Before we explore this question we need to establish something. If the issue is Safety then that always goes First – and by safety we mean “a risk of harm that everyone agrees is unacceptable”.
This is incorrect. And what makes it incorrect is the word only.
Experience teaches us that it is impossible to divert people to focus on quality when everyone is too busy just keeping afloat. If they stop to do something else then they will drown. And they know it.
The critical word here is busy.
‘Busy’ means that everyone is spending all their time doing stuff – important stuff – the work, the checking, the correcting, the expediting, the problem solving, and the fire-fighting. They are all busy all of the time.
So when a Quality Zealot breezes in and proclaims ‘You should always focus on quality first … that will solve all the problems’ then the reaction they get is predictable. The weary workers listen with their arms-crossed, roll-their eyes, exchange knowing glances, sigh, shrug, shake their heads, grit their teeth, and trudge back to fire-fighting. Their scepticism and cynicism has been cut a notch deeper. And the weary workers get labelled as ‘Not Interested In Quality’ and ‘Resisting Change’ and ‘Laggards’ by the Quality Zealot who has spent more time studying and regurgitating rhetoric than investing time in observing and understanding reality.
The problem here is the seemingly innocuous word ‘always’. It is too absolute. Too black-and-white. Too dogmatic. Too simple.
Sometimes focussing on Quality First is a wise decision. And that situation is when there is low-quality and idle-time. There is some spare capacity to re-invest in understanding the root causes of the quality issues, in designing them out of the process, and in implementing the design changes.
But when everyone is busy – when there is no idle-time – then focussing on quality first is not a wise decision because it can actually make the problem worse!
[The Quality Zealots will now be turning a strange red colour, steam will be erupting from their ears and sparks will be coming from their finger-tips as they reach for their keyboards to silence the heretical anti-quality lunatic. “Burn, burn, burn” they rant].
When everyone is busy then the first thing to focus on is Time.
And because everyone is busy then the person doing the Focus-on-Time stuff must be someone else. Someone like an Improvementologist. The Quality Zealot is a liability at this stage – but they become an asset later when the chaos has calmed.
And what our Improvementologist is looking for are queues – also known as Work-in-Progress or WIP.
Why WIP? Why not where the work is happening? Why not focus on resource utilisation? Isn’t that a time metric?
Yes, resource utilisation is a time-related metric but because everyone is busy then resource utilisation will be high. So looking at utilisation will only confirm what we already know. And everyone is busy doing important stuff – they are not stupid – they are busy and they are doing their best given the constraints of their process design.
The queue is where an Improvementologist will direct attention first. And the specific focus of their attention is the cause of the queue.
This is because there is only one cause of a queue: a mismatch-over-time between demand and activity.
So, the critical first step to diagnosing the cause of a queue is to make the flow visible – to plot the time-series charts of demand, activity and WIP. Until that is done then no progress will be made with understanding what is happening and it wil be impossible to decide what to do. We need a diagnosis before we can treat. And to get a diagnosis we need data from an examination of our process; and we need data on the history of how it has developed. And we need to know how to convert that data into information, and then into understanding, and then into design options, and then into a wise decision, and then into action, and then into improvement.
And we now know how to spot an experienced Improvementologist because the first thing they will look for are the Queues not the Quality.
But why bother with the flow and the queues at all? Customers are not interested in them! If time is the focus then surely it is turnaround times and waiting times that we need to measure! Then we can compare our performance with our ‘target’ and if it is out of range we can then apply the necessary ‘pressure’!
This is indeed what we observe. So let us explore the pros and cons of this approach with an example.
We are the manager of a support department that receives requests, processes them and delivers the output back to the sender. We could be one of many support departments in an organisation: human resources, procurement, supplies, finance, IT, estates and so on. We are the Backroom Brigade. We are the unsung heros and heroines.
The requests for our service come in different flavours – some are easy to deal with, others are more complex. They also come with different priorities – urgent, soon and routine. And they arrive as a mixture of dribbles and deluges. Our job is to deliver high quality work (i.e. no errors) within the delivery time expected by the originator of the request (i.e. on time). If we do that then we do not get complaints (but we do not get compliments either).
From the outside things look mostly OK. We deliver mostly on quality and mostly on time. But on the inside our department is in chaos! Every day brings a new fire to fight. Everyone is busy and the pressure and chaos are relentless. We are keeping our head above water – but only just. We do not enjoy our work-life. It is not fun. Our people are miserable too. Some leave – others complain – others just come to work, do stuff, take the money and go home – like Zombies. They comply.
Once in the past we were were seduced by the sweet talk of a Quality Zealot. We were promised Nirvanah. We were advised to look at the quality of the requests that we get. And this suggestion resonated with us because we were very aware that the requests were of variable quality. Our people had to spend time checking-and-correcting them before we could process them. The extra checking had improved the quality of what we deliver – but it had increased our costs too. So the Quality Zealot told us we should work more closely with our customers and to ‘swim upstream’ to prevent the quality problems getting to us in the first place. So we sent some of our most experienced and most expensive Inspectors to paddle upstream. But our customers were also very busy and, much as they would have liked, they did not have time to focus on quality either. So our Inspectors started doing the checking-and-correcting for our customers. Our people are now working for our customers but we still pay their wages. And we do not have enough Inspectors to check-and-correct all the requests at source so we still need to keep a skeleton crew of Inspectors in the department. And these stay-at-home Inspectors are stretched too thin and their job is too pressured and too stressful. So no one wants to do it.And given the choice they would all rather paddle out to the customers first thing in the morning to give them as much time as possible to check-and-correct the requests so the days work can be completed on time. It all sounds perfectly logical and rational – but it does not seem to have worked as promised. The stay-at-home Inspectors can only keep up with the more urgent work, delivery of the less urgent work suffers and the chronic chaos and fire-fighting are now aggravated by a stream of interruptions from customers asking when their ‘non-urgent’ requests will be completed.
The Quality Zealot insisted we should always answer the phone to our customers – so we take the calls – we expedite the requests – we solve the problems – and we fight-the-fire. Day, after day, after day.
We now know what Purgatory means. Retirement with a pension or voluntary redundancy with a package are looking more attractive – if only we can keep going long enough.
And the last thing we need is more external inspection, more targets, and more expensive Quality Zealots telling us what to do!
And when we go and look we see a workplace that appears just as chaotic and stressful and angry as we feel. There are heaps of work in progress everywhere – the phone is always ringing – and our people are running around like headless chickens, expediting, fire-fighting and getting burned-out: physically and emotionally. And we feel powerless to stop it. So we hide.
Does this fictional fiasco feel familiar? It is called the Miserable Job Purgatory Vortex.
Now we know the characteristic pattern of symptoms and signs: constant pressure of work, ever present threat of quality failure, everyone busy, just managing to cope, target-stick-and-carrot management, a miserable job, and demotivated people.
The issue here is that the queues are causing some of the low quality. It is not always low quality that causes all of the queues.
Queues create delays, which generate interruptions, which force investigation, which generates expediting, which takes time from doing the work, which consumes required capacity, which reduces activity, which increases the demand-activity mismatch, which increases the queue, which increases the delay – and so on. It is a vicious circle. And interruptions are a fertile source of internally generated errors which generates even more checking and correcting which uses up even more required capacity which makes the queues grow even faster and longer. Round and round. The cries for ‘we need more capacity’ get louder. It is all hands to the pump – but even then eventually there is a crisis. A big mistake happens. Then Senior Management get named-blamed-and shamed, money magically appears and is thrown at the problem, capacity increases, the symptoms settle, the cries for more capacity go quiet – but productivity has dropped another notch. Eventually the financial crunch arrives.
One symptom of this ‘reactive fire-fight design’ is that people get used to working late to catch up at the end of the day so that the next day they can start the whole rollercoaster ride again. And again. And again. At least that is a form of stability. We can expect tomorrow to be just a s miserable as today and yesterday and the day before that. But TOIL (Time Off In Lieu) costs money.
The way out of the Miserable Job Purgatory Vortex is to diagnose what is causing the queue – and to treat that first.
And that means focussing on Time first – and that means Focussing on Flow first. And by doing that we will improve delivery, improve quality and improve cost because chaotic systems generate errors which need checking and correcting which costs more. Time first is a win-win-win strategy too.
And we already have everything we need to start. We can easily count what comes in and when and what goes out and when.
The first step is to plot the inflow over time (the demand), the outflow over time (the activity), and from that we work out and plot the Work-in-Progress over time. With these three charts we can start the diagnostic process and by that path we can calm the chaos.
And then we can set to work on the Quality Improvement.
13/01/2013 – Newspapers report that 17 hospitals are “dangerously understaffed” Sound familiar?
Next week we will explore how to diagnose the root cause of a queue using Time charts.
For an example to explore please play the SystemFlow Game by clicking here