1. Introduction to Lean Six Sigma
Steve Carleysmith
Reo Process Improvement Ltd
www.reoprocessimprovement.eu

2. Customer focus
2

3. Think:
Who is the „customer‟?
What activities make up the process?
How can I do the job smoothly?
How can I avoid the Seven Wastes?
for each
“process”
3

4. • Why does your organisation exist??
• Purpose of a company
– get customers
– make money
4

5. Who is the Customer?
• The customer is anyone who uses a product or service.
• This means anyone who chooses, pays for and uses or
products.
• The internal customer is whomever you pass your work to.
5

6. Who are customers?
• Anything useful that we do - must have a customer
• Internal customers, within the organisation
– next stage of production; HR; Marketing, Exec Team
• External customers, generally outside the company
– anyone who chooses, pays for or uses our product
– shoppers (choose, pay, use)
– service user (choose, pay, use)
– shareholders (seek dividends and capital growth)
– charity user
– doctors (choose)
– patients (use)
– NHS (pays)
6

7. Why is the Voice of the Customer so
important?
or
7

8. Breakout - Voice of the Customer
1. What is your product and/or service and who are
your internal and external customers?
2. What is the value you deliver to each customer?
3. What perception do your customers have of your
product and service?
1. How do you know?
2. Are you asking the right questions?
Feed key points to rest of the group.
8

9. Customer focus - recap
• most dissatisfied customers do not complain
• we need to delight the customer
• we have internal customers and
external customers
• measure how you meet the customer requirements
• anything we do not adding value for the customer is
waste…
9

10. Principles of Lean Thinking
10

11. Lean Principles
• Specify value in the eyes of the customer
• Identify the value stream and eliminate waste
and variation
• Make value flow at the pull of the customer
• Involve, align and empower employees
• Continuously improve knowledge in pursuit of
perfection
11

12. Lean Six Sigma
Understand our processes
Add value, create flow
Drive out waste, reduce variation
Better cost, quality & delivery
Delight the customer
Raise job satisfaction
reduce waste hit the target
12

13. Non value adding time
or
13

14. Value added and non value added
:.:
granulate and tumble blend compress coat release
dry
0.5h 1h 0.5h 4h 1h 1h
Typical process time start-to-end = 5-10 days
Value-added time = 7 hours
Non-value added but essential = 1 hour
Value-added time as % of total ~5%
14

15. How much activity is non value added?
Typical real values
Physical manufacture
5% value adding
60% non value adding
35% necessary but not VA
Information processing
1% value adding
49% non value adding
50% necessary but NVA
Value is perceived by the customer… 15

16. Time Value Map
Map the process activities on a time line with value-
adding above and non-value-adding below
value adding activities
timebase
start endeg days
non-value adding activities
This is an essential tool for visualising non-value-added activities and
wasted time – part of the value stream map…
16

17. Quick NVA exercise ??
• Mention 7 wastes
• show consultant‟s timeline
17

18. Value adding processes
The value stream will comprise both value adding and non value
adding processes
Value adding = a process that
transforms, for the first time,
material or information to meet Non value adding = processes
the needs of the Customer (big that take time and resources
C) but do not add to the
Customer‟s requirements
(many of these processes will
This is a critical definition for
appear to be necessary, given
LeanSigma thinking
the current system of working)
Non value adding processes and
activities typically account for 95% of
the time that a product is in the value
stream
18

19. The Seven Wastes
19

20. Listen to the Voice of the Customer
• pulling the value
or
20

21. Lean targets NVA areas…...
use new version ??
Most lean opportunities are in non value added areas
Traditional approach
(blue 95%) focuses on Value-
Adding activities
There are three main cost drivers: (“efficiency”). Typically
5% of total costs.
1. The hidden factory (or Cost Of Poor
Quality)
2. Time
3. Inventory Lean approach focuses
on the 95% non-value
adding activities through
quality, waste and
variation elimination,
and employee
involvement.
21

22. The Seven Wastes...
• waste is anything that does not add value for the
customer (internal and external)
22

23. The Seven Wastes - to find NVA activities
Defects Anything faulty
Overproduction Producing more than is immediately
needed
Transportation Excessive transport of product (can be
information)
Waiting Waiting for parts or information
Inventory Raw materials, WIP (work in progress) and
finished product more than necessary
Motion Bad ergonomics – reaching, lifting,
stooping
Processing OVERprocessing – doing non value adding
processing
plus the 8th waste of
untapped human potential!
23

24. In the office
Defects Forms filled in wrongly;
Use of wrong codes
Overproduction Producing info not used;
Reworking data in different ways.
Transportation Excessive movement of information
between departments and sites
Waiting Waiting for data not available;
Waiting for other groups to act.
Inventory Paperwork held and batched instead of
processed as received.
Motion Reaching for difficult to get at files . Walking
to central photocopier.
Processing Excessive numbers of meetings.
Reports too detailed and not read.
24

25. In the workshop
Defects Fitting wrong parts.
Using wrong lubricants.
Overproduction Doing stuff not needed.
Replacing good parts?
Transportation Parts and tools are a long way away.
Waiting Waiting for tools.
Waiting for parts to be delivered.
Inventory Too much stuff stored.
Too many tools of same type?
Motion Poor ergonomics – too much bending
and stretching to do the job.
Processing Doing work long before it‟s needed.
25

26. In the laboratory
Defects Incorrect data entries.
Contaminated samples; ghost peaks.
Overproduction Results of analysis not used;
Data put into multiple databases.
Transportation Excessive movement of samples
between departments and sites
Waiting Waiting for instruments & supplies.
Waiting to log in on PCs.
Inventory Samples held and batched instead of
processed as received. Tested
samples held awaiting data review.
Motion Walking to distant parts of building and
site. Poor ergonomics of bench
instruments.
Processing Unnecessary peer review.
26

27. Healthcare
Defects Medical errors
Wrong patient
Overproduction Testing or treating early to balance
workload
Transportation Moving samples, specimens, patients,
equipment
Waiting For bed assignments, lab results
Queuing for appointments
Inventory Pharmacy and lab supply stocks
Beds occupied unnecessarily
Motion Searching for patients, medication,
charts, tools, supplies & paperwork
Processing Multiple bed moves
Excessive paperwork
27

28. Exercise
In groups identify some DOTWIMP examples of waste in your
workplace
Defects
Overproduction
Transportation
Waiting
Inventory
Motion
Processing
28

29. The Lean Sigma journey.
Empower people to...
simplify to PDCA slide ??
Understand the customer needs.
Map the internal processes (value
stream) and eliminate waste and
variation
Make value flow, pulled by
the customer
Involve everyone.
Go round the cycle again
-strive for perfection!
29

30. Lean Six Sigma Principles - recap
• Specify value in the eyes of the customer
• Identify the value stream and eliminate waste
and variation
• Make value flow at the pull of the customer
• Involve, align and empower employees
• Continuously improve knowledge in pursuit of
perfection
• So how do we understand flow?.......
30

31. Batch size, inventory & flow
31

32. Flow of value to the customer
information flow
product/service flow customer
inputs
perceived
stream of value-adding operations
value
32

33. Batch versus one piece flow
Traditional batch processing:
Process 1 Process 2 Process 3
Cycle time Cycle time Cycle time
10 minutes for 10 minutes for 10 minutes for
10 parts 10 parts 10 parts
Total Batch Processing Time :
30 minutes for 10 parts
33

34. Disk turnover experiment
• 20 products to be processed (disks)
• five work stations + customer
• start timing (customer raises order for 20)
– time to get first product
– time to receive all products
• Station 1 turns 20 disks over.
• Passes them to Station 2 to turn over
– and so on
• Stop timer when customer has 20 disks.
• Start again, processing one disk at a time.
• Compare times.
34

35. Batch versus one piece flow
Small batch (single part) processing:
Process 1 Process 2 Process 3
Cycle time Cycle time Cycle time
1 minutes for 1 minutes for 1 minutes for
1 part 1 parts 1 parts
Total processing time : 12 minutes for 10 parts
Only 3 minutes for 1st part
35

36. What is inventory?
• raw materials or information for processing
• work in progress (WIP)
• finished goods or completed output
• any part of the product or output not being worked on
– i.e. parts or information in NVA time
36

37. Cycle Time cf. Lead Time IMPROVE ??
• Cycle time: the repeat time for a particular production
operation i.e. how often things come off the production line
– If we process 50 bikes per 400 minutes, cycle time for that process is 8
minutes
– If we process 2880 dividend payments in 8 hours continuous operation,
cycle time is ??
– Excludes account equipment downtime, set up, changeovers...
• Lead time is the total time from starting a series of operations to
completion. For example
– From order to despatch
– From first use of information or materials to finished product to customer
– All inventory increases lead time by WIP x cycle time
– If 7200 dividend payments await processing and the cycle time for the
process operation is 10 seconds, what is the lead time in hours ??
NB These definitions may vary – be explicit for each application.
37

38. Exercise
• Where do you have inventory in your processes?
– raw materials or unprocessed information
– work in progress
– finished goods or product
– office processes: orders, invoices for processing
• How does this affect lead time (start to finish)?
38

39. Push vs Pull
• Push - produce as much as possible, builds inventory
• “Build for stock”
• “Ensure people are busy”
• “Keep the machines running”
• not at all lean!
Process 1 Process 2 Process 3
Inventory Inventory
39

40. Pull
• Pull - produces product or do work at the request of
the customer or next down stream operation.
• Pull reduces WIP and controls production between
processes
• Pull is lean
When does process 3 operator work?
Information
kanban bin
Material Material
– one item only
Process 1 Process 2 Process 3
Full Full Don‟t work
Empty Full Don‟t work
Empty Empty Can‟t work
Full Empty Work
40

41. Exercise
• Where could you use lean thinking (customer focus and
removal of wastes) to improve a process?
41

42. Recap on Lean and Six Sigma
• Lean thinking is about improving flow to the customer
and reducing wastes (non value adding activities).
• Six Sigma tools identify and reduce variation (of quality,
time, cost)
• Common themes are customer focus and process
thinking
• Work from facts & data collected in the workplace
• Root cause analysis is a key tool for lean and Six
Sigma
42

43. Process thinking
43

44. Process thinking
Input-process-output (IPO) NB Processes under
control must have
information feedback
feedback
Process
inputs outputs
Process thinking
Activities convert inputs to outputs via a process.
There is always hierarchy of nested processes.
44

45. Manufacturing
Raw
Materials
& Compo- Manufac-
nents turing Packaging
Distribution
Customer
These can be IPOs or SIPOCs linked
45

46. Exercise - flowcharting
1. Choose a process with problems(s).
2. Using stickies, draw a map of the process.
3. Add problems as different coloured stickies on the
process map.
4. We‟ll return to this in root cause analysis.
46

47. The Value Stream
47

48. The value stream is....
the set of specific activities required to
design, order and provide a specific product,
from concept to launch,
order to delivery,
and raw materials
into the hands of the customer
after Womack & Jones (1996) p311
48

49. The Value Stream
information flow
product/service flow customer
inputs
perceived
stream of all value-adding and NVA operations value
Value stream is everything that is currently done to supply the customer
49

50. Value stream for cola - steps
Mine Ore 500,000 tonnes
mountain 4 weeks
Smelter Hot Roller
Reduction Mill 2 hrs Hot roller
30 mins 1 min
Remelter
Can Warehouse Can Maker
Cold Roller
10 secs
Bottler
1 min Tesco Store
Drink
5 mins
Recycle
Bottler Warehouse Tesco Warehouse Center
Home
After: Welcome to Detroit. Frank Hennessey,
Chairman, Detroit Regional Chamber, Chairman, EMCO Ltd.
After Womack and Jones
50

51. Value stream for cola – lean?
Eight firms involved.
Fourteen storage points
Picked up and put down 30
times.
24 percent of raw material
scrapped
319 days to do three hours of
value-added work.
51

52. Tesco One Touch Replenishment
1 2 3 4 5 6
Cola Tesco
RDC RDC
1 2 3
Cola Tesco
RDC X Dock
30% Lower Logistics Costs
52

53. Tesco One Touch Replenishment
53

54. VALUE STREAMS AT TOYOTA
Value Stream Organization
Body Interior Chassis Elect. Proto.
Eng.
John Shook • David Verble May 1, 2001
54

55. The value stream map
Kaizen improvements move the process
towards the Future State
55

56. Table Assignment
• What are the value streams for your
businesses?
• What added value does the customer see?
• How could you reduce the lead time of
product order to customer delivery by
removing non value added activities?
56

57. The Journey
Future State,
Current State,
target condition, Vision
situation, As Is
To Be
57

58. Visioning Exercise
Current State (baseline)
Future State (achievable)
Vision (the perfect process)
Exercise
Think about a process that you work on.
Imagine how the “perfect process” would feel.
What would people be doing and feeling?
Feed back to the group
What is the vision for your organisation?
58

59. The Value Stream - recap
• The Value Stream
– high level
– sub-processes
• Value Added activities add value perceived by the
customer; NVA activities don‟t.
• Value Added Time mapping
• Value Stream Mapping
• Current State and Future State
• Visioning
• Align all the organisation and measure progress
– hoshin kanri and Balanced Scorecard
59

60. Constraints ??
60

61. 5S ??
61

62. History of ??
62

63. Features of Lean and Six Sigma
“......primarily a new approach to
management, not a technical
program.”
”.....many things......can be seen as: a vision; a
philosophy; a symbol; a metric; a goal; a
methodology."
“........also a creativity program.”
“All the technical expertise in the
world will fail....unless the working
environment is receptive”
63

64. Lean Principles
• Specify value in the eyes of the customer
• Identify the value stream and eliminate waste
and variation
• Make value flow at the pull of the customer
• Involve, align and empower employees
• Continuously improve knowledge in pursuit of
perfection
From Womack and Jones “Lean Thinking”
64

65. Central theme of Lean is Central theme of Six
flow and the elimination of Sigma is to create
waste. Waste is any processes and products
activity that does not add Lean which are nearly defect
value for the customer. and variation free.
Six
The approach is typified
The approach is typified
by Toyota Production Sigma
by Motorola and
System (TPS).
General Electric.
Key measurement for
Key measurement for
Lean is value adding time.
Six-Sigma is variation.
shorter
lead
lower
times
proven
costs higher
quality benefits !
65

66. History of lean & Six Sigma
• Lean • Six Sigma
– 1945 on: Japan: Shigeo Shinko – 1970s “Our quality stinks”: Motorola
shows batches cause delay quotation
– 1948 on: Deming in Japan – 1986 Motorola Trademark;
– 1953 Taiichi Ohno develops “Motorola University” Bill Smith
Toyota Production System – 1995 General Electric (Jack Welch)
– 1960s-70s: Shigeo Shingo poka + wider application
yoke & “stockless production” – 1990s Motorola publish Six Sigma;
– 1990 Womack and Jones use DMAIC introduced
the term “lean” – 1999 application to finance and
– ...and in 1996 publish transactional processes
“Lean Thinking” – ~2000 Lean Six Sigma in use
Shigeo Shingo Taiichi Ohno
Bill Smith Jack Welch
66

67. Benefits: use BW colourful slides
67

68. Tea-making
68

69. Lunch
69

70. Root Cause Analysis
Solving problems and finding solutions
70

71. Why have a structured approach?
When confronted with a problem, it‟s tempting to jump to a solution. However, misdiagnosis of the
reason for the problem may result in an inappropriate solution that doesn‟t address the problem,
or worse, creates new problems.
• The Jefferson Memorial (Washington, DC) was
deteriorating because of frequent washings.
• The washings were needed due to so many bird
droppings.
WHY were there so many birds?
• There was an abundance of birds because hundreds
of existing spiders provided a ready food supply.
• The spiders were feasting on the thousands of midges
that were attracted by the lights the Park Service
turned on at dusk to illuminate the monument.
The Park Service considered:
But by identifying the real root cause,
• Eradicating the birds in some came up with a simple, cheap
manner solution:
• Using pesticides to eliminate the • To delay turning on the spotlights
spiders and midges until 1 hr after sunset.
• The midge population decreased,
breaking the food chain. 71

72. Solution jumping
72

73. Root Cause Analysis General Method
1. A significant event (problem) occurs
2. Define the problem statement
– wwwwh, what goals of the organisation are affected?
3. Can the cause and solution be quickly identified using 5
whys? – finish, but care!
4. Understand the process in more detail
– flowchart & timeline: sequence of events
– use diagrams, drawings and photos
– interviews and narrative chronology
5. Use RCA tools to seek root causes
– fishbone, logic tree, change analysis, barrier analysis
6. Verify causes are correct
– OR go back 2, 4 or 5
7. Find possible solutions
8. Select solutions, analyse risk, implement 73

74. Why is root cause analysis important?
“Eighty-five percent of the reasons for
failing to meet customer requirements
are traceable to issues in the process
itself rather than to employees… The
responsibility of management is to
change processes rather than exhorting
individual employees to do better.”
W. Edwards Deming
We need to understand the process that the customer depends
upon – what works for them, what does not and how we can make
a verifiable improvement.
74

75. Quality and Human Errors
Human error problem can be viewed in two ways:
– the people approach
– the system approach.
Gives rise to different philosophies of quality or error
management
http://www.xytheme.com/wp-content/uploads/2009/02/human_error.jpg 75

76. 76

77. People Approach
(not good)
• The person approach focuses on errors and
procedural violations of people
• It views these errors as arising from
forgetfulness, inattention, poor motivation,
carelessness, negligence, and recklessness.
• The associated countermeasures are directed
mainly at attempting to reduce variability in
human behavior:
– writing another procedure (or adding to existing ones)
– disciplinary measures
– threat of litigation
– retraining, naming, blaming, and shaming.
77

78. System Approach
(good)
• Humans are not perfect and errors are to be expected
– Errors are seen as consequences rather than causes
– Errors happen not by the awkwardness of human nature but
because of poor processes
• The system approach looks for recurrent error traps in
the workplace and the organizational processes that
give rise to them.
– Solutions change the conditions under which humans work e.g.
mistake-proofing (poka yoke)
– A central idea is that of system defences or barriers.
– All hazardous technologies possess barriers and safeguards.
– When an adverse event occurs, the issue is not who blundered,
but how and why the defences failed.
• Ask “how did the system fail the people?”
78

79. System Approach
• We cannot change the human condition, but we
can change the conditions under which humans
work .
Failures are like mosquitoes.
They can be swatted one by
one, but they still keep coming.
The best remedies are to create
effective defences and to control
them in the swamps in which
they breed. The swamps, in this
case, are the ever present latent
conditions for failure.
79

80. Discussion
• What are your experiences of root cause analysis?
– how did you select a problem?
– what method did you use?
– was it successful or not?
– why?
http://www.thinkreliability.com/Root-Cause-Analysis-CM-Basics.aspx
80

81. Root Cause Analysis General Method
1. A significant event (problem) occurs
2. Define the problem statement
– wwwwh, what goals of the organisation are affected?
3. Can the cause and solution be quickly identified using 5
whys? – Quick fix, but care!
4. Understand the process in more detail
– flowchart & timeline: sequence of events
– use diagrams, drawings and photos
– interviews and narrative chronology
5. Use RCA tools to seek root causes
– fishbone, why-why cause tree, change analysis, barrier analysis
6. Verify causes are correct
– OR go back 2, 4 or 5
7. Generate possible solutions
8. Select solutions, analyse risk, implement 81

82. The Problem
Statement
“A problem well
stated is a problem
half solved”
Charles F Kettering
82

83. Example problem/UDE statements
• Not “the widgets are faulty!” but:
– The widgets from line xx between dates yy and
zz are out of specification on the aa measure.
• Not “lots of forms are wrongly filled” but
– Over the last 3 months, 1 in 25
application forms for the ZZ
Department from USA customers
are incorrectly filled in on
questions 3 and 5.
• No assumptions; no solutions
83

84. Exercise
• The production supervisor reports: “One
of the feeders which add flour to the mix
has stopped. It is seized or jammed and
the motor may have burnt out. Production
of cupcakes has stopped and the
maintenance shift is on another urgent
job.”
• Make a suitable problem statement:
– what company goal is affected?
– what are the wwwwh?
– what additional information
may be needed?
– what information is not needed?
84

85. Objectives and success measures
• What are your measures of a successful solution?
– avoid cost increase
– prevent late delivery
– prevent defects
– improve customer relations
– make a permanent fix
• Can you make a rough financial assessment
– cost of RCA and implementing fix
versus
benefits from permanent cure
85

86. Example
• What is your cost of problems on a product or process?
– think direct (tangible) costs and indirect (intangible) costs
– reputation, lost business, customer dissatisfaction?
• What is the cost of training and teamwork on RCA?
• How do these costs compare?
86

87. What is “Root Cause”?
87

88. What is a “root cause”?
• “the most basic reason for an undesirable event (or
condition)” – the “fundamental cause”
• why are we finding the root cause?
– we ultimately want a solution!
– so find root causes that enable solutions
• RCA ultimately enables us to find solutions for
problems
– solutions are also called Corrective Actions or Corrective
and Preventive Actions (CAPAs)
Analogy: treat the symptoms of an
illness (swine flu: paracetamol and
decongestant), or discover and treat the
root causes to the problem (virus:
swine flu jab, antivirals Tamiflu and
Relenza)
http://www.webweaver.nu/clipart/trees2.shtml 88

89. Root cause – one or many?
• There will generally be more than one root cause
• Flight Safety International state that the fewest number
of links in aviation accidents was 4, with the average
being 7.
• For industrial applications the number of errors (root
causes) can be 10 to 14**.
• The RCA method must therefore deal with complexity
**http://www.plant-maintenance.com/books/0849307732.shtml
89

90. Multiple root causes
90

91. Exercise
• Have you encountered any problems having just
one root cause?
• What accidents or incidents have you experienced
with multiple root causes?
91

92. Why do we need a structured method
for root cause analysis?
For every complex
problem there is an
answer that is clear,
simple – and wrong.
H.L. Mencken
1880-1956
92

93. Overview of RCA
• Define the problem (in terms of the company goals)
• Analyse to find the root causes
• Implement solutions (to meet company goals)
There is no single method for root cause analysis.
We will look at methods and tools that cover
nearly all types of problem.
93

94. Methods and tools for RCA
• 5 whys
• fishbone (Ishikawa, cause and effect diagram)
• why-why cause tree (fault tree, cause and effect tree...)
– plus process understanding (mapping, data collection…)
• others that we will not cover today
– change analysis (e.g. Kepner-Tregoe)
– barrier analysis
– events and causal factors charting
94

95. Root Cause Analysis General Method
1. A significant event (problem) occurs
2. Define the problem statement
– wwwwh, what goals of the organisation are affected?
3. Can the cause and solution be quickly identified using 5
whys? – Quick fix, but care!
4. Understand the process in more detail
– flowchart & timeline: sequence of events
– use diagrams, drawings and photos
– interviews and narrative chronology
5. Use RCA tools to seek root causes
– fishbone, why-why cause tree, change analysis, barrier analysis
6. Verify causes are correct
– OR go back 2, 4 or 5
7. Generate possible solutions
8. Select solutions, analyse risk, implement 95

96. 5 Whys problem statement,
undesirable effect or care
delivery problem
problem
Why?
Tip: keep asking why until you can see solutions
- this is usually between 4 and 6 times
Symptom
Why?
Why?
Symptom Symptom
Why? Why?
Why?
Symptom Symptom Symptom
Why? Why? Why?
Symptom Symptom Symptom
Why? Why? Why?
ROOT CAUSE ROOT CAUSE ROOT CAUSE
96

97. 5 Whys: late in operating theatre
The patient was late in theatre, it caused a delay.
Why?
There was a long wait for a trolley.
Why?
A replacement trolley had to be found.
Why?
The original trolley's safety rail There was no spare trolley
was worn and had eventually
broken.
Why? Why?
It had not been regularly Faulty trolleys awaiting
checked for wear. repair
Why? Why?
No routine equipment check. Investigate further.
Possible solutions:
• Routine checks
• Repair all trolleys
• ...?
Modified from (c) NHS Institute for Innovation
and Improvement 2009
97

98. Exercise
• Practice 5 Whys
• Choose a problem that you have encountered recently
• Apply the “5 Whys” to this problem
– how effective is it?
98

99. 5 whys and a quick fix
• 5 whys can find root cause(s) and a quick solution to get
operations running again
• BUT beware of leaving the quick fix as the permanent
solution
• ALWAYS check further on root causes and look for
solutions giving sustained improvement
• Understand the process…
99

100. The Process Flowchart (Map)
There are usually 3 versions of each Process Map
What you What you What it
Want it to be... Believe it is... Actually is...
100

101. Root Cause Analysis General Method
1. A significant event (problem) occurs
2. Define the problem statement
– wwwwh, what goals of the organisation are affected?
3. Can the cause and solution be quickly identified using 5
whys? – Quick fix, but care!
4. Understand the process in more detail
– flowchart & timeline: sequence of events
– use diagrams, drawings and photos
– interviews and narrative chronology
5. Use RCA tools to seek root causes
– fishbone, why-why cause tree, change analysis, barrier analysis
6. Verify causes are correct
– OR go back 2, 4 or 5
7. Generate possible solutions
8. Select solutions, analyse risk, implement 101

102. Fishbone Diagram / Ishikawa Analysis
Cause and effect analysis
Causes
Manpower Machines Materials
Effect
Mother
Measurements Methods
Nature
1. Called Fishbone diagrams, Ishikawa diagrams, or „6M‟ analysis.
2. Logical organisation of possible causes for a problem or effect.
3. Generate possible causes 1) from brainstorm 2) using the headings as a prompt
4. For admin applications, can use people, places, procedures, policies.
Worked example: poor mpg in a company van 102

103. “Cause and Effect Tree” or “Logic Tree*” for
Paint Failing Quality Check Solutions
*A Logic Tree may use AND and OR
symbols for more complex cases.
Root
causes
Set Service Level
Problem Agreement with
statement supplier
I Tubing is
Dents are in
standard Order higher quality
tubing as
industrial tubing
Arrow shows “caused by” I = investigate supplied
quality.
I I I Tubing is
Tubular frame Dents are
Dents are in the dropped into Use Correx sheets to
fails paint Holes are visible appearing
metal tubing kanban bins separate parts
quality check** during handling
causing dents
I I I
Bumps are Metal particles Metal is braze
Manual brazing Train brazers
visible under the paint spatter
Examples
**The actual problem Use guards of
statement should be more barriers
specific (effect on goals
and wwwwh)
Inspect pre-painting
I
Autobraze
103

104. Solutions
Finding, Selection & Implementation
104

105. Solution Finding
• List the root causes
• Gather advice
– process experts, facilitators
• Review existing information
– has this sort of problem happened before?
– relevant information in the databases?
• Use innovation methods
– brainstorming
• Select the best solutions, check risks, implement
Innovation = creativity + application
105

106. The Challenge of Change
Leadership and Culture
106

107. “ It is not necessary to
change... Survival is
not mandatory.”
W. Edwards Deming
107

108. Your view?
• Do you know of change programmes?
• Why were they successful or otherwise?
108

109. 109

110. Recap
• What are the key ideas of lean?
• What is the value of root cause analysis?
– What are the key tools?
• What are the human issues with process improvement?
– How do we promote change?
110

111. Recap of the day
• Introduction to lean thinking and Six Sigma
– History
– Principles
– Benefits
• Value added and non value added activity
• Customer focus
• The Seven Wastes + Eighth Waste
• Process thinking and the value stream
– Process mapping
– Batch size, inventory and flow
• Root cause analysis
• The challenge of change
• Back in the workplace
111

112. Implementation
• What ideas do you have for
– a project using lean principles?
– an application of root cause analysis?
• What are your next steps in lean and root cause
analysis?
112

113. END
Excellence is a journey, not a
destination!
113

114. Cupcakes – example problem
statement
• “The production of cupcakes has stopped
on line L2
during B Shift
at xx hrs
because flour is not feeding from machine FF3.”
• From company goal affected and wwwwh.
114

115. What is Lean and Six Sigma?
• A structured method for improving processes
– “Improve” means reduce costs, increase quality, reduce times
– “Process” is any series of linked activities for a useful function
• Lean and Six Sigma work together
Lean: improve flow and reduce waste
Six Sigma: minimise variation in processes (statistical; not
covered today)
• When applied, will
– reduce costs
– improve quality
– shorten process times
– improve employee engagement
115

116. Some common terms
• “Lean”, “Lean Thinking” and “Six Sigma” are industry-
standard terms
• “Lean Sigma” or “Lean Six Sigma” is the combination of
the two
• Lean Six Sigma sometimes called “operational
excellence” or “service innovation”
116

117. 117

118. 118

119. 119

120. 120

121. Benefits of lean
• Toyota became the largest and most successful car
company in the world
• Tesco is the dominant UK supermarket
• Dell “The „direct model‟ that Dell operates, where customer orders are
taken directly by the company and then built to order, uses all the principles
laid out by the Toyota Production system but also adds many more.”**
• IBM Microelectronics Dublin “Inventory down 72%; Cycle Times
down by 66%; Space Requirements reduced by 36%; Productivity
increased by 20%” in 3 years**
• Less information on transactional processes & service
industries. Lean projects in:
– National Health Service
– insurance
– finance (RBS)
– Starbucks
**http://newsweaver.ie/madeineurope 121

122. What is in and out of Lean and Six
Sigma?
IN SCOPE OUT of SCOPE
• reduced lead & cycle times • marketing strategy
• waste reduction • pricing policies
• reduced variation • business deals
• efficiency increases • tax efficiencies
• quality improvement • transfer pricing
• employee engagement • move to low cost countries
• customer engagement • some business process re-
• focus on repeating engineering (revolution)
processes
• continuous improvement
(evolution)
122

123. DMAIC & team charter?? SKIP
123