Guest Blog from Lynn Reed

The Hidden Cause of Quality Failures

You have to read the previous blog about common cause failures of quality systems to get a foundation and understanding before reading this. As mentioned in the previous blog on quality failures, it became increasingly evident that the five common cause failures for quality seemed somewhat superficial and didn’t dig deep enough in terms of the core problem. The hidden causes that the study uncovered were the result of a simple thought experiment using a basic problem solving tactic taught in most every class where the subject of problem solving comes up – asking “WHY” multiple times till you drill down to the bottom of the well. Many times, the simplest of experiments can yield discoveries that show the true nature of the issue.

According to most experts in the field, quality systems generally tend toward being reactive to the circumstances encountered day to day. Companies that are truly proactive are few and far between. Why? Well, Deming might say it can all be blamed on management failure. Crosby (another noted quality guru) might say it is failure to measure real organizational performance metrics (cost of quality). Still another (for example, Juran) might say it’s a lack of preventive action on the part of the company or Jim Collins might claim it’s a matter of getting the right butts in the bus seats while on the road to greatness. While not claiming my analysis to be earth-shattering like some of the great thinkers on quality, the thought experiment does give one pause to consider the possibilities. What if part of the core problem is a fundamental lack of awareness by the decision maker with no or, at best, limited / obscured risk assessment abilities?

From the earlier blog on this subject, a decision maker will make the right choice if they see the problem coming. They would put in place a barrier to prevent the “causative agent” from affecting the outcome. What follows is the result of the “WHY” thought experiment.

The earlier diagram is easy to follow (the yellow blocks are the core causes): 

1)      Q: Why was there a significant quality failure? A: No barrier to cause was in place.

2)      Q: Why was there no cause barrier? A: No preventive (proactive) action was taken.

3)      Q: Why was there no preventive action? A: There is a basic lack of awareness.

4)      Q: Why is there a lack of awareness? A: There is no or a flawed risk assessment process.

5)      Q: Why no/flawed risk assessment? A: Decision makers have no/limited risk assessment skills, no performance indicators to warn them, or, in some cases, they have tremendous business pressures (in a hurry, too much to do, too costly, etc.).

The no risk assessment skills and bad performance indicator scenarios need a final round of “WHY” to drill down a little further. At the bottom of the well, at least a portion of the core causes to major quality system breakdowns are:

1)      Lack of basic risk assessment tools (fundamental to decision making)

2)      Lack of understanding of cost of quality (performance metrics)

3)      Business pressures that are pushing decision makers into the wrong decision.

The first two are fixable with improvements to education within the college ranks or as part of adult education for professionals (an area CIS can offer a service in). The latter (business pressures) can be helped with risk assessment education but, ultimately, it is mitigated by a moment of pause. Decision makers must be capable of rapid risk assessment as well as be good problem solvers. Neither is taught well at the college graduate or undergraduate levels and to which many business owners (an older generation with perhaps no college education) may never have had exposure to.

In the final analysis, it’s a matter of knowing when a risk is acceptable and when it is not and making the decision quickly. Without the proper skill sets and time to think, decision makers are left with their intuition, gut reaction, or past experiences to make decisions – all of which leaves the organization open to potentially unacceptable risk and failure. Deming got it right in the end; this piece of the puzzle is a management failure of sorts. There are benefits to getting it right – sound decision making builds organizational trust and foster a high morale among the troops engaged in the daily work of the organization. Every good leader needs a mechanism to assess risk and, if they lack one, should take the necessary steps to acquire a method(s) to assess risk.