Problem solving: what was the last change?

This post could be a sequel of “Yeah, problem solving” in which I used Peter Senge’s quote: “Today’s problems come from yesterday’s solutions”.

Quite often people we consultants meet are puzzled by a problem they can’t understand:

  • a reliable process or machine suddenly seems out of control,
  • steady performance dropped unexpectedly and with no apparent reason,
  • sudden quality issues with trusted supplies,
  • etc.

Our experience lead us to investigate the last change made, precisely because of the “wisdom” of Peter Senge’s quote: chances are that a modification (fixing a problem) led to unexpected Undesirable Effects and causing new a problem to appear.

Of course, the modification to look for is seldom the worried person’s ones, which he/she would most probably remember and perceive the possible cause-to-effect relationship.

No, the modification more likely happened outside the span of control and without the knowledge of the impacted people.

A modification leading to a problem in a lengthy process can happen far away (both in process steps and location) from the point the problem appears, letting the people perplexed about this reliable process now out of control.

Purchasing and procurement choices are unfortunately often the unintentional culprits, buying a slightly different grade of material, changing a supplier or accepting a low quality batch with the best intentions: cut costs or ensure timely deliveries.

When facing a puzzling problem the investigation should follow “the last modification path”.

This isn’t always easy though. The Undesirable Effects brought up by the change may be minimized or even neutralized for a while, long enough for everybody to forget about the nature of the change, when it happened and its consequences then.

That’s precisely why some industries with strong safety and regulatory constraints like aeronautics or pharmaceutical have to be cautious about any modification (needs approval after thorough risk assessment) and capture every information about virtually anything (dates, manufacturing conditions, persons in charge, certificates…), in case an investigation must find the root causes of a deviation (or worse), long time after the triggering action occurred.

When the problem cannot longer be neutralized by the former forgotten fix, it looks like a new problem.

Searching for the last change is often a good guess, yet not always leading to the root cause. Keep in mind that some modification correlate nicely with the apparition of the problem, but correlation isn’t causation.


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Yeah, problem solving

Most people love to solve problems and feel the satisfaction of getting rid of some nasty tricky problem. It’s an outdated but still lasting belief that management is about problem solving. Problem solving turned in some cases into the managers’ and engineers’ holly mission and in some minds, the more problems the manager/engineer solves, the better manager/engineer he/she is. This kind of problem solving can be addictive, hence the Arsonist Fireman Syndrome.

On the other hand, thanks to Lean Management, enlightened managers understand it is crucial to refrain from solving problems and develop their subordinates’ ability to solve problems themselves instead.

Note that all the above is about problem solving, not problem avoidance or problem prevention. And if today’s problems come from yesterday’s solutions, as stated in Peter Senge’s “The 11 Laws of the Fifth Discipline”, in a world requiring increasingly fast decisions (read solutions), we’ll never run out of new problems to solve.

So what’s wrong with problem solving?

There are at least 2 major issues with actual problem solving practices.

1. Quick fixes

Solutions to problems are most often quick fixes made of the first “best” idea that popped up. Problem solving is not very often a robust and standardized process, systematically rolled out. In fact formal problem solving processes seldom exist even if everybody is claiming solving problems.

If known, simple structured approaches like PDCA are disregarded and ignored, pretending the situation requires quick reaction and not “unnecessary paperwork!”

Often, the problem seem to be fixed, giving credit to the firefighters and reinforcing their belief in their “way” of handling.

It is not really surprising that the same problem keeps showing up as the fixes did not eradicate the problem’s root cause, and the problem itself was never really studied, hence understood.

2. No risk assessment / risk mitigation

If formal and structured processes to tackle problems are seldom, the solutions’ risk assessment is even more seldom. And if the rush to quick fixes leaves no time for properly analyzing the possible problem root causes, no need to mention non-existing attempts to figure out the possible risks these quick fixes bring with them.

Chances are that the ill-prepared and hastily put in place solutions generate unexpected Undesirable Effects. What may fix one problem may well cause one or several others to appear.

That’s how quick and dirty troubleshooting usually come at the expense of later longer efforts to cope with a situation that possibly grew worse, and how Peter Senge’s quote: “Today’s problems come from yesterday’s solutions” makes the most sense.

What solutions?

  • Choose yourself a structured problem solving approach, there are several available. Try it and if proven suitable for your purpose make it your standard way of approaching a problem.
  • Make sure the implemented solutions will really kill the problem by measuring on a long time horizon if the trouble has disappeared for good. The Quality Operating System is perfect for that.
  • Explore the Logical Thinking Process, the sole complex problem solving methodology I know which includes a systematic “Negative Branch” check to avoid or mitigate Undesirable Effects as by-products of the implemented solution.

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Bill Dettmer refining some points about Logical Thinking Process

In this video, an excerpt of Bill Dettmer‘s Logical Thinking Process (LTP) training course in Paris, June 2015, Bill refines some points about LTP.

First, the two first tools (Trees) of the LTP, namely the Goal Tree (GT) and Current Reality Tree (CRT) are based on facts. The others, Evaporating Cloud (EC), Future Reality Tree (FRT), Prerequisite Tree (PRT) are based on high probability things will happen as planned.

The components of a Goal Tree, called Necessary Conditions (or NCs) are factual needs necessary to achieve the Goal. The Current Reality is described in a CRT in a way that can be checked and proven, based on facts.

As soon as the people are working on the future, from Evaporating Cloud on, it can only be described in probabilities, as things may not exactly turn out as planned. Theory of Constraints’ Logical Thinking Process may need to rely on other tools and methods than Negative Branch Reservation (NBR) to mitigate the risks.

Furthermore, the time to accomplish the necessary tasks is an evaluation at best.

Finally Bill summarizes what Logical Thinking Process is:

a structured way to move from an ill-defined system level problem to a fully implemented solution.

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Performance improvement: simple things can earn big results

Silly things can cost a lot in terms of productivity and output.  In this video interview, Philip Marris  asks me about lessons learnt while helping a pharmaceutical plant to improve productivity and deliver drugs to patients faster.

It is about how simple actions solve those silly small problems and bring big results at literally no cost.

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5S in hospital

5S are as well an approach, philosophy and methodology to better workplace organization, foundations for efficient and safe work, as well as insuring quality and continuous improvement. They originated in their current form* in industrial workshops in Japan, leading many people to think “this is a production thing“.

The following video shows a good example of the application of the 5S principles in a Toronto hospital.

*I believe 5S preexisted in different forms, especially in the TWI cards during WWII.

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10 signs you need consider Logical Thinking Process

Here are 10 signs pointing to the need to consider using the Logical Thinking Process in order to help you solve your complex problems and structure your transformation plan.

Don’t know what The Logical Thinking Process is?
>The Logical Thinking Process in a nutshell

This article was originally written to promote the Logical Thinking Process training course with Bill Dettmer and Marris Consulting in Paris, an event I am involved in. I could not help but replicate it here!

The Logical Thinking Process is a great help if You:

  1. do not know how to properly state your Vision and Goal
  2. are unsure about what is required to achieve your Goal
  3. are afraid of costly and questionable “nice-to-haves” your staff is asking for
  4. have no benchmark for orienting and monitoring all efforts
  5. have no idea how far your organization is from the Goal
  6. are stuck with conflicting objectives or constraints
  7. do not know what to do to close the gaps and achieve your Goal
  8. are afraid about possible negative side effects and obstacles of your plan
  9. are uneasy about how to communicate the necessary changes
  10. would like to have a list of prerequisites for successful change

1. You do not know how to properly state your Vision and Goal

Surprisingly many employees, from shop floor to top managers, don’t know precisely what the Goal of the company is or have different views on it. How can they align their contribution if the Goal is not clear or understood in different ways?

The Logical Thinking Process starts with a clear and unambiguous Goal statement, an absolute must in order to meet success. A powerful multipurpose tool will help: the Goal Tree.

2. You are unsure about what is required to achieve your Goal

The Goal Tree describes all required Necessary Conditions to be fulfilled for achieving the Goal. These Necessary Conditions are listed from a sound and robust analysis using only “necessity-based logic”, in a scientific approach.

3. You are afraid of costly and questionable “nice-to-haves” your staff is asking for

With the Necessary Conditions listed, only those complying to the logical “necessity-based logic” will be kept. All others, not strictly necessarily will be discarded.

This is a very powerful means to filter out all the personal wishes and “nice-to-haves”.

4. You have no benchmark for orienting and monitoring all efforts

Once the Goal Tree is completed, it is a system-wide benchmark of what is required to achieve the Goal. The Goal Tree is then used to check the status of each Necessary Condition and the overall progress towards the Goal.

A Goal Tree is valid as long as the business environment does not drastically change, so the few hours investment in building the Tree is definitely worth it.

5. You have no idea how far your organization is from the Goal

Besides the Goal Tree, the Logical Thinking Process provides other tools among which the Current Reality Tree, describing the actual state of the organization in regards of gaps to the Goal.

The Current Reality Tree is built starting from difficulties and problems encountered by the organization and goes down to the very few root causes, discovered using the cause-effect logic.

Treating the few root causes will solve many problems at once as they are only multiple Undesirable Effects related to a same cause.

6. You are stuck with conflicting objectives or constraints

Among the obstacles on the road to the Goal, conflicting objectives or constraints are common. To tackle these conflicts, the Logical Thinking Process provides a tool called Conflict Resolution Diagram. Based like the other tools on logic, it helps to debunk myths and false beliefs as well as find win-win solutions to conflicts.

7. You do not know what to do to close the gaps and achieve your Goal

The Logical Thinking Process depicts the desirable future state with a Future Reality Tree in which the previously listed obstacles and problems have been removed or by-passed with appropriate solutions.

The “difference” between the Current Reality Tree and the Future Reality Tree are the gaps to fill in order to achieve the Goal.

8. You are afraid about possible negative side effects and obstacles of your plan

Simple elegant or sophisticated solutions may look good on paper but can mess up more than solve current problems. Fearing something could go wrong and lead to a worse condition can paralyze initiatives.

In order to prevent possible negative side effects, the Logical Thinking Process provides “stress test” and robustness assessments. Among them, any possibility for negative side effects to develop is scrutinized.

If one pops up, an appropriate preventative countermeasure is defined. At the end of the analysis, the robustness of the solution is guaranteed.

9. You are uneasy about how to communicate the necessary changes

The Logical Thinking Process and its tools provide robust and straightforward means to communicate what the necessary changes are, why and how to make the change happen.

As everything is based on sound logic, it is free from any emotional biases and verifiable by anybody, making the communication very robust and compelling.

10. You would like to have a list of prerequisites for successful change

Everybody wants a clear roadmap and concrete examples about what is to be done.

The Logical Thinking Process provides a logical Prerequisite Tree, listing all steps and Intermediate Objectives along the path to reaching the Goal.

The Logical Thinking Process is surely the most structured and robust way to lead the transformation of an organization, from its difficulties to its success.

If one of these 10 signs applies to your organization, you really should consider the Logical Thinking Process.

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Announcing the Logical Thinking Process training, Jan 2016 in Paris

I used the opportunity to advertise the next Logical Thinking Process 6-days course (from 13th to 20th January 2016 in Paris, France) to tryout the PowToon animation app.

It took me three attempts to get to this:

Here is the link to more information and registration: Logical Thinking Process: Strategic Navigation and Complex Problem Solving

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What coaching means to me – part two

A coach is a person able to teach, train and advise someone, to improve skills and/or practice and to make his/her coachee reflect about achievements and how to improve from the lessons learned.

It takes some experience and skill to coach others, that’s why I am not comfortable hearing the words coach or coaching that often is business, these words being used way too lightly in my opinion.

>Read What coaching means to me – part one

Many of the alleged coachings are nothing more than a kind of facilitation or workshop moderation. Coaching may sound better and please the facilitator’s ego, but it isn’t coaching.

What coaching means to me is living a significant part of time with the coachee on the shop floor or gemba (can be an office, warehouse, hospital, whatsoever) and making use of real problems to help him/her to improve his/her ability to cope with unexpected and random situations.

It may well need a structured approach, a set of principles, methods and a toolbox, but real-life problems are seldom solved in the way the examples in training classes depict.

Many of the real-life problems need a bit of creativity because they may be similar to previously experienced ones, but slight differences can hinder the same solutions to apply. A coach should have the ability to find a way to overcome this kind of difficulty and design a suitable experiment for solving the problem.

When a problem arises, it is an opportunity for the coach to see how the coachee is approaching it, and if needed give some advice and later feedback.

The coach does not need to know the solution and have answers to everything, but at least have the ability to analyze and make out a way to attack a problem in a structured way, then help his/her coachee to do the same without too much interference. After all, it’s the coachee’s golden opportunity to learn.

Except when regulatory constraint, if so-called coaches keep sticking to the book or procedures and are reluctant to “experiment”, it’s usually a sign of lack of experience and/or maturity. The stronger the cling, the less useful the “coach”.

The “coaching” mentioned in part one is therefore more about procedure reinforcement than real coaching. Its value lies maybe in the rollout of the Lean program but not in developing people’s skills.

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How sound logical thinking improves fishbone diagrams

Fishbone diagram is known by different names: Ishikawa diagram, cause-and-effect analysis or cause-and-effect diagram. Fishbone diagrams are popular on shop floors as they are easy to understand visual tools.

The principle of a fishbone diagram is to list all possible causes leading to an effect (usually the problem to solve) and to sort them into “families” sharing commonalities.

These families are the main bones of the diagram. In order to get a fishbone diagram started a common way is to go for the famous “5Ms”, standing for Man, Machine, Material, Method, Mother Nature.

The five Ms are common families of causes of trouble experienced in industry and became a kind of standard to start a cause and effect analysis. Typically, one draws a triangle (the fish’s head holding the effect to analyse), a horizontal line which is the fish’s backbone and five slant bones from the horizontal one with the 5M’s at their end.


Note that a fishbone diagram must not be limited to these five Ms and it is not mandatory to use them. The 5Ms are just a convenient mnemotechnic.

A fishbone diagram is an appropriate support for brainstorming and ordering the outputs. The different named main bones will lead to explore the relative families of causes and propose ideas of potential causes. Then, the various ideas can be sorted according to the family each main bone stands for.

Yet too often I see fishbone diagrams cluttered with listed causes that are not likely to influence the effect. This is maybe where nicknaming the cause-effect diagram / analysis “fishbone” leads to forget what should be looked for: cause-to-effect relationship.

Now a true cause-effect relationship should respond to the “if [cause] then [effect]” sentence. If the proposal makes no sense, the cause-to-effect relationship is questionable.

A variant may be “if [cause] then [effect] because [justification]”


If the issue to solve is a frequent drive motor overload on a conveyor belt causing a circuit breaker to shut off. The proposal “rain” as such will not be valid: “if (it) rain(s) then drive motor gets overloaded” is not logically sound, as nobody can understand a direct link between rain and circuit breaking.

The proposal may be refined and rephrased. It could be that the person thinking about rain was actually considering the supplement of weight of transported goods when they get soaked by rain: “if it rains, then goods get heavier when soaked and if goods are heavier, the power required to move the belt may cause the breaker to shut off”.

If no logical relationship can be established between the proposed cause and the effect under study, the proposal may be discarded for the sake of efficiency.

Using the “if [cause] then [effect]” sentence will filter out irrelevant proposals and get better diagrams.

A valid proposal would be “worn out ball bearings”, expressed in full sentence like: “If ball bearings are worn out, then the drive motor gets overloaded because the belt dragging increases”.

Improving the cause-effect analysis

When using a cause-effect diagram, it can be improved in two ways:

  1. Ask participants to bring ideas compliant to the cause-effect relationship, which somewhat constrains the brainstorming
  2. If the brainstorming phase should be kept uncensored, collect all proposals and then check each of them with the “if [cause] then [effect]” sentence before placing it onto the diagram

An additional benefit of using the “if [cause] then [effect]” sentence is to improve the proposals’ statement. Too often elder cause-effect diagrams are undecipherable because of the way the proposed causes have been stated. Using full (short) sentences with sound logic will help anyone to read the diagram, even if not involved in its construction. Such diagrams will still be understandable long after they’ve been drawn.

Final reminder

Having nice logically sound causes in a cause-effect diagram does not insure the causes actually exist. Therefore after populating such a diagram with possible causes, it is mandatory to check their existence and reality on the spot. In Lean-aware companies, we would say go to the gemba!

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Why 5S’s Scrub & Shine is not (only) about cleaning

This post refers to the third S of the series of 5 from the 5S methodology and which stands for Seiso, which can be translated as ‘cleaning’ or for the sake of verbs starting with an S: Shine, Scrub, Sweep, Sanitize and the like.

Once a certain state of cleanliness has been reached, any abnormality should be visible and trigger a corrective action.

A nut or a bolt found on the floor should immediately call for an investigation: is it fallen off the product which is manufactured or from the machine near by? Is it fallen off the tightenings box delivered to the assembly line?

In each of these three cases a missing nut or bolt can lead to a serious problem:

  • the product may not be assembled correctly
  • the machine may be affected in some way
  • the assembly line may be stopped because one part is missing in the precisely counted supplies

Therefore, picking up the nut or bolt and throw it into a trash bin is no good practice. Worse would be simply putting it back to a box holding similar parts on the line.

  • Simply disposing parts is not grasping the opportunity to solve potential problems and to improve the situation by solving it
  • Putting it back into a box may end up putting it into the wrong box, potentially leading to a later problem

Many people convinced to be knowledgeable about 5S would pick up the stray nut or bolt and get rid of it in any way they consider best and think they did the right thing about 5S.

In fact they help housekeeping, not 5S.

They may pick up stray parts over and over again if nothing is done to understand the origin, cause and designing a robust solution for it not to happen again.

The true 5S spirit would grasp the opportunity to understand where the part came from, why, and how to prevent other parts to fall onto the floor or how to prevent potential later problems.

A seemingly unimportant part as a nut or bolt may be critically important and if missing can lead to a catastrophe.

Until being absolutely certain this is not the case, any discovery of stray material (or document) should be suspected as source of potential major problem and trigger an investigation.

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