root cause analysis
In Their Natural Environment
I scheduled a meeting this week and a room for our meeting. During the course of our conversation, we began to discuss process and other items related to the their work. Gratefully, I had enough awareness to stop the conversation and we, as a team, walked out to the Gemba and continued our discussion there.
I scheduled a meeting this week and a room for our meeting. During the course of our conversation, we began to discuss process and other items related to the their work. Gratefully, I had enough awareness to stop the conversation and we, as a team, walked out to the Gemba and continued our discussion there.
Respect for People, Underutilized People, and Waste
The two pillars in Lean Thinking are Continuous Improvement and Respect for People. What is not well understood is that most of what we know as The Toyota Production System comes from these two pillars. The Lean sub-culture tends to over-emphasize the “tools” of Kaizen, but miss the point altogether, since the tools stem or originate from one of the pillars above. The relationship between the 2 Pillars and Waste is subtle, but important.
The two pillars in Lean Thinking are Continuous Improvement and Respect for People. What is not well understood is that most of what we know as The Toyota Production System comes from these two pillars. The Lean sub-culture tends to over-emphasize the “tools” of Kaizen, but miss the point altogether, since the tools stem or originate from one of the pillars above. The relationship between the 2 Pillars and Waste is subtle, but important.
Poka-Yoke Pharmaceuticals
King Pharmaceutical (NYSE: KG) recently had a drug approved by the Food and Drug Administration (FDA). Their drug, Embeda, has an interesting property: If you take the medication as prescribed, it works fine; if you abuse the medication, it ceases to work. This is Poka-Yoke (ポカヨケ) for Pharmaceutical drugs.
King Pharmaceutical (NYSE: KG) recently had a drug approved by the Food and Drug Administration (FDA). Their drug, Embeda, has an interesting property: If you take the medication as prescribed, it works fine; if you abuse the medication, it ceases to work. This is Poka-Yoke (ポカヨケ) for Pharmaceutical drugs.
Unappetizing Spaghetti Diagrams
A Spaghetti Diagram is a simple visual tool to demonstrate the flow of material, flow of information, and flow of money in a process. The word “spaghetti” is descriptive because it describes flow that is not easily understood, can’t easily be followed, or if the flow is literally all over the place. Indeed, a Spaghetti Diagram represents a point-of-departure: what does the current state look like and what are the exact improvements we need to make?
A Spaghetti Diagram is a simple visual tool to demonstrate the flow of material, flow of information, and flow of money in a process. The word “spaghetti” is descriptive because it describes flow that is not easily understood, can’t easily be followed, or if the flow is literally all over the place. Indeed, a Spaghetti Diagram represents a point-of-departure: what does the current state look like and what are the exact improvements we need to make?
The Source of Dirt
In Amazon’s 2008 letter to shareholders, Jeff Bezos shares about a Kaizen event he participated in:
At a fulfillment center recently, one of our Kaizen experts asked me, “I’m in favor of a clean fulfillment center, but why are you cleaning? Why don’t you eliminate the source of dirt?”
I’ve spoken numerous times about Bezos on Lean Thinking, some of which are here, here, here and here but there are many more — just browse shmula.
In Amazon’s 2008 letter to shareholders, Jeff Bezos shares about a Kaizen event he participated in:
At a fulfillment center recently, one of our Kaizen experts asked me, “I’m in favor of a clean fulfillment center, but why are you cleaning? Why don’t you eliminate the source of dirt?”
I’ve spoken numerous times about Bezos on Lean Thinking, some of which are here, here, here and here but there are many more — just browse shmula.
Customer Service and the iPhone
related update
In some organizations, the Customer Service function is largely viewed as a cost center, draining resources of the firm. I maintain that this viewpoint is largely false and is one that less mature companies support. I believe that Customer Service is an accurate litmus test of the overall health of the firm — indeed, Customer Service can play a very strategic role in the overall health of the product, service, and Firm.
In some organizations, the Customer Service function is largely viewed as a cost center, draining resources of the firm. I maintain that this viewpoint is largely false and is one that less mature companies support. I believe that Customer Service is an accurate litmus test of the overall health of the firm — indeed, Customer Service can play a very strategic role in the overall health of the product, service, and Firm.
The Atomic Rules of Kaizen
Systems that are internally consistent and externally pragmatic stem from just a few rules. Systems with exceedingly many rules typically fail or will not endure. For example,
- Most mathematical truths stem from just a few axioms
- Music stems from just a handful of finite notes
- Most Martial Arts stem from a few principles of angle, attack, force, etc.
Systems that are internally consistent and externally pragmatic stem from just a few rules. Systems with exceedingly many rules typically fail or will not endure. For example,
- Most mathematical truths stem from just a few axioms
- Music stems from just a handful of finite notes
- Most Martial Arts stem from a few principles of angle, attack, force, etc.
Jeff Bezos and Root Cause Analysis
unrelated update:
I’m always impressed when CEO’s demonstrate Deming-like behavior as they lead; it’s rare, but there’s almost a magical, mobilizing, and inspiring force that happens when CEO’s or corporate leaders behave in a respectful, inspiring, common-sense, and thoughtful way.
Today, I’m reminded of an experience back in 2004 while I worked for Amazon.com — something Jeff Bezos did that I still carry with me to this day.
unrelated update:
I’m always impressed when CEO’s demonstrate Deming-like behavior as they lead; it’s rare, but there’s almost a magical, mobilizing, and inspiring force that happens when CEO’s or corporate leaders behave in a respectful, inspiring, common-sense, and thoughtful way.
Today, I’m reminded of an experience back in 2004 while I worked for Amazon.com — something Jeff Bezos did that I still carry with me to this day.
Not Accountable, Not Responsible
Team size can make a big difference in the success of your service or product. What is counterintuitive for most people is that the larger the team size, the lower the likelihood of success for your service or product. Why? Entropy can set in and large teams are inherently bad vehicles for communication. More insipid, however, is that the larger the team, there is a higher likelihood of accountability and responsibility being diffused across the team.
Team size can make a big difference in the success of your service or product. What is counterintuitive for most people is that the larger the team size, the lower the likelihood of success for your service or product. Why? Entropy can set in and large teams are inherently bad vehicles for communication. More insipid, however, is that the larger the team, there is a higher likelihood of accountability and responsibility being diffused across the team.
Maintain Forward Tension
One principle in Wing Chun is the maintaining of forward tension. To explain, I’ll draw the distinction between Tension and Energy and show how this principle in Wing Chun can be applied to Change Management.
Tension is a type of Energy
A Wing Chun maxim goes as follows:
soft and relaxed strength will put your opponent in jeopardy
One principle in Wing Chun is the maintaining of forward tension. To explain, I’ll draw the distinction between Tension and Energy and show how this principle in Wing Chun can be applied to Change Management.
Tension is a type of Energy
A Wing Chun maxim goes as follows:
soft and relaxed strength will put your opponent in jeopardy

