Consequences for repeat nonconformances - Carelessness, lack of focus

[Bobh@pte]

I am wondering if anyone else has encountered this problem?
We have an internal web site which anyone in the company has access to
for the purpose of identifying an "issue". An issue can be a customer complaint, internal n/c, supplier n/c, internal audit finding, etc...

We are at the point where we have people who are making the same mistakes. When an issue is generated, the requirement is stated, (What the customer wanted), the issue is stated, (What went wrong), Interim action taken is stated, (We sent the customer the correct product and brought back the incorrect product). The report is then emailed to the "accused" who must, (with the aid of the department manager) state the root cause, state the intended corrective action and implement preventive action where applicable. The department manager is responsible for reviewing the employees response and closing out the "issue" if it passes muster. The results are stored in a database for analysis.

What do some of you do with people who continually make some of the same errors? Training is not an issue, it really boils down to carelessness, lack of focus and just not doing the job completely. The errors are of the minor nature, but still can cost between 25-50 dollars per issue.

We are in the process of trying to decide what to do in these types of circumstances. This is an inside sales function of the company, who along with the shipping fuction account for 70% of the errors reported. These are the type of errors where the 5 whys stop at "duh".

Anyone care to share any ideas?

[Wes Bucey]

In Reply to Parent Post by Bobh@pte

I am wondering if anyone else has encountered this problem?
We have an internal web site which anyone in the company has access to
for the purpose of identifying an "issue". An issue can be a customer complaint, internal n/c, supplier n/c, internal audit finding, etc...

We are at the point where we have people who are making the same mistakes. When an issue is generated, the requirement is stated, (What the customer wanted), the issue is stated, (What went wrong), Interim action taken is stated, (We sent the customer the correct product and brought back the incorrect product). The report is then emailed to the "accused" who must, (with the aid of the department manager) state the root cause, state the intended corrective action and implement preventive action where applicable. The department manager is responsible for reviewing the employees response and closing out the "issue" if it passes muster. The results are stored in a database for analysis.

What do some of you do with people who continually make some of the same errors? Training is not an issue, it really boils down to carelessness, lack of focus and just not doing the job completely. The errors are of the minor nature, but still can cost between 25-50 dollars per issue.

We are in the process of trying to decide what to do in these types of circumstances. This is an inside sales function of the company, who along with the shipping fuction account for 70% of the errors reported. These are the type of errors where the 5 whys stop at "duh".

Anyone care to share any ideas?

Almost every time I have investigated a similar complaint of
carelessness, lack of focus and just not doing the job completely,
I have found the process, itself, allowed for folks to make such mistakes very easily.

It seems to me the root cause investigation you cite may not have been rigorous enough. There are a lot of reasons for this, none of which has to result in assigning blame or creating an adversarial atmosphere within the workplace. It is enough to start again with more attention to the root cause investigation.

Let me further suggest you consider calling in an experienced person to help you find ways of mistakeproofing the processes which seem to result in the most frequent errors. Be sure to enlist the operators who have made such errors to help look for ways to short circuit the mistake cycle you witness.

As Deming and his Red Bead experiment have proved time and again, most nonconformances are due to process failures, NOT operator failures.

[Bobh@pte]

Wes,
I understand Deming and his philosophy and consider myself a disciple of most of his theories and principles. I have also told most of our managers at one time or another that operator failure is almost always the fault of management You can imagine how they react to this, but when I prove it to them, I can and have changed the minds of even some of the most stubborn. But... When you have evidence that 8 out of 12 people are successful with the existing procedures that accompany this process???

Example: Customer ABC orders xxxxx, he states on his purchase order he wants this order shipped UPS next day air. The sales agent sends the order UPS ground and the customer calls and complains. This happens even though there is a double check system in place. Another issue.

Example: Customer SSS places an order which is non taxable, the information is available in our customer database. The sales agent fails to read the customer comments which clearly state "non taxable". They calculate the tax and add it to the order. The customer of course refuses to pay the tax or short pays when billed. Agent response: I forgot to read the comments.

Example: Shipping receives receives a shipper. Lets say everything is perfect and right with this shipper. Shipping pulls and ships the wrong product. The product is labeled correctly, the shipper is correct, all the shipping person has to do is make sure what they pull matches the shipper.

So, can we not deduce that at some point we have to rely on the employee to carry out the steps of the written procedure. If they are trained to carry out steps one through five and omit step three I will of course find out why.

I'm saying there comes a point where we say, if you would have followed the procedure.......

Bob H

[Craig H.]

Bob,

Often with boring repetitive tasks people will put their mind in neutral and run on a kind of autopilot. The trick is to design the process so that there are few variations, IMO. That said, it seems to me that if the situation you describe is the norm, where most of your mistakes occur, I have two words for you to consider:

Bar Codes.

Bar code labels for the shipping boxes, for the shipping label (is that a next day label or not?) and for the product (is that really a model 129a?). There are lots of products and lots of vendors out there who can help.

Just a thought.

[Jim Wynne]

All three of your examples seem to be prime candidates for mistake-proofing:

In Reply to Parent Post by Bobh@pte

Example: Customer ABC orders xxxxx, he states on his purchase order he wants this order shipped UPS next day air. The sales agent sends the order UPS ground and the customer calls and complains. This happens even though there is a double check system in place. Another issue.

Seems like the answer might be for the shipping person to have direct access to the customer requirements. It wouldn't prevent mistakes completely, but it removes a layer of opportunity for mistakes.

In Reply to Parent Post by Bobh@pte

Example: Customer SSS places an order which is non taxable, the information is available in our customer database. The sales agent fails to read the customer comments which clearly state "non taxable". They calculate the tax and add it to the order. The customer of course refuses to pay the tax or short pays when billed. Agent response: I forgot to read the comments..

It shouldn't be a very difficult thing to fix the system so that whether or not tax is added is a function of a computer lookup rather than a manual entry by the sales agent.

In Reply to Parent Post by Bobh@pte

Example: Shipping receives receives a shipper. Lets say everything is perfect and right with this shipper. Shipping pulls and ships the wrong product. The product is labeled correctly, the shipper is correct, all the shipping person has to do is make sure what they pull matches the shipper.

See Craig's good suggestion in this thread regarding bar coding.

In Reply to Parent Post by Bobh@pte

I'm saying there comes a point where we say, if you would have followed the procedure.......

One reason that managers get paid more than others is that it's expected that they'll be able to evaluate these types of situations and identify the problems. In some cases, the problem will indeed be employee competence (15% of the time, using Deming's rule of thumb), and in those cases action should be swift and decisive. When a system has been optimized (i.e., not perfected, but made to work as well as can be reasonably expected) anything that impedes its functioning needs to be dealt with. The question here is, are you sure your system is optimum?

[Wes Bucey]

Honestly, Bob, nobody is trying to beat you up here.

In my original post, I wrote

Let me further suggest you consider calling in an experienced person to help you find ways of mistakeproofing the processes which seem to result in the most frequent errors. Be sure to enlist the operators who have made such errors to help look for ways to short circuit the mistake cycle you witness.

I recognize mistake proofing is NOT intuitive. It can be an eye opening experience when someone else walks in and immediately spots multiple opportunities to mistake proof processes previously thought to be perfect.

As much knowledge and experience as I may have, I continue to learn new things every day. I may have a permanent dent in my forehead where I whack myself with the heel of my hand and shout, "Of course! Why didn't I see that before?"

Take our advice. Discard pride and preconceptions about how good and perfect the processes are and whether the staff are incompetent or saboteurs. Take another look! Get some help and don't be afraid to accept advice. I think the odds are slim you will find a lot of Covers willing to accept your pronouncement regarding "carelessness, lack of focus and just not doing the job completely."

The very fact some of these errors occur repetitively enough for you to recall them could have been a clue (if the frequency had been charted [Pareto]) to identify and prioritize mistake proofing targets.

[Bobh@pte]

Thank You for your assessments gentlemen. I'm going back to the drawing board.

[Craig H.]

Bob, if you can, why not let us know what you find? I think we would all be interested. Maybe we can learn from you about a new approach, a new way of looking at something.