bloghotdogphoto23eee

The Secret Ingredient to Fixing Systems Problems


Cindy Hutter
Cindy Hutter

In full disclosure, I didn’t see this firsthand. The photo was passed on to me with the caption, “You had one job.” Instead of the chuckle it was intended to elicit, the message made me a little irritated. I started to think of all the places where there was a breakdown in the system that allowed these mislabeled products to hit the grocery shelf.

No matter how automated a factory is, surely someone must have noticed that the incorrect packaging was being used on the hamburger buns. Did a factory worker raise a red flag? If she did, was it ignored? As the stock boy was unpacking the hamburger rolls at the local grocer, didn’t he notice? Was he on such autopilot that he genuinely missed it? Or did he simply think it wasn’t a big enough issue to care?

What about every other stock boy or girl at all the supermarkets that received the mislabeled products. Did none of them notice? If someone did notice and called the manufacturer, did the company care? Did the bun company call back the mislabeled products? What happens if someone eats one of those buns and has an allergic reaction because the product inside was not as advertised on the package?

Yes, the difference between a hamburger bun and hotdog bun, which most likely are made with the same ingredients and the same process, sans the shape, won’t likely cause harm. However, what if that mislabeling was on a product that contained peanuts? Or a household cleaner with toxic ingredients? Or even a medication? These might have serious consequences.

Working in a quality improvement organization, we view undesirable outcomes as the byproduct of poorly performing systems. We teach that to uncover the problem in a system causing the unwanted result, you need knowledge or information.

It sounds simple enough. Of course you need knowledge and information to get to the root of a problem and make a change that will hopefully result in improvement. But more often than any of us like to admit, decisions get made without enough knowledge.

For example, I bought a Kindle because I thought it would help me to read more. It hasn’t. Whether I have a hard copy or an electronic copy of a book isn’t the issue; it’s carving out time to read that is the problem. If I had spent even a few minutes asking myself questions about why I don’t read enough, I could have saved the money I invested.

Or to go back to our bun example, the bun company’s vice president of operations may decide the root of the problem is a shortage of hamburger bun bags at his factories. But, even after the additional bags arrive at the factories, the mislabeling issues continue. A little knowledge seeking, perhaps talking to some of the workers, would lead him to the real problem: workers can’t detect the blue and green colors that are meant to distinguish the hamburger and hotdog bun bags or simply can’t read the language.

The mantra in quality improvement is “every system is perfectly designed to get the results it gets.” Regardless of your system of choice—your workplace, your home, your community—you’ll need knowledge to improve the system and get the results you want. It’s impossible to be a change agent without being a knowledge seeker first.

About these ads

2 thoughts on “The Secret Ingredient to Fixing Systems Problems”

  1. Great questions…this also triggers all the questions about safety and reliability of systems. Typically major failures require alignment of multiple errors–and preventing them requires understanding the system and building in reliability. Very cool example.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s