Saturday, May 26, 2007

Drive Thru Order - WRONG AGAIN!

Drive Through Quality

Are you one of those people who have to check your order before you leave the fast food drive thru parking lot? I sometimes do and I sometimes don’t depending if I have gotten a wrong order from the restaurant before. Time also is a factor because well just because.

When I do check and the order is it is wrong I then have to pull over to the reserved parking for the Drive Thru and walk inside and wait in line or I hold it up saying “wrong order.” I have even got so upset when I got home and pulled the food out of the bag I drove back through the drive thru and waited for an exchange of order.

I estimate my order being right about 75% (3 out of 4) of the time. I can also say it happens at all of the fast food restaurants I visit (especially the Big 3, - arches, crown & young girl).

It happened again two nights ago to my wife. The order was 4 fish sandwiches, 2 large fries and a diet cola. Total was around $12.00 dollars. She wanted to get home and change because she had just left an exercise class. As she started to unload the bag some expletives came shouting of the chicken. “I don’t believe this, they gave me the wrong order.” Didn’t you check before you left I asked?” No, I was in a hurry.” Being rather hungry I hoped the wrong order was salvageable. Nope, there was one cheeseburger, two small fires, two small chicken nuggets with sweet and sour sauce and one small cola (not diet).

Since it would take about 30 minutes for a round trip I decided to have a bowl of cereal. My wife ate the nuggets and the dogs had some fries. After my second bite of Rice Chex I called the restaurant and asked for a manager (a long wait).

I explained the situation and of course he offered to replace the wrong order. Then he said, “Sir, most people check their order before leaving the premises.” Being a retired Quality Director and Adjunct Professor of Process and Quality Systems and a frequent checker of my meal before leaving I could not hold back.

Sir, let me explain it this way, you are telling me to order a new car, pay for the car and find out later it was not the car I ordered because it has the wrong wheels and interior color. The salesman offers to take some money off if I take the wrong order or the dealership will provide me with a loaner until the car I ordered comes in a few weeks.

He replied that my example was - you hear it all the time the great comeback of everyone. “Sir, You are comparing apples and oranges, clearly you would be more upset if the car was not correct.”

No, I replied, “You are telling me it is my responsibility to check my order at the end of the conveyor belt. You are telling me that I did not lose faith in your business and my customer satisfaction is not in jeopardy. You are further telling me that that you don’t care if you lost a customer or an unknowable amount of revenue.

The manager was in no mood for a lecture on customer satisfaction he apologized again and hung up the phone. Unfortunately what happens is sometimes customers complain, some customers tell others, some customers use the company in their next Quality Lecture and some customers write about it in their blog and some customers just go away.

That is the unknowable amount of dollars that a company cannot predict. Why, because they have no idea how many customers have left and will not return. Most just get angry and drive to the next dealership or restaurant and say.

I guess the others don’t want my money!

Another qualityg example of the “Demise of American Management.”

Monday, May 14, 2007



Planning a Root Cause Session is basically an easy task; it has 4 Phases (Preparation, Analysis, Verification and Implementation) with major activities that need to be accomplished.

The amount of work and time that is required in each phase depends on the amount of data that exists and how experienced the group is in Root Cause Analysis. Cycle Time for conducting a session and getting results will vary depending on the complexity of the problem/process and whether or not the group is Functional (shorter) or Cross-Functional (longer).

Following is a synopsis of each phase and the major steps that are required to conduct a Root Cause Analysis:


The Preparation Phase is important so that the Analysis Phase can be devoted to brainstorming potential causes to a previously identified problem. Identifying Customer Pain, Developing a Problem Statement and Developing the Main Categories to be brainstormed provides the group direction as to what specifically needs to be analyzed.


The Analysis Phase is when the group is led by a facilitator to brainstorm probable causes to the Problem Statement created in Phase I. It is vital that all members be allowed to participate and that all ideas are recorded and considered for analysis.


Verification is where the group has identified probable root causes it may be necessary to verify the impact they have on the overall problem. When the root causes have been verified the group can begin suggesting/brainstorming potential solutions.


Implementing Countermeasures/Solutions and monitoring them for effectiveness is critical for the overall success of Root Cause Analysis.

Part III - Breaking Down and Defining the Four Phases -
Preparation, Analysis, Verification and Implementation at

Saturday, May 12, 2007

Root Cause Analysis - Part I - Introduction

The following write-up in on Root Cause Analysis. Some of what you will read is unique to me, other ideas and suggestions are an accumaulation from a number of sources that I pieced together over the years as I applied this Tool. You will not find an Ishikawa Diagram Below. The Ishikawa Diagram is better served for presenting some facts, it is NOT what Root Cause Is, Sorry!

Whether our jobs are in Operations, Sales, Engineering or Quality, or any other function within our organization we should become familiar with the concept of root cause analysis and how it can benefit our day-to-day job functions.

Each day we encounter problems or obstacles that make it difficult to perform our jobs or meet our goals. Every employee who performs their work function on a day-to-day basis becomes a problem solver. In our efforts to improve our work processes or to control and prevent defects, errors and obstacles, we all should be looking for the root cause that is causing the disturbance so that we can implement prevention solutions to avoid reoccurrence.

Symptom - An indication something is wrong (i.e. engine warning light flashes).

Root Cause - Something that produces the departure from a normal function or expected result (coolant level low).

Problems can come in many ways. Read my Post on the 3 Types of Problems at:

Note: - Many people, especially quality consultants (they need to prove they know more than you) will have lenghthy and confusing definitions, just keep it simple.

It is first important to clarify what is meant by prevention activities or solutions, or maybe it is better to clarify what are not prevention activities. Correcting errors, removing defects, reworking, redesigning or modifying are not prevention activities. They are fixing activities. These actions may or may not be a result of prevention actions, but they themselves are not preventive steps. Prevention has to do with WHY the order is incorrect, WHY the system repeatedly goes down, or WHY the software won’t work. Performing root cause analysis is not just action taken after a problem arises, but rather a technique that becomes a day to day work function that creates a mindset that constantly searches for ways to improve the work process and implement actions that will prevent out of control situations from happening. Clearing up a problem (no matter how fast/good) after an outage or an order doesn’t go through the system correctly the first time is not prevention. We need to design prevention into how we do things. This is what root cause analysis was intended to be used for when it was developed for continuous process improvement activities.

In order to conduct a systemic root cause analysis investigation the following items need to be available:
  • A process is required for identifying, documenting, and comparing the causes producing the problem that need correction and prevention.

When a problem occurs most experienced workers can immediately provide an answer to what they think will solve the problem. However, in may cases we will find that if the problem solving is done solely through the eyes of experience, the solutions suggested many times tend to be one-dimensional (non-systemic). For example, take service order fallout. An Order Writer sees something he/she can do to get the order through the system. The MIS Analyst sees as a solution to the same problem a way to change the input screen to avoid the problem. The Order Writer Supervisor sees a way to change the procedure to avoid the problem. The Sales Manager suggests that the work be contracted out as the best solution to the problem. While all of these actions may be valid, the objective of a true root cause analysis is to accurately obtain all of the causes, and to document them in a manner that provides sound decision making support for the Provisioning Department.

It is important to have an end-end perspective (systemic) view of the situation as well as the availability of objective data prior to dispersing resources (dollars, people) to correct a problem. Do we change input screens because there is a Temporary Order writer filling in for two weeks? Do we contract the work out because our initial training is not adequate? Do we write a new procedure for all because one area never got the last revision? The answer to these questions are “It Depends,” once all the facts are known we can make better decisions, to make them independently most often results in a temporary fix to a symptom, or worse, tampering with the system.

  • It is important to understand “Systems Thinking.”

Employees work in a system. "Management Owns The System. A system is a whole consisting of two or more parts, (1) each of which can affect the performance or properties of the whole, (2) none of which can have an independent affect on the whole, and (3) no subgroup of which can have an independent affect on the whole. In short, then a system is a whole that cannot be divided into independent parts or subgroup of parts.

When conducting root cause analysis we need to determine if the problem is an end result of many activities or inactivities, decisions and omissions that are part of how we are operating; or is the problem the first result of someone coming in contact with an existing condition that waits quietly to cause problems once it is put into operation. A good root cause analysis process should produce information that describes the type of system with which we are dealing. If our analysis techniques drives the analyst or team to produce only one root cause, or requires that the analyst or team to select a prepared brainstormed list of suggested causes that suggests that only one part of the system as being the most significant, then we have lost sight of the whole system. What happens next is the root cause analysis becomes subjective and highly prone to error based on the person who has the most authority or orator skills. It is for these reasons that meaningful root cause analysis must first focus upon the whole causal system. Prevention solutions cannot be implemented reliably without this type of focus.

  • It is important to understand the functions and procedures of the systems involved.

Once we know and understand the principles behind organizational structures and alignments, the mystery surrounding causes is replaced with fundamental, practical systems knowledge. That is, Process Management principles can be applied in order to design and ensure continuing control of processes and systems. The first premise of Process Management is that when principles are properly applied the result is predictable success; and when principles are not properly applied, the result is predictable non-stable system failure. With the essential layout of the whole causal system, and the understanding of functional principles, root cause analysis provides the opportunity to design quality into our operations, and to isolate and remove systemic non-value added activities.

  • Inside any organization, you must have In-Process Controls that prevent and monitor your systems.

Part of the root cause analysis process is identifying the points in the causal process where internal control exists. If the root cause method simply allows the analyst to provide an opinion of what he/she considers to be one of the problem areas we have not utilized this investigative tool properly.

Root cause analysis should therefore provide a means to decipher and systematically validate the cause and effect relationships in the system, so that process owner(s) making the decision have a means of validating the data upon which the solution is to be made based on customer and corporate goals. The process owner(s) overall knowledge of the organization’s finances, planning, goals and limitations, along with the capability to validate data better assures sound decision making and improved operations control results. Because we control what happens in our systems with policies, procedures and practices, a successful root cause analysis must identify prevention opportunities for continuous improvement, as well as identify those required corrections and fixes that are more obvious and immediate.

In summary, root cause analysis is the systemic process of obtaining and displaying data about counter-quality activities within an organization’s systems and processes; then identifying and analyzing them for decision makers to make sound preventive solutions.

click to enlarge

Dilbert © by Scott Adams

Remember - “Every time something is wrong, it costs money.”

Root Cause Analysis Part II - Planning a Root Cause Session -

Check Out Data Collection & Analysis Too

Also see Pareto Chart Analaysis @

Wednesday, May 09, 2007

How to "GROW" a Coaching/Planning Session

“GROW” - Partnership Coaching/Planning

The following guidelines can be used by a manager, team leader, or group, for conducting a coaching or planning session.

G = Goals

1) What would we like to accomplish in the time we have available (1 month, 1 year, etc...) ?

2) What would make this time well spent?

3) What would ultimate success look like to you ?

R = Current Reality - describes as accurately as possible the current situation.

1) How do you know your perception of “X” is accurate?

What tells you that is the case?

2) Whom else might we check with to get more data/information about the larger perspective?

3) What have you tried so far?

4) What are your beliefs about this situation?

O = Options - options for potential actions without judging the ideas merit or practicality, initial focus is on “quantity” not quality of options. Quality comes later as you reduce options down.

1) If money, time or resources were no obstacle, what option might you choose?

2) What might some “Sky The Limits” options look like?

3) Who else could help?

4) May I (we) offer some options that were thought of while you were describing your options?

W = What’s Next

1) What are you going to do and by when?

2) What’s next? What steps are involved?

3) How might you minimize/remove the barriers/obstacles?

4) What are the contingencies if you can’t remove the barriers?

5) How will you monitor performance and collect data for feedback over time for predictability?

6) On a scale of 1-10, how confident are you that we will do this?

It takes time and nurturing to GROW a good employee or team. There are no shortcuts, take the time and do it right and it will pay off big dividends in the future.

Monday, May 07, 2007


As I drove by a park last week I saw hundreds of people running and jumping all around some tents with food, drink and games. I pulled over to watch as others were enjoying a dunk booth and running games.

While music was blaring from set up stereos it looked like a “happy” time for all attending. It was not a carnival; it was a local law firm having a company summer picnic for its employees.

It reminded me of a time in the late 70s to the early1980s when I worked for AT&T/Ameritech Michigan Bell. We had countless picnics, some sponsored by the company but mostly just set up by employees who enjoyed each other’s company. The picnics were held at least twice a month with a softball game as the main attraction. Many times they were department versus department or union versus management. Yes, management came in their shorts and tennis shoes and acted like real human beings. Everyone got to know each other’s families and most generally cared about others well being.

It was a time when loyalty to the company and union still meant something. Wearing your company logo on shirts with company initials was done with pride. It was not unusual to walk down the hall or catwalk and have a Senior Leader call you by your first name. At the time we had over 35,000 employees at Michigan Bell (close to one million nationwide). Today, just over 13,000 are employed at AT&T Michigan Bell/Ameritech/SBC/SBC AT&T.

The end came when the government broke up the Bell System in 1984 with what was known as “Divestiture.” By 1986 most of the Michigan Bell executive team was replaced by outsiders in Chicago where Ameritech located its headquarters. When I say outsiders I mean new executives were brought in to shape up the “Bell Heads (employees)” to get ready for competition. It was at that time the company picnics stopped.

A new company picnic was now taking hold, it consisted of two or three people sitting around a conference table taking a call or hiding from their boss so they could at least get a full lunch.

Dilbert - by Scott Adams

In 1985 some employees had the choice to stay with Ameritech or AT&T. Those that stayed with AT&T lost their jobs within two years. In 1986 it was the year that employees no longer wanted to get together because that is the year that Downsizing began to take place. Employees with long-time service were asked to leave and those that remained began to view co-workers not as friends but as competition for jobs. However, there was no focus on the outside competition because there was no competition regardless of what was said by the new leadership team in Chicago.

Too many outside executives began to take hold and the tradition of what was once one of the best-run companies (you try Standardizing processes for close to one million employees in at least 45 states and Canada) in the world started to deteriorate at rapid speed. The new execs usually stuck around for about two years, just enough time to leave bodies and bad decisions in their paths. They were there to get noticed and to get promoted, if that did not happen in two years they left for new opportunities and to continue their wrath at other companies. There were no faces on the employees, just numbers.

If you look at the successful Regional Bell Operating companies like Verizon, SBC and Bell South you will find that they are still led by Telecom people. Those that went the way off listening to “outside consultants” and how to compete in the new market place were taken over by SBC or acquired by other telecom companies (i.e., AT&T, Bell South, Ameritech, PacBell).

The most recent are Bell South and AT&T being taken over by SBC. For the past 10 - 15 years AT&T was taken over by outside executives and consultants that ruined a great company. Oh, they will tell you it was the government regulations that were at fault (some truth to that), but mostly it was the asinine decisions and short term startegies made throughout the late 80s and 90s that led to the demise of AT&T.

Thanks to the company that held the company picnic, it was nice to remember when I was proud to work for my employer.

It's mazing to recently read so many articles and quaotes by current CEOs proudly pontificating they are going to strive for employee loyalty and being a good community leader.

Far worse is the the arrogance and stupidity by some CEOs (NWA, Auto Companies, etc...) to try and justify paying their Execs huge amounts of money because they don't want lose their most talented people, especially as the company is losing tons of money and heading down the toilet.

Dr. Deming words still ring true today "Management Owns The System."

qualityg says ... Mr. CEO and High Priced Execs that means you!!

Wednesday, May 02, 2007

Who's on First? Data Collection, What's on Second? Data Analysis

In an earlier post “Data Collection? That’s One Tough Job, Buster” ( I stated I would write more on Data Collection.

The following is an accumulation of information (different sources) I learned over the years, the application of this information and the methods used are mine. I hope it can help others.
One of the most overlooked criteria’s required prior to data collection activities is to create an
“Operational Definition.”
An Operational Definition is a precise description that tells how to get a value for the characteristic you are trying to measure. It includes what something is and how it is to be measured. The key word is characteristic (s). It is also important to understand that you may need a separate definition for each subject area. For example, Employee “A” may have a different definition than Employee “B”. The purpose of an Operational Definition is two-fold:

- To remove uncertainty so everyone has the same understanding
- To make sure that no matter who does the measuring, the results are always the same The following is an example Operational Definition I used when I worked in the Voucher Department:

“An error-free expense report includes receipts for all items on the Expense Form over $25.00 and does not include any receipts for items not included on the Expense Form. There are no math errors and expenses are coded properly.”


“The starting time to measure customer response time is when the customer enters our store and when the customer leaves.”

Think of the Operational Definition in Data Collection as you would the Problem Statement for Root Cause Analysis. Both should be stratified (i.e., broken/categorized) to provide a focus that can be measured and understood by all involved. Without this we will probably conduct meaningless data collection studies and reports (unfortunately I’ve done that many times when pressured for data).

Do NOT allow this process to be come bureaucratic, a nice guide (checklist) to follow that I inherently use when doing data collection or when I have no idea where to start aquality conversation is I ask myself Who, What, Where, When, Why and How (by “What Method”):

1. Clarify Data Collection goals

• Decide why you are collecting data

• Decide what data you need to collect
Decide how much (sample size) data you need to collect (i.e., are you looking for point in time or for an on-going trend)

• Decide What you will do with the data once you have it

2. Develop an Operational Definition

• Define what you are trying to evaluate

• Decide how you will attach a value to what you are trying to measure (develop data collection form and corresponding data base if necessary)

• Decide how you will display/record the data (i.e.; graph/chart, spreadsheet, report, etc.)

• Determine the period of time you will conduct the data collection activities

3. Test for Data Consistency

• Determine factors that may cause your data to vary from one item to another (i.e., people, your own subjectivity, location, time, size, different process, etc.)

• Reduce impact of those factors

4. Data Collection

• Train all involved in study to ensure consistency (use associated data collection forms and input data base if required)

• Make data collection procedures error-proof

• Have frequent process checks (do a sample test on small group) to determine if data collection forms and tools are accurate and appropriate (i.e.; does the data look reasonable and actionable)

By following these guidelines you will not only improve your data collection activities, you will also reduce cycle time in analyzing and displaying your data with the appropriate graphs and charts.

p/s -
When you can measure what you are speaking about and express it in numbers, facts, theory or application, then you know something about it, but when you cannot measure it, envision it, or provide meaningful information about it, or if you cannot express it in numbers, your knowledge or so called expertise is of an insufficient and unacceptable type.