Why Our Process Improvement Fixes Fail
This post looks at why our process improvement fixes fail. More importantly, it gives you tangible ways to help fix those problems.
There is a psychological pattern that causes many of our process improvement fixes to fail. Over the past forty-plus years, I have seen tens of thousands of corrective and preventive actions. After a while, a pattern began to emerge. I saw the same pattern with attempts to address ‘unsafe act’ and ‘unsafe condition’ audit findings.
It wasn’t just the ‘weak fix’ pattern many people see in their organizations. You know what I mean by weak fixes. Think of your favorite retraining, procedure expanding, and punishment focused changes. Instead, it was a pattern of a less visible nature.
In a nutshell, here is what I saw:
Our fixes tend to be weak, and in turn fail, when we blame people and equipment for our problems.
The root causes we select set the stage for weak versus strong corrective actions. Those root causes are a result of the root cause questions we ask, how we collect and analyze evidence, and the design of the root cause analysis process itself.
As Henry Ford said, “If you always do what you’ve always done, you will always get what you’ve always got.”
What Causes Your Process Improvement Fixes to Fail?
When a person attempts to write a corrective action to address a human error, they tend to gravitate towards the recommendation of a relatively weak fix. For example, if we want to write a corrective action to address the problem of people not wearing the right work gloves, what do we often recommend?
Most people say we should make sure gloves are available. Plus, we should remind the employee of the requirement, and need, to wear gloves. Some might even want to punish the non-glove wearers. How effective are these fixes? What is the probability that people will always wear the correct gloves in the future?
We don’t address the work system gaps or weaknesses that fail to prevent errors.
This, I believe, is the core reason corrective and preventive actions fail. Our Western culture conditions us to blame people, the weather, and equipment.
We fail to see the ever-present connection between human error rates and weak work system design. Weak designs equate to high error rates for any human! All too often we expect micro-level error rates – rates below one-half of a percent! You cannot sustain such low rates without exquisite work system design.
More Reasons Why Our Process Improvement Fixes Fail
We don’t know our real error rates, costs, and risk levels. Many more errors occur daily on the job than we capture. Also, risk levels are often higher than we expect due to team member, skill level, and work setting changes. We won’t invest significant money if the problem is not large enough.
However, how well does our investigation and analysis capture the problem’s true magnitude? How effective are we at risk level estimation? When we underestimate risk, we often under-design our safeguards. Risk level should drive safeguard design and use.
We fail to evaluate and improve our existing safeguards. Most people use the same safeguards every day to minimize errors. It does not seem to matter if the risk level for a day’s work fluctuates or not. In other cases, some work teams only have ineffective safeguards, such as weak supervision, poorly written work instructions, and no formal training to rely on.
Does Your Root Cause Analysis Process Contribute to Fix Failure?
Too many organizations rely on weak fixes that fail. Examples include reminders, discipline, and retraining. What is the case in your company? Why does this happen? Often, this is a result of the root cause analysis approach we use to find root causes.
The design of traditional approaches such as the 5 Why technique or fishbone analysis allow us to view human error and equipment failures as root causes. My experiences teach me that this is a bad thing to do. It is an analysis process error to blame problems on people and equipment. The better option is to use a root cause analysis approach that looks for the systemic reasons a person makes mistakes.
Additionally, most process problems have a path to failure. However, we often fail to hunt for that path. In other words, multiple errors and failures across the process or value stream build on each other. Some call this the path of causation. An effective root cause analysis process looks at all the errors and failures that could help prevent a problem or make it less severe.
Two Final Reasons Why Our Process Improvement Fixes Fail
We often underestimate what it takes to create and sustain human behavior change. Lecturing people for an hour won’t make them change. You can threaten them or be nice to them, but the outcome is the same. Preventive actions in the form of work system change are necessary to drive behavior change that lasts.
We fail to make distinctions between corrective (short-term) and preventive (longer-term) fixes. In many cases, the two types of fixes for a given problem are different. The preventive action is not necessarily an extension of the corrective action. Instead, it is often a higher order form of work system improvement. For example, instead of improving how we replace a part each time it breaks, we switch to a more reliable part.
THAT’S ENOUGH GRIPING … NOW, LET’S LOOK AT HOW TO FIX THINGS!