Hi everybody, I am Sean. This is everyday quality, a
podcast about quality management systems.
And we're going to try not to put you to sleep today because
we're going to talk about a, an exciting topic that well, in in
our world, it's a pretty exciting topic.
It's something that we're going to tackle because every quality
professional has probably felt this at some point in their
lives. Maybe not said it out loud, but
at some point your corrective action, preventive action system
loses efficacy. It stinks and it's undeniable.
Everybody, they, they get to a point where they're just like, I
don't want to do corrective actions anymore.
It's it's kind of defeating sometimes to constantly be
finding problems and and needing to address them.
But this, this corrective action fatigue is, is what we're going
to talk about. You know that, that feeling
where you're in your weekly Kappa meeting and everybody's
filled out the the forms were were nodding through all of the
like, all right, what action is do next, do your thing, Where
are you at? But nothing changes.
And if you don't have that visible improvement, if you
don't have that action happening, it starts to drag and
the Kappa process becomes ineffective.
So today we're going to talk about, you know, why that
fatigue can set in, what it cost us and and how to fix it,
hopefully. So let's get into it.
The Kappa system is what I call it corrective action, preventive
action. It's AI don't know actually if
preventive action. I don't think preventive action
is a a modern thing in ISO. I got it from the the Med device
world where you do have to do those kind of religiously.
But maybe yours is just a a car system.
Maybe it's a a just a corrective action system.
Whatever you call it, it's what you do to fix things after
they've gone bad or after the problem has been noticed.
It is an improvement tool. You know, every, every time I do
an internal audit and I find myself auditing corrective
action management review and internal audit, I find it a bit
silly cause ultimately it's auditing improvement three
different times to see if it's really effective in its many
forms. The corrective action systems
should be your, your coolest improvement tool 'cause
everybody gets involved. So, so that's why these are are
major. They should be utilized to the
best of their ability. But if something goes wrong in
that process, then it loses efficacy.
So let's let's go into to that. So the corrective action system,
you know, the a bad thing happens, you dig in, you find
the root cause, you make the change and prevent it from
happening ever again. It is absolutely what plan do
check act is all about and it's really what's improvement in ISO
9001 and risk management and AS 9100 and everything else is
it's, it's the, the heartbeat of that system quality is
improvement. So care active action is there
to make that happen. But when it comes to the the
execution, you know, sometimes the Kappa can become more of a
paperwork process. Yeah, I love Kamishi.
By audits, that term literally means paper theater.
But that's can be what a corrective action system
becomes. If you're just looking to get
the stamp, get the signatures and then move on without
actually learning anything, it becomes ineffective.
You get bored with it. I think that fatigue is what
happens when people stop taking that process seriously.
If it becomes viewed as a rubber stamp process, then you've lost
all efficacy in it. You go through the motions, you
fill out the paperwork, but you don't feel what that system
should be doing, which is making life easier for everybody.
So Kappa fatigue could look like it's it the, the corrective
action itself could sit open for months or years well beyond the
the real period where you can do anything effective to address a
specific issue and months and years open.
This is modern manufacturing. You won't have the same people
on the team a year, two years after a corrective action has
been opened. So this needs to be an effective
tool, if for no other reason than to keep up with the market.
We need to collect and catalog all of that knowledge that we
learn to and, and corrective action is the, the system that's
going to get you there. But if we aren't writing it
down, getting it done quickly, you know, somebody that's with
the company for for two years, they might not see that third
year, but they're going to take a lot of knowledge with them.
I don't know anybody that's not working less than 70 hours these
days. So you'll learn a lot in that,
that two year period. So maybe that's, that's just me,
but it could also present itself as the the same problems
reappearing again and again and again.
Corrective action stops things from happening again and again
and again. So if you are finding repeat
problems, your system doesn't work.
Or maybe you hear the phrase in the background and I'll you'll
hear this from non quality folks day in, day out.
They could be saying, you know, hey, maybe let's not do this as
a Kappa. That'll really slow everything
down. If you hear that your system
needs a refresh, you need something else to kind of boost
participation in this thing again, because if Kappa is
viewed as a roadblock, people will find a way around.
They'll go another route. And that doesn't help your ISO
stuff whatsoever. So why?
Why could Kappa fatigue actually be happening in a facility?
I've seen it, you've seen it we've all seen it.
Let's get it out in the open and and talk about it.
So why does this this happen? There could be many causes nods
are you've seen a a few of these in your workplace.
You know your system could be overused if everything becomes a
Kappa. Minor issues even.
You know, maybe a production run had a slight defect on a part
that costs a penny to make. Don't do a full blown corrective
action for that. Nobody cares.
It's not worth the the time and effort put in if you're looking
at cost of poor quality. That prevention or detection
cost there just goes through the roof and you can't really
justify spending $1000 on a product that you're only going
to make $400.00 on. So if it becomes a paperwork
exercise, your system isn't going to be well liked by the
people that you as a quality professional are putting in
charge of that. So just try not to overuse a
assistant. You know, let's not get into
diagnosis yet. Overuse could cause fatigue.
It could be poorly prioritized. Not all problems are created
equal, but many systems and systems that I've run, we treat
it the same way. Like Nope, this is a problem and
it affected one department, but your problem that affects 5
departments was detected later, so we aren't going to engage
with that. That's not the way to run it.
You need to do that, that full FMEA thing with your RPN
numbers, risk priority date, too much coffee, RPN.
So if you've got a high consequence or high likelihood
of recurrence, high severity, sorry, that's not severity, not
consequence. Tackle those first.
Put your resources into that. If it is really just a potential
late processing of a USMCA form like that's low consequence,
don't worry about it. Another main cause could be the
administrative burden. You know, if you've got a lot of
paperwork, forms, templates, due dates that are tight, it could
become just a a checklist exercise.
You know you want a good, solid, easy to use process.
I'm getting into diagnosing, sorry.
But if you're using like in an 8D form that is for some reason
10 pages long, nobody's going to use that.
Nobody. You know that a three form is
really great for organizing the discussion because you're able
to write everything you need on one sheet of it's a giant sheet
of paper, granted, but everybody is able to kind of see and do
and, and work with just one sheet of paper to get everything
they need. Taking that form from the the
written stuff that that everybody works on in a
conference room or, or preferably where the problem
happened, moving that from the the form into a more usable
format later on. That's time consuming, but
quality can take care of that. Let the people that know how to
solve it, solve it. Write it down in an easy to use
format and they'll get it to you.
Don't make the the paperwork the important aspect of a corrective
action. You need to document it.
Yes, you need to do that. You need to make sure that
everybody is aware of the importance of the paperwork, but
don't make the paperwork the greatest burden.
You could see lack of ownership as a a key figure in everything
that the Kappa system has to deal with.
You know, quality doesn't own corrective action, but because
quality is in charge of the corrective action process in
most places, it's always viewed as kind of like, oh, quality's
going to deal with the the corrective action.
Quality knows our stuff. We know how to make sure the
system is effective. We're going to check it, we're
going to audit it. We might not know what the the
product engineers know. So they need to own the solution
side of it. They need to own the action side
of it. I could tell my engineers all
day long, like, hey, maybe you should try building it better.
That's not a solution though. That's that's my solution.
I don't fully understand exactly what they need to do from the
mechanical side. I know the statistics.
I'll do the math all day long. I'll do the monster math all day
long. You never know.
But the quality is going to be there to monitor, track and make
sure that these corrective actions are done on time.
But they should not be the ones coming up with how to fix it
'cause that's just going to anger everybody.
And then maybe in some places it's just straight up cynicism.
Maybe your culture isn't right for corrective action.
We've all seen that. When the culture says, hey, you
know what, just say it was an operator.
Say we had a training issue. Then that becomes pervasive and
that ruins any kind of efficacy that your corrective action
system is going to do because it becomes a blame thing.
Repeat after me. People don't fail, processes
fail. And the corrective action system
is there to make sure that the process is effective enough so
that it is at a point where if somebody does fail, they really
had to go out of their way to, to make it happen.
So when it's not a true root cause analysis that's going on,
just, Oh yeah, the operator was the, the, the problem there.
We fired him. Moving on.
That is not analysis. That is avoidance.
And we want to get rid of that. So maybe those, those, those
items sound familiar. You know, overuse of your Kappa
system, poor prioritization of what corrective actions need to
be taken on paperwork burdens, ownership and accountability
issues and just not understanding how the Kappa
system should should work. Maybe those sound sound
familiar. So it doesn't mean though, that
your QMS is broken. It just means that the system
needs a little bit of a, a refresh, recalibrate it.
You know, we all work with, with calibration systems as well.
And now you see when, when the the corrective actions are
staying open longer and longer and longer and longer that
something is out of whack. So recalibrate, get it back in
order and we can do this. You know, it's just, it's just
people. So what does fatigue, the Kappa
fatigue do? Well, first, the the system
loses credibility. You know when when leadership
sees dozens of corrective actions with no progress, they
start to see quality management as a a formality.
They just are like, we're going to do this for the audit.
If that phrase is in your building, it is time to fix
things. That's because if the system is
a checklist, if it is a formality, if it is just a
series of boxes that everybody has to deal with once a year
before the surveillance auditor comes in, it's not a function.
Next, the the lack of attention to a corrective action system
slows improvement. And there's nothing worse,
nothing more deadly to a culture than having the system not have
an impact. If every little thing is in the
pipeline, nothing gets the attention it deserves.
And that is something we need to, to avoid at all costs,
prioritize properly and make sure people see the results of
these actions that you're taking.
Because if you aren't taking action, if everybody is thinking
that good things are going to happen once we identify a
problem, but nothing happens, it just drains the energy.
Your quality team spends more time managing the tracker than
solving problems. And that's, that's not good.
You've got these zombies just walking around instead of doing
continual improvement. They are just making the
motions, going through the, the act of improving things without
actually doing anything. So I've already discussed a
whole bunch of fixes 'cause I, I can't not, but that's, that's
kind of a problem too. You know, if if you are in a
system where the whole team immediately jumps to, OK, this
went wrong, how do we fix it without this went wrong?
Or rather, instead of this went wrong, let's look at it, figure
out why, and then fix it based on the why.
That is a big problem too. That is the one that I run into
all the time. I actually had a a production
manager one time at a a shop. Had a whole bunch of of stuff
running. Got a big old whiteboard next to
the machine center. That was the the source of the
issue. We wrote up a problem statement
and we started A5. Why Now the production manager
stops the conversation and he says, well we all know why.
No, we don't. No we don't.
We didn't hear from the operator, we didn't hear from
the the setup team, we didn't hear from the quality
inspectors, we didn't hear from the engineers that are are
tasked with making sure the process is effective.
We didn't hear anything from our materials people.
We lost a lot of knowledge, we lost a lot of participation.
We lost a lot of energy when that production manager just
stood up and said, hey, we know why this happened, let's fix
that. We didn't fix it.
It came back because we didn't take the time to do a proper 5Y
or a fish bone to solve that. OK all right so that's that's my
little rant story We're coming back to it.
How do we fix fatigue? That is a a big, big problem
because fatigue becomes culture. Culture is difficult to to turn
around, but we can fix it. So let's talk about solutions.
Here's a Kappa system recovery plan.
Bunch of steps here. First, triage all your your
existing corrective actions. If you see your system in need
of recalibration, take a look at everything you have open and
decide what deserves a full corrective action.
The quick decision rule does. Does it?
Does this issue pose a risk to product quality, safety or
compliance or your system? If not, fix it, log it as kind
of a maybe that is your your preventive action.
Maybe it is a action taken to address risk.
Write it down somewhere, but you do not necessarily need a full
corrective action and all of the time and energy that should go
into that because you have other things to deal with.
Next, make it visual. Visual management is key, and
information hidden behind computer screens on a server
somewhere becomes information you have to seek out.
So you have to be thinking about it in the first place to think
to to even want to learn what corrective actions you have
open. If you don't have it posted, it
will be forgotten and it really becomes a scheduled activity.
That doesn't help. So if you post your corrective
actions, get them out in front of where everybody can be.
Write down the problem statement, write down a due
date, write down an owner, make it in front of people and it
will drive accountability. Next, empower the ownership of
these corrective actions. And remember, quality owns the
process, not the actions. That's, that is how I I try to
frame all of my corrective actions at at my offices.
If quality is in charge of the corrective action system and its
results to make sure that corrective actions are closed,
then we can push to make sure that these things are closed and
effective. Effective is the the key here.
Quality cannot know everything. Quality cannot be the sole owner
of what needs to be done. So quality guide, mentor, verify
the people who own the processes though that your corrective
action is issued to you. Maybe you've got a machinist
center owner. They need to own corrective
actions related to the machine centers.
That's how you build Bion, all right.
Make sure that they know that they are in charge of this.
They are to report back to quality, and quality is going to
make sure that their name on that visual board is set and
ready to go next. Shorten the loop.
If you don't have a regular Kappa meeting, schedule one.
Do it once a week. Just makes it easier, makes it
more viable. Provides that feedback input.
I always set my internal corrective actions to still have
a 90 day correction plan. Far too many times working in in
medical. Did we try a shortened
corrective action plan and we just didn't have the data ready
to go? So still do 90 days even in a
general industry thing make sure is to make sure that the product
has run, that we're able to get the data all organized.
Anything that comes from a customer though, that's got to
be done within two weeks, just just make it done.
Get it done. It's got to be fast.
Got to get a plan and then you can go in and verify it later
on. Next, celebrate closing that.
So in a in a proper 8D. That last step #8 is to
celebrate. Get the team together.
Let them know that they did a good thing by closing this.
Make it public. I'm not above embarrassing
people, but do what you need to so but as the the more that you
celebrate the closure of Kappas, the more that you let people
know that actual improvement has happened because the problem was
identified, resolved, addressed properly.
That really builds up a culture that avoids Kappa as a
punishment activity and becomes a a victory activity.
Next, you don't want to to train people on corrective actions
just to fill out the forms. You want to train people on root
cause analysis. You want to get people curious,
train curiosity. Train them to to go around, ask
why, ask how, ask when something needs to happen.
The more that you train people to ask questions, the more that
they will become the detective that'll find and identify all of
those risks that may be a real problem ahead of time.
So you want to train to make sure that people understand that
their role is about being curious, being a problem solver,
being one step ahead of the problem, not just training them
to be compliant to a Kappa system.
So, yeah, so Cabo fatigue is, is real.
It happens when when good systems are effective.
Because once once you get a good system in place, you're going to
find corrective action opportunities all over the
place. And that's an OK thing.
That is fine. There's nothing wrong with
corrective actions. Need to find balance, need to
find the way to address the culture side, need to make sure
that people are aware of their role in all of this and they
need to be responsible for what is going on.
This Kappa fatigue discussion, you know, it's not about bad
people, bad standards, bad practices.
It's often volume, red tape, misaligned priorities,
misaligned ownership, these, these all kind of collide in one
spot to build a problem for your system's efficacy.
So triage your issues, put something up.
Visual management is going to help empower your people to to
make actions, shorten your process, make sure that they're
done quick. Celebrate all of those victories
that you get when something's closed out.
Show that improvement is being made because when a Kappa works,
it should not just be paperwork. It should show progress.
So that is that is it for for this one.
I've talked far too much far too long.
So I want to hear from you though.
Send me your your Kappa horror stories.
Maybe you've fixed a Kappa system yourself.
Send me that cool info. I definitely want to hear all of
that. You can reach out.
I'm going to pull up the e-mail address because I always
forgets. Give me one second here.
Everyday quality. Man, I really need to get better
at this. everydayqualitypodcast@gmail.com
is going to be our best way to to chat.
You can also e-mail my little consultancy group.
We are Co quality system. Man, again, I, I've got to I got
to verify it got to verify it yes, Co quality systems.
You can check out COQ ms.com For more information and reach out
for with with any questions that you may have on your quality
system. And that I really think that is
that is it for me today yes, thank you for listening reach
out and I want to hear your cool Kappa stories and we'll talk
more soon. Thanks everybody.
Bye.