by Lee Fried, on 13 Jun 2007 07:53 am
The Journey

Learning From Our Mistakes

Popularity: 21%

This last week we had our first big problem become visible in the Model Line area and boy was it a good opportunity to learn.  Over the last four months we have been very busy pushing forward rapidly with implementation.  In are largest production area every team in in the process of being reorganized with the goal of taking us from a specialist model to generalist work cells.  At the same time we are redefining our management systems and putting in place a Daily Management system with a focus on standard work and visual controls.

As you can imagine there are a lot of moving parts.  Because we have to keep the production line moving at the same time we make the changes it is often challenging to keep everything in alignment no matter how much you plan.  Every team is going through cross-training, Kaizen events are happening across the division and managers are learning how to integrate PDCA thinking into their management practice.  The best analogy to decsribe our task at hand is that it is like changing the tire on your mountain bike as you are rushing down a steep hill. 

So getting back to the problem.  With all hands on deck and focused on the tactical changes we lost visibility of what was happening at the macro level.  Each team was falling behind a little bit, which we expected because of the training and improvement which resulted in increased inventory.   While the problem was not to large at any given team, when you add it up across the teams the levels were not acceptable.  The problem really became visible when our IT system had some challenges and our inventory levels suddenly jumped.  Managers that knew there was a problem found themselves in a situation where they did not know where to turn to raise the issues.

It was clear that we had a flawed management system and in the spirit of PDCA it was time to adjust. We had defined escalation paths within teams, but we had not adequately defined them across teams.  As the teams were pulled together this week we made many corrections and it was an amazingly rich learning experience.  It was a very hard couple of weeks on the management team, but it was amazing to watch them problem solve and learn together.  Moving forward we are implementing a new dashboard, we are re-defining our escalation paths, designing “rings of defense” and we are adjusting our checking processes.  Already our inventories have begun to drop.  In reflection I believe this will turn out to be a very good mistake to have had happen, because sometimes it take a mistake this large to really make the changes that are needed.

One Response to “Learning From Our Mistakes”

  1. on 14 Jun 2007 at 6:45 am 1.Curious Cat Management Improvement Blog » Management Improvement Carnival #13 said …

    [...] Learning From Our Mistakes by Lee Fried - “It was clear that we had a flawed management system and in the spirit of PDCA it was time to adjust. We had defined escalation paths within teams, but we had not adequately defined them across teams.” [...]

Trackback This Post | Subscribe to the comments through RSS Feed

Leave a Reply