The Root Cause of a Process which does not produce the desired outcome is that the process took the wrong turn at the fork in the road. This fork in the road could be anywhere in the process from the very first step to the last input. If the process does not give the desired outcome, find the fork in the road.
A simple distraction of the process is a fork in the road.
Often this happens in organizations, where errors slowly develop and nobody notice and captures these variations.
|By testing the process it is possible to make changes before getting to the Fork in the Road.|
The first step is to pick the Ace in the first row as the card, then apply the process, and continue each time with the next card in the row, until the Spade of King was picked. This gives 13 sample testing rounds to evaluate the process. When documenting the layouts, it becomes a trend that the card in the 2nd deal is in rows 4-5-6 or 7, which then will be card number 17-18-19 or 20 of the 3rd deal, or the 5th card in the row. When knowing the row, the correct card is picked.
An Enterprise Training System of a process should be to train individuals to understand the process in addition to perform the process. By understanding the process it is possible to recognize, make correction and changes so that errors do not happen.
An Enterprise Testing System of a process should test the process by applying scenario to the intent of the process. When a new process is developed, it is often assumed that it will function as intended, and therefore testing is not required. However, when the Testing System is not implemented, a potential error may not be discovered until it has caused an incident.
An Enterprise Review System of a process should review for Statistical Process Control. When there is no Review System established the process is an assumption. When one assume, the facts are not captured.