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Serious consequences occur when the underlying symptoms are not addressed,
when the quick fix is accepted as a final, permanent solution. Excessive
reliance on containment or ERAs will create a repeating cycle. Problem
containment is an addiction that will only get worse until root causes are found
and addressed.
Establish Team
Establish a small group of people with the process and/or product knowledge,
allocated time, authority, and skill in the required technical disciplines to solve
the problem and implement corrective actions. The group must have a
designated Champion and Team Leader. The group begins the team building
process. (See Flow Chart 2)
It's important to remember that you haven't yet moved from the "observations"
phase of the process. Any information you develop in a comparative analysis
must be facts, not opinions, and must be true only for the symptoms information.
Don't rule out any facts that might be valid answers. If it is a fact and it answers
the question, write it down.
Remember to defer critical thinking at this step in the process. You will eliminate
possibilities at the next step.
If additional information reveals that a theory cannot fully explain why the
problem happens eliminate it from consideration.
To understand how the problem escaped to the customer and identify the
escape:
• Review the process flow focusing on the location in the process where
the root cause occurred.
• Determine if a control system exists to detect the problem.
If non exists, the development of a new control system must be considered in the
problem solution.
Prevent Recurrence
Modify the necessary systems including policies, practices, and procedures to
Prevent Recurrence of this problem and similar ones. Make Recommendations
for systemic improvements as necessary. (See Flow Chart 10)
Steps for Preventions:
• Review the History of the Problem
• Analyze how this problem occurred and escaped
• Identify affected parties & opportunities for similar problems to occur and
escape
• Identify the System's, Policies, Practices, and Procedures that allowed
this problem to occur and escape to the customer
• Analyze how similar problems could be addressed
• Identify and choose Preventive Actions
• Verify Preventive Actions
• Verify Effectivity
• Develop Action Plan
• Implement Preventive Actions
• Develop Systemic Preventive Recommendations
• Present Systemic Preventive recommendations to Process Owner.
Points to Remember
1. There is no such thing as perfection. Products and services can always be
improved. If one process has been optimized, others can be enhanced.
2. Change is not always good. Looking for opportunity to make improvements
does not mean looking to change everything. Think of the reason for change.
3. What is adequate today will not be tomorrow. Change never ceases,
especially our industry. Even if we have reached the top in our field, tomorrow
someone will redefine “the top”. Continuous improvement requires all to be
more than just sufficient, the bar is always rising.
4. What works and what seems logical are different. For each theory that
works, 99 others do not. Ideas deserve to be tested. They must be before they
are accepted.
5. Realize that each new idea may create new problems. Watch for the
potential repercussions of each quality improvement you make. Check your
finished product against a list of quality objectives.