Practical

Problem Solving
The Toyota Way
Scott Davis
Managing Partner
Lean Associates, Inc.
Lexington, KY 40517

All materials copyright Lean Associates, Inc. No part of this presentation may be
copied or reproduced without written permission of Lean Associates, Inc.
 “EVERYTHING we do is for the
purpose of showing us where the
problems are. We must constantly
identify problems, find their
causes, and solve them in order to
improve for the long-term.”
Toyota Trainer

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 When is the Best Time to Find a Problem?

• Before it BECOMES a problem!

• If you discover a potential problem you
are able to take corrective action
• Fire Prevention
• If you discover a situation AFTER it is
a REAL problem you can not prevent
the problem
• Fire fighting
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 What We Are Trying To Do

Core Philosophy: Elimination of WASTE

(COST) (Increase the amount of value)
Why we
do it!
How we Surface
Creating Continuous Flow Problems
do it!

Measure the Throughput Time

How we know
we did it! (Indicator of success)
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 Correct Flow of Lean Thinking
 Purpose, Values, Philosophies (Beliefs)

The things we are taught and believe

 Principles and Concepts (Ideas and Way of Thinking)

Thinking that orients our beliefs

 Strategies for execution

(The approach to things guided by our principles and values)
The method of executing our principles

 Tactical (HOW to apply Lean Tools)

The doing part (the solutions)

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 Philosophy
Waste Elimination

Performance Measure Principle

Reduced Lead Time Create Continuous
Process Flow

Strategy
Create Interdependent
"Connected" Processes
Result
Waste is
Lean Tools Reduced!
Method
Kanban, Supermarkets,
Pull System
Defined FIFO Lanes

Reason
Problems are Surfaced
Quickly and are Critical

Control Method Effect

Utilize Visual Controls so Problems Must be
That no Problems are Corrected Quickly
Hidden
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 The Four Step Process
Step One: Find and Clarify Step Two: Find the Root
the Problem Causes
– Understand the current – Ask clarifying questions
(when, where, how)
situation
– Narrow the focus
– Set standards as the
– Brainstorm possible causes
foundation for PPS
– Determine the most likely
– Surface the problems contributors
– Build consensus and – Determine the greatest
alignment actual contributors
– Clarify goals and targets – Confirm the root causes

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 The Four Step Process
Step Three: Identify and Step Four: Confirm and
Implement Countermeasures Follow Up
– Brainstorm – Verify plan effectiveness
countermeasures – Modify implementation
– Evaluate and prioritize plan
countermeasures – Confirm the results
– Develop the – Standardize effective
Implementation Plan countermeasures
– Develop Future Steps

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 Why are we here?
1. Recognize the importance of
Practical Problem Solving.
– Purpose
– Process
– Payoff
2. Skills development: learn the
Practical Problem Solving Process!

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 Do we have problems?

What are some of the “problems” you have here?

•List problems on the board
There are NO SHORTAGE of problems in ANY
work area!
•Can we SEE problems?
– Accidents, near misses, defects, scrap,
performance to schedule/budget, attendance??
Problem Solving skills are essential for all
employees!

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 Why use Practical Problem Solving?
• Because “No Problem” is a problem!!
• Problems are opportunities to learn and develop.
• Hiding problems undermines the continuous
improvement philosophy.
• Solving problems is necessary for achieving our
goals.

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 The Goal

The ultimate goal of PPS is not

just to solve the problem at
hand!
The goal is to make problem
solving transparent and
teachable in order to create an
organization of problem
solvers.
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 Problem Solving Opportunities

Strateg ic Very
Strateg ic Strateg ic few big
In itiative In itiative In itiative
problems

Few
Project
Pro ject Project medium sized
Project problems

Pro ject

Many
small
problems

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 Focus of the Problem Solving Method
Problem Solving Opportunities Point of Pain
(Large, Vague, Multiple Problems)

Clarify the Problem

Go Genchi Genbutsu Shugi

Problem Defined = “principle of the
and real place and real
Most Likely Contributors See thing”

Basic Cause/
Five Whys? Why? Direct- Effect Investigation
Investigation to
Why? Cause
Root Cause
Why? Cause
Why?

Why?
Root
Cause

Countermeasure

Share Best
Practices
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 Step 1: Find and
Clarify the Problem

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 Junk Words
• It is a long way to the store
How many blocks? ______
• There are a lot of people waiting in line at Wal-Mart.
How many people in line? ______
• There are a lot of mistakes.
How many mistakes are there? ______
• It takes a lot of work to do lean activities.
How many hours does it take each week? ______
• We have a big problem with defects.
How many defects is that? _______
• These things take too much time to do.
How much time do these things take per day? ______

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 The Four Step Process
Step One
Step One: Find and Clarify Step Two: Find the Root
the Problem Causes
– Understand the current – Ask clarifying questions
(when, where, how)
situation
– Narrow the focus
– Set standards as the
– Brainstorm possible causes
foundation for PPS
– Determine the most likely
– Surface the problems contributors
– Build consensus and – Determine the greatest
alignment actual contributors
– Clarify goals and targets – Confirm the root causes

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 How do we typically find a Problem??
Yes Things are No
working
well?
Yes Have you
Don’t touch it!
touched it?
IDIOT!!
No

Will it
Does anyone Yes Yes
blow up in
know? your face?

No No
No
Can you blame Pretend you haven’t seen it
someone else?

Yes
No Problem
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 Understanding the Current Situation
What is a Problem?

Ideal Situation
or

Standard
Where you want to be.

Quantifiable G
A Problem
P

Current Situation
Where you are now.

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 Problem or Opportunity
What do we do?
Standard or
Goal KAIZEN ZONE

The
Problem

Actual
Performance
Problems MUST be corrected
Kaizen is opportunity for improvement

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 Criteria for Problem Definition
What do we need for a problem to exist?
1. An Actual “Current Situation”
2. A Desired Situation (Goal or Standard)
3. A Gap between actual situation and goal
4. Extent of the problem
– How long has the condition existed?
– Is it getting better or worse?
– What are the characteristics?
(Consistent/Variable)

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 Setting Standards: foundation
for practical problem solving
CURRENT SITUATION VS. STANDARD

• Seek facts relating to when the standard is achieved and

when it is not.
• Define important details about the current situation vs. the
standard situation.
 What’s different?  How often?
 When is the problem  Where is the problem located
occurring (not occurring)? (not located)? Find the POC
 What’s changed?  When did it start?
 What is the trend?

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 Problem Relationships
Higher cost is a result of
poor operational capability,
quality and service

COST Why you do what you do,

and who you do it for.
•Right thing
•Right time
•Desirable products
•Internal customers (others
CUSTOMER
doing their jobs
SERVICE

OPERATIONAL
CAPABILITY
QUALITY
• Productivity • Defects
• Efficiency What you have to do • Scrap
• Equipment well to provide service • Rework
• People
• Materials

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 Surface the Problems
Select Problems Using The 80/20 Rule

20 % of Problems Lead To

80% of the
Opportunity
80% of Problems

Lead To
20% of the
Opportunity

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 Surface the Problem
Problem Identification
Guidelines to Gather relevant facts:

 Go to the actual location where the

problem is occurring (the GEMBA)
 You MUST GO SEE for yourself
(Genchi Gembutsu Shugi)
 Get facts yourself by observing, don’t
make assumptions
 Do not rely upon data gathered by
other individuals or reports

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 Case Study Example:
The Current Situation
• Actual: Average just over 3% paint
defects
• Standard: Less than 1% paint
defects
• Gap (Problem): Paint defects are
2% over the standard
• Extent: Problem has been consistent
for long-term (over 1 year)
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 Case Study Example
• Rationale for solving the problem:
 Defect is found after paint is cured
and repair is more difficult.
 Rework requires additional set-up
of paint system.
 Rework affects cost and delivery

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 Team Exercise Part One:
Surfacing Problems

• Let’s go “find” some problems

– Look for “facts,” not feelings
– Understand the current situation
– 30 minutes
– Go where the problem occurs
– Select teams

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 Exercise One Review

• What did you see?

• Did you see problems?
• How do you know they were
problems?
• How do the things you saw prevent
you from achieving desired
results?

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 Learning to
Present your
Thinking Using
A3
Lean Associates, Inc.
P.O. Box 5448
Berkeley, CA 94705
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 What is an A3?

• Communication tool
• Tool to develop logical thinking
• Provide a common language
• Way to organize vast amounts of
information in concise format

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 Typical A3 Report
What’s Included

1. A clear reason for the report (story)

2. A clear presentation of facts, not opinions
3. An objective analysis of data
4. A specific, rational conclusion
5. Recommended actions:
• Short term / Long term
6. Monitoring activity/ next steps /follow up

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 A3 Thinking

• Understanding Causality
• Seeking Predictability
• Ensuring Ongoing, Unending Learning

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 What is the Story You are Telling?

• An effective way to communicate is

to tell a persuasive story

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 36
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 Case Example:
Understand the current situation

1. Problem Statement - Paint defects on the Powder Coat Line are 2% over the standard and
have been for over 1 year
Actual Current Situation Average just over 3% paint defects

Desired Situation (Goal or Standard) Paint defects should be less than 1%

Gap between actual and desired Paint defects are 2% over the standard

Extent of the problem Problem has been consistent for long-term (over 1 year)

Rationale for solving the problem -Defect is found after paint is cured and is more
-Rework requires additional set-up of paint system difficult to repair
Other Comments
- Rework has potential impact on customer delivery and increases cost

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 Team Exercise Part Two:
Build Consensus and Alignment

• Complete the Problem Statement (section 1)

of the A3
• Make sure you can verify the four criteria.
• List the rationale for solving the problem.
• List any other issues related to the problem.
• 20 minutes

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 Exercise Two Review

• Each team share their problem with the

other teams
• Discuss and clarify the problems
• Does everyone agree that-
– The problem is correctly defined
– Facts were presented
– The problem should be solved

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 Clarify Targets and Goals

• Target characteristics
– Do What? (Improve/Increase or
Reduce/Decrease)
– To What? (Defects, productivity, cost,
etc.)
– How Much? (By a specific amount and
get back to standard)
– By When? (Set an aggressive date)
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 Case Example:
Clarify targets and goals

2. Target / Goal
3.5 Paint Defect Reduction Target
3
Do What Reduce 2.5
% 2
1.5
To What Paint Defects
1
0.5
How Much 2% 0
9 9 9 9 9 9 9 9 9 9 9 9
2 00 2 00 2 00 2 00 2 00 2 00 2 00 2 00 2 00 200 2 00 2 00
/ / / 1/ 8/ / / / / / / /
By When 26-Jun-09 10 17 24 5/ 5/ 15 22 29 /5 12 19 26
4/ 4/ 4/ 5 / 5 / 5 / 6 6 / 6 / 6 /

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 Team Exercise Part Three:
Clarify Targets and Goals

•Complete Section Two (targets and goals)

of A3
•15 Minutes
• Set Targets and Goals
 Do What
 To What
 How Much
 By When

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 Exercise Three Review

• Each team share their targets and goals with

the other teams.
• Discuss and clarify the targets and goals.
• Does everyone agree that-
– The the targets and goals are appropriate for the
problem
– They are specific and measurable
– Targets and goals are aggressive but realistic

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 Step 2: Finding the
Root Cause

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 The Four Step Process
Step Two
Step One: Find and Clarify Step Two: Find the Root
the Problem Causes
– Understand the current – Ask clarifying questions
(when, where, how)
situation
– Narrow the focus
– Set standards as the
– Brainstorm possible causes
foundation for PPS
– Determine the most likely
– Surface the problems contributors
– Build consensus and – Determine the greatest
alignment actual contributors
– Clarify goals and targets – Confirm the root causes

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 Analysis to Find Root Causes

• The key to effective problem

solving is to find the root cause(s)
of the problem.
• This step requires detailed study
and observation!
• This is where the majority of time
is spent in problem solving.

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 Finding Root Causes of Problems

• “Root Causes” are things that are

happening that lead to the problem.
• Root Causes are at the bottom of
every problem.
• The Root Causes are often hidden
from view.
• Finding Root Causes requires
digging.

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 Watch out for traps

• Not clearly understanding the needs of the organization or

area
• Not clearly stating the needs (defining the situation)
• “Knowing” the “answers” prior to exploration
• Just listing the “problems” and “getting started doing
something”
• Jumping from “problem” to “solution” without clear
understanding and analysis
• Putting too much on the “to do later” list and not doing
enough now

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 Steps to finding the
Root Causes of a Problem
1. Ask Clarifying Questions: What, when,
where or how the problem happens
2. Narrow the focus
3. Brainstorm Possible Causes
4. Determine Most Likely Contributors
(develop your theory)
5. Determine Greatest Actual Contributors
(conduct your experiment)
6. Confirm the Root Cause.

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 Narrowing Focus

L A R G E P R O B L E M
Many Possible Causes

Most Likely Causes

Point of Cause

5 Why Process

Root Causes

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 Ask Clarifying Questions:
Where to Look for Root Causes

Point of Point of
Point of
Occurrence Recognition
Cause

The Point of Where the problem The problem is often

Cause may not physically occurs detected at a later
be at the Point of time. The worst is
Occurrence when it is at the
customer.

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 Relationship of
Problem/Symptom/Cause
THESE
PROBLEM AS A RESULT OF
THE PROBLEM
SYMPTOMS
(Virus)feel well)
(Don't EXIST
(Aches and Fever)
LEADS TO
ANALYSIS

ROOT CAUSES

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 Relationship of
Problem/Symptom/Cause
SYMPTOMS:
PROBLEM AS A RESULT OF
THE PROBLEM
Increased Cost,
(Reduced Efficiency) Poor Customer
Service
Quality Issue
Causes

Therefore

Quality
(Errors and
Omissions)

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Copyright 2007 Lean Associates, Inc.
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 Examples: What/Where/When
• Machines, equipment and tools
Precision
Reliable and Repeatable
Cycle time fast enough (too fast)
Correct settings
Fixtures / Tooling
• Any other issues like hitting things with a
hammer to get them into the machine.

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 Examples: What/Where/When
• Environment (Workplace Layout)
Lighting
Temperature
Work Position (Reaching / Overhead)
Extreme Effort
Noise
• Any other issues like extra effort or
difficulties with work.

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 Examples: What/Where/When
• Work Method and Procedures
Standard method defined and
followed
Correct pace
Over-processing
Evidence of correction or rework
• People (Man)
Skills and Training
Absenteeism
Turnover
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 Examples: What/Where/When

• Materials, parts, products

Incoming quality
Size, shape, tolerances
Material shortages, or outages
Extra effort required to “make parts
work”

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 Narrow the Focus using Data
Problem Tracking Data Collection Sheet

Problem: Paint Defects on the powder coat line are 2% over the standard
Why? Quantity of Surging defects is high
Reason: Need to brainstorm possible causes for surging

Possible Causes for Problem Frequency Total

Paint Surging (Splatters) 17

Heavy Paint 5

Thin Paint 12

Contamination 2

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Other 6
 Narrow the Focus (Closing the Gap)

20 % of Causes Lead To

(Critical Few)

80% of the Gap

80% of Causes
(Lots of
Miscellaneous)
Lead To
20% of the
Gap

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 Case Example:
Narrowing the Focus
Analysis of Paint Defects by Type
18
16
14
# Defects

12
10
8
6
4
2
0

Heavy Paint
Thin Paint
Paint Surging

Contamination

Other
(Splatters)

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 Brainstorm Possible Causes
• “Go and See” to completely understand.
• Develop possible causes based on
experience (educated guesses) and
observation.
• Group and Organize (Example:4 M’s 1 E)
• After Brainstorming, clarify to ensure
complete understanding (list then clarify).

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 Case Example:
Brainstorm Possible Causes

Defect Rate in Powder Paint

Why?
Paint Surging (Splatter)
Why?
Man Method Machine Material Environment

Lack of Operator Worn Paint Poor

Training Technique Gun Clumps Lighting

Don’t Motion Set Up Wet Faraday

Care Up Down Wrong Powder Trap

Side to Hose Defects on Mask and

Side Kink Parts Suit

Wrong Dirt in
Hose Parts

Worn
Venturi

Pump
Worn
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 Brainstorm Possible Causes
Brainstorming Worksheet
Problem Statement:

Possible Causes: List all possibilities without judgement

People

Method

Material

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 Team Exercise Part Four:
Brainstorm Possible Causes
• Brainstorm Possible Causes for the Problem
• Use the brainstorming worksheet as a guide
• “Go and See” to make sure you are not
missing any possibilities.
• Use your knowledge and previous
experience to gather ideas.
• Narrow, group, and organize your ideas.
• 40 minutes

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 Exercise Four Review
• Focus review on the brainstorming process
rather than specific causes generated.
• What were the challenges of brainstorming?
• What were the benefits?
• Discuss any main ideas generated by
brainstorming.
• Don’t review every item- just some of the
more surprising or perhaps previously
unknown ideas that you believe warrant
further investigation.

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 Determine the Most Likely Contributors

Based on your facts, narrow the list of possible

causes and decide on three (3) items you consider to
be the “Most Likely Contributors”.
• Narrow the focus based on actual results.
• Use “logic”-do the results make sense?
• Look for consistency/variability: can we
isolate the cause?
• Are we closing the gap between Point of
Recognition and Point of Occurrence?
• “Consensus Rules” in making decisions.
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 Determine the Most Likely Contributors

To determine “Greatest Actual Contributors”

investigate the Most Likely Contributors
further:
– We must PROVE or DISPROVE
through experimentation.
– We can always change our theory if we
prove these are not actual contributors.

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 Determine the Most Likely Contributors:
The Scientific Method
• Observation – Go see problem at the point of occurrence
• Theory – Ask what, when, how, and who to find possible
causes

• Hypothesis – Identify what you believe are the Most Likely

Contributors

• Experiment – Conduct experiments to verify Most Likely

Contributors are ACTUAL causes

• Results – Evaluate and verify Greatest ACTUAL Contributors

• Conclusions – Prove or disprove your theory and
hypothesis based on results of experiments
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 Why Experiment To Prove Theories?
The Culture of Problem Solving

• Galileo gravity experiment

Which falls faster?

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 Example of Worksheet
Most Likely Contributor Selection Worksheet
1. Review list of Possible Causes.
2. Combine any items that are the same or similar
3. Clarify any items to ensure all members understand the meaning
4. Use a voting method to decide which are the 3 Most Likely Contributors
5. Select items that happen most often or contribute the most to the gap (problem)

Most Likely Contributor #1

Why do you believe this is a Most Likely Contributor? (List any obsevations or data)

What ideas do you have to prove that this is an actual contributor to the problem?

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 Case Example:
Determine Most Likely Contributors
• Determined that the defect is actually a clump of
paint on the surface (not contamination).
• Found that the hoses and venturi were in
specification.
• Faraday Trap is inside corners and defect is on the
outside of parts.
• Tested up-down motions and could not duplicate
problem.
• Tested old and new guns- no difference.
• Operators showed concern and desire to solve
problem.
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 Case Example Continued:
Process of Elimination

Defect Rate in Powder Paint

People Method Machine Material Workplace

Lack of Operator Worn Paint Poor

Training Technique Gun Clumps Lighting

Don’t Motion Set Up Wet Faraday

Care Up Down Wrong Powder Trap

Side to Hose Defects on Mask and

Side Kink Parts Suit

Wrong Dirt in
Hose Parts
Experimentation
Worn
allows us to prove or Venturi

disprove our Pump

Worn
theories.

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 Most Likely Contributors:
Team Exercise Part Five
• Use the Most Likely Contributor Worksheet as a
guide.
• Narrow your list of Possible Causes to three (3)
items that have a high likelihood of being actual
contributors to the problem.
• List your thinking as to why you believe your
selections are Most Likely Contributors (theory).
• List any ideas to prove your thinking (hypothesis)
• 20 minutes

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 Exercise Five Review
• Focus review on the selection process
used to narrow to the Most Likely
Contributors
• Do the reasons listed sound
reasonable?

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 Go See and Experiment:
Determine the Greatest Actual Contributors

Defect Rate in Powder Paint

Method Machine

Operator Set Up
Technique Wrong

Point of
Occurrence

Go to the Point of Occurrence and experiment

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 Factors to Verify With Experiments

• Operator Technique • Incorrect Equipment

Theory Set Up Theory
 Excessive “wiggling”  Air Pressure
High/Low
 Rapid movement
 Powder Flow
High/Low
 KV Setting High/Low
 Fluidization of Powder

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 Results of Experiments
Set Up Test
Air Pressure KV Powder Result

+ 10 PSI No Change No Change No Problem

+ 20 PSI No Change No Change X

Problem

+ 20 PSI + 2.O No Change X

More Problem

+ 10 PSI +2.O No Change X

Problem

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 Case Example:
Greatest Actual Contributors

3. Cause Analysis Greatest Actual Contributors (Top 3)

Method Set-Up Set-Up

Spraying Technique Air Pressure Setting too high KV Setting too high

Why?

Why?

Why?

Root Causes

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 Team Exercise Part Six:
Greatest Actual Contributors
• Go to the workplace to observe the Most Likely
Contributors
• Determine experiments to prove Greatest Actual
Contributors
Conduct experiments if possible.
• Complete section 3 (Cause Analysis) of the A3 to
this point (Greatest Actual Contributors only)
• Don’t try to identify ROOT CAUSES at this time!

• 30 minutes

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 Exercise Six Review
• Each team:
– Share their process with the other teams.
– Explain the 3 Greatest Actual Contributors and
why they were chosen (results of your
experiments).
• Does everyone agree on the following
items:
– The logic from the problem to the Greatest
Actual Contributors makes sense?
– The team should pursue these actual
contributors through root cause analysis?

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 Confirm the Root Cause:
Five Why Investigation
• Why did that happen? Therefore!

• Why did that happen? Therefore!

• Why did that happen? Therefore!

• Why did that happen? Therefore!

• Why did that happen?

Root Cause
Therefore!

 Work backwards from the root cause to the problem

statement saying “Therefore” between each “Why”
statement
 If you can proceed logically from the last “Why” statement
to the problem statement, the process was done correctly
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 Case Example:
Confirm the Root Cause

Defect Rate in Powder Paint

Why?
Paint Surging (Splatter)
Why?
Spray Technique KV Setting High Air Setting High

Why?
Rapid Incorrect Incorrect
Movement Setting Setting

Why?
Cause Cause Cause Cause Cause

Why?
Keep digging to get to root causes!

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 Why ask “why” 5 times
If you stop short, you have only detected a partial cause
and not a “root” cause

For example:
In the old Cavalry days a battle on the frontier was lost
• The general at the time only asked “why” one time and he
was told “because our soldiers became dismounted from
their horses”
• He immediately ordered his men to undergo rigorous
“riding” remedial training

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 Why ask “why” 5 times
• If the general knew about 5 Why Analysis and had
asked “why” a few more times, he would have
discovered:
• Why did the soldiers become dismounted?
– Because the horses were going lame
• Why were the horses going lame?
– Because they were throwing a horse shoe
• Why were they throwing a shoe?
– Because they only had 3 of the required 5 nails installed
• Why were there only 3 nails installed?
– Because the blacksmith ran out of nails and spread the
remaining nails as far as he could
By not asking enough “Why’s” the action taken didn’t
address the true root cause.
85
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 Common “Five Why” Mistake
Problem Statement: The defect rate is over goal
Why?
Too many defective parts
Why?
Parts are assembled incorrectly
Why?
Operator error
Why?
Parts don't align correctly
Why?
Poor design
Why?
Root Cause?? Designer didn't design correctly

• The “root cause” points responsibility to someone else.

• It may be true, but it does not help us solve the problem.
• The “root cause” can’t be corrected.
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 Effective Root Cause Analysis
Problem Statement: The defect rate is over goal
Why?
Too many defective parts
Why?
Parts are assembled incorrectly
Why?
Operator error
Why?
Parts don't align correctly
Why?
Parts can be oriented incorrectly
Why?
Root Cause?? No error proofing device

• We can correct the root cause.

• The solution is obvious!

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 Case Example:
Confirm Root Cause

3. Cause Analysis Greatest Actual Contributors (Top 3)

Method Set-Up Set-Up

Spraying Technique Air Pressure Setting too high KV Setting too high

Why? (Does spraying technique cause splatter?) Why? (Is the air pressure set high?) Why? (Is the KV setting high?)
Gun moved rapidly causes paint to surge Someone set incorrectly Someone set incorrectly
Why? (Is the gun being moved rapidly?) Why? (Did someone set incorrectly?) Why? (Did someone set incorrectly?)
It is not clear what the correct setting is It is not clear what the correct setting is
Operator uses a wiggling back and forth motion Why? (Is the setting not clear?) Why? (Is the setting not clear?)
Why? (Does the operator use this motion?) Proper setting not marked on the Proper setting not marked on the
Operator believes that moving back and forth gauge gauge
increases coverage Root Causes

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 Team Exercise Part Seven:
Confirm the Root Cause
• Continue asking “Why?” to find root cause.
• Confirm that you have found the root causes
(Can you make the problem occur or stop?)
• Test using the “therefore test”.
• Complete the Cause Analysis (section 3) of
the A3.
• Show any information related to the root
cause analysis.
• Highlight the root causes identified.

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 Exercise Seven Review

• Each team share their root cause analysis

with the other teams.
• Explain the “Five Why” process used to
verify the root causes.
• Does everyone agree that-
– the logic of the Five Why’s make sense?
– the root causes have been verified and proven?

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 Wrap Up Step Two

• HOMEWORK:
• Work on previous team assignments.
Complete or update sections 1, 2, and 3.
• Do you need to conduct any
experiments?
• The Facilitator will be available for
coaching.
• Questions?

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 Step 3: Identify and
Implement Countermeasures

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 The Four Step Process
Step Three
Step Three: Identify and Step Four: Confirm and
Implement Countermeasures Follow Up
– Brainstorm – Verify plan effectiveness
countermeasures – Modify implementation
– Evaluate and prioritize plan
countermeasures – Confirm the results
– Develop the – Standardize effective
Implementation Plan countermeasures
– Develop Future Steps

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 Brainstorm Countermeasures

• Problems are never truly “solved”, they

are merely kept in control (minimized).
• This control is called a countermeasure.
• The countermeasure must be used
constantly to control the problem and
remain effective.
• Failure to use the proper countermeasure
will allow for reoccurrence (defects).
• There is no “absolute” countermeasure.

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 Brainstorm Countermeasures

• Emphasize quantity over quality.

• Suspend judgment-let ideas flow.
• Let one idea build upon the next.
• Record ideas rapidly for as long as you can
without stopping.
• The Rule: The countermeasures must relate
to the problem!!

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 Evaluate Countermeasures
Countermeasure(s) should always be evaluated on
their ability to achieve your target/goal.

• They should be effective:

– Can you test the countermeasure?
– Will this countermeasure be enough to achieve the
target/goal?
– Will this countermeasure prevent recurrence of the
problem?

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 Evaluate Countermeasures

They should be feasible.

• To Determine how feasible the countermeasure may be,

ask the questions:
– Can it be done by the team?
– Can it be done now?
– Is it low cost?
– Must it be done by outside resources?
– Will management/others buy into the solution?

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 Evaluate Countermeasures
They should have impact!
• Ask what impact might this countermeasure have on:
– Other processes and people?
– My job?
– My team?
– Other operations?
– The company as a whole?

• Will the countermeasure create “new” problems?

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 Prioritize Countermeasures
High

 First Priority
“Just Do Its”
 “High Priority”
o Evaluate these first &
o Second wave implement ASAP
Potential Value

 Prioritized
list of ideas
to be further
evaluated
 Second Priority
 “Defer”
 “Just Do Its”

o Evaluate later o Second wave

Low
Difficult Easy
Ease of Implementation

o Operational Risks (irreversible?)

o Need for capital
o Timing/resources required

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 Prioritize Countermeasures
Keep both a short term and a long term
perspective in mind.
•Short Term Countermeasures
– What can fix the problem immediately?
– Does it help achieve the target or goal?
– Implement Short Term Countermeasures while
developing Long Term Countermeasures.
•Long Term Countermeasures
– Offer the best combination of results.
– Does it really deal with the root cause of the
problem?
– Does it really achieve your target or goal?
– Will it prevent recurrence of the problem?

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 Case Example:
Evaluate and Prioritize Countermeasures

4. Countermeasures
Testing showed that it is possible to recognize the defect at the point of occurrence. Developed spot check procedure
Short-Term (Temporary)
Mark gauges with correct settings
Implement process confirmation of gauges 4 times per shift by line leader
Long-Term (Permanent): Use JI to re-instruct operators correct spray speed, distance, etc.
Build in Spot Inspection at paint booth to prevent defect from going into oven. Repair can be made easily at paint booth.
Put lock on gauge setting to prevent changing without line leader awareness

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 Develop the Implementation Plan

In the Problem-Solving Process, effective implementation

cannot be assumed. Proper planning IS REQUIRED.
• Develop a Plan to implement
countermeasure(s)
– Define necessary actions
• List actions required
• Sequence of actions required
– Specify who will do what, when, and where
– Test your thinking.

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 Develop the Implementation Plan
 Evaluate the Implementation Plan
 Ask “what if?” to anticipate problems with the plan (Impact)
 Critical areas to question/validate include:
 Tight deadlines
 Costs
 Unclear responsibilities
 Possible adverse reaction
 Commitment by others to follow through
 Modify the plan if necessary
 Communicate the Plan
 Use the A3 format.
 Discuss with management, peers, and
others affected
 Execute the Plan

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 Case Example:
Develop the Implementation Plan

5. Implementation Plan
What will be implemented Who When Where Status
Behind
1 Color gauge face green showing proper setting range Kora S 4/30/2009 Paint Booth Complete
In front of
2 Develop visual cards indicating gauges checked 4 times per shift Kim M 5/5/2009 Paint Booth Complete

3 Add spot inspection of problem area into standard work Michael M 5/5/2009 Paint Booth In Process

4 Install lock out on gauges Matthew M 5/20/2009 Gauges Scheduled

5.

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 Team Exercise Part Eight: Evaluate & Prioritize
Countermeasures; Develop Implementation Plan

• Identify potential countermeasures (short-term and long-term)

• If possible, test effectiveness of temporary countermeasures.
• If a problem can’t be stopped, can it be controlled? (Example:
presort incoming material so that defects don’t get to the line)
• Prioritize countermeasures and complete “Countermeasures” (section
4) of the A3.
• Complete the “Implementation Plan” (section 5) on the A3.
Define necessary actions
List the actions required
Sequence of actions required
Specify who will do what, when, and where
• 30 Minutes

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 Exercise Eight Review

• Each team share their countermeasures and

implementation plans with the other teams.
• Explain how the countermeasures were
determined and prioritized.
• Share the results of any tests.
• Use the A3 to show the plans.

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 Step 4: Confirm and
Follow Up

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 The Four Step Process
Step Four
Step Three: Identify and Step Four: Confirm and
Implement Countermeasures Follow Up
– Brainstorm – Verify plan effectiveness
countermeasures – Modify implementation
– Evaluate and prioritize plan
countermeasures – Confirm the results
– Develop the – Standardize effective
Implementation Plan countermeasures
– Develop Future Steps

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 Verify Plan Effectiveness

• Monitor the progress of the

implementation plan
• Was the implementation plan
completed?
–Was the target or goal achieved?
–Is it necessary to go back to
identify additional
countermeasures?

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 Verify Plan Effectiveness

• Verify the effectiveness of the

countermeasures
–Did the countermeasures
effectively control the root
causes?
–Has the problem been
controlled?

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 Modify Implementation Plan

• Evaluate results
• Was the experiment successful?
• Decide upon appropriate action(s)
• Modify implementation plan if
necessary
 Select new Countermeasures

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 Confirm the Results
• Countermeasures only control the
causes of problems
• They must be constantly applied to
prevent recurrence of a problem
• Countermeasures must be regularly
confirmed to make sure they are still
in place and being followed

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 Confirm the Results
• Identify what must be monitored
• How will it be checked?
• Identify the frequency to check
• Who will be responsible?
• How will you make it visible so
that everyone knows the
countermeasure is working?

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 Confirm the Results:
Follow Up and Tracking

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 Confirm the Results:
Countermeasure Follow Up & Tracking

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 Standardize Effective
Countermeasures

• Build countermeasures into the standard

work
• Make countermeasures visual and easy
to see and confirm
• Apply error proofing thinking so that
countermeasures can not be omitted

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 Case Example:
Confirm and Follow Up

6. Follow-Up and Verification Weekly Number of Paint Surge Defects

Check Method
Visual check of gauges and confirm inprocess inspection
Check Frequency
Once at start of shift and any time the problem is detected
Who will Check?
Line Leader will check and will turn process confirmation card
over to indicate that the check has been complete

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 Develop Future Steps

1. Wrap up any remaining items

2. Request for assistance for issues outside
control
3. Hand off responsibility for problem to
owners
– Sustaining Countermeasures
– Continuous Improvement
4. What problem will be tackled next?
– Ensure alignment and agreement

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 Develop Future Steps:
The Art of “Hansei”

• “Hansei” means deep reflection and

self learning.
– build on past success/learn from failures
– What did not work according to plan?
Why?
– What will you change next time?

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 Case Example:
Develop Future Steps

7. Future Steps and Recommendations

Currently the team needs to continue to monitor the results and verify the countermeasures. One countermeasure remains to be
implemented and is scheduled.
Line Leader will have daily responsibility to confirm countermeasures and to confirm any time the surging defect occurs.
The Team plans to go back and work on the thin paint issue which is the next highest defect category

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 Confirm and Follow Up:
Final Team Exercise
• As a group, discuss what might be required to complete
section 6 (Follow Up) of the A3 report.
– Will it track progress to the target set in section 2 of the A3?
– Identify who will check, how, and when will results be tracked and
reported?

• Discuss how we might complete Future Steps and

Recommendations (section 7) of the A3 report.
– List any recommendations needed to further reduce the problem
(help from others, etc.)
– How will we do Hansei? Based on our learning, discuss what you
would do differently next time and why.

• 20 minutes

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 A3 Example

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 Wrap up and Report Out

• Present A3’s to management team.

• Share your thoughts on the class
– Lessons Learned
– Benefits
• What you will do next? What now? What
will we do TOMORROW?
• How can we transform from Externally
Driven to Internally Focused?
• How will we support each other? Teach
others?

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