Reporting mistakes or near misses are an important topic to me, yet it is the least discussed in the business world. Why is there not a cultural environment allowing reporting of mistakes or near misses? What brought this to mind was an article on poka-yokes titled, “It’s Not Rocket Science” by the Old Lean Dude of GBMP (Bruce). This was also brought out in the book, “The Nun and the Bureaucrat” by Louis M. Savary and Clare Crawford-Mason, which was accompanied with a documentary CD titled, “Good News . . . How Hospitals Heal Themselves”. The point being made was, how can we improve our processes if we keep wanting to point blame for mistakes and near misses?
My experience has been, when team members tell me they inadvertently induced something into the process to create a bad part (caused variation), or just plain mixed up the sequence, I would say out loud “Cool, there is something I can improve!” And I thank them for giving me this opportunity (yes, I really do that). The team member now becomes my customer whom I have to satisfy.
As the Old Lean Dude pointed out, hassles create stress for the employee. Think of it as employee harassment if you will. We have been educated on harassment and how it can affect people. In harassment you do not say or do certain things that can be construed as offensive, making the other person uncomfortable, making the other person wanting to stay away from you, work in another area, or sometimes just plain quit the company. In other words, stress. Punishing team members for mistakes becomes stressful too. The environment for reporting should be the opposite of harassment, meaning you Want to report you did something wrong that created the defect or defective product / service / information, and without ridicule or fear of a write up.
The nice thing about a team member reporting a mistake is that they made it, they can tell you about how they made it, and most likely they have a solution to prevent it from happening again - a poka-yoke. Is their suggestion always the best one? Sometimes, and sometimes not, however Never say No to their suggestion. Think about it, ask yourself why would they choose such a solution, how does it affect safety, the process, quality, the human side of standardized work? Can everyone else use the poka-yoke with the same success? Does it add too much cycle time or perhaps reduce cycle time? There are many questions to ask. As you ask, use that team member as your sounding board, weighing the pros and cons, developing a better mouse trap by piggybacking of the team member’s solution to developing perhaps a better solution. Do not revert to the 8th waste - under-utilization of human resource.
Another piece of information from both the above references was “near misses”. It seems all of the team members know about the near misses, but never the supervisor. I agree. Near misses are caused by the process, and the team members have learned how to deal with them because the supervisor does not want to. These near misses may be a greater portion of waste than we realize. It causes the team member to develop work arounds. It burdens the team member with more responsibility/hindrance to meet TAKT. This is where production boards need to be put in place and the team members allowed to write in misses and mistakes that caused missed pitch/cycle/TAKT in the process. This should be a “no blame” board. It is then the supervisors Standardized Work to review this board, assign responsibility to resolve these issues, set the due date for closure, and to report to management.
Communication is the most sought after tool, yet it is one of the lower skill sets each of us have. We may talk well, persuade well. But do we listen well, empathize well, show concern in our posture, facial expression, and eye contact. Why are team members afraid to report mistakes? Is it because supervisors do not care or not wanting the added responsibility? Or, is this totally different in that the team member is tired of reporting and seeing nothing ever done? Most likely both.
One other credit I want to give to the Old Lean Dude is the quote he cited, “Creativity comes from involvement” by Rollo May. And as the Old Lean Dude wrote, “No one cares more about the quality of a job than the person doing it . . .” Mistakes are good. We learn from them. I have made plenty and will make plenty more, and will be very vocal admitting when I do. How else do we (or the process we work within) improve?
I would like to leave you with the following quotes:
“Motivation is everything, tools and methods are secondary. Any tool or method will work if people are motivated. And no tool or method will work if people are not motivated.” – Michinkazu Tanaka (What I learned from Taiichi Ohno)
“People working together with integrity and authenticity and collective intelligence are profoundly more effective as a business than people living together based on politics, game playing, and narrow self interest.” – Senge
“I have not failed. I’ve just found 10,000 ways that won’t work.” – Thomas Edison
And lastly:
“Never listen to the shop veterans . . . wisdom is born from the ideas of the novices.” – Taiichi Ohno
My experience has been, when team members tell me they inadvertently induced something into the process to create a bad part (caused variation), or just plain mixed up the sequence, I would say out loud “Cool, there is something I can improve!” And I thank them for giving me this opportunity (yes, I really do that). The team member now becomes my customer whom I have to satisfy.
As the Old Lean Dude pointed out, hassles create stress for the employee. Think of it as employee harassment if you will. We have been educated on harassment and how it can affect people. In harassment you do not say or do certain things that can be construed as offensive, making the other person uncomfortable, making the other person wanting to stay away from you, work in another area, or sometimes just plain quit the company. In other words, stress. Punishing team members for mistakes becomes stressful too. The environment for reporting should be the opposite of harassment, meaning you Want to report you did something wrong that created the defect or defective product / service / information, and without ridicule or fear of a write up.
The nice thing about a team member reporting a mistake is that they made it, they can tell you about how they made it, and most likely they have a solution to prevent it from happening again - a poka-yoke. Is their suggestion always the best one? Sometimes, and sometimes not, however Never say No to their suggestion. Think about it, ask yourself why would they choose such a solution, how does it affect safety, the process, quality, the human side of standardized work? Can everyone else use the poka-yoke with the same success? Does it add too much cycle time or perhaps reduce cycle time? There are many questions to ask. As you ask, use that team member as your sounding board, weighing the pros and cons, developing a better mouse trap by piggybacking of the team member’s solution to developing perhaps a better solution. Do not revert to the 8th waste - under-utilization of human resource.
Another piece of information from both the above references was “near misses”. It seems all of the team members know about the near misses, but never the supervisor. I agree. Near misses are caused by the process, and the team members have learned how to deal with them because the supervisor does not want to. These near misses may be a greater portion of waste than we realize. It causes the team member to develop work arounds. It burdens the team member with more responsibility/hindrance to meet TAKT. This is where production boards need to be put in place and the team members allowed to write in misses and mistakes that caused missed pitch/cycle/TAKT in the process. This should be a “no blame” board. It is then the supervisors Standardized Work to review this board, assign responsibility to resolve these issues, set the due date for closure, and to report to management.
Communication is the most sought after tool, yet it is one of the lower skill sets each of us have. We may talk well, persuade well. But do we listen well, empathize well, show concern in our posture, facial expression, and eye contact. Why are team members afraid to report mistakes? Is it because supervisors do not care or not wanting the added responsibility? Or, is this totally different in that the team member is tired of reporting and seeing nothing ever done? Most likely both.
One other credit I want to give to the Old Lean Dude is the quote he cited, “Creativity comes from involvement” by Rollo May. And as the Old Lean Dude wrote, “No one cares more about the quality of a job than the person doing it . . .” Mistakes are good. We learn from them. I have made plenty and will make plenty more, and will be very vocal admitting when I do. How else do we (or the process we work within) improve?
I would like to leave you with the following quotes:
“Motivation is everything, tools and methods are secondary. Any tool or method will work if people are motivated. And no tool or method will work if people are not motivated.” – Michinkazu Tanaka (What I learned from Taiichi Ohno)
“People working together with integrity and authenticity and collective intelligence are profoundly more effective as a business than people living together based on politics, game playing, and narrow self interest.” – Senge
“I have not failed. I’ve just found 10,000 ways that won’t work.” – Thomas Edison
And lastly:
“Never listen to the shop veterans . . . wisdom is born from the ideas of the novices.” – Taiichi Ohno
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