Académique Documents
Professionnel Documents
Culture Documents
Presented by:
Communication of Problems
Concern
What is wrong? What is different than what should be? May be recognized as a symptom, (effect), or as a failure condition, (failure mode) Define in terms of requirement, (language of organization)
Requirement
What should be Must be defined and valid Can be found in procedures, policies, drawings, specifications, etc. #1 reason problems are not effectively solved is that Requirement is not clearly known or defined Reference where Requirement can be found State as defined in Requirement document
Evidence
Demonstrates requirement is not being fulfilled Data initially gathered associated with problem Objective evidence collected while auditing process or system Must be verifiable Can be tangible, a statement of admission or observed
Impact
How big is the problem? How much does it cost? Is the customer affected? Is it affecting fulfillment of organizational goals? Refer to effect and severity ranking on FMEA for performance impact Also consider cost impact In the case of auditing findings: typically, auditors do not cite Impact as this could be viewed as subjective Impact should be determined by auditee upon their review of the audit finding
Types of Problems
Simple, cause known; Just do it issues Complex, cause unknown; need to dig deeper issues Sometimes the financial impact of a problem dictates how it will be classified
Just Do It Issues
Typically isolated, sporadic incidents Are easily fixed; apparent cause tends to be known Often recognized during process planning and reflected in PFMEA Addressed through troubleshooting, (diagnosis and remedy) and reaction plans on control plans, (control of nonconformity) Can be fixed by process owner; addressed at process level Occurrence should be monitored ongoing for cost and impact
Troubleshooting
Recognize problem condition Communicate problem condition to process owner
Implement remedy
Dig Deeper Unanticipated conditions which occur May also be anticipated issues for which actual level of risk is now determined to be unacceptable Require concentrated investigation to understand source of problem and process factors leading to problem condition to allow appropriate solutions
Process of Origin
Known
Method
Troubleshooting; rework
Considerations
Seen before; can live with impact when problem recurs Data-driven investigation to determine actual factors causing problem condition Taking action possibly on wrong process; not using data to confirm root cause
Dig Deeper
Unknown
Unknown
Fire-fighting
Prioritize Problems
Most organizations should only be actively working on 35 disciplined problem solving efforts, (Dig Deeper issues), at a time to balance the use of resources and get the most effective solutions; (no one person should be working on more than 2 Dig Deeper teams at any given time) Impact portion of CREI statement facilitates prioritization of problems for allocation of problem solving resources Management is responsible for establishing the priority
The Secret to Solving Problems The source of every problem is a process: typically
the gap is found in the output of the process
The cause of every problem is one or more process factors not behaving as they should Understanding the relationship between process factors and process outputs is important to effective problem solving Data about the process and the problem is required to gain enough understanding to effectively solve any problem The result of any problem solving effort is increased knowledge about processes and their outputs
Components of Process
Environment (space, layout, etc.) Evaluation (plan, gages, etc.)
Input (Materials)
Process View
Products/Services = output of producing Processes
Sequence process steps between first and last process step to reflect current process flow
Brainstorm process steps which occur between first and last identified process steps
When?
Who?
How
Containment
A process factor which directly defines the reason for the problem when it is present and is having an influence on the process and its output.
Direct Process Cause = at Process of Origin Actual Root Cause = previous process factors contributing to Process Root Cause, (planning) System Root Cause = management system policy/practice contributing to Actual Root Cause
No
No
Can cause be controlled or eliminated? Yes Identify possible actions for either controlling or eliminating cause
No
No
Controls working?
Yes Analyze why controls are not working at the process where problem originated
Product Process
Defect/Detection Condition of cause controls to detect problem Direct process Factors at cause, (trigger at process of origin process of origin triggering problem, (5Ms) Actual root cause, (led to trigger cause) Linkage to planning processes that trigger cause
Fishbone, What processes (cause & have similar effect) trigger cause?
Plan System
5 Why with What other Hypothesis processes testing affected? System Cause Analysis Other affected mgt. policies
Were the planned controls in place? Were the planned controls working? What is the capability of these controls? Assists in identifying appropriate interim actions as well as identifying the defect/detection root cause
Other Opportunities:
Fishbone Diagram
PROCESS:
Material
Man
Gap:
Mother Nature
Method
Machine
Fishbone Process
Involve personnel from process of origin in brainstorming of potential causes at the process of origin triggering the problem Develop a sketch/list of the process factors, (man, material, machines, methods, mother nature), related to the process of origin After brainstorming, review each identified cause to establish:
If the cause is actually a factor at the process of origin If the cause makes sense based on the operational definition of the problem
Prioritize remaining causes as to their possible contribution to the problem condition Develop hypothesis test to evaluate each potential cause at the process of origin
Process of Origin:
Related to process? Feasible based on operational definition? Priority to confirm Method of confirmation Results of confirmation
Task Analysis reviews process in detail; helpful for operator dependent process Change Analysis identifies differences; extension of Is/Is Not analysis; expands on application of timeline Both these tools must be applied with a location context, (process of origin)
5 Why Analysis
Ask Why does this happen? for each identified process cause from Cause & Effect diagram Differentiates between process, (direct) cause and underlying root cause Each level of causes identified in 5 Why analysis must also be confirmed via testing in order to verify root cause Deeper levels of 5 Why Analysis which get into Planning processes will require interview-type data collection
Hypothesis Testing
Design hypothesis and select methods for testing hypothesis - state how potential cause could result in described problem; decide what data to collect that would prove potential cause; establish acceptable risk of decision outcome; determine sample size; develop action plan for study Prepare to test hypothesis - organize and prepare materials required to conduct study; collect data during study Analyze results of test - analyze data using appropriate statistical tools, (t, F, Chi-squared tests) Interpret results - conclusions from study; does data establish potential cause as reason for problem?
System Causes
What in the system allowed this problem/cause to occur Identifies why the process root causes occurred based on current management policies/practices Often not readily measurable Data obtained through interview By identifying system causes, systemic improvement can be made in order to prevent recurrence of problem in other similar processes Typically addressed once process root causes of problem are known and confirmed
Problem Solutions
There are always at least 3 possible solutions related to each level of cause Therefore, at least 12 possible solutions could be identified for a problem investigation if all levels of cause are investigated! Management provides solution selection criteria as basis for evaluating possible solutions
P o s s ib le S o lu t io n s M a t r ix
R o o t C o n f i r m e E lim in a t e C o n t r o l D e t e c t G a p d C a u s e (s ) D e fe c t: D ir e c t : A c tu a l: S y s te m :
3 Possible Solutions
Eliminate root cause preventive control; often referred to as error-proofing; eliminates causal factor leading to problem condition Control root cause process detective control; implement actions to monitor cause condition so action can be taken on process factor before problem occurs Do nothing reactive control; continue monitoring for problem condition; defect detection solution; may be required when root cause cant be eliminated or controlled economically or technically; this solution may include accepting interim action as permanent solution
Solution Selection
Allow brainstorming of possible solutions at all levels of confirmed causes and the 3 possible categories of solutions Then apply solution selection criteria provided by management to evaluate each possible solution as well as refine the brainstormed ideas Have data available re: actual costs associated with problem, (initial impact, revised impact based on data collection/analysis, anticipated future impact if no action is taken)
CRITERIA MATRIX
SOLUTIONS A CRITERIA 1 MUSTS 2 3 4 n* 1 WANTS 2 3 4 n* RATING TOTALS
* reflects any number of variables that are appropriate to include in the analysis.
n*
Implementing Solutions
Actions to eliminate and control causes require change Change management tools should be applied when implementing solutions Change Management Tools FMEA Risk assessment Resource planning Contingency planning Training Evaluation Verification
Brainstorm possible solutions for each confirmed root cause Permanent solution implementation Establish solution selection criteria Evaluate results of permanent solution Evaluate possible solutions vs. solution criteria Remove interim actions Develop action plan to implement selected solutions Team verification of solution vs. goals Evaluate solution risks and impact on other processes
Develop contingency plan for solutions Finalize problem solving report, lessons learned Establish solution effectiveness measures Team celebration and disbanding of problem solving team Trial plan for solution implementation
Other Opportunities
Identified typically while collecting data for Is/Is Not Analysis, Root Cause investigation/confirmation, solution evaluation Record these other problems/opportunities Share these problems/opportunities with team champion to get direction on how to address: (change scope of current problem solving effort to include; management assigns another team to address) Dont allow these other opportunities to distract from the focus of the problem solving effort These Other Opportunities become the Bonus of an effective problem solving effort
Expansion of Knowledge
Managements Role
System Establish problem solving culture Provide problem solving process Ensure training of all personnel in problem solving process and related tools Prioritize/categorize problems based on magnitude/risk Audit/review effectiveness of problem solving system Each Problem Appoint Team Champion Define SMART goals for problem solving effort Provide resources and time to support problem solving team Establish solution selection criteria Authorize Team Plan as contract for problem solving effort Periodically review progress of problem solving teams