Problem Solving Technique: Step 7- Documentation, Lesson Learned and Promotion (Corrective Action)

“ Incorrect documentation is often worse than no documentation” — Bertrand Meyer

Introduction

We all try to work each day from the premise that we are doing our best. However, sometimes, for reasons out of our control, we don’t get the best result. Like we forget to inspect our vehicle for the pollution check or fail to pay the premium for the life insurance. Although we did face similar problems in the previous years too due to an inadequate reminder system, we falter repeatedly.

Objective

The purpose of a quality management system is to help businesses improve their abilities to consistently meet customer or regulatory requirements. A major component of a successful system is a corrective action program that adequately addresses nonconformances. Quality pioneer W. Edwards Deming introduced the Plan-Do-Study-Act (PDSA) cycle as a planning, implementation, and continuous improvement tool.

In the problem-solving technique (like the 8D Model), whatever actions that we have taken will not suffice and sustain unless the organization has a strong and effective system of documentation, lessons learned and promotion of awareness.

In this article, we learn how documentation can help the organization to have more transparency, solid & lasting corrective actions, empowers the team, can capture the experiences & changes for future events and developments.

Definitions (ISO 9000: 2015):

Complaint (clause 3.9.3): Expression of dissatisfaction made to an organization related to its product or service or the complaints handling process itself where a response or resolution is explicitly or implicitly expected.

Corrective Action (Cl 3.12.2): Action to eliminate the cause of nonconformity and to prevent reoccurrence.

Correction (Cl 3.12.3): Action to eliminate a detected nonconformity

Complainant (clause 3.1; ISO 10001: 2018): Person, organization or their representative making a complaint.

Detailed Information:

The following are the 7 key steps for problem-solving.

Define the Problem
Correction, Containment, Interim Action
Root Cause Analysis: 3 Layered 5 Why Analysis (3L5Y), Ishikawa Diagram
Implementation of Corrective Action
Effectiveness Evaluation
Horizontal Deployment (Yokoten: Japanese)
Documentation, Lesson Learned and Promotion of Awareness

As per the PDCA cycle, once the organization implements the Correction and Corrective Actions (Do), verified their effectiveness (Check) and horizontally deployed, the last logical step is to ensure that all the relevant documents are reviewed, updated and communicated to all the stakeholders.

Documentation:

Example:

Problem: 100 assemblies (moulded components) rejected at the customer end (OEM) due to fitment issue

Correction and Corrective Action:

100% segregation done at the organization, supplier and customer end
Further despatch to the customer stopped
Moulding fixture modified and moulding process parameter reviewed and updated. A new moulding fixture will be made to control the specifications.
Alternate moulding machine (800T) to be qualified for further production
Communication to supplier, incoming/in-process/final inspection
Incoming, in-process and final inspection check-sheet reviewed and updated
All the documents reviewed and updated

Define the Problem:

CFT formation
Pictures
Customer inspection report
Report of the failed sample
Test data from the customer
Invoice details like date, lot number

Correction, Containment, Interim Action

Communication with the client
Details of the quantity under question
Records of the rework, repair, segregation, scrap, deviation
Result of the correction, containment, interim action

Read More: https://bit.ly/IshikawaDiagram

Root Cause Analysis: 3 Layered 5 Why Analysis (3L5Y), Ishikawa Diagram

5 Why analysis sheet for the Occurrence, Detection, Systemic failure
CFT who conducted the analysis
Identification of the final root cause for each Layer

Implementation of Corrective Action

Review of the internal and external context, related risk analysis
Proposed corrective action, responsible person, poka-yoke implementation, calibration plan
Details of the training, Skill Matrix
MSA Study and Process capability planning for the special characteristics
Documents reviewed and updated like Drawing, Process Flow Chart, FMEA, Control Plan, SOP, OPL-One Point Lesson, Skill Matrix, Machine History card, Supplier PPAP, procedures etc.
Shelf-Life monitoring plan
Laboratory testing plan
Contingency planning
4M Changes (Man, Machine, Material, Method)
Process revalidation
Reviewing and redefining performance indicators like OEE, Customer complaints, Rejections, Warranty, COPQ, Inventory Turns, Customer satisfaction results (Quality, Delivery)

Effectiveness Evaluation

Updation of the internal and external context, related risk analysis
Lesson Learned
The effective date of actual implementation
Calibration records, Poka Yoke Monitoring records
Updated FMEA & its rating, tool history card, Machine history card, preventive action check sheet
Tool Duplication plan
Effectiveness of 4M Changes (Man, Machine, Material, Method)
Updated skill matrix, Competency mapping
Shelf-life monitoring results
Laboratory test results
Contingency planning trial reports
MSA Study results and Process Capability results
Status of performance indicators like OEE, Customer complaints, Rejections, Warranty, COPQ, Inventory Turns, Customer satisfaction results (Quality, Delivery)
Updation of the distribution list
Communication to the concerned personnel and relevant interested parties
Make sure that personnel are aware of the amended requirements and have understood
Internal audit results (System, Process, Product, Layered)
Management review output

Horizontal Deployment (Yokoten: Japanese)

Updation of all documents which can be impacted in future

Lesson Learned:

Most managers understand the importance of lessons learned on current and future projects/customer issues. Capturing and regularly updating the lessons learned can keep the project/organization on track. In the long run, it can also help continually improve how organizations execute projects/manage customer problems. They are experiences distilled from past activities that should be actively taken into account in future actions and behaviour. The experience may be positive, as in a successful new development or negative, as in a mishap or vehicle recall.

Lessons Learned Steps

What information should be shared with other plants, departments, products, processes, suppliers?
Consider similar/same products, processes, and equipment
State lessons learned in a manner that would make sense to someone not familiar with the specific cause or issue
Should be specific and avoid being too general
Lesson learned can be documented centrally and can be accessed easily by interested parties

Lessons Learned examples:

Component mixing (Different Hardness) in heat treatment and similar can happen in the incoming inspection (steel bar of different grade but same diameter)
Production planning: Product A followed by product B (similar geometry) and both can be mixed in the assembly line
Welding operations – boundary samples of what is acceptable and what is not are needed
Operation of critical machine controls (i.e. diverters) must be verified at an appropriate frequency
Operator work instructions must include steps to be taken after machine breakdown

Industry Challenges:

How often all the relevant documents are reviewed and updated?
How often concerned machine operators and supervisors are communicated and clear about the implemented action plan?
How often does the organization record and review the lesson learned from the complaints and rejection analysis?

References:

IATF 16949: 2016

ISO 9001: 2015

ISO 9000: 2015

OEM Supplier Manual

CQI 20: Aug 2018, 2^nd Edition (Effective Problem-Solving Guide)

Industry Experts

This is the 148^th article of this Quality Management series. Every weekend, you will find useful information that will make your Management System journey Productive. Please share it with your colleagues too.

In the words of Albert Einstein, “The important thing is never to stop questioning.” I invite you to ask anything about the above subject. Questions and answers are the lifeblood of learning, and we are all learning. I will answer all questions to the best of my ability and promise to keep personal information confidential.

Your genuine feedback and response are extremely valuable. Please suggest topics for the coming weeks.

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