Lean Thinking from Itchy Toes to NASA

About a month ago I consulted a physician about itchy toes, for the third time in about a year.  Through this process, I was able to reflect on Lean thinking, organizational culture, how we present problems, and what this means for the effectiveness of our problem solving.

My toes began itching more than a year ago. It was the rainy season. I was wearing heavy socks. “Moisture,” my physician Dr. A, said it appeared to be something like athlete’s foot, a fungal infection, and prescribed medicine for that. I applied the cream on my toes daily and it appeared to solve the problem for a time.

About six months later the problem came back as itching and swelling. Dr. A was not available so the appointment was with Dr. B who was a dermatologist. Even though this was in mid-winter and cold outside, I wore sandals. “Frostbite,” concluded Dr. B. I was skeptical, but the prescription this time was warmer socks and shoes, no anti-fungal cream. I self-medicated with a few organic balms, to limited effect.

As the warmer weather in May allowed me to wear sandals barefoot, the current state of my toes was made visible. I could ignore the discomfort, but they looked abnormal. Not convinced by the opinions and interventions of either Dr. A or B, I rolled the dice again and met with a different physician. This time I wore thin socks and shoes. Dr. C took the time to prod and poke my toes, understand my medical history, and review possible causes. He didn’t rule out athlete’s foot but said, “I’d like to throw everything at this,” and prescribed blood tests as well as two medications to relieve the symptoms right away. His approach worked and I’m happy to report that my toes look and feel better than ever.

What did I learn from this process? Dr. A was ready to jump to a solution. Seeing itchiness and dampness, he concluded athlete’s foot. He did little to explore root causes and went for the high percentage solution, and moved on to his next patient. Dr. B saw my sandals, the slow circulation in the tips of my toes and jumped to frostbite. It rarely freezes here, and my sandaled feet wouldn’t be walking outside if it was freezing. With the first two doctors there was no exploration of the possibility of non-obvious root causes creating the symptoms, only solution-jumping.

At the most basic level, problem statements must be clear and free of suggested causes or solutions. By presenting toes that itched, first in thick socks and then in sandals, I had biased Doctors A and B to jump to a quick conclusions, leading them to assign solutions without adequate investigation. The responsibility for effective problem presentation lies with the presenter, the patient.

Dr. C was willing to consider multiple root causes. He ordered blood tests to get a better understanding of the background condition of the patient. He prescribed multiple countermeasures for immediate containment, or “Throwing everything at it,” recognizing that the symptoms may be the result of more than one cause. Another example of Lean thinking by Dr. C was putting the responsibility for daily performance management back on the person closest to the process, in this case, me the patient. He asked me to take photos of my toes each day to keep a visual record of changes. This helped me to commit to the treatment, to see the countermeasures through.

This situation reminded me of an interview with a NASA director after one of the space shuttle accidents. Engineers had recognized the potential problems, but were not effective in communicating them to management. There was a culture of laughing at people who brought up concerns about potential problems. The changes at NASA extended beyond removing the culture of fear about bringing problems forward, it required leaders to recognize that they had to overcome their own biases and become better listeners.

Not everyone is good at communicating a problem clearly. Patients may unintentionally present the problem to the doctor in such a way as to bias them. Engineers may dive deep into technical matters without providing the listening manager with necessary context. A3 documents are riddled with poor problem statements. Lean leaders, doctors, engineering managers – in a similar regard all need to help develop the problem presentation ability of those they serve. In fact, the purpose of the first four steps of practical problem solving (a.k.a. Toyota Business Practice a.k.a. A3 thinking) is to grasp the current situation, present the facts, recognize existing opinions or preconceptions as such, and clearly state the problem. Only then can we attempt to diagnose the problem or prescribe effective solutions.


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