Checklist Manifesto by Atul Gawande... Review of the week

Today, I will start writing about some books, articles, and sources of information about Lean & also 6 Sigma. Since I´m close to 1000 visits to this blog, and I´m super excited, wanted to share with you my thoughts on The Checklist Manifesto by Atul Gawande.

I came across this book, because I was struggling to implement a control tool on a warehouse and needed to get some fuel about what others have accomplished or what other organizations have implemented with success. The Title, The Checklist Manifesto was for me, intriguing. As I have stated on other posts, my background is on the Manufacturing Side, so I remember that once I ran an experiment to try between different tools and demonstrate, with data, which one was the most effective to avoid mistakes. Checklist, was the last tool. Which in my studio meant that it was the least reliable tool of all. Because usually we all start with great enthusiasm using it, but eventually stop doing it, and obviously, doesn´t work anymore. In my studio, a better tool would be a poka yoke, or an error proofing. Andons, proved to be more effective than Checklists, so my curiosity grew. What can a surgeon teach me about how to control a process? I asked my self. Also thought that when there is stagnation in one´s mind, anything out of the box, could lead to pretty good ideas. So I gave it a shot.

Glad I did, the book was a revelation to me. Not because it was a bout checklists, but because it was well written, sometimes looks like I was reading a novel instead of a book about check lists and because If you read carefully, will find elements from Lean that, I don´t think were put there intentionally but In Dr. Atul Gawande may lie a lean thinker, and I´m not sure he is even aware of it.

The chapters will get you in a instant. From the description where a patient almost dies in a hospital because some extraordinary situation at the beginning of the book, to the story where Dr. Gawande almost kills a patient and how his Checklist helped him to save the patients life. There are also good episodes about flying complications and how aviation uses Checklists to control the uncontrollable, or to expect the unexpected. In one chapter Gawande, writes about how flying in poor weather conditions (extremely cold conditions) may lead to ice in the gasoline (or should I say turbosine). This small issue may lead to one potential catastrophe, as one of the engines would not receive enough fuel, and fail. How should captain and first officer  handle an issue like that? With a Checklist, Dr. Gawande should have answered. 

The book isn´t about Checklists. I believe the book talks about Standard Work and how Standard Work helps any industry, from aviation, to construction to health improving the way they work on a daily basis. The book is really about Standardization and describes the discipline to follow procedures. In it, Dr. Atul Gawande gives great examples. Like the terrifying case, that happened a few years ago, where an US Airways flight had to land in the Hudson River. In that case, Dr. Gawande, examines how a goose strike had the plane lost both engines, forcing Captain Sullenberg to land on the icy waters of Hudson. This January, was five years from that "lucky" event. As I was explaining, Dr. Atul examines and concludes that it was due to the exceptional discipline of captain and his first officer, that this miracle was possible. There is no surprise, Standardization requires a great degree of discipline to make sure we stick to the procedure. And often, the results are surprising. That´s why in my studio Checklists didn´t work. But to me, the book talks more about why is Standardisation needed. I believe it is first of all, because it helps to stabilize any process. Removes variation from it. Sets the ground for improvements. Not easy, but the benefits outlooks the sacrifice. I believe this is why, the captain following the procedure, was able to land on Hudson River. Also, the process was really robust and helped the captain to get a good result. In the Book you will read about Dr. Atul´s attemps to set up a checklist for his operating room, and how experimentation was vital, and allowed innovation. This is key. This is really what Lean is about. Experimenting, learning and evolving.

This is really what Lean is about. Experimenting, learning and evolving.

The other nice part that I found in this book, was when Dr. Atul tells how he joined an organization to improve safety across different hospitals in the world. That story reminded me, the old one about the Toyota Sienna development for the American market. I found similarities in the way Dr. Atul went to Gemba and visited the hospitals that would implement the Checklist. How he saw the problems each hospital faced and how each hospital adopted the Checklist, twisting a little bit, to make it fit to each organization, talks about experimentation, learning and improvement.

I´m sure there are other details that I forgot to mention, but this two principles are so clear in the book. So I urge you to read it with fresh eyes. My advice is to read it and see if you can identify some other similarities to the ones explained here, and why not, comment weather or not agree with this review.

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How Lean Affects the lives of practitioners; a personal journey

To my eyes, looks like Lean practitioners are preparing themselves at all times. It`s not surprise that a typical Lean practitioner writes about the latest book he has readen, share with the audience personnel reflections on situations from work or from his/her own impressions about the latest news.

They seem to be well informed, with the aim of improve their lives, expand their knowledge and looking for weaknesses, in order to improve.

Lean practitioners seem to be constantly preparing themselves
 absorbing knowledge from other authors.

This is intrinsic in the Lean methodology/philosophy. The aim for continuous improvement, never be satisfy, seak for perfection. Lean really gets to the heart of the people. First because they seem to take pride and joy on their work. Also because they believe what they preach. Lean is, for me, about people as it is a system to advance and overcome obstacles. Being people one of the key elements on it, should`t surprise us that Lean practitioners, try to improve their lives as well as their work.

Lean is a journey, a personal one.

It is common that when talking about Lean, companies and practitioners say it is a journey. It`s true. So much has happened, since Toyota started with the idea of stop manufacturing looms and started manufacturing cars. Also so much happened since Deming taught the western industry how to remain competitive and defeat Japanese competition.

And much more, since most big companies started to embrace Lean and some, started to combine it with Six Sigma. Lean has evolved too. But the main principles, remain. Despite the technology, new trends, competition and troubles in the world (Remember 2008 recession) Lean is still the way to improve with the people, and therefore achieve break through results. For pratitioners it`s hard to separate the knowledge and experience acquired through lean from their lives. Usually, Lean practitioners, add their personnel learnings into Lean deployments and their work in general, which seems to resemble old Buddhist masters than business men.

One key characteristic I have found in them, is the knowledge in themselves. They are able to know their weaknesses  as well as their strenghts. That, I believe is a signal of humility and the continuous quest for perfection. Because as you know what to improve in yourself, would be easier to actually improve and evolve as a person and practitioner.

Sharing some personal improvements.

I don`t consider myself an expert or highly skilled Lean practitioner. Since I have been practicing Lean for 6 years now, and still got so much to learn. But right now, I`m going through a period of transformation. Both physical and mental. Since I have started a new nutritional regime to improve my weight, and finally my health.  also through a mental change, since I`m working with a therapist to improve certain aspects in my personality that will improve my quality of life, and I`m sure, will impact my professional life as well.  I know this aren´t the final changes I would be doing. I feel that the more I know about Lean, the more I embrace change easily. I know too, this isn´t easy. Many people do not embrace change as easily, mainly because every change involves leaving old ways and try something new. But to be honest, once one start practicing Lean, and when results are visible it´s  almost like a drug. You can´t stop trying new things.

But not everything is cool in change. For me, accepting that help was needed, wasn´t that simple. Sometimes, may get the feeling that no help is required, since in reality, we help people, we don´t get help. Ego is speaking. And to be honest is tough, accepting that we aren´t superman. It takes guts and humility to understand that before practitioners, we are humans. And as any other human we, sometimes need help. Sometimes that help comes in the form of a therapist, or a personal trainer, or a mentor. Or sometimes a friend, who is able to listen and give some advice. 

It´s true. Lean changes people for the better.

Thanks for reading, I would love to read about changes in your personal life, work or else. Or maybe you're reading something that´s worth telling us about. Please leave a comment or just share if you like this post.

Western Obsession for recipes and The five why`s technique.

These days I have thought a lot about how western culture seems to be seeking recipes for success in all areas. In general we all look to follow a method, a scientific way to find solutions, to find success, to achieve what companies such as Toyota has in almost a century of making cars. I guess that`s why people in general is a fan of Checklists. Speaking of which, I will be reviewing The Checklist Manifesto by Dr. Atul Gawande in a future post. But anyway. I believe we like this tools because we believe it is a safe way to go into the wild. To reduce risks, and to maximize the chances of success.

This is no trivial because this obsession I believe, lead Motorola & GE to develop the well know 6 sigma methodology.

I have no evidence to support this last statement but I believe that`s why 6 Sigma was born on this side of the planet, well a little bit up North. But as the next article about Six Sigma in Asia sort of explains, difference between Western and Asian Cultures are noticeable.

Lean on the other hand, comes  (as we all know) from Japan, born within the walls of Toyota and to my eyes, Lean is first about people and principles, and when followed and applied, derive in efficient tools that can be apply to a wide range of situations. I believe that cultural difference were significant and were crucial when the first western learners took these information and export them into the US. Of course language was the greatest barrier to fully understand the principles and tools from Toyota. But I think that it was also the obsession to have a recipe for success, which lead to receive some sort of distorted tools and lack of understanding of principles. Fortunately there are leaders such as Mark Graban, Steven Spear, Karen Martin, John Shook, and many others that have helped to clarify and expand the knowledge across industries.

Why?

All this introduction is to support the following story. I was recently working with a crew making a root cause analysis. Claims have been high for the past weeks and we wanted to know why. It is a requirement that the root cause analysis would be conducted through a Fishbone diagram, a 5 whys technique or both. I prefer other techniques or tools since I believe this could be biased if these tools aren´t supported by evidence. I will explain later why. In this sense, I have always asked myself, how did the creator of the 5 whys defined that 5 were enough? Why asking why and not when, how, who, and others? And why corporations are so emphatic to specifically use 5 whys only? I believe this tool didn´t captured correctly the spirit of improvement, when first brought to America. The key point here is to dive into the issue and asking why,  accompanied by who, when, how, how many etc. Of course, also having facts, and/or data. Understand the problem is the main idea. During the session to capture ideas and define what was the root cause, I didn´t use the 5 whys as the company demands. Instead, requested evidence, data, facts and it was more like a dialogue. A discussion with the team members, to understand the underlying issue causing all of the symptoms. I guess we did a pretty good job, and more important is that people got involved. My personal conclusions are that sometimes you got to use the tool that fits better the problem you`re facing. Or as the Lean practitioners say, according to the problem that you`re trying to solve.

Why do I think these tools could be biased?

Because the way they have been thought. For example, I was taught that a 5 whys technique, you should start asking why is this problem happening? answering because..., and then ask why again on the response given, and answer again, and after asking 5 whys you´ll have the root cause. But if this is based on unverified assumptions our mind can trick us, and lead the solution where our subconscious wants. I´ll give an example:

On the same exercise, one of the team members pointed out the valid fact that we had new personnel and if training was´t complete and properly executed of course quality would decrease. We have an unusual high rotation, influenced by a number of different factors. So we dived on the lack of training of new personnel. Everybody agreed that it would be an issue. But is it an issue today? not sure. One of the supervisors said, "I think it does´t have anything to do. We know our training isn´t the best but is not the main issue right now".

Lets conduct a 5 whys before knowing how the story ends.

Lack of training on new personnel.

Why? Because there isn´t enough time to train. 

Why? Because our supervisors are in a hurry. 

Why? Because they need the job done. 

Why? Because they don´t like to give explanations. 

Why? Because they may be under evaluated. So the problem is originated by the trimestral evaluations right? But wait, what if we dive a little bit?

What if the issue isn´t due to the evaluations?

The issue must be due to the training program right?

Ok, will see what the 5 whys reveal.

Lack of training on new personnel.

Why? Because the training program isn´t properly designed. 

Why? Because it was designed by HR. 

Why? Because no operator or supervisor was involved. 

Why? Because they were busy. Why? because they didn´t have time. 

Why? Because needed to get the jobs done. Wow! this tool is really efficient right?. Both analysis lead to the semestral evaluation. So if we wanted to fix this issue, all we have to do is get rid of the semestral evaluations.

That would have been the answer if we didn´t have evidence. Note that I just conducted this analysis just with assumptions. The action on eliminating the semestral evaluations would have an effect on the organization. No doubt about it, but I`m not sure that would have an impact on claims.

I asked why to the supervisor, and he replied:

"Because the people with higher mistakes, are experienced people and relatively new people, look". And showed his graph were it was clear that something in the process apart from training, was causing the claims. But the  evidence suggested that training, even though, might be susceptible of improvement was´t the primary source of variation creating claims. Everybody agreed and we moved on to the next possible cause.

Thank`s for reading. If you liked this post, please share. If you do not agree with me, please share some knowledge. If you didn´t like it, please tell me why. That´s how we can improve.

Having the right tools to succeed .

A year ago, I was making some improvements to a small laboratory where steel was tested for both, physical and mechanical properties. One young engineer told me, while we were changing the layout for each of our desks:

"You know, somebody told me once, that you are as good as the tools at your disposal".

I didn´t truly believe this back then, but a few months later and even now, I totally agree. It is true that to be successful in life and at work, you need to have the right tools at the right time. Not only tools, but also the right systems, the right thinking and the right people to perform.

When I was a quality Engineer working as Chassis VRT, one of my responsibilities was to check for vehicle´s alignment on a daily basis. I used to check SPC charts for each and everyone of the alignment characteristics. I used to spend like two hours everyday analyzing, identifying trends, making decisions wether or not make and adjustment on alignment pits. Used to check for CpK, special cause variation, common cause variation, and the usual stuff you should check when using SPC to understand what´s going on with the process, as you can learn if you read Understanding Variation: The key to managing chaos which is a great book that helps to really understand what data is telling you. Anyway, I´m not here to discuss how great this book is. Instead I want to reflect my thoughts on the tools to be really effective. So, back to cars alignment, even though it was kind of boring and it was really a routine, now looking back, it was pretty cool. Because the information was at my disposal anytime, real time. So if I was having a trouble with alignment and decided to make and adjustment, almost immediately could see the effect of that adjustment on my SPC chart. I used to ask to the SPC coordinator to increase the sample to validate if my decision was right or wrong. 

IMR Chart from Minitab. The ones that I used to analyze alignment
were almost identical to this one.

This approach of discipline and careful analysis lead to the cars under my responsibility to be number one within Ford´s lineup in Northamerica, regarding alignment. But this success isn´t entirely mine. Have to give credit to the company who had the right tools at the right time for me to perform. Without an SPC program would have been very difficult to understand what was happening on the floor. Without a system that would give me information on real time, would´t have been able to detect problems and correct quickly to protect the customer. Without the person, doing the audit, couldn't write on my resume that I lead that car line to be the best in NA for alignment. My message isn´t that you need a fancy software, spend millions on a system for you to be successful. But to recognize that if you want to perform, need the right tools at the right time. Ford used a software to gather data. But could it be a sheet of paper instead of the fancy software to record the data? Of course it could! Could it be that the operator doing alignment, performed the audit as well? Hell no! cycle time wouldn´t have allowed. Also, alignment audit needs to be really precise and  at that time, cycle time was 10 min. per vehicle. 

Many companies fail to recognize this simple statement, and embark in a journey to practice lean without a foundation to sustain and to get the best of it. Do not change the old managerial practices or just want to implement tools, without changing their minds. Some others want to adopt a 6 sigma approach, without SPC programs, without tools to help the practitioner to perform analysis in a quick manner. Or without a data base to simply extract information for analysis. 

Organizations need to stop thinking that simplicity means austerity. Some do not want to expend on tools that are necessary for the workers to perform. In my example regarding vehicle´s alignment, I felt it was my responsibility to perform and respond, since I had everything I needed to get results. For me not getting results under those circumstances, meant failure. That´s the kind of engagement and pride we could introduce in the life of workers. As Mark Graban explains so well on his blog, on the book The Good Jobs Strategy many successful organizations prove that investing on the right things will benefit the bottom line.

Have you ever felt like don`t have the tools you need to perform? How is that making you feel? If you do have the tools to perform, Do you feel compelled to success? Please join the discussion and share your thoughts.

Thanks for reading, will be in touch.