Causes of mistakes

6, February 2017

Surgery on the wrong side!

surgery-on-wrong-brainThis is a ridiculous medical blunder.

Yet, your biggest blunder could be to blame the doctor for his carelessness.

Pause for a moment to think this accident through.

Firstly right and left can be easily mistaken – depending on the point of reference.  Not to mention that shape of skulls may not be entirely similar from one person to another.  Most likely, the patient is unconscious during and throughout surgery.  In the operating theatre, the standard operating procedure is to place a sanitised cloth over the patient except for a reasonable size hole showing the location for the incision to be done.

Of course, the whole preparation procedure for surgery would be carried out by a team of Operation Theatre nurses. If the cloth does not have proper marking, it could be easily disoriented.  Those who do ironing of clothing will be familiar with how easily it is to flip a garment upside down. Not to mention that certain clothing designs are wearable from both sides!

Then of course, the surgeon concerned should have checked before making the incision, which under normal circumstances, would be a normal course of action.

The fact of this case is that the surgery was done on the wrong side of the brain.

In life, as in work, we have always been quick to point out the party at fault.  This may or may not be correct.

Slide72Inside the 12-steps of Problem Solving posted by me in the previous posts are areas which can help us not to make mistakes. The intent is to move away from single cause for problems until we have satisfactorily ruled out the other unlikely causes.

If we take the trouble to examine them, almost all problems have more than one cause’


Conflicts in Team – Understanding each other is not enough

11, April 2015

In the recent Team Excellence Symposium (TES) organised by the Singapore Productivity Asssociation, I was one of the Assessors called to check several team project reports and presentations.

TEAM.  If one were to check through the Assessment Checksheet, one will find 12 mentions of the word ‘team’ in the 40-item Assessment Checksheet.  This is hardly surprising. The reason for the emphasis on TEAM is this – getting a project to yield results is not the end of it.  For the solution to continue to be effective, the team have to come together, work towards improving it.  The goal or objective and of achieving savings of time or generating increasing revenue is a great thing, but not the ultimate goal of a problem solving project.

CONTRIBUTOR.  The real goal of project is if it will continue to yield results as long as possible. Environment changes, and a good team must learn and relearn; adjust and modify in order to keep the productivity up.  The Work Improvement Team is a special unit that allow each members to learn, grow and to work as a contributor; feeling a sense of personal achievement through his involvement with the team.

SYNERGY.   When the deliveryman managed to send the item to the correct destination faster and on time; when the packer ensures a scratch-free product reaching the client, each of them knows that they have played a complementary role for overall success of their team.  Each member of the team knows that the output that is more the sum of the individuals’ contribution.   This is commonly known as synergy, but synergy needs a ‘super-structure’. Individuals are by nature, is self-serving.  Until each member develop an understanding for each other’s role synergy may not be achieved.  And in reality, the development of team-ness (team spirit) is not a simple growth path.

GETS WORSE BEFORE GETS BETTER.  The simplest way to describe this is that … things will get worse before they get better.  In my classes I often show this chart to help explain to them the development of teams (adopted from Tuckman):

Team Development Stages

Once a team is formed, the productivity of the team (output) actually goes down.  This is the stage when people in the team are finding their personal position in the team; every member is learning how to combine their strengths with the rest; determining who is strong in which area, and who needs help in which.

That is where conflict comes into the picture.  At this stage (named ‘storming’, according to Tuckman), team members must learn to manage conflicts or they will not progress. If conflicts are resolved in a healthy manner, all will benefit and move forward. The Leaders play a key role in helping the team set some extraordinary goal for this to happen. There are many ways and approaches the leader can use.

There are several conflict resolution options which can be chosen and there are fundamental steps to develop healthy conflict resolution process; resolution strategies should be designed according to the team’s composition, their areas of strength, maintenance of internal power balance, a micro-culture or norm of group behavior starts; and eventually the team members find a positive ‘fit-in’ in team.

So conflict in teams can be expected.  But the are ways to resolve them.  There are steps and tools that all members should learn.

Once the initial conflict is resolved positively, the team will go onto a steep upswing of the curve!

Improving Conventional Brainstorming – Ideawriting

28, February 2014

BRAINSTORMING. I want to introduce here, a variant of conventional brainstorming which is much more effective than that most of us are familiar with. In conventional approach. To review, here are the basic steps of conventional Brainstorming.

(Step 1)  Write down the topic to brainstorm (To find a solution to the frequent breakdown of ABC Machine)
(Step 2)  Remind team members of the basic rules (one by one, ‘pass’, speed, time limit for the session (which is usually <10 minutes)
(Step 3)  Start the contribution of ideas from the team (Leader/recorder to jot down ideas)
(Step 4)  Grade the ideas (Grade A, B, C, and D) together
(Step 5)  Pick out the Grade A ideas to develop further, discard the grade D ideas. When time permits, move onto Grade B and Grade C ideas.

Weaknesses.   Although useful, there are several inherent weakness of conventional Brainstorming.  Firstly, it assumes that everyone present think at the same speed – which we know is not the case. Those ‘fast thinkers’ will become impatient as they have to wait for the slower ones to finish before he is given his next opportunity to speak again. Naturally, the session, instead of stimulating their creativity, stifles theirs. On the other hand, the naturally slower (but careful) and creative member of the group feel pressured to think ‘faster (or more carelessly)’. Forced to think faster, this member will inevitably.

IDEA WRITING.  Idea Writing is a more liberal approach compared to conventional Brainstorming, and it is less likely to lose ideas.

1)  Set everyone around a round table.  Reserve an empty space in the centre

2)  The leader writes the subject on a white-board for all to see.

3)  Allow clarification of the subject for brainstorming before starting.  Give all members a A4 size white paper.  This can be lined or without lines.

4)  Each member copies the Subject Title on the top of the page.

The subsequent steps can be divided into three phases (A) Compilation   (B) Consolidation  (C) Refinement. These are explained below.

A.  COMPILATION. (i)  Each member enters one idea on the top of his paper and return it to the empty centre space (ii)  He then exchange a random with another member’s returned paper (iii)  Continue to enter ideas and exchange until he is exhausted. He is allowed to read others’ ideas and build on them (iv)  Leader stops the exercise after 10 to 15 minutes

Brainwriting 1COMPARE TO CONVENTIONAL BRAINSTORMING.   The advantage over conventional brainstorming is that, everyone can put out ideas at their own pace, and they can also view others’ ideas at the same time.  While conventional brainstorming is going in a linear, single file, Idea Writing is simultaneously allowing all members to suggest and think at their own pace in suggesting ideas.  No one feels pressured, no one feels restricted, it is free-flow of ideas, or everyone is allowed to pour ideas at their own pace. When I conduct these sessions, I can see the ‘fast thinker’ going fast and are happier, while the ‘slow and careful’ thinkers are also enjoying their intense moments.


(i)  At random, each member will pick one paper.
(ii) The member to the right of the leader will start reading the idea, one at a time.

While the leader is reading from his list, all the other members are tasked to check the ideas on the list he is holding, to see if there are duplicates.  Duplicated ideas are eliminated.  This is how ideas are eliminated – if the member suspects that there is a duplicated idea on his list, the member reads out and check with the originator (the one who pen the idea).  Note that, it is easy to know who wrote the idea – as the idea is in the originator’s own handwriting.  If the originator agrees that it is the same idea read out, then the idea is cancelled. The originator can object and assert that it is not a duplication by offering a clarification on how his idea differs.  This way, everyone can have a chance to speak out.  When the list is completed, the next member will start reading his list. Brainwriting 2COMPARE TO CONVENTIONAL BRAINSTORMING.  Very often in conventional brainstorming, the ideas are written down by the leader on a flip chart. There are times when the leader ‘rephrases’ a contributor’s idea.  After several minutes, it is possible the contributor may not be able to ‘recall’ what his ‘actual idea was’ as the idea was actually rephrased.  Sometime the distortion is even greater, if the writer is not the leader. Sometimes the contributor ‘had to agree’ with the leader’s words/sentence as he or she is under pressure to agree with the one who is writing.  In Idea Writing, each pens down their idea in their exact words.  Furthermore, at this point, time is set aside to listen to the contributor.


(i)  Once the discussion is completed, the leader will collect all the papers and consolidate the ideas which are not cancelled.  These are unique ideas.  The team can choose to discuss, expand, combine, or even create new ideas from here.
(ii)  A list of good ideas will emerge. Brainwriting 3 Brainwriting 4

You will notice that by this time, everyone is talking and expressing their ideas freely…a sharp contrast to the serious Traditional Brainstorming.

Try it.

IQC Assessment Scores (Star, Gold, Silver, or Bronze?) – What do they mean?

22, April 2012

As an Assessor for SPA, I had given my endorsements for Golds, Silvers, Bronzes and of course, some Stars for several years now.  I use to assess for the Singapore Productivity and Standards Board since those days in the 1990s.  I have seen many inspiring projects and many more impressive ones.

However, I must also say that I had come across several good projects, especially those with very impressive results (big savings); or projects which benefited many people in the company, as well as projects that add great economic value.  BUT the team of Assessors decided that they couldn’t give them anything more than a Silver award.  Needless to say,  for some of these cases, the teams’ managment submitted their ‘appeal’ for a reviewed of the results.

It is always disheartening to see the reaction of their management when those impressive projects were not awarded a Gold Award.  Worse. those impressive ones reveived Silver and sometimes, the less-impressive ones, Gold!

To understand the real meaning of the Award system, one must understand two basic qualifying requirements.

First, the team must understand that they have to provide appropriate and sufficient evidences for each and every criteria mentioned in the evaluation sheet.   My simple advice : What Assessors do not see, Assessors cannot award points.

Secondly, each section or step of the project must be clearly explained and logical.  The project report is drafted to provide a clear explanation on the project.  It should start from the time the team identified the problem, carry out the experiment and compile the results.

But it is equally important that the report be an interesting read for the Assessors.  Why must it be interesting? Imagine you are in the position of the Assessor, who had to read 6 projects or more for each session that they signed up for.  If your project is easy to read, and interesting, surely it will attract more reward points, otherwise, it attracts questions!

Remember, Assessors are busy people and they are not from your company.  They are not familiar with your company, department nor your team’s problem.  The onus is on the team to help the Assessors find opportunities to award points.

Thirdly, you need to understand that the assessment points are not scored as if it is a  ‘common Maths test’.   In a common Maths test, 100 points means each answer matches the expected answer.   In mathematics, there are very few questions with two answers.  However, for the IQC Assessment criteria, every project is unique and therefore to satisfy the criteria, it is possible to have more than one answers.

Points are awarded not because a project achieves the target it sets out to achieve, but what is equally important is how the team arrives at the solution.  The team must explained how the solution was designed and implemented to make it work, and continue to work even after the team ‘ended’ their experiment.  Being not just right once but the solution had continued to be effective.

Thus the project assessment is more like an essay test.  Your ‘project essay’ is being asessed to see if it covers sufficient scope (concept), whether there are sufficient illustrations (facts/evidences).  Your assay must also have a sound argument.  The flow of your argument must be logical, your project must be meaningful, and your solution, interesting.

It must also show a reasonable level of maturity of the candidates participating in the experiment.  In the same way, the assessment of an IQC project during the TES (Team Excellence Symposium) assessors are looking for coverage of the assessment items and how the team argues their case.

IETEX Criteria (2012)

4, April 2012

Back in the early 2000s, SPA had the far sight to initiate the IETEX Assessment framework.  Today, I was told that there is a fair amount of interest in this accorlade.  For the benefit of my clients, I would like to share some of my observations and suggestions on how to interpret the IETEX assessment template.

The IETEX is held against a set of criteria which is slightly different from the TES (Team Excellence Symposium) criteria.  The IETEX criteria was originally based on the established assessment framework of the American Society of Quality assessment items.  Between the TES Assessment Criteria and the IETEX Criteria, there are some items which are different, but most of them are similiar.   This is really good news for those teams who would like to collect both these awards, as one only need to make minor enhancements to their IQC reports in order to meet the IETEX requirements.

You can make a comparision between the set of slides I posted in the earlier blog on the Enhanced IQC Assessment Criteria and you will be able to see the differences..Here goes :

IQC Enhanced Assessment Criteria (Feb 2012)

26, February 2012

Another upgrading of the WITs Assessment Criteria by Singapore Productivity Association was released in early Feb or late Jan 2012.

By studying the criteria carefully, team members, facilitators and  managers will do well to know how points are allocated. 

In my years of consulting, WITs and IQC teams wants to know whether they measure up to other teams.  They want to be assessed on how effective their teams’ problem solving methodology compares with the outstanding teams.  Agood place to start – the Assessment Criteria.

There are several valuable ideas ‘hidden’ in the criteria.  Over the years, teams who regularly participated in the Team Excellence Symposium (or convention, as it used to be known as) actually discover for themselves a whole deeper understanding of the problem solving process.  

For instance, one team, I coached begin to appreciate the importance of target setting, and that the target is the anchor for the problem definition.  They begin to see that without a ‘firm target’. the problem cannot be defined clearly.

Analysis is really the final stage of the data (evidence) collecting process.  Those in the healthcare industry will know that doctors who are good, pay a lot of attention to gathering the historical progression of a disease.  For instance, to understand Diabetes better, and to be able to advise the patient on the best treatments available, the doctor will do well to examine a complete history of the patient’s background, type of physical activities he is involved in, his normal diet composition, sugar intake, carbohydrate intake. is important.  Similarly, decisions must be based on sufficient (not complete) and relevant data.  

Finally when it comes to implementation, managers of large companies are interested in getting buy-in of the internal stakeholders during the implementation of a nw procedure.  If people are not supportive of the solution, whatever change that is being implemented will not be sustainable.  How and how much was the buy-in is crucial.

Together with the write-up on the Assessment Criteria (2012),  I have also extracted the key focus of each of the ‘items’.  While the criteria write-up is a view from the Assessors’ perspective, my objective here is to provide a perspective to help the team members and facilitators view the criteria from their angle.  

Another milestone for another company

27, August 2011

Team Excellence Symposium (2011)

Having completed their project, the teams registered themselves for the annual symposium on problem solving.  My partner and I took on the task of coaching the teams in their final presentation and drafting of their report.  The assessment of the project reports, together with a stage presentation, covered the areas of problem selection and definition, analysis and solution design as well as results and achievements.

Two teams competed and the recognition came in the form of : Certificate of attendance, Bronze, Silver, and Gold.  The exceptionally outstanding team were given Star (hardly 5% of the cohort will be given Stars).

Results:  1 Star and 1 Gold!