Category: Trouble Shooting

Lean Healthcare – Sunnybrook Surgeons given a hands-off way to Kinect

Kinect for Xbox 360 logo
Image via Wikipedia

An article in today’s Toronto Star titled “Surgeons given a hands-off way to Kinect” clearly demonstrates how improvements can be realized in our work environment.  One of the concerns in the operating room is maintaining a sterile field during surgery.  Doctors cannot physically touch any devices away from the sterile field for fear of breaking it and have only 1 of 2 choices if they need to review MRI’s or CT scans:

  1. Scrub in and out every time, which according to the article can add up to two (2) hours per surgery, or
  2. Hire an assistant to page through the records for them.

In the search for a better way, Matt Strickland, a first year surgical resident at the University of Toronto and electrical engineer, and Jamie Tremaine, a mechatronics engineer, who both studied engineering at the University of Waterloo, joined forces to help solve this problem.  Together, they devised a system using the XBox Kinect with the help of Greg Brigley, a computer engineer and also a University of Waterloo graduate.

Using their technology, doctors can now scroll through as many as 4,000 documents using simple hand motions, literally integrating access to information into the surgical process without jeopardizing the sterile field.

Why is this significant?

Matt Strickland was the assistant providing the necessary “documents” to the doctors performing the surgery.  This is a very impressive application of thinking outside of the box.  I highly encourage you to read the article.  Serendipity is seldom the source of repeatable innovations, however, in this instance we’ll take it just the same.

This example demonstrates another reason to include everyone in the problem solving process and also reaffirms that there is always a better way.  You just don’t know where your next solution will find its roots.

On a final note, I have to wonder if the creators of XBox even considered this application!

Until Next Time – STAY lean!

Vergence Analytics
Twitter:  @Versalytics
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The Invisible Gorilla

Just when you thought everything was under control, someone asks you about something that isn’t even on your radar.  Our perceptions can be deceiving and are not always as accurate or reliable as we think.  This is nicely documented and demonstrated in this article and video that we found on Yahoo today:  The Invisible Gorilla.

If the above link doesn’t work, cut and paste the following link into your browser:  http://ca.news.yahoo.com/s/yahoocanada/100713/canada/_invisible_gorilla__test_shows_how_little_we_notice

What does this mean to the lean practitioner?  Waste and other factors that can influence the performance of our operations are not always where we expect to find them.  Similarly, too much focus on one area can cause us to miss out on many other opportunities as well.

Often times a fresh eyes approach can reveal simple opportunities that are easily overlooked as the complex solution is being sought after.  We highly recommend using video as an integral part of the process review and assessment.  It is so much easier to play it back and review than attempt to recall our perception of the events of interest.

What we perceive may deceive if we aren’t careful with our analysis and the conclusions we are looking to draw.  Yes you may find what you were looking for but … what did you miss in the process?

Until Next Time – STAY lean!

Vergence Analytics

Foundations of Failure

The problem with many of the problems we find ourselves having to contend with at any given time is that we learn of their existence after the fact (when the damage is done) or after discovering that the results we were looking for simply didn’t materialize.  As we learned from Michael A. Roberto’s book, “Know What You Don’t Know“, there are a number of reasons why problems don’t surface until after the fact.  I highly recommend reading “Know What You Don’t Know” as well Steven J. Spear’s “Chasing the Rabbit” as both books present numerous examples and extensive research that span across a wide variety manufacturing and service industries.

In many cases, the pathology of a given problem reveals that much of the information surrounding a given failure, or series of failures, is “common” knowledge.  In isolation, many of the contributing factors appear to be insignificant or irrelevant.  However, when we review all of the “insignificant” bits and pieces of evidence as part of the whole, we discover that it is these “pieces” that make the puzzle complete.  This was certainly the case with 9-11, Three Mile Island, The Challenger, and perhaps even the most recent economic collapse.

The expression, “If it ain’t broke, don’t fix it”, comes to mind as I think of problem solving in the general sense.  Even today, we find this philosophy is embedded deep within the culture of many corporations.  In some cases, the designs are so fragile, that any deviation from normal or intended use may result in failure.  Broken plates and glasses remind us that they are not intended to be dropped – either intentionally or by accident.  We are also painfully aware that the absence of past failures does not automatically exclude or make the process or product immune from future failure.  There are too many examples of failure where past successes are suddenly shattered by a catastrophic failure.

Of course, many products are subject to numerous hours of testing in varying degrees of severity and exposure limits.  Yet somehow, these tests still do not capture all of the possible failure modes that are observed in practice.  Too many product recalls are evidence of our inability to anticipate the vast array of problems that continue to haunt manufacturer’s around the globe.  Just maybe the the “If it ain’t broke” expression needs a little rework itself.  If it ain’t broke please break it – or at least try!  Computer hackers around the world having been giving Microsoft and other major corporations their fair share of problems as they continually find and develop “new” ways to break into very sophisticated and high tech systems.

Our Foundations of Failure model is based on the premise that every failure has a known and identifiable root cause.  The challenge for today’s companies is to learn how to identify problems before the product makes it to market or the process is released to manufacturing for production.  The objective is to instill an innate ability to constructively critique your concepts and designs to identify and anticipate the “What if …” scenarios that your product or service may be subject to.

Perhaps an even greater skill to be learned is to identify and anticipate how the product or process may be used or abused – with or without intent or malice.  From this perspective, lean manufacturing principles and standardized work can certainly help us to map our road to success.  Technically, if the ideal process and it’s inherent steps are performed as specified, then any deviations from the prescribed process or design are subject to a system breakdown or product failure.  As discussed in “Chasing the Rabbit“, this was (and is) certainly the case for the US Nuclear Submarines.

Are your system, process, and product specifications documented to the extent that deviations from their intended purpose or function can be, or are, readily identified?  Is it even possible to forecast or anticipate every possible failure mode?  Is it fair to suggest that prescribing a solution to a problem suggests that the original scope of the problem was or is fully understood?

As we have learned from the numerous failures in our financial markets and the collapse of many high profile businesses and companies around the globe, common symptoms and effects of failure may be the result of radically different root causes:  ignorance, negligence, willful misconduct, and even fraud.  We need to implement systems and processes that are robust and assure our future successes are built on solid fundamental business practices.  When the foundation is faulty, the entire business enterprise is at risk.

In summary, the first step is the most critical step.  The first few steps of any new initiative, process, product, or service, form the foundation of all decisions that follow.  Just as a building requires a solid foundation, so do our future successes.  I recall a little sign that was posted in a retail store that read as follows:

Lovely to look at,
Lovely to Hold,
But if you drop it …
Consider it Sold!

Until Next Time – STAY lean!

Toyota: Managing Nightmares

The Nightmare

Toyota continues to be plagued by recalls.  The current acceleration issues (either floor mats or “sticky” accelerators), braking issues on the Prius Hybrid, and now reports in the USA of steering problems with 2009 and 2010 Corollas.  While the majority of the news reports focus on the next steps to repair faulty vehicles, the real nightmare is the human tragedy that was and may still be pending until these issues are resolved.

What is also surprising is the scope of the recalls as they extend to include 2004 model year vehicles.  This is a lot for one company to absorb over such a short period.  It is clear that a flawed design can bring a company to it’s knees overnight.  In the wake of this nightmare, it is also disappointing that Toyota has been less than forthcoming with their communication strategy.

Toyota Lessons Learned

A crucial lesson for Toyota and other companies is to learn to recognize when a problem is really a problem.  Rather than dismissing a fault or failure as a remote possibility or “highly unlikely event”, the key to solving any problem is acknowledging that one exists.  This may have been the greatest error of all in this case.

As consumers we may be too naïve to think that companies are operating with our best interests in mind and not necessarily putting the interests of their stakeholders first.  To be more specific, there is a very fine line between managing solutions, managing risk, and managing a profitable business.  Problems without resolutions or preventable measures are subject to risk management strategy and the price of many products on the market today include a company’s costs to manage risks and potential liabilities.

Responsiveness versus Excuses

Is it the investment or the lives that were lost that call for varying degrees of “investigation”, problem solving, and government intervention?  The timeline of events leading to the recall for accelerator issues spans months and perhaps even years when the problem was first reported.  What does it take before a company finally decides that an event has statistical significance?

The lesson that all companies can learn from this is that the value of human life cannot be measured or dismissed by a risk assessment or  an extremely remote chance of recurrence.  There is little comfort in statistics if you happen to be that one person in a million that has the problem.  We are not suggesting that Toyota dismissed prior reports of problems; we are simply asking “out loud” if they could have had cause to act sooner.

Some media reports have suggested that Toyota grew too fast over the past few years.  How would that have any impact on the design of the vehicle?  Toyota design changes are typically perceived as enhancements and improvements over time.  Yes, Toyota gained significant increases in market share as interest in hybrid vehicles grew with ever increasing gas prices.  Yes, increased volumes place an unprecedented strain on resources throughout the supply chain and perhaps even more so for those suppliers that have been surviving on reduced staff and personnel.  None of these are excuses for a failed design.  This was not a manufacturing defect as we understand it.

Toyota Trust

Unfortunately for Toyota, this recall is not a nightmare they can just wake up from – it is a bitter reality.  Although Toyota vows to improve quality, this needs to be demonstrated.  These same words were uttered by Toyota President Katsuaki Watanabe in 2006 as investigations were pending for the recall of over a million vehicles for a faulty steering component that was initially discovered in 2004.  Akio Toyoda now finds himself making similar commitments again in 2010.

When we consider the number of vehicles produced, we also have to consider the effectiveness of the solution seemingly contrived over recent weeks or, for the benefit of the doubt, months.

How do we really know the proposed solution is effective?  The reality is that we don’t.  As with the discovery of the original defect, only time will tell.  Despite all the testing performed to simulate “the real world”, it is crucial to understand that tests are only simulations – they are not real life.  Even though a failure is predictable, it is not always preventable and just because it didn’t happen doesn’t mean it can’t happen.

Restoring consumer confidence and trust will take some time and Toyota’s crisis management skills will certainly be challenged.  The communication strategy to date has been less than admirable by some accounts, while others continue to praise Toyota’s product line and have re-affirmed their confidence in the company.

Owing to their own lean principles, we are hopeful that Toyota will continue to embrace problems as opportunities to learn and to strengthen the company  and its products.  Toyota is the last company we would expect to see with this number of problems on their hands at any one time.

Our disappointment with Toyota is the lapse between discovery and fix, and subsequently the lapse in communication as the recalls are officially made public.  To this end, Toyota’s reputation may be waning.

Until Next Time – STAY lean!

The Zeigarnik Effect and Lean

Have you heard of the Zeigarnik Effect?  If you have, you’re probably among the few of us that can appreciate how the Zeigarnik effect can affect our thinking processes.  What application could this possibly have with lean?    Consider that the human brain views an unanswered question the same as an incomplete task.  The brain must satisfy it’s innate desire to answer the question.  Lean is not a solution but rather a journey that continues to identify and stimulate ideas that lead to more unresolved opportunities.

The Zeigarnik effect is easier to demonstrate by way of example.  How many times have you been in a conversation while trying to recall someone’s name?  Failing to remember, you keep asking yourself, “What was that person’s name”?  Suddenly, after a few hours or even days later, the name comes to you out of nowhere.  The “Aha, that’s it” moment arrives.  Our subconscious mind continues to work on the problem, searching for a resolution, while we’re busy doing other things.

Is it possible to harness the power of the Zeigarnik effect in lean manufacturing?  Do we attempt to resolve a condition by settling with a less than desirable solution or settling for the one that just seems to work?  With respect to lean, there are many questions that beg to be answered:

  • How can we make this process faster?
  • How can we cut the cycle time?
  • How can we reduce the number of steps to make these parts?
  • Why do we carry all this inventory?
  • Where are we most vulnerable
  • How can we improve the quality of this product?
  • What can we do to eliminate waste?
  • What would happen if …?
  • Why do we do this or that…?

We all understand the power of questions.  The news media and marketing experts are constantly confronting us with questions that need to be answered.  In the case of news media, they entice us to read the story or stay tuned.  In the case of marketing and advertising, they present their product or service solutions.  As lean practitioners, we are continually asking questions.

The evolution of lean thrives by asking the right questions.  Many of the lean tools in use today have been around for many years.  Even in organizations where lean is not a core focus, people are passively aware that lean exists.  They may also have acquired an unrealistic definition of what lean really is.  For companies that have yet to integrate lean practices, this preconceived notion of what lean is may actually hinder your efforts.  The team may be disengaged at the onset of any initiative because they think they know it already.

The prescription for maintaining momentum in your lean journey is simple:  Ask more questions than you hope to ever have answers for.  Engage your team by asking questions.  Although simply asking “Why?” can generate a lot of activity, we should be very specific with our questions.  Keep asking questions until the answers stop flowing.

As students in school, we expected the teachers to know the answers to the questions they were asking.  In a lean organization, even the teachers are students.  Are we asking the right questions?

Until Next Time – STAY lean!

A brief article that discusses the Zeigarnik Effect can be found at the following link  http://businessmindhacks.com/post/zeigarnik-effect-in-depth.

Using TRIZ for Problem Solving – Resources

In our first post on this topic, “Using Triz for Problem Solving – Introduction“, we provided a very basic introduction to TRIZ.  In the spirit of TRIZ, it is not our intent to rewrite or redefine the TRIZ process when excellent information is already available.  Our intent is to identify the few of the many excellent and exceptional resources that we have found.

What is TRIZ?

To learn more about TRIZ and it’s applications we suggest visiting the following web sites that present a tremendous amount of information on the development and application of TRIZ.

TRIZ Principles

40 Inventive Principles with Examples:

Examples for each of the 40 Inventive Principles can be found at the following link:  http://www.triz-journal.com/archives/1997/07/b/index.html

TRIZ Resources

The Contradiction matrix:

As you will have learned from reading the “What is TRIZ?” page from the link above, one of the tools of TRIZ is the Contradiction Matrix that consists of 40 elements.  The TRIZ Contradiction Matrix is available as an Excel Spreadsheet through the following link:

http://www.triz-journal.com/archives/1997/07/matrix.xls

The TRIZ Journal ARTICLES:

The Triz Journal presents many informative articles.  One very intriguing article, “TRIZ / Systematic Innovation Enhances Hoshin Kanri“, by Darrell Mann and Ellen Domb, demonstrates the principles of TRIZ in a unique application.

An excellent article, “Create a High Performance Culture with Hoshin Kanri”, by Frank Deno can be found at the following link http://www.realinnovation.com/content/c080623a.asp

WEB Sites:

TRIZ Books:

A number of books are available on the topic of TRIZ.  Click here to preview the selections currently available.

TRIZ Challenges:

TRIZ is not without its challenges.  Although TRIZ has evolved over many years, it still remains relatively unknown and few companies seem to be ready to adopt this problem solving method.

An excellent article, “Enhancing TRIZ with Dr. Deming’s Philosophy“, by Ellen Domb and Bill Bellows, presents some interesting insights to this challenge.

We typically tend to avoid “labels” for the method we are using to solve a specific problem.  Unlike a surgeon “requesting specific tools (scalpel)” while performing an operation, our strategy tends to be a blended “hybrid” approach to problem solving; TRIZ happens to be one of the more effective methods that we have learned to use over the past few years.

The acceptance of TRIZ may be attributed to the current struggles many companies experience simply attempting to complete an 8D or 5-Why.  Of course, that would only be true of companies who are void of the Lean principles and methods – right?  TRIZ also has a perceived complexity that does not lend itself to ready adaptation as a company-wide problem solving tool.

We would recommend reviewing the many available books on the topic of TRIZ.  Integrating a tool such as TRIZ will require someone to become the leading expert.  Click here to see the various book selections that are available.

Unfortunately, for many companies, the discipline or the structure is simply not there to support effective problem solving efforts.  Perhaps if more time was spent solving the real problems, they would have more time to solve problems not yet realized.

Remember to get your TRIZ – Click Here!

Until Next Time – STAY Lean!

Using TRIZ for Problem Solving – Introduction

Using TRIZ for Problem Solving – Introduction

A famous quote from Albert Einstein, “The problems that exist in the world today cannot be solved by the level of thinking that created them.“, applies to the discussion of problem solving and more so to the topic of TRIZ, The Theory of Inventive Problem Solving, developed by Genrich S. Altshuller.

TRIZ – Theory of Inventive Problem Solving

Genrich S. Altshuller developed TRIZ based on his search for a standard method to solve problems.  At the very basic level, once a problem is identified the objective is to determine whether a similar problem has already existed elsewhere.  If so, study the solution and determine whether it can be incorporated into the current solution being sought.  Taken one step further, consider the possibility that a different perspective of the problem may also present a unique inventive solution.

It does not seem too far fetched that the problem to be solved has occurred elsewhere in a completely different context.  The solution that is found may also be out of the context but the concept may lead to an innovative solution for the current problem at hand where one never before existed.

The application of TRIZ requires an open mind.  We often bring our “tool box” of experience to the table and draw on those tools and our wealth of knowledge to create a solution.  TRIZ is a tool that can be used to create completely new and unique solutions to a given problem.  This doesn’t mean that we need to abandon our current technology and know-how; it simply means that there may be other options where the current know-how and / or technology may not apply or it may be applied in a manner that is quite different than it is today.

Identify the Real Problem to be Solved

Any problem solving method can only be successful if the true root cause is identified.  Once found, a clear and concise problem statement must be formulated to assure that the solution developed and implemented indeed addresses the true root cause.

Searching for Solutions:

Once a problem has been identified, the next question is, “How do we solve it?”  There are a number of techniques that can be used such as brain storming and idea mapping, however, one seldomly used technique is TRIZ:  Theory of Inventive Problem Solving.

Every day we are challenged with a diverse range of problems from machine malfunctions to defective parts.  The very nature of any company’s operations requires an immediate fix to restore operations to “normal”.  Recognizing that a problem exists is not the same as understanding what the problem is and effectively solving the problem requires that we have identified the true root cause and not just the symptoms.

Many tools are readily available to even help us address these concerns or identify where opportunities exist to make improvements.  Unfortunately, these tools seldom provide the solution to the problem.  Too often we are trapped inside the box of current thinking, technologies, standards, methodologies, present knowledge, and even company policy.  Our own levels of thinking and plausible solutions are influenced and limited by our current understanding and knowledge of the problem as well as our own experiences.

The Basis for Using TRIZ to Solve Problems:

Technology

In some cases, product or part designs themselves may be constrained as engineers and designers work to generate a design tailored to a specific, known, technology.  Quality Function Deployment is one strategy that provides a platform to explore alternative design and process approaches before committing to a specific technology or process.

It is worth noting that, although product design is critical, processes and technologies used to manufacture the product itself are often overlooked and seldom are the process constraints and their affects ever considered.  There are many examples where numerous hours are wasted attempting to develop tools using traditional technologies to produce parts that conform to the wishes of engineers and designers.

How do we actually go about solving problems where the technology or the design present constraints that prevent success?  This is the basis for TRIZ:  We have clearly identified the problem to be solved, now we need a solution to resolve it.

Problem Classifications

Although problems may have varying degrees of difficulty, the solutions for them can only fall into one of two overly simplified categories:  Known or Unknown.  While this classification may appear simple on the surface, consider the unknown solution.  Is it truly unknown or is it only unknown to you.
  1. Known:  Surrogate process already proven and only requires adaptation for the current situtation.  The “problem solver” has an awareness or experience related to the solution.
  2. Unknown:  Typically, solutions are often limited by the scope of experience of the person or person(s) attempting to solve the problem.
    1. The problem solver is not aware of the solution’s existence (Personal)
    2. The solution is outside the problem solver’s scope of experience, training, or field of expertise, but may exist within the company (Company)
    3. The solution is not known within the company but is known within the industry (Industry)
    4. A solution can be realized although it does not presently exist (Outside Industry).
    5. Requires an inventive solution that goes beyond improving the existing condition and is not known to exist anywhere.
  3. Although a solution may be found or developed internally, it may not necessarily be ideal.  We recommend continual review of trade journals, going to trade shows, and networking not only with industry peers but outside your areas of expertise as well.

We will pursue the TRIZ methodology as both a learning and problem solving method.  Often times the solution to a problem requires a different perspective to achieve an effective resolution.

Applying TRIZ in the real world:

TRIZ can be used to develop solutions in a wide range of applications.  As Contingency Plans are developed, you may determine that a solution is required to address a problem or crisis that company has not yet experienced.  As we have discussed, the information or solution to the pending “crisis” may already exist elsewhere.  Similarly, improvements to Overall Equipment Efficiency may require solutions to be developed to address problems or opportunities that are inhibiting continued improvement. 

We will continue to pursue the application of TRIZ in the real world and present a more detailed case study.  

Note:  We would also recommend and encourage you to visit http://www.mazur.net/triz/ for an indepth presentation and detailed discussion of TRIZ.  This site provides greater detail and background that is presently beyond the application or scope of this series.

Until Next Time – STAY Lean!