Five Most Terrifying Words for a Lean Thinker

The check was not performed.

These words were spoken today during a meeting to review an ongoing and complex problem solving effort within Gemba. These words chilled me to the bone. The failure to perform a check is far more dangerous than failures due to errors of inattention, lack of knowledge or poor communication. We also have these faults in abundance within our company, but in this instance the responsibility to insure that checks were in place and being performed was solely mine.

Possible root causes for this missing check include not caring enough to check, caring but not understanding the process thoroughly enough to establish a correct check point, and not setting the expectation for others to set in-process checks closer to the work and at an earlier stage. It all goes back to the need for standard work at all levels, from routine process to leader standard work.

Taiichi Ohno both scolded and redeemed us for failing to check when he said “Check is to do hansei.” When we check and find fault we need to reflect back on ourselves and how we can improve both the process and ourselves. In lean circles we say “a problem is a gift”. I must stop buying such expensive gifts for myself…

3 Comments

  1. sharma

    April 4, 2010 - 6:54 am

    Dear Jon,
    I would suggest mistake-proofing in this case(if possible), which would not leave the performance of checks to chance.
    If you can present the details of the CHECKS that you failed to perform, maybe we can get a lot of suggestions here, which will be a great learning experience for all of us.

  2. George

    April 6, 2010 - 12:36 pm

    Jon, one of my experiences with a supplier (in 2006) was that they were not checking poka-yokes to ensure they functioned as designed. I requested they list all poka yokes at each station and have the operators confirm their correct function at start-up.
    As the story goes, the quality manager took ‘responsibility’ and stated that the process would be in place within a week, but in the interim he would personally check each of the poka-yokes and send me a daily check-off list. By week 3, we received defective parts which indicated at-least 2 poka yokes were not operational, yet I was still getting the daily check-off list from the quality manager.
    I won’t get into what happened to the quality manager, but the moral of the story is that check lists require a solid culture of audit and accountability; otherwise individuals may ‘check’ off without checking.

  3. Jon Miller

    April 15, 2010 - 11:42 am

    Hi Sharma. Thanks for your offer, but too embarrassing! It’s just management basics that I need to practice.
    Hi George. I have had the exact same experience at a Japanese-owned auto supplier. They had pokayoke systems that were implemented but did not have the support / maintain / check / update systems around them because of language and cultural barriers and assumptions that nodding heads meant “I understand.”