In Jeffrey Liker and Gary Convis’ book, The Toyota Way to Lean Leadership, Gary recounts the story of a young Toyota manager, Yuri Rodrigues, learning the lessons of root cause analysis while working at a Toyota plant in Brazil. A quality problem in the trim department was traced to the wrong torque being applied by technicians. Yuri suggested the plant purchase modern wrenches that would stop automatically when the right torque was applied. His leader replied, “Do you want me to buy new $400 wrenches for everyone in the plant? Because if you’re telling me that is your solution for the problem, that’s what I’ll have to do. I suggest you go back and observe the team members to really understand this problem.” Upon further research, Yuri discovered the ultimate root causes to be poor training and a lack of preventative maintenance.
I like this story for a couple of really important reasons:
Root cause analysis is hard
Purchasing modern wrenches would have been an easy solution, but another quality problem caused by the same lack of training and preventative maintenance would have occurred shortly down the line. In long-term care, fixes are commonly applied to a surface issue, but there is little work on the root causes, and the daily work is filled with a prioritization of firefighting activities.
Ultimately, a lot of unnecessary waste could be eliminated by uncovering the common root causes for many of the problems that plague the industry and addressing those instead of continuing to manage crises. Unfortunately, finding root causes takes tenacity, insight, and an engaged workforce that can critically examine work practices.
Error-proofing is not always the right (or only) solution
Error-proofing is an important part of building quality into processes, but it’s not always the best approach to a problem. In this case, an automatically-stopping wrench might make it easier to use for untrained technicians, but it would just push the problem into another area of the work. Creating “idiot-proof” systems rarely leads to sustainable quality. Rather, error-proofing goes hand-in-hand with expertise and fully-trained employees.
In contrast, solutions in long-term care oftentimes perpetuate the root causes of poor training and a lack of employee engagement by trying to make it difficult for line staff to influence the process. These bottom-line focused solutions might solve one issue, but the core cause is still there.
Problems are rarely caused by a single issue
When Rodriguez went back to the line to study the problem, he discovered not only the wrong torque being applied to the trim, but also that the preventative maintenance program was missing. This example demonstrates one of the most important– and sometimes overlooked– benefits of a rigorous root cause analysis process: the identification of multiple causes, each of which might need a different countermeasure.
Too often, we stop after identifying the first problem and miss other contributory factors, which only leads us back to quality issue. In most cases, we need to focus on root causes, not just root cause.
Workers are not the problem
An easy answer to the problem would have been to tell workers to stop over-tightening the bolts. Lean thinking, however, teaches us that this is mostly a wasted effort, and will have little lasting impact on quality. Instead, the point that lean makes over and over is that workers are not the source of problems in most organizations, systems and processes are. The lean value of respect for people demonstrates that with fair treatment and proper tools and resources, employees can actually solve most of the challenges confronting an organization– they just need to be unshackled from dubious mandates and ill-conceived systems.
Too often, line staff in long term care are blamed for poor performance and quality problems. Broad inservicing and rampant memos take the place of thoughtful training and effective communication, and the disciplinary process is quick to engage staff unlucky enough to be singled out by management. To drive sustained results, we need instead focused root cause analysis and a culture that supports long-term quality improvement and value creation.