Tag Archives: root cause analysis

Lean Six Sigma and Project Management – triangles and (virtuous) circles

By Elisabeth Goodman and John Riddell

On 6th July, we held a very enjoyable second iteration of our APM workshop on this topic in Norwich, having run it previously in Stevenage in May.

As with the previous seminar, our audience ranged from people and organisations with very limited knowledge of Lean and Six Sigma, to those who had adopted it as a way of working.  So the challenge was, in 1 to 1 ½ hours, to give enough of an overview of Lean and Six Sigma for those who were new to the subject, without boring those with already a fair amount of expertise.

At the same time, our goal was to make the session as interactive as possible, with discussions and exercises that would enable people to actively reflect, learn from each other, and more importantly, consider if and how Lean and Six Sigma could assist them in their roles as Project Managers.

Our mapping of Lean and Six Sigma against the project triangle seemed to resonate with the delegates i.e. with Lean aiming to reduce time and cost, and Six Sigma aiming to increase quality.

We achieved an excellent level of discussion and interaction in both seminars, and here are some of the conclusions that the delegates came to.

There are many Lean and Six Sigma tools that people have already found to be useful and/or anticipate being useful.

Examples of tools highlighted during the discussion in Norwich were:

  • Kano (and Voice of the Customer)
  • Time value map
  • Use of historical data
  • Control charts
  • 5 Whys
  • Gemba
  • Poke Yoke
  • Pareto Analysis

Our audience in Stevenage listed more or less the whole gamut of Lean and Six Sigma tools!

Lean and Six Sigma can definitely enhance the delivery of projects.

Delegates were unanimous in this,.  One break-out group suggested that Lean and Six Sigma fits particularly well with the operations area of organisations, and that process improvement initiatives will lead to projects.

Delegates identified several ways for how Lean and Six Sigma could enhance the delivery of projects.

Using Lean and Six Sigma at the start of a project (during the concept and definition stages).

The Define, Measure and Analyse stages of the Lean Six Sigma DMAIC framework and associated tools can be very effective in identifying the problems which will lead to generating and/or justifying projects.

They help to define what the problems are and how to address them, and also to define the project brief.

Tools such as Pareto analysis help to identify the things that are important, and make sure that the biggest issues are tackled first.

Process analysis will help to eliminate waste before implementing new (e.g. IT) solutions.

The Lean Six Sigma tools and the data-based approach create greater confidence.

Delegates particularly liked the ability to use robust data collection techniques and tools such as force-field analysis to structure their thinking.

They also liked the ‘5 Whys’ for getting at the root causes of problems and surfacing clients’ real issues.  They also suggested using ‘5S’ to organise information (not just physical things)

The Improve stage of DMAIC can help with the implementation stage of projects

It can help with the definition of roles in a project, in particular in relation to sponsors and to ensure that the project is focusing on what is of value to the customer (this also happens at the Concept and Definition stages of projects), and relating that to the realization of benefits.

The Control stage of DMAIC (and Knowledge Management) can help with project close out

Many delegates were already familiar with the idea of capturing learnings at project close-out, but they liked the fuller ‘After Action Review’ (AAR) frame-work and the emphasis on considering who can learn from the lessons learnt.

They also liked how the various visual tools of Lean and Six Sigma could help with ‘highlight reporting’ in project management.

The Lean and Six Sigma and Project Management ‘virtuous’ circle may go on infinitely or break and re-start depending on the organisation.

Our presentation included a suggested overlay of the Lean and Six Sigma DMAIC structure over the project lifecycle.  Delegates pointed out that this may be the case in organisations such as Pharmaceutical R&D where projects are the regular way of working.  In other organisations, the DMAIC structure continues into the operational way of working once a project is completed, although it may in time spawn new projects.


  1. Elisabeth Goodman is Owner and Principal Consultant and John Riddell is Consultant at RiverRhee Consulting– a Business Consultancy that helps business teams to enhance team effectiveness for greater productivity and improved team morale.
  2. To see previous newsletters and blogs on subjects relating to Lean and Six Sigma, and Project Management see the RiverRhee Consulting newsletter, and Elisabeth Goodman’s blog site.

Why thinking in terms of burning platforms and tipping points is not sufficient to drive change

The term ‘burning platform’ has its origins in a real life/death scenario faced by an oil worker in the North Sea and now commonly used to help change agents and stakeholders articulate organisational or personal motivation (WIIFM – What’s In It For Me) for change. ‘Burning platforms’ form the basis of ‘sticky’ or unresistable messages to motivate change.

Malcolm Gladwell’s book ‘The Tipping Point’ explored how ideas, messages and behaviours can spread through a combination of opionion leaders (social influences) and ‘sticky’ messages. Ideas reinforced by Andrea Shapiro’s ‘Creating Contagious Commitment’ – an excellent reinforcement of the role that people (contacts), infrastructure / environment (context), and messages (content) can play.

Change agents recognize the importance of training to build the capabilities that people need to adopt new ways of working.  They also understand the importance of leadership in role modeling, rewarding and reinforcing the right behaviours, and the influence of the organisational ‘climate’: what has gone before, and interdependencies with other competing changes.

What the authors of ‘Influencer – The Power Change Anything’ add to all of the above is a focus on identifying the ‘vital few’ behaviours that will enable change.  They describe how demonstrating or practicing these behaviours can result in the development of new personal beliefs, i.e. through direct personal experience, or through the vicarious experience of storytelling: anecdotes, television series etc..

Their approach is further supported by a coherent synthesis of 6 sources of influence acting on motivation and capabilities.

The basis and support for this approach is graphically illustrated by examples drawn from society and organisations around the world.

The ‘vital few’ behaviours are identified by the equivalent of root cause analysis: what is the root cause of the problem in situations where unwanted situations are occurring?  The authors also identify the equivalent of ‘good practice’ situations where people are demonstrating the right behaviours: they call these people ‘positive deviants’.  They recommend detailed observation and analysis as a way to identify the ‘key vital’ positive behaviours occurring in these situations.

The 6 sources of influence are summarized in the following table:

Level Motivation Capability

(Drawn from psychology)

Making the undesirable desirable

(intrinsic satisfaction)

This is about getting people to try the new behaviours, perhaps adding an element of competition, creating a sense of pride and ownership, tapping into personal passions, helping people appreciate and aspire to what can be.

Surpassing your limits

(coaching and practice)

People need an opportunity to practice new behaviours in a safe environment, with clear and frequent feedback , interim milestones and deriving learnings from any setbacks.


(Drawn from social psychology)

Peer pressure

(social motivation)

Peers can influence each other through approval, disapproval, praise, ridicule, acceptance, rejection.  They can act as opinion leaders (champions) if respected (knowledgeable, trustworthy, helpful) and well connected.  This is where leaders can influence through role-modelling and where it is important to understand resistance.

Strength in numbers

(social capital and the wisdom of crowds)

Groups working together will perform better than an individual: they will build on each others’ ideas, and help an individual to succeed.  It requires collaboration and a recognition of interdependence: a translation of ‘me’ problems into ‘we’ problems.


(Organisational theory)

Rewards and accountability

(structural motivation)

The important thing here is to reward the right behaviours and to do so in a timely and appropriate fashion without compromising expectations of what constitutes everyday or long-term behaviour.  It also includes effective warning and ultimate action against what is the wrong or unacceptable behaviour.

Change the environment

(structural ability)

This includes buildings, space, sound, sight i.e. non-human interventions.  There is a connection here with some Lean and Six Sigma concepts in that it includes the use of visual information or data: signs, guidance, metrics.  It also includes the concept of ‘propinquity’ (physical proximity) of people and things, layout, design (e.g. to avoid mistakes).

What ‘Influencer’ implies but does not spell out, is the importance and approach for effective communication to support change.  Our previous blog: Communicating change – some practical procedural guidance may still be a good source for such information!


  1. RiverRhee Consulting enhances team effectiveness using process improvement, knowledge management and change management.  Follow the links to find out more about RiverRhee Consulting and about Elisabeth Goodman and John Riddell
  2. Influencer – The Power to Change Anything, by Kerry Patterson et al, McGraw Hill, 2008
  3. Communicating change – some practical procedural guidance http://wp.me/pAUbH-2z
  4. How to successfully implement business change http://slidesha.re/gskGyJ


High performing organisations: interweaving process improvement, knowledge management and change management.

Approaches for building strong quality foundations are well documented in the manufacturing industry, but also occur across all business sectors and types of organisation such as flight airlines, the navy, health services, pharmaceutical research & development and education systems.

Steven Spear, in ‘Chasing the Rabbit’1 discusses, with examples from the above, how this quality foundation for high performing (or ‘high-velocity’) and leading organisations rests on 4 main capabilities.  These capabilities are a graphic illustration of the importance of process improvement approaches such as Lean and Six Sigma, of knowledge management, and change management for effective team performance.

The 4 capabilities of high-velocity organisations

  1. Design: A clear definition of customer expectations.  Documentation of the end-to-end process and associated roles for delivering these outputs, using the organisation’s cumulative knowledge of existing best practices. This is even worth doing for 1-off operations to enable learning and adaptation as a result of unexpected occurrences.
  2. Improve: A commitment to seeking out and addressing problems as they occur. Involvement of key players in a ‘scientific’ approach to understand the problems (identify root causes), test solutions, implement counter-measures and resolve the problems (‘swarming’).  The importance of exploring a range of solutions and taking time to learn from them rather than converging on one too soon. Using cross-functional and possibly cross-company collaboration to tap into wider knowledge and expertise.
  3. Share knowledge: Sharing what was learnt about the problems and how this learning was acquired so that the whole organisation can benefit from the new knowledge gained.  Local discoveries become systemic discoveries (‘the multiplier effect’).
  4. Develop capabilities: The role of leaders in continuously developing everyone’s ability to detect and solve problems and share new knowledge (self-diagnosis, self-correcting, self-innovating and self-improving).  The leader as ‘learner-in-chief’, mentor and guide in establishing the right combination of behaviours throughout the organisation.

Problems are the consequence of complex systems and imperfect people

Steven Spear emphasizes that problems are to be welcomed as an opportunity to continue learning.  Each problem should be treated as a “consequence of imperfect people trying to design perfectly something very complex”.  By studying problems, rather than working around them or firefighting, the individual’s and the organisation’s knowledge, and the processes that they operate can continue to improve. The mastery of the complex interactions between people, processes, and what people are working on is never complete.

High-velocity organisations stand out from the pack in:

  • Their focus on process from start to finish, order to supply, end-to-end, rather than departments operating in silos – structure
  • Their attention to each problem as it crops up – dynamics
  • Their determination to make the best use of the talent within the organisation – capabilities
  • Their commitment to keep learning is reflected in the dynamic duo which I’ve described elsewhere2 between short-term stability (or standardization) and longer-term agility and responsiveness (innovation).

Through these they achieve quality, flexibility, efficiency and safety.

Concluding thoughts: extracts from ‘Chasing the Rabbit’.

I’ve selected some quotes from the book, which I think illustrate the points that Steven Spear is making particularly well.

The importance of design:

“No team can design a perfect system in advance, planning for every contingency and nuance.  However… people can discover great systems and keep discovering how to make them better.”

The importance of improving and problems:

“There’s something important you don’t know about me, but if you listen. I’ll tell you” (the process talking)

“Problems are not a never-ending plague to be endured but a never-ending guide to improvement”

The importance of sharing knowledge:

“Organisations depend on their ability to accumulate useful knowledge more quickly than their competitors.”

“One must create the ability in his staff to generate clear, forceful arguments for opposing viewpoints as well as their own.  Open discussion and disagreement must be encouraged so that all sides of an issue will be fully explored.” Hyman Rickover (Founder and long-time leader of the US Navy’s Nuclear Power Propulsion Program).

The importance of capability development:

“The point of process improvement is to improve the participants’ process improvement capabilities by coaching them as they try to improve the process.”

“It is arrogant to believe that anything we have created cannot be improved.  It is pessimistic to believe that we are incapable of ever improving something that is flawed.”

Steven Spear suggests that the winning mindset for high performing organisations is that of humble optimism.  I would add: it is also one of focused determination combining the best of process improvement, knowledge management and change management (or behavioural) approaches.


1. Chasing the Rabbit. How market leaders outdistance the competition and how great companies can catch up and win, by Steven Spear. McGraw Hill 2009.

2. How Lean can bring real benefits to innovation in Pharmaceutical Research Six Sigma & Process Excellence IQ, 8th January 2010, http://www.sixsigmaiq.com/article.cfm?externalID=1720

3. Elisabeth Goodman is Owner and Principal Consultant at RiverRhee Consulting, using process improvement and knowledge management to enhance team effectiveness.

Follow the links to find out more about RiverRhee Consulting, and about Elisabeth Goodman.

The problem with relying on intuition for process improvement and decision making.

In a previous blog “There’s more to decision making than meets the eye… or why we shouldn’t dismiss gut feelings“, inspired by Malcolm Gladwell’s book ‘Blink’1, I made a case for the discretionary use of intuition in decision making.  I argued that:

  1. There seems to be a particular role for intuition when: a) encountering very new or different options for which known criteria are just not valid; b) where decisions based on intuition just cannot be explained in a logical way
  2. There are circumstances where it would be quite risky to rely on one’s intuition: a) when under tremendous stress; b) when there is just too much information to be digested; c) where our subconscious ‘houses’ prejudices that we are not conscious of.

Comments from my readers suggested that other practitioners of Lean and Six Sigma also see a role for intuition alongside factual based analysis of problems and root causes, in the evaluation of potential solutions, and in decision making.

Having now read Ben Goldacre’s book ‘Bad Science’2, I have some new reflections to add to this discussion.  Goldacre cites three main problems with intuition.

1. Our brains are conditioned to look for and ‘see’ patterns, and causal relationships where there may be only random noise.

Goldacre gives examples of random sequences of numbers that, when presented to people, ‘reveal’ clusters and patterns when statistical analyses would show that none exist.

The ability to rapidly and intuitively spot patterns of activity, and causal relationships between them, may, in the past, have been an important survival mechanism for humans, but could today be very misleading in process improvement where, for example, we want to make sure that we focus our efforts on addressing the truly significant problems.

Approaches such as Pareto analysis, quantification of issues (or Undesirable Effects – UDEs) and matrix diagrams can help us to review data more objectively and thereby focus on the right things.

2. We have a bias towards positive evidence.

In the words of Francis Bacon, quoted by Goldacre: “It is the peculiar and perpetual error of human understanding to be more moved and excited by affirmatives than negatives.”

We are much more likely to pay attention to findings that prove our theories, than to those that do not. That is why, in another quote in Goldacre’s book, Darwin made a point of noting every piece of negative evidence that he came across.

Goldacre expands on this bias further by saying that we:

  1. Overvalue information that confirms our hypotheses
  2. Seek out information that will confirm our hypotheses

Our natural bias towards positive evidence is also why process improvement and change management exercises such as force-field analysis, SWOT (Strength, Weakness, Opportunities, Threats) analysis, FMEA (Failure Mode Effect Analysis) and Six Thinking Hats can be so powerful.  Knowledge Management practitioners also make a point of capturing ‘deltas’ or ‘what could be improved’ in learning reviews, retrospects or ‘After Action Reviews’

These tools, when applied to process improvement and decision making, encourage us to think about what might prevent our solutions from succeeding rather than getting carried away by how wonderful they are!  They also help us to present this understanding more clearly in our communication activities or dialogues with our stakeholders (sponsors, colleagues and customers).

3. Our assessment of the quality of new evidence is biased by what we believe.

If we are aware of this potential pitfall we can aim to be more receptive to opposing views.  In a team of people that have been working together for some time, common beliefs may be more predominant than instances of opposing views.

An effective team leader could look out for and encourage differences of opinion as a potential way of overcoming the team’s bias in assessing new evidence.  Discussions with customers, suppliers and other stakeholders could also be very powerful for this.


Now that we know that we can be additionally blinded by our need to see patterns, causal relationships, and confirmatory evidence of what we believe, we need to be doubly cautious in applying intuition for process improvement and decision making.

As change practitioners know, we value resistance from stakeholders as this highlights potential areas for consideration that those implementing the change may be blind to.  We know now that we should also value resistance from stakeholders as a counter-balance to the risks of intuition.

However, we should continue to bear in mind that there is a role for intuition in certain circumstances.


(1) “Blink.  The power of thinking without thinking” by Malcolm Gladwell, Back Bay Books, 2007

(2) “Bad Science” by Ben Goldacre, Harper Perennial, 2009

(3) Elisabeth Goodman is Owner and Principal Consultant at RiverRhee Consulting, a consultancy that uses process improvement and knowledge management to enhance team effectiveness.

Follow the links to find out more about RiverRhee Consulting, and about Elisabeth Goodman.

Powerful quotes for strong performing (effective) teams

Followers of my blogs will know that I have been reading Stephen Covey’s “The 8th Habit” and have found it very inspirational both from a personal perspective, and for the various ways in which I help teams become a strong foundation for their organisations.

I particularly liked the following quotes which Covey includes in his book:

There is nothing so powerful as an idea whose time has come.” Victor Hugo. This is very pertinent to Change Management.  How many times have I and others I know tried to introduce a new way of thinking or working that we think is absolutely right for the situation, only to find that we just can’t make it happen.  And then, maybe a few weeks, months or even years later, it’s suddenly easy to do, and everyone else is adopting the idea as if it was their own: like ‘pushing against an open door’?  The skill is in recognising when it’s the wrong time to introduce this kind of change, and when it’s the right time..

There are a thousand hacking at the branches of evil to one who is striking at the root.” Henri David Thoreau. This to me is very relevant to why we do root cause analysis in process improvement. It’s all too common a failing to try to treat the symptoms of a problem, rather than to look at the causes.  We can spend a lot of unnecessary and ineffective energy addressing the symptoms of a problem, rather than finding the root cause and tackling it once and for all.

The difference between what we are doing and what we’re capable of doing would solve most of the world’s problems.” Mahatma Gandhi.  This is of course a very powerful call for each individual to find their ‘voice’ and be great rather than merely mediocre.  It applies to any organisational unit too.  For a team, it’s about understanding roles and responsibilities and how each team member can contribute and help the other team members to achieve the organisation’s goals.  It’s about ensuring that the team members understand what customers value and is working on the right things, before spending time on process improvement to do things right.

To every man there comes in his lifetime that special moment when he is figuratively tapped on the shoulder and offered a chance to do a very special thing, unique to him and fitted to his talents.  What a tragedy if that moment finds him unprepared or unqualified for the work which would be hist finest hour.” Winston Churchill.  This quote seems to bring us full circle to the first and subsequent ones in this blog i.e. recognising when the time is right, understanding where ones energy is best spent, being clear on what our customers value, playing our role within the tangible or virtual team(s) that we are a member of to achieve a truly great performance, and lasting value. Empowerment in a nutshell?

I’d love to hear from you if you find the above of interest – comments here or contact me via: http://www.linkedin/in/elisabethgoodman