76 - Coupling

Good morning. 

How many times have you experienced a problem of some kind at work and you just fixed it?

Isn't that what we're supposed to do - fix problems?

I've been in hundreds of meetings where someone would report a problem and the others would kick around a few solutions until something sounded feasible or until the boss said "do that," and that was the extent of the problem solving they did.

What usually happens when we just fix a problem is that after a period of time, could be short, could be long, the problem returns.

We get involved in this cycle of problem-solution-problem-solution that a bunch of people have described as like playing Whack-a-Mole at the arcade.

If you get a chance to stop and think about why the problem keeps returning, then we start making progress on eliminating the problem or obliterating the obstacle.  But even when we stop long enough to do a root cause analysis, often that analysis is sloppy and comes to wrong conclusions.

Let's say we have a problem where an employee ended up with a cut on his hand that required stitches and counted as a couple of Lost-Time days at work.  That's a reportable and recordable injury, so we do a cause analysis so we can complete the corrective action report and get back to work.

In the cause analysis, when we asked why the worker got cut, we say that the cause was "the banding material was sharp." 

That was the end. 

You could also conclude that the worker didn't follow the standardized work for that job, so our solution ends up being to retrain the worker and make sure they wear their personal protective equipment.

It's often very convenient to focus on how the worker screwed up and so we list training as a countermeasure to lots of problems.   But when we realize that there is sharp stuff all over the place, and we use it everyday, we have to ask what was different about this instance that caused the cut? 

Something in the process was coupled with the sharp end of the banding material.

In many cases, yes the worker may have made a mistake, but in many other cases, they could be following the process and the process could be weak.  Focus first on the process. 

Can we redesign it so that the problem can't return?   Rather than just punishing the worker, (yes, retraining is a form of punishment) maybe we need to fix the process that we designed.

Sometimes it takes an outside perspective to help you see these kinds of couplings.  That's where I come in.  I coach teams through this problem solving approach to improve their skills.  Maybe it's time you brought me in to beef up your team.  Send me a message or give me a call. 

Have a great day and I'll see you tomorrow.