Big D, little d, what begins with d?

When I was very young, (according to my son, when dinosaurs roamed the earth), I had a book entitled, "Dr. Seuss's ABC: An Amazing Alphabet Book!" It was one of my most favorite books and I remember the silly animals and items Dr. Seuss created to make an impression as to each letter of the alphabet.

Each alphabet character started with a new page and a new phrase. Something like this: "Big A, little a, what begins with A? Aunt Annie's alligator, A...a...A!" And so it went through the entire alphabet. It was silly, as only Dr. Seuss can be. It was hugely entertaining and somehow, learning surreptitiously insinuated itself amongst all the mirth and fun. Little did I realize, at such a tender age, my career in business would find another meaning for the phrase "Big D, little d, what begins with d?"

Some years later, (read 'a lot of years'), I was employed by a Fortune 500 company (not the one I am engaged with now), and they discussed the value of diversity as a means for competitive advantage. This organization divided diversity into two distinct groups: Big D and little d. The Big D represented protected classes. Those things, which to most of us, are obvious: Race, Creed, Color, Gender, Religion, etc. The little d represented those things which were not so obvious: Where you were raised (Midwest or Rocky Mountain West, urban or rural), where you went to school (Utah State University or Harvard, Trade School or higher education, high school or college degree), what you do with your spare time (watch TV or read a book, race a car or race to the store).

This organization taught and I personally agree with, the idea that the true value of diversity is getting past the Big D. That is not to say that the Big D is not important; it is. But that is like saying a wedding cake is important. Everyone at the wedding can see it and knows it's there. You can't really have a wedding without one. Comments abound on how it looks, the delicate floral frosting, the subtle colors and so forth. When people really get interested in the wedding cake is when it is cut. Does it have filling or not? If so, what kind of filling is it? Is it a white cake, yellow cake, chocolate cake, spice cake or some combination in layers? That's when the wedding crowd starts making the decision to take action on how big and how often they will have a piece of cake.

Diversity is the same. We need to get beyond the obvious. Doing so allows us to see what the real competitive advantages are. Reference my blog post about the IDEO company, (as well as any blog posts with the label "Diversity".) Any way, the IDEO company: they leveraged the little d and got fantastic results in what is now known as the shopping cart project. Investigative teams are the same way. It is the little d that truly delivers results.

The problem is that it is difficult and challenging to try and find the little d and what value it will have on the Investigation and the Investigative Team. Doing so requires discipline and forethought. Lead Investigators that exercise this type of deliberation, will have much more robust investigations. The risk of not understanding and leveraging the little d is Cognitive Myopathy.

So...Big D, little d, what begins with d?

A good, robust Investigation!

Root Cause Investigation of the Month Winner

On my pager, I was just sent a page from a colleague (not more colleagues!?) to look at my email account at work. When I did, I was surprised to find that I had been selected, in my Corporate Division, as the Root Cause Investigation of the Month Winner. What I was even more gratified by, was that the things that I think are truly important to a good Root Cause Analysis, were all listed as components of the selection criteria.

The body of the text in the announcement included the following:

"Strong points include: 1) Performed thorough fault tree analysis of the situation and provided data for those paths both pursued and eliminated, even though confirmed root cause could not be identified, 2) Employed investigative tasks to obtain SME contributions, 3) Supplied solid data to support impact conclusions and final disposition, 4) Employed good technical writing practices, and 5) Demonstrated adherence to [appropriate] tools. In addition, the [investigative] team exhibited curiosity and open-mindedness."

My intent in sharing this is not to toot my horn, so much as to illustrate that development of this skill set is highly valued by organizations. There are not a great many individuals that are willing to do what it takes to seriously develop these skills. Doing so requires you to make yourself vulnerable by soliciting feedback, and credible, by acting on that feedback. Demonstrating these behaviors with each investigation will drive improvement of your skill set, as well as your capability within the organization.

The Root Cause Investigation of the Month Winner is...

[Insert your name here]

Just do it!

Years ago, before I had written my first book, I saw a movie entitled, "Throw Mama From The Train." The film starred Billy Crystal. Crystal's character was an instructor at a community college teaching creative writing. At the end of his classes, he would close the session with the line, "...and remember, a writer writes."

Not long ago, I had opportunity to read a book entitled, "How to Run Seminars & Workshops: Presentation Skills for Consultants, Trainers and Teachers." I read a comment in the book, that paraphrased, stated that outlining is not writing, talking about writing is not writing, only writing is writing. This holds true for investigators in two different ways.

First, an investigator cannot complete an investigation without the appropriate activity taking place. An investigator, investigates. It doesn't matter if you are a Six Sigma Green Belt or Black Belt, an investigator using Root Cause Analysis, or any other methodology. Nothing happens until you start investigating.

Second, an investigator writes. all the investigation in the world is meaningless for others to learn from, unless, the investigation, and the results of the investigation are documented. Furthermore, many organizations require approval of the investigation from many different functions, as well as different layers of management in the organizational structure, requiring a technical document describing the investigation and it's results. An investigator writes.

What does one do if they don't really like to write? An investigator, investigates. An investigator writes. To quote a Nike ad that will be easily remembered...

"Just do it!"

Johnny Appleseed and Fault Tree Analysis

As a child in the sixties (as opposed to a child of the sixties, if you know what I mean), I learned about an American folk hero, part legend, part reality, named Johnny Appleseed. He would travel the frontier, what we now call the Midwest, planting apple trees. Little did I know, that later in my adult life, I would venture to and settle down in, the literal stomping ground of this icon of American folk lore.

Born John Chapman, Johnny Appleseed was an American pioneer nurseryman who introduced apple trees to large parts of Ohio, Indiana, and Illinois. He became an American legend while still alive, largely because of his kind and generous ways, his great leadership in conservation, and the symbolic importance of apples.

What does Johnny Appleseed have to do with Fault Tree Analysis? Well, I thought you would never ask. And if you didn't, I'm going to tell you anyway! Johnny planted apple seeds and they grew up into trees. As investigators, we get loss events planted on us, but that's OK, cause that's what we do. Our Fault Trees grow down into trees, much like a root system.

1. You start with the Loss Event.
2. From the Loss Event, you identify Causal Factors. These may be locations in a value chain, or activities on a time line. Either way, Causal Factors are high level hypotheses as to the occurrence of the Loss Event.
3. From the Causal Factors, you identify the Root Cause Categories. These are hypotheses subordinate to each of the Causal Factors. You can begin to see how this tree grows.
4. From Root Cause Categories, you then have your Near Root Cause(s), which are further hypotheses as to the Loss Event, subordinate to the Root Cause Categories. Now you're really drilling down.
5. Finally, from the Near Root Cause(s), you derive Root Cause(s). These are subordinate, still, to the Near Root Cause(s). They are still hypothetical, until validated otherwise through qualitative and/or quantitative data. (This process is the Verification Log, which I will discuss in another post.)

As you can see, the Fault Tree has now grown and you have the makings of a robust investigation on your hands. (For an example of a simple Fault Tree, you can click on the image below.)




Hmmm....

Perhaps Johnny Appleseed could have benefited from using Fault Tree Analysis to determine why apple trees and conservation were lacking in the Midwest at the time, rather than plodding around the country side.

Just a thought.

When The Lead Investigator Is Happy...

Yesterday, I was speaking with yet again, another colleague (I have a lot of colleagues!), and shared with her (we'll call her Christine, her real name is Christine), this concept of SMIs. Although I found the term intriguing myself, Christine really enjoyed it and was quite animated. Here, I believe, is why:

1. If you acknowledge someone as an SMI, and you bring them into the investigative team as an SMI and if they embrace the idea of being an SMI, this has great potential to bring an air of fun and light-heartedness to the investigation. In my view, a sense of fun, makes what would otherwise be a tedious investigation, go much faster and more interesting.
2. If the SMI understands clearly their role as such, then they will have the added value of being consciously critical, asking the difficult why's without fear or reservation.
3. If the SMI is comfortable and has fun with their role on the investigative team, then you have clearly established a safe environment for the investigation to take place in.

Actually, all these points are indicative of a safe environment. Christine's animation about the SMI concept, is because she holds these three things in high esteem. She knows the value of a safe environment for an investigation, especially a difficult one.

One of the single most important aspects of an investigation, is that the environment IS safe for all the investigative team members. This allows for a forum where anyone can speak wit hout fear of judgment or repercussions outside the investigation. Especially SMIs. When team members can operate without fear, then ideas and interaction flow freely, accelerating the investigation.

This makes the Lead Investigator very happy. And you know what they say:

When the Lead Investigator is happy, everyone is happy!

(By the way. Today is my son's 20th birthday. He is in Spain and I haven't seen him since February 18th. So here is my message to him: ¡Cumpleaños felices Lorin Douglas! )

Subject Matter Idiots

I was in yet another conversation, with yet another colleague, as we discussed the value of having someone who is not close to the process, to be on the investigative team. He is a Six Sigma Black Belt and told me that his group called these people SMIs. Like a goof, I asked what an SMI was and he responded, "Subject Matter Idiots."

We had a good laugh, but his point is well made. You want someone who knows nothing about the process being investigated. They are not afraid to ask questions that won't be asked by people who, because of their expertise, may not consider the question at all. Not because they are above the question, but because they are too close to the process, for the question to even be on their radar screen.

I like to think of this concept as a painting by Claude Monet, credited with starting the "Impressionist" era in art during the late 19th century. Monet used textured "dobs" of paint to create an impression of what was seen by the observer of the painting. Consider his work, "Sunflowers", a famous still of sunflowers in a vase on a table. If you were to get as close at this work as you physically could and look at it, all you would see were "dobs" of oil paint in rich yellows and oranges, with some greens, which made no apparent sense at all. But as you stand back, you can see the collection of color swaths come together to make sense of something meaningful to the eye of the observer.

Investigations are similar. Subject Matter Experts (SMEs) are too close to the process. Whereas an SME cannot see the broader view because of their Cognitive Myopathy, an SMI has no Cognitive Myopathy. Without such a filter, there are no rules and anything, or any question, is fair game.

I have been involved with investigations where SMIs took the investigation down the path to true Root Cause by asking the "why" questions no one else could see.

When you need a fresh perspective, don't be afraid to leverage a Subject Matter Idiot.

More On Congnitive Myopathy

I was in a conversation with a colleague recently. We were discussing the importance of Group Think and how to avoid it during investigations. As we talked I had an epiphany: Group Think, Tunnel Vision and Myopic thinking can be distilled down to one term, which is Cognitive Myothapy. (I just did a quick Google search and the term "cognitive myopia" already exists, so I am going to lay claim to Congitive Myopathy, caps and all!)

At any rate, during this discussion I referred to, my colleague shared with me his thoughts on Cognitive Myopathy. He decided that every time he runs an investigation, he tells everyone to check their old paradigms at the door. He also said, if they insist on sticking with their old paradigms, that he requires them to produce the data to prove those paradigms correct. He gave an example of a massive investigation he was involved with.

Let's call my colleague "Kris" (that's actually his real name). He had a group of engineers, scientists and operations people trying to find the root cause of the Loss Event that had occurred. There was a great deal of equipment involved. Each piece of equipment had an "owner" responsible for it. As the group was building the Fault Tree and certain pieces of equipment came up as hypothetically contributing to the Loss Event, there were vehement denials. Kris would simply tell the equipment owner(s) that he had no problem with their assertions, but that he would include that equipment on the Fault Tree until data had been produced to support those assertions. Clever, eh?

I thought this was a masterful way to get the equipment hypothesis on the Fault Tree without having a blood letting take place. Once on the Fault Tree, you don't ever take off the hypothesis, you just upgrade, or downgrade the Confidence Rating or Fault Value (read as probability), assigned to it. No harm, no foul.

Kris is a great investigator, but I believe he is even better at facilitating difficult investigations. Doing so requires that the facilitator know how to recognize the potential for, and manage Cognitive Myopathy. I thought this was one of the most diplomatic ways to handle a difficult situation regarding an entrenched paradigm I had ever heard of. I'm going to use it myself.

So just remember, if you choose to ignore the potential for Cognitive Myopathy to creep into your investigations...

...Let the blood letting begin!

Group Think is Thoughtless

In the 18th Century, the Vienna General Hospital had a serious problem. There was a high degree of infant deaths due to puerperal fever. Data for infant deaths became available in 1784. From 1784 to 1822 the infant mortality rate was about 2%. From 1823 to 1841 infant mortality was about 7% and from 1841 to 1846 it jumped yet again to nearly 10%.

Women plead not to be admitted unless they had to be, knowing their babies had just as good a chance at survival, outside the hospital as in. Physicians studied this phenomenon and could come up with no cause as to why. Doubly perplexing was that infants delivered by mid-wives had a mortality rate of 0.6% as opposed to the infants delivered by the physicians and medical students, which had the near 10% mortality rate.

In 1846 Dr. Ignaz Semmelweis agreed to a three year contract to work at the hospital, beginning that year. He became aware of the problem, pored over the data and learned that in 1823, pathological anatomy began at the medical school, where physicians and medical students would dissect and study cadavers. Midwives did not attend the medical school, and as such performed no pathological anatomy. The physicians and medical students would complete their anatomy classes and then attend to the obstetrics of the hospital, now being carriers of cadaverous contamination.

Upon recognizing this issue, Semmelweiz instituted the practice of hand washing in chlorine after a physician or medical student completed a pathological anatomy. This was instituted in 1847. Infant mortality rates from 1847 to 1858 were about 1.6%, significantly lower than the nearly 10% mortality rate before.

During the decades prior to the investigation of Semmelweiz, the physicians in the hospital could not begin to fathom that anything they were doing would be the cause of the increased infant mortality rates. This is a classic example of Group Think. Group Think is found in organizations (larger than one individual). Tunnel vision and myopathy are synonymous with group think, but can also apply to the individual.

I read a book once, entitled, "Leadership and Self-Deception: Getting Out of the Box," in which the example was given of an infant learning to crawl. The infant gets up on its hands and scoots around by pushing itself back. Eventually, it gets wedged against something and cannot scoot back farther, becoming trapped. Frustrated, it screams and cries and pushes back harder, but to no avail. The paradigm of the infant does not allow it to consider that it might be the source of its own problem. If it could see the problem, it may not be able to do anything, if much about it, because it may not have the capability to change direction without pushing back. Intervention is nearly always required.

This is the hallmark of Group Think, Tunnel Vision and Myopic thinking. That is why it is important to have the emotional maturity to allow someone else to challenge the thought processes we are engaged in. This is critical to a good investigation. Having someone on your investigative team who will challenge the process can get others to see and think about things in a different way. This is necessary to a robust and successful investigation.

Group Think is thoughtless.

Loss Events & Losers

Nobody wants to be a loser. In order to not be a loser, an organization must understand what a Loss Event is. Understanding what a Loss Event is, will enable the organization to investigate the cause of the Loss Event, identify Root Cause, and the appropriate Action or Counter Measure(s) to correct the Root Cause. However, before any of this can happen, the organization must understand what a Loss Event is.

Simply put, a Loss Event, is where something is lost in the process of doing business. I don't necessarily mean the type of loss that would prompt you to go to the lost and found. Rather, the loss is typically measurable in monetary terms, for most businesses. Losses can be the dollar value of down time, defects, a safety incident; you can think of as many examples as there are companies in operation.

The problem is, that any loss event represents lost revenue to the organization. If the loss event is down time, then you have the cost of not producing product, the cost of replacing equipment that was damaged or in disrepair, the cost of labor during the downtime, etc. If the loss event is defects, then you might have the the cost of rework, lost opportunity cost if you cannot rework and have to scrap, cost of equipment or line time to do the rework, cost of overtime to execute the rework or manufacture replacement product, etc. If the loss event is a safety incident, you can follow nearly all the same paths for the cost involved, but you might have some different costs such as doctor's visits, workers compensation, etc.

The point is, that a loss event, in the simplest terms a business can understand, is the erosion of revenue and/or profits. In order to understand the cause of the loss events, organizations will employ formal Root Cause Analysis (RCA). I personally like to use a Fault Tree when doing RCA. Using RCA methodologies will drive the investigator to Root Cause. Knowing Root Cause will enable the appropriate Actions or Counter Measures. The appropriate Actions or Counter Measures will prevent the Loss Event from occurring again. Prevention of another, similar Loss Event provides an incremental increase in the revenue and profits of the organization.

Organizations that have not figured this out, or choose to ignore Loss Events, are Losers, (fiscally of course!)

Ooops!! I could have had a...

I enjoy doing meaningful, robust investigations that really get to the root of the matter. They allow me to be involved in improving whatever process is impacted. This is something I find a great deal of satisfaction in.

The other day, I asked for feedback on a presentation I was giving for approval of an investigation I am working on. The investigation was not one of the type I had done before, was exceptionally high profile and had a very compressed time line for the level of effort and detail that would be required. I was given some reference numbers, in our database, of similar investigations I could review, and perhaps use as a template for my investigation.

Well, I did just that and started digging in. However, I was so zoned on completing the investigation, that I missed one of the key fundamentals I usually adhere to; I failed to utilize Fault Tree Analysis as a means of getting to Root Cause. I am not a disciple of Fault Tree Analysis. I AM A ZEALOT!! And yet, I failed to do what I am normally quite disciplined about doing.

Back to my feedback on the presentation: I was asked, "Where is your Fault Tree Analysis?" After trying to justify myself, I gave up and capitulated to what I knew was the truth; I had buried my nose so deep in the template, that I failed to do a thorough investigation.

I was forced (by my own behaviors) to rework my work (terribly painful on a personal level) and build my Fault Tree. The end result of the investigation was no different, but the Fault Tree provided substance to what I had done with the template and made it easy for the approvers to see my conclusion and how I had gotten there. In the end, I was glad I had to rework my work. (That's kind of a catchy phrase!)

I've now put together a little checklist for me to follow, so that when I am steeped in a big investigation, I won't slap my forehead with the heel of my palm and say, "Oooops!! I could have had a...

...Fault Tree!

Leadership: Make or Buy?

I received feedback on my thoughts about the post entitled, "Investigators As Leaders" (Monday, 28 SEP 2009). It is possible that I may have unintentionally implied that some are born as leaders and that is what type of individual some organizations seek to hire.

For this I apologize. Leaders are both born and made. Some are born with a natural disposition toward leadership and quickly begin showing this natural talent as they grow up and engage with others. It is important to note that this does not dismiss such individuals from further developing their talent. Sports authorities are trained to quickly ascertain raw talent, and then to develop that raw talent.

History is filled with those who "should have been". I personally believe that there are few people in history that naturally rise in leadership capability because of raw talent. My belief is that the majority of those who demonstrate truly great leadership, did so because they had desire and heart: The desire to be good leaders and the heart to see it through. This is not easy to do.

The film "Miracle" (which I just reminded myself to add to my favorite movies on this blog), is a great metaphor for leadership. The coach of the Olympic U.S. Hockey Team portrayed in the film, did not go after the most talented hockey players of the day. It was not a dream team. He took players that had already demonstrated desire and heart and which had not necessarily "arrived" professionally in the sport. Once picked, he pushed his team hard, time and again, until they coalesced into a championship unit. He developed them.

Many companies choose to hire leadership skills and buy technical skills. Just as the coach in "Miracle" recruited people that had already demonstrated desire and heart, companies that hire for leadership do the same thing. It is incumbent on the candidates to prove to the company that they have been working to develop those skills. Furthermore, the development does not stop when the candidates pass through the doors on the first day of work. Companies that focus clearly on recruiting leadership, constantly challenge, develop, provide feedback, coach and opportunity so that leadership is further developed within the organization. Such organizations find it more cost effective to hire or "buy" resources that have already demonstrated desire and heart in developing leadership. The alternative of bringing someone in and to "make" them a leader is far more costly because of the unknowns; the risks involved.

Ultimately, the intent of message was that we should constantly be striving to develop our leadership skills. It matters little, in the big picture, if we are investigators, teachers, scientists, managers, etc. Leadership is essential to getting things done, effectively and efficiently; including investigations.

If I misdirected anyone on the intention of my thoughts, please accept my apology.

Bottoms Up!

There is a hierarchical structure to investigations. The key of any investigation is to get to the bottom of things, or rather, identify Root Cause. Until you get to the bottom of things, it is impossible to identify any real possibility to correct the issues causing the loss event and affect organizational improvement.

Key to identifying Root Cause and solving the problem is "cause of the cause" or "5 Why Analysis", both are very similar. Conceptually, you ask what the cause of the loss event was. Once you have a general idea, then you ask yourself what the cause of that was (cause of the cause) or why that happened (second layer in 5 Why Analysis), you continue to ask the same question, "Why did that happen?" until you can no longer go any further. Data suggests that you typically find Root Cause after asking "Why?" no more than 5 times.

Here are some hierarchical definitions that will help you in your investigations (it is important to note these are not original with me, and are generally considered standard in formal Root Cause Analysis):

1. Loss Event: This is the occurence of some event that caused a loss, of one sort or another, to the organization. e.g., machine failure, safety issue, suspect analytical result, etc.
2. Causal Factor: This is a generalization as to the cause of the loss event. Consider it the first "why" in 5 Why Analysis.
3. Root Cause Category: This is cause of the cause, or the second layer in 5 Why Analysis.
4. Near Root Cause: More cause of the cause and the third layer in 5 Why Analysis.
5. Root Cause: Cause of the cause and the fourth layer in 5 Why Analysis.

Fishbone diagrams and Fault Tree Analysis are good ways to get a graphical view of how things are shaping up. Build in a time line and you now have a two dimensional view of the loss event and all the factors impacting it.

Once you get to the BOTTOM of the loss event, you can finally serve UP some Corrective Actions that will drive organizational improvement.

Hence, Bottoms Up!