a few examples of how human nature gets in the way of common sense:

· We gather in tribes of the same function. Perhaps we do this to share stories or to keep the boss happy for promotion. Cross-functional process teams, not departments, serve customers.

· Employees learn that authority figures are not interested in problems. Employees keep quiet in fear of reporting potential (and actual) failures to meet requirements.

· Authority figures focus on reducing short-term costs. They have little or no regard for something as nebulous or avoidable as quality.

· Authority figures measure production output. They may even count defective output for their bonus. They seem to place little or no value on planning and designing reliable processes.

· Authority figures rely on inspection. Paying the price of sorting bad product from good product. Instead of investing in helping teams to get their processes right.

· People with quality in their job titles gather in the “we know best” department. Many do not develop their organizational systems to help the workers to deliver quality.

· Collections of wordy quality procedures are called systems. Disengaged employees know compliance is the rule.

· Undocumented but crucial parts of management systems (such as care and respect) are ignored, neglected or deemed unimportant.

Alienation and frustration may be the consequence.

Or can we be courageous and take action to encourage our other behaviours?

We may end up with process-based management systems that enable self-directed work to help teams to determine and fulfill stakeholder requirements.

Quality professionals may need to start by learning human factors. Then we can remove the fear by change the blame culture.

We can show how managing quality reduces costs and how managing short-term costs reduces quality and increases long-term costs.

Let us turn the authority figures into leaders, managers and supervisors. Leaders helping their process teams to understand and fulfill requirements.

Let us collaborate to manage quality so we reduce costs.

This is how we improve the rewards from our work for customers, employees, shareholders and leaders.

Why always seek to reduce variation?

December 13, 2011

Thanks for asking why we should always seek to reduce variation (after taking the actions mentioned earlier).

Agreed, innovation in revealing and fulfilling yet more customer needs (including the psychological need for expectations to be satisfied) is indeed the key to success in a consumer-driven economy.

So is the design and operation of reliable production processes through mistake-proofing.

Unreliable processes may cause the people involved to increase the amount of work in progress “just in case” something goes wrong with an earlier process (or be idle).

Customers are expected to pay directly for this wasted inventory (and time) up and down the supply chains. The rest of us pay the avoidable environmental costs of waste.

Competitors with reliable processes waste less so they can afford to reduce their prices while making more profit to share with employees, shareholders and as taxpayers.

Competitors with reliable processes may yield more as taxpayers, attract more investment and attract more creative employees for innovation.

Our economy (some of the taxes could be invested in educating and training people for more creative and fulfilling lives) and our environment thereby benefit from reliable processes. .

Hence, we can see a virtuous cycle arising from the widespread design and operation of reliable production processes to result in products that fulfill the needs of paying customers.

Processes with more dependability should be a result of developing and running process-based management systems.

Within these systems people may cost effectively eliminate the “vital few” special and common causes of variation after designing to eliminate causes of nonconformity.

Such is the importance of organizations running reliable processes to result in needed goods and services.

Reasons ISO 9001 projects fail or succeed

September 26, 2011

Big Q thinking says everything the organization does is for quality. Organizational thinking in this way can result in highly successful holistic system development projects. Some organizations, though, are stuck in little-q thinking, perhaps kept in that state of mind by their dying QC department.

Since 1986 here are four reasons we have observed for organizations failing to obtain the full benefits of ISO 9001:

1. The leaders are not willing volunteers in developing their system.
2. The leaders ignore the system that actually is their organization.
3. The leaders delegate implementation of procedures written around ISO 9001 instead.
4. The quality professionals do not include the financial processes in the management system.

The key to developing a process-based management system is to go with the flow of work in the organization.

Embark on a voyage of discovery rather than implementing a standard:

A. Discover what the organization already does to determine customer requirements (and get paid for meeting them).
B. Discover what the organization already does to fulfill these and other requirements.
C. Discover the processes in the management system (and determine any new ones needed by the management system).
D. Discover what is done in each process to prevent nonconformity instead of how nonconformity is detected.

Telling an individual to implement ISO 9001 is not a good idea. The system development project needs a cross-functional team that is able to analyze its system, determine its key processes and analyze each of those key processes and their interactions.

Just a few of the management system’s processes need to be newly designed and implemented after training of the process team.

Respect the system that is the organization otherwise the system development project will fail. One way to do this is to use the “as-is rule”. Document the process lightly as it is not as you would like it to be. Then, by using and improving the management system it will cause any needed improvements and grow the detail where needed.

What if the process is so bad it does not conform to the standard? Well then, use the two-week rule: record the nonconformity and say “you have a fortnight to correct the process then we will re-document the improved process as it is”. If too difficult to correct in two weeks then feed the nonconformity into an early corrective action using the newly developed management system.

A summary of common mistakes:

i) Leaders not showing their commitment to requirements.
ii) Putting the documented procedure ahead of the process.
iii) Ignoring the system that is the organization.
iv) Implementing ISO 9001 instead of developing the organization’s existing management system.

The system should help people to determine and meet requirements including the requirement for continual improvement. The procedures should be owned by the people not the “we know best department”. That way QA is delivered as a result of everyone using their management system to fulfill requirements.

Learn how to do this for yourselves here.

More Prevention = Less Cure

June 20, 2011

Crosby succeeded in helping organizations to realize that defects need not be inevitable.

For many organizations this was the beginning of their serious investment in their system of prevention.

Such investments in the removal of common cause variation from the system reduced the money wasted on detection and failure (the price managers once were happy to pay for not preventing nonconformity).

ISO 9001 specifies what must be done for the management system to prevent nonconformity (covering two of Crosby’s four absolutes).

All this prevention should enable organizations to remove common cause variation from the system instead of dealing with an abundance of misbehaving processes. Drive out special causes of nonconformity with PONC information (see C below).

Ongoing cycles of repeated preventive action (and corrective action) further improve the management system and its processes.

As your management system matures invest in three more processes:

A. Analyzing failure modes (and success modes) and their effects (preventive if FMEA/SMEA is used during design)
B. Mistake proofing processes and products (preventive)
C. Reporting the price of nonconformity (reactive)

Crosby’s “zero defects” said it is better to prevent defects than to rely on statistical process control and we agree.

Prevention of Nonconformity by Design

May 11, 2011

Even competent people make mistakes. Consumers misuse poorly designed products perhaps injuring themselves or others. Competent employees may not operate confusing, boring or complex processes as intended. Human factors should be considered when planning and designing systems, processes, goods and services.

The development, use and improvement of the management system should prevent problems instead of relying on their detection. Relying on warning labels to warn customers is less effective than planning and designing products so they cannot be used or operated wrongly. Verifying services and goods is less effective than designing delivery or manufacture to avoid nonconformity.

Unsustainable wastes arise from poor design failing to protect stakeholders from incurring more and more of these losses. Additional resources used to make good the poor quality further damage the environment and adversely impact sustainability.

The prevention of nonconformity in goods, services and processes is a paradigm change from the control of nonconformity. Sorting bad product from good product is less efficient than prevention to stop the design of nonconformity or situations that cause nonconformity.

Prevention focuses first on reducing complexity in design. The most expensive mistakes can then economically be prevented in delivery or manufacture by mistake-proofing. Remaining causes of variation that result in any defective products may then be eliminated. This progression applies to the design of all products and the processes and tooling necessary to deliver conforming products.

Prevention offers a more robust approach to quality assurance than appraisal. It may require major changes in management philosophy, such as shifting the responsibilities for quality assurance into the operating organizations to remove complexity from designs, mistake-proofing service delivery, mistake-proofing manufacturing, statistical process control and verification. Conventional quality assurance organizations may change or decrease in size and importance in organizations applying the prevention principle.

Hence, design is the only way to prevent nonconformity when creating and delivering goods and services.

An organization preventing nonconformity by design will:

1. Establish the metrics for prevention of nonconformity by design (starting with design simplification criteria);

2. Identify the stakeholders affected by the system, product, its processes and the related outcomes;

3. Determine the needs of the customers and the concerns of other stakeholders;

4. Specify measureable and achievable characteristics of the product;

5. Specify the critical methods, resources and controls (including mistake-proofing as required) for correctly making, delivering and safely using conforming products;

6. Fulfill the system, product and process designs with capable processes.

7. Monitor and measure the design process per the established metrics; and

8. Review the design process against stakeholder satisfaction information.