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Are You Fixing the System or Just a Person?

by Kelly Moore
May 17, 2016

Are You Fixing the System or Just a Person?

by Kelly Moore
May 17, 2016 | Comments (4)

When I am coaching individuals on 5-Why problem solving, I frequently see the analysis stop short. Many times the problem solving will end with the cause and resolution of the individual event – short of the identification of the system failure. Without a system fix, the failures will continue and the countermeasures might be cumbersome. I saw this first-hand on a business trip just a few weeks ago.

It was early in the morning and I was racing the clock. Hastily I slung my backpack over one shoulder. I grabbed my coffee in one hand and keys and cell phone in the other, already thinking about what route I would need to take to get to the plant site I was visiting. I had only been to this site once before, and I didn’t want to be late today. Still not fully awake, I clumsily opened my hotel room door, only to stop short. A morning newspaper lay in the doormat position in the hallway, waiting for me. I contemplated pretending to not see it and stepping over it, verses courteously picking it up. Aggravated at the balancing act I now had to attempt, I retrieved the unrequested newspaper, careful not to spill any of my belongings in the process.  

When I later spoke to the manager I offered suggestions that would allow a hotel guest to indicate no newspaper was desired. For example, they could implement visual management, like a colored magnet on the door or a card on the door handle. I spoke of the potential cost savings since the hotel would then know exactly which guests were not interested in the paper. I thought the manager would be excited.

Not exactly. Instead he pulled a crumpled piece of paper from a drawer and told me, “No problem, I’ll take care of you.”  He told me he kept a list of room numbers of those who come to the desk and ‘complain’ about the delivery. I saw that list and immediately envisioned the poor deliveryperson having to double-check every door, every morning, against a random list of handwritten room numbers. How would the deliveryperson even know when a ‘complaining’ guest had checked out? I did not add my room to that list.

I can remember another plant visit where I saw this same problem. Prior to my visit, there had been an incident where a material handler brought the wrong labels to the line – and the line operator used them without even realizing they weren’t the right ones. As countermeasures, the material handler and the line person were retrained on the process and an extra step was added: a supervisor had to sign off on all materials being introduced to any line before any of said materials could be used.

One of my gemba walks took me to the plant’s packaging area, where I saw multiple lines down – all waiting on the supervisor’s approval. The department manager was aggravated because his team had had to keep retraining material handlers and line personnel to ‘pay attention,’ and the supervisor quality-check was impacting their production output. It was interesting that an outsider, I could see the system of picking materials had a problem that had not been solved. The work group knew that retraining people was not the answer – yet they accepted it as such.

The reflection of the hotel problem and the packaging problem got me thinking: how often do our solutions fix a person (or single event) rather than a system? Are we allowing a temporary containment countermeasure to remain as a long-term fix – piling on layers of cumbersome work-arounds which are left to become a part of others' everyday work?

It also raised another question about my own development that I think is important for every leader to consider: as a leader, how can I do a better job in teaching my employees, my organization, to improve their problem solving abilities so that they can actually fix the entire system, rather than just 'fixing' a person over and over? Only when that happens do I begin to Lead with Respect and help drive my organization further along its journey of continuous improvement.

Tell me, which type of fix does your organization make most often?

The views expressed in this post do not necessarily represent the views or policies of The Lean Enterprise Institute.
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4 Comments | Post a Comment
Mark Graban May 17, 2016
2 People AGREE with this comment

That's an interesting reaction from the hotel manager. But, maybe it's not too surprising since he apparently didn't share your view of a "problem." People generally aren't going to be interested in suggestions or possible solutions if they don't agree there is a problem. 

In the workplace, it would probably be better to get agreement that there is a problem and then ask the manager (or their staff) to brainstorm solutions... I guess the hotel manager already had a "solution." Maybe it worked even if it didn't seem the most elegant solution... it goes to show how hard it is to try to improve somebody else's process.


Reply »

Steve Tennis May 17, 2016
1 Person AGREES with this reply

We most definitiely retrain the operator, implement a check sheet and require a sign off by someone!!!!

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Kelly Moore May 19, 2016

Hi Steve,

When pressed to ask a couple more whys the packaging area found that the right label and the wrong label had identical artwork and only differed by one number is a nine-character alphanumeric string which the material handler (and line person) manually interprets.  The labels were located in the storage warehouse side-by-side. Thus, the process was setting up the people to fail.

The current countermeasures have been to physically separate labels in the warehouse by re-locating one of the labels to a different location and, when the labels are brought to the line, institute a practice of the line person verbally reading the SKU out-loud to the handler from the line instructions (a separate copy - not the material handler's picklist) while the material handler then physically checks the SKU on the labels.

A search of the warehouse revealed  instances of other similar labels co-located and corrections to label locations were made.  The only training needed was the verbal reading - making sure the operators understood the why.  The lines now aren't delayed waiting on a supervisor and this mistake hasn't occurred since.

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Raphael Pochart May 24, 2016

Hi Kelly,

Thanks for your input. We have lot of example showing that we only fix the person. I like the idea of teaching employees to get all the organization on board rather than just reacting to single issues.

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