Learning Organization

A company veteran and maintenance manager, let’s call him Roy, knows that one machine hiccups now and then. He and his maintenance team have gotten together informally, to discover the root causes of the machine failure, and now know how to repair it, which they do every few weeks, quietly, unbeknownst to most in the organization. The problem keeps happening, and Roy’s team keeps fixing it, holding those informal root cause analysis sessions and improving to the point where those machine hiccups cause little disruption.

Then, a similar hiccup happens in another of the company’s plants, and the other shoe drops. Downtime mounts because employees in this department, unlike Roy’s, have no idea how to fix it. Reports get filed. People get punished. A major incident investigation ensues involving multiple levels of workers and management—all for a problem others in the company already know how to fix.

This scenario is more common than many realize. If the root cause analysis and resulting remedies had been communicated clearly, documented, and shared throughout the organization, the machine breakdown in the other plant wouldn’t have caused such a disruption. The lessons learned by Roy and his team would be captured for the benefit of both Roy’s team and the rest of the organization.
Management gurus call this “organizational knowledge,” in which knowledge gained in one department is spread throughout the organization, in turn creating organizational memory. Organizational memory doesn’t go way when an experienced employee transfers or retires. It allows people to build on what others learned previously. It also eliminates learning curves so that new employees start far ahead of where their predecessors did years before. This occurs by implementing a problem-solving process and then sharing the gained knowledge throughout the organization.

Causes, Effects, and Learning
All problem-solving tools—be they root cause analysis using Cause Mapping, plan-do-check-act (PDCA), total productive maintenance (TPM), total quality management(TQM), or anything else—hinge on understanding cause-and-effect relationships and, most important, how these relationships achieve goals. In other words, problem-solving tools analyze the work process, a series of steps leading to a desired result. If a work process fails, a team can use visual tools such as a Cause Map to determine the system of causes that led to the failure.
The Cause Mapping process begins by first defining a problem in terms of the impact to the organization’s overall goals. People may not agree on what the problem is, but all agree on an organization’s overall goals. For instance, if someone trips over cabling, falls and breaks his leg, some may view “the problem” as bad machine placement; others may point to poor cable organization; and still others may blame inefficient floor layout. None of these perspectives are wrong and all should be included in the incident investigation. But everyone agrees that the injury negatively impacted one important overall goal: zero injuries.
On the Cause Map, the overall goals are placed to the left. To their right go the causes that negatively impacted that overall goal. The map builds left to right, with arrows pointing left, backward through time (that is, the event, followed by the preceding series of causes and effects that led to it):

This Cause Map is used to uncover the best solutions, which are then integrated into a new and improved work process map. A process map also reads left to right, but progressing step by step, forward through time.

As the day-to-day work of the organization uncovers more inefficiencies or issues, the Cause Map-process map cycle is repeated. People identify a work process flaw, and a Cause Map uncovers ways to eliminate it. Because no organization is perfect, the cycle of finding problems, then discovering and implementing solutions never stops.

The Cause Map-Process Map Cycle
Here’s how an improvement cycle might start at an organization implementing the Cause Map method for the first time:

1. An incident occurs. One machine continually breaks down, and an investigation is launched to analyze the existing work process.
2. Define the problem.
   • As discussed, people often don’t agree what “the problem” is. It often depends on one’s point of view. So the investigation team starts by identifying the affected overall goal that wasn’t met—that is, zero machine breakdowns. From here onward, every issue is defined within this context.
   • The team talks to various people connected with the incident to obtain all viewpoints (that is, all versions of “the problem.”) Like a journalist, they ask the basic Ws: what, when, where. (“Who” is purposely left out, because concentrating on “who” leads to finger-pointing and blame.)
3. Analyze the problem.
   • Based on information from interviews and investigation sessions, the team identifies causes and places them on a Cause Map, showing how each cause relates to others.
   • Each cause box on the map also shows the evidence supporting it. If one or more causes do not have evidence, they aren’t discarded but instead market with a question mark to indicate they are possible causes. If and when enough evidence is gathered, the possible cause is either confirmed as a cause or crossed off as a disproved cause. Accompanying photos or diagrams illustrating specific causes or events are brought into the investigation.
   • The team develops a timeline that describes when each cause and incident occurred.
4. Identify and implement the best sulutions.
   • Immediately above the cause boxes the team writes in possible sulutions (though not every cause has or requires a sulution).
   • Not every possible sulution will work. Some might cost too much or take too long. Others simply may not be reasonable for the issue at hand. So the organization determines the best sulutions and integrates them into an improved work process, developing new work procedures and process maps.
   • The organization identifies action items and due dates for implementing the work process change.
5. Another incident occurs. A challenging deadline is missed. A technician notices the machine’s placement in the plant causes part flow problems. Machine placement has always been an issue, but with machine reliability and efficiency improved thanks to the previous Cause Mapping session, another issue steps into the limelight.
6. Define the problem. An overall goal—100-percent on-time delivery—wasn’t met. And though one worker believes machine placement causes part flow inefficiencies, it isn’t the only cause. A Cause Mapping investigation starts again with the team interviewing everyone invulved, uncovering moltiple viewpoints and the system of causes that led to the incident.
7. The cycle continues.

Spread the Word
Just one department going through this improvement cycle isn’t enough to foster a learning organization. What if employees in another division experience similar issues? They may perform a root cause analysis, develop a process map and Cause Map, and come up with similar solutions. But why do all this work? If information from the original root cause analysis were shared with the entire organization, all could use it as groundwork for improving their own operations.

Sharing information becomes especially important with safety issues. A root cause analysis revealing a safer process in one area of the organization could prevent injuries elsewhere. Not sharing the information may lead to needless bodily harm in other areas of the company. In any organization, nothing should be more important than worker safety.

Every problem offers an opportunity for improvement. Developing and analyzing the Cause Map, the incident-investigation team brainstorms the best solutions, and then integrates those into the work process, which is then shared with the rest of the organization. As the improvement cycle continues, processes become better, training improves, and learning becomes more efficient.

Harnessing Knowledge
Organizations have a lot of knowledge on the payroll, and we don’t necessarily communicate this knowledge as effectively as we could. Understanding the process, the cause-and-effect relationships in a Cause Map makes for an objective, structured approach to improving the way a group communicates when working through an issue. Presenting the process visually helps people recognize the importance of executing the work process effectively. Analyzing problems promotes proactive thinking, spurring people to examine work processes, foresee potential problems and, again, refine the work process further to prevent them from happening.

Using proper root cause analysis and other problem-solving methods, a company can transform into what Brian Joiner calls a “rapid learning organization.” In his book, Fourth Generation Management, Joiner uses curves to describe this transition. An organization might have an “eyelash learning curve,” which (appropriately) looks like a series of eyelashes. The tips represent when the old employee leaves; when he leaves, so does his knowledge, making the curves dip down drastically. The new employee starts with the same knowledge his predecessor did when starting the job years or even decades before. The previous employee may have spent years learning new ways to perform his job better, but all that knowledge goes out the door with the old employee.

Why did the employee leave? Perhaps it’s for better opportunity at another company, one that shares knowledge and may indeed be a learning organization. At the new company, he participates in root-cause-analysis and other process improvement sessions, which may include people from other departments, so they can analyze problems from a fresh perspective. Again, the results are shared throughout the organization.

Because everyone is engaged, solving problems, and becoming efficient, job satisfaction increases and turnover rates drop. If someone does leave, refined work processes are in place to facilitate efficient training. The new employee arrives, learns the ropes, and continues to engage in improvement initiatives. Joiner depicts this with his “rapid learning curve” that climbs in waves, with new employees beginning almost where previous employees left off.

These aren’t superhuman employees. They learn efficiently simply because the organization has refined work processes. Within such organizations, good communication, clear documentation, and continuous improvement pervade. And learning never stops.

Reference
Joiner, Brian L. 1994. Fourth Generation Management. New York: McGraw Hill Inc.