Most people don’t realize how often they actually do mistakes. Every wrong move or thoughtless action, even if you can recover it immediately, is still a mistake that could have been possible to perform flawlessly. In general, people don’t admit doing errors, especially publicly in fear of becoming shamed. Six Sigma suggests as the source of the most of the cost in the products the so called Hidden Factories, or error corrections that are performed by the employees without informing the management, to avoid taking the blame, but incurring nevertheless the cost of the error. However, the belief that the mistake that you just made would be your fault is actually not true! If you just made an error, it’s actually not your fault! Instead, you should point your finger to the designer.
At Toyota the Kaizen continuous improvement and learning organization uses the following framework for blaming and learning from mistakes. You can adapt this philosophy also on your personal life, but I discuss it from the entrepreneur’s point of view.
1. Blame the Instructions
If you don’t have instructions how to perform a specific task, the work design and management is to be blamed. The definition of the management and entrepreneurs is actually not do any work, but to manage the organization of work, meaning how exactly you should perform your tasks and which tasks should be performed in the first place. The work of an entrepreneur is to organize the factors of production so that you can convert ideas into practice filling out a market niche. The work of the managers is to find optimal organization of the work for a given problem. The worker should not be interested of the management of the work, since it’s not his primary interest, as long as the company stays afloat and employment is guaranteed. Similarly, a manager or entrepreneur who is not interested in the continuous improvement of the work processes is not performing his job properly.
The current and western management nomenclature tends to omit the first and primary factor of production as irrelevant – the standardization of work. However, the as any basic economics book can tell you straight-on, without standardization of work there is no economies of scale and the work remains ad hoc in nature and economically unfeasible. In the western countries the emphasis is put on the innovation, or the Deming’s PDCA -cycle, how to improve the current work process by radical innovation. Unfortunately most often the basics are forgotten in the fuzz of innovation and the management fails to standardize the work after or before the innovation, resulting in utter chaos and high costs. No wonder that the jobs are continuously being outsourced to China and India.
Secondly, if by a miracle a standardized work process would exist in your organization, the instructions might well be incomplete, inaccurate and ignorant of the most common error modes. The first corrective action at Toyota is aimed thus on improving the instructions so that the by following them the work can be performed succesfully.
Yet a more advanced philosophy for standardization is the Six Sigma -approach that tries to identify and mitigate the sole possibility of producing an error. The Japanese call this principle as Poka-Yoke, or error-proofing. The idea is that by eliminating the source cause for errors the work process can be performed flawlessly producing significant quality and cost improvements.
2. Blame the Machines
If despite improving the instructions you still make them, you must turn the look on the machinery and tools that you are using to perform the task. For example if your computer is crashing and preventing you from performing your work, it’s not the fault of the instructions or yourself, but of the computer. Thus you should find a new tool or machine design that makes it impossible to perform such an error.
The Designed for Six Sigma (DFSS) -method tries to achieve exactly this. 80% of the quality problems can be tracked back to the design board, and thus it is not possible to reach the higher levels of quality (5 and 6 sigma) without taking the high quality in account already on the drawing board. The DFSS tries to eliminate the potential for producing Critical-to-Quality (CTQ) error in advance by for example preferring usage of proven components, analysing the potential error modes (FMEA) and the Voice of Customer.
The Japanese have developed a 14 level model of intelligent machine automation (Jidoka). The idea is to convert the machines to automatically detect errors in themselves. The idea comes from Toyota’s founder’s Sakichi Toyoda’s automatic weaving machine that automatically detected a broken loom. Six Sigma suggests of using simple automatic pass/fail -gates for investigating the quality level on a production line. The same idea is called as Test-Driven Development in software engineering, where you before starting of the coding define the end product by writing automated unit and acceptance tests.
3. Blame Yourself
If you are not able to follow the instructions or the standardized process, it’s your fault. In this case Toyota considers a task for you that you are able to perform according to the instructions. However, before blaming on the human factors, one should consider the two previous steps if they have rendered the work inhumane to perform, and if the blame can be still be placed on the Work and Machine Design first.
Of course, if you are unable to follow the Kaizen continuous improvement -cycle, the blame is truly only on yourself 🙂