Proactively Using Lean/Six Sigma
with TapRooT®
©Copyright 2009 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
What do Proactive Improvement, Lean/Sigma, and TapRooT® have in common?
Fix it right the first time before before a problem reaches the customer, the patient, the employee, the community, or the bottom line ($$$).
Caution: Don’t make changes until you understand what and why first…. Tempting Low Hanging Fruit will bite you back Every time!
©Copyright 2009 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
Where do Audits Fit into Your World?
Significance
Serious Incident: 1-5 Incident: 30 - 100 Near Miss: 100 - 1000 Behavior or Equipment Violations: 1000 - 4000
Analysis
Root Cause Analysis Then Fix
Root Cause Analysis Then Fix
Categorize
Repair
Categorize
Repair
Is this good Enough?
Fix Only if
Adverse Trend
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Senior Leadership often Depend On and Support these Processes in Times of Crisis
©Copyright 2009 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
Ice-Berg Theory and the Other End!
If the largest part of the Ice-Berg needs to be audited…..
How thorough is your IceBerg Audit?
Note: Diver (Auditor) not to Scale of the Ice-berg!
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Guess what…. More than one Ice-Berg!
Limited on what we can focus deeply on!
©Copyright 2009 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
The Problem of Perspective and Clarity of Audits!
Accounting
EH&S
Really talking about the Same Problem but can’t see past your corner of the world to realize it.
Operations
Senior Leadership
©Copyright 2009 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
The Truth Behind the Reality of what Gets Focused on and Supported
“The greater the impact of fixing an audit, the faster the problem is likely to be fixed.”
“When the net benefit of fixing the problem is higher, the problem probably will be corrected faster.”
©Copyright 2009 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
The Focus of Cost
Audit Focus
Warranty
Management Focus
Cycle Time Scheduled Material Cost
Preventative Maintenance Late Fees HR and Safety Costs EPA Fines and Penalties Unplanned Material Rework Labor
Direct Labor
Direct Costs Cost Savings
Indirect Costs Cost Avoidance
©Copyright 2009 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
Lean
1) Map out Value Stream 2) Identify Value/ NonValue Add 3) Analyze Lead Time 4) Identify Constraints/ Inefficiencies 5) Develop plan and Implement 6) Sustain and continually review 1) 2) 3) 4) 5) 6)
Six Sigma
Define Measure Analyze Improve Control Don’t forget about Design for Six Sigma and Enabling Growth Models
TapRooT®
1) Get Started 2) Determine Sequence of Events 3) Define Causal Factors 4) Analyze each Causal Factor’s Root Causes 5) Analyze each Root Cause’s Generic Cause 6) Develop & Evaluate Corrective Actions 7) Report & Implement Corrective Actions
Improve Quality Eliminate Waste Reduce Lead Time Reduce Total Costs
Reduce Variation Improve Process Capability Defect Prevention Stability Design Excellence ROI
Solve Problems.. What and Why Develop Effective Correction Actions Improve Sustainability of Corrective Actions ROI and Cost Avoidance
©Copyright 2009 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
Solution to Clarity and Perspective: Talking the same Risk and the same Company!
Accounting
All TapRooT® Trained Employee
Lean/ Six Sigma Black Belts And Green Belts Senior Leadership
©Copyright 2009 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
Say what? Speak my language please!
TapRooT® Perspective Separate Organizations (Boundary) Incident, Accident, Sentinel Event, Worst Problem Lean/Six Sigma Perspective Customer, Vendor, Contractor Undesired Effect, Defect, Customer Complaint
Independent Checker (Person who checks the work before task continues)
Procedure
In-Process Quality Control
In-Process Checklist
Just a couple but KEY terms to start with
©Copyright 2009 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
Isn’t 6σ a Math Term? 1% or .2% Defects Per Million
No more math!
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Numbers Only Help when you Understand why you selected them in the First Place!
©Copyright 2009 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
Six Sigma: Understand Your Company
Costumer Needs
Supp ly Chai n
Proc ess
Prod uct Deliv ery
Barriers to Success
“Know thy Value Chain/Stream!”
©Copyright 2009 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
Lean: Understand Your Processes
For Each Process there are “Critical” Inputs and Outputs that Must be Measured!
“Know thy Process!”
©Copyright 2009 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
Tie in TapRooT®’s Audit Process to Costs and the Other Tools that Management Use! TapRooT®
1) Flow chart processes 2) Perform Audit & Record Successes and Issues 3) Identify & Define Significant Issues 4) Anayze Issues’ Root Causes 5) Analyze each Root Cause’s Generic Cause 6) Develop & Evaluate Corrective Actions 7) Report & Implement Corrective Actions
By tying in Risk Avoidance AND Direct and Indirect Cost Savings we have a Chance to Change the Business!
©Copyright 2009 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
Lean Waste and TapRooT® Example
Problem: Individual cut their leg with chainsaw while cutting through timber
Initial Solution Ideas for Chaps not being used and unavailable:
Provide everyone a pair of Chaps Store Chaps in Tool Crib
Two Additional People cut their legs for the same reasons above….. WHY?
©Copyright 2009 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
Lean Waste Categories that should have been Utilized with Corrective Action during SMARTER!
Defect Overproduction Inventory Over processing Motion of Employees Transport and Handling Waiting
Recent Additions Confusion Unsafe Underutilized human potential
Ordered one pair of Chaps for every employee, with many on back-order. Employees near tool cribs with shortages had to wait until others were done with their Chaps Tool cribs were located far away from log cutting work areas.
©Copyright 2009 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
Auditing Using A Functional Swim Lane
Customer Design Spec. Group Engineer Group Quality Manufacture Group Supply (Over-Processing Waste)
Start
Following the Sequence of Transactions in a Process
End
Low Hanging Fruit or is it?
Is it Non-Valued Waste but Required because of Regulatory Guidelines?
©Copyright 2009 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
A Functional SnapCharT® Swim Lane We added Conditions!
Now you can determine: Is it Waste? If so what kind: Non-valued or Non Valued but Required Is the process as designed or what happened?
Was it an Equipment of Human Performance Error?
What Best Practices (Basic Cause Categories are missing? Don’t know the Root Causes Yet!
©Copyright 2009 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
A Reminder: TapRooT® Theory Understanding the Causes of Human Error
The absence of best practices leads to human error. Implementing good practices can stop human error:
Good Procedures Good Work Direction Good QC Good Training Good Communications Good Human Engineering
Good Management Systems
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Page 15
A Reminder: TapRooT® Theory Definition of "Root Cause"
A Root Cause is the absence of best practices or the failure to apply knowledge that would have prevented the problem (or significantly reduce the likelihood or consequences of the problem).
During an Audit, A Problem would be a Significant Issue instead!
©Copyright 2009 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
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Page 14
Quality Functional Deployment (QFD)
Proactive TapRooT® Tools that can help a QFD: 1) Change Analysis 2) Equifactor®
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Network Map and Stakeholder Analysis to Influence w/o Authority
Proactive TapRooT® Best Practices that can help: 1) Communication 2) Work Direction 3) Management System
©Copyright 2009 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
Theory of Constraint
Proactive TapRooT® Tools that can help at the Bottleneck: 1) CHAP (Critical Human Action Profile) 2) Equifactor®
3) Change Analysis if the Bottleneck just started
4) Safeguard Analysis
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Understanding the SPC Metrics… just a little more
Companies Lagging Indicator
Risk Rating Value 1
Risk Rating Value 2
What should a significant decrease in a Risk Rating Value demonstrate?
Have a top driver here, Investigate!
Do not have a top driver; Evaluate Need to Deep Dive Audit
©Copyright 2009 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
For an Effective Audit and Design Review… Understand Where you are Going and Why It Works or Doesn’t Work!
©Copyright 2009 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
References
Images 1) Car pile up: http://www.insurevents.com/images/car%20wreck.jpeg 2) Ambulance Wreck: http://www.ncacc.org/awards/ocpa/2004-dotherightthing.html 3) Texas City Explosion: http://www.arabnews.com/2005/03/bp25_.jpg 4) Defective Tire: http://www.moodyrrlaw.com/img/Defective_Products.jpg 5) Defective Bike: www.sheldonbrown.com/harristrailrcy.html 6) SPC Chart: http://www.qualityamerica.com/SPCTopics/SPCExcelTutorial/image/xbarchartfinish.gif 7) Scale: http://images.veer.com/IMG/TIMG/PDP/PDP0343120_T.JPG 8) Chaps: http://www.labsafety.com/images/xl/Kevlar-Chainsaw-Chaps-LSS_i_LB18042.jpg 9. QFD: http://www.datasmith.net/system/files/images/HOQMatrix.png 10. Network Map: www.anecdote.com.au/archives/social_networks/ 11. Stakeholder: http://www.odi.org.uk/Rapid/Tools/Toolkits/images/stakeholder_grid.gif 12.Iceberg 1: TapRooT® 13. More than one ice-berg: http://www.travelswithsheila.com/day7biggestberg1.JPG.jpg http://images.brisbanetimes.com.au/2008/11/13/267046/sink375_gallery__545x400-600x400.jpg http://1.bp.blogspot.com/_Es5C1U7Ynfc/SZ4rQQ87OnI/AAAAAAAAHJE/OLW2-mY_mkQ/s400/Picture+2.png http://igoralexander.files.wordpress.com/2009/06/sinkingship.jpg 14. Swimming Diver: http://www.divesource.com/aboutus.html
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