Análise de risco

Aquando da próxima vez que alguém, no seu sistema de gestão da qualidade ou ambiente, lhe falar na necessidade de actualizar a análise de riscos da sua empresa, lembre-se deste evento no Hospital de Amadora-Sintra com o fornecimento de oxigénio.

Qualquer organização tem um desempenho limitado pelo seu elo mais fraco. Qualquer organização que precise de aumentar a capacidade de produção, remenda o elo mais fraco, para depois, a seguir, encontrar outro elo mais fraco e assim sucessivamente. Aquilo a que se chama a Teoria das Restrições aborda este tópico.

Alguns dos constrangimentos são claros e sabemos quando vão aparecer, por exemplo, a limitação de pessoas. No entanto, outros são mais invisíveis e só são considerados quando se manifestam.

Uma das formas de prevenir a sua manifestação consiste em fazer periodicamente uma análise de risco.

Não menospreze este exercício.

Practicing the noble art of cheating (part V)

Part I, Part II, Part III e Part IV.

Let us go back to the last picture of Part IV ...

... and let us select the elements of the cause-effect relationship that are in red.

These elements are coded because they were written by someone individually, ideally even anonymously, so that the elements are more freely evaluated by all.
And now, with the group in front of the relationship we can ask:
- Why does A2 happen? What may be behind A2?
- Why does B2 happen? What may be behind B2?

Speculation will start to arise and we may agree on a first cause

Whe have safety accidents because staff do not know the risks.
Why staff do not know about security risks?
Staff do not know about security risks because we do not train staff.
E also have staff accidents because we have no safety protection systems in place.

Good practice is to ask "why" at least 5 times. In this way we move towards root causes, something that influences the end result and can be manipulated by us.

Successively asking why sometimes leads us back to a point already described, namely:

Do you see that? Do you see a loop there?

This technique leads us to identify a cycle that conspires in a normally dangerous way. Especially when they have the power to accelerate autocatalytically. The more accidents occur, the more potential is created for new accidents to occur in the future. Who taught me the ABC of systemic thinking, Peter Senge, places at the center of these cycles the icon of an avalanche descending through a mountainous ridge. The farther down, the more voluminous and destructive the avalanche.

We do not train staff because we have no time available for training.
Why do we have no time available for training staff? Because we lack human resources!!! So, we went back to the starting point.

The exercise should also be done by looking ahead for the future. Can any of the post-its on the board be the cause of something still to describe?

Now instead of "why" I use the expression: "And" as a way of appealing to a criterion of importance.
For example: we lack human resources. And? Why should we worry about this? What may be the consequences of this situation?

If staff is lacking, then existing staff must systematically extend their working hours.
The SME owner could comment:
- And? or "So what?" This is not a problem. I do not pay them overtime.
- OK! And what can happen because of the systematic use of overtime, paid or unpaid?

- People saturate, get tired, want to live their extra work life.
- And?

- Some say goodbye and leave the company. Others begin to fall ill and often fail to come to work. Others come to work, but without the necessary attention.
- And?

WOW! See what just happened?

We identified three more cycles that conspire to maintain and worsen the status quo. How can a company aspire to enter a virtuous cycle if, in this restricted scope alone, we find four vicious cycles. And as long as these cycles are not broken we are wearing bandages, we are making corrections, we are feeding imbalances that we will sooner or later be unable to contain, to hide, to control.

For simplification let us only use three cycles:

Now we have to identify all sticky notes that have no upstream arrows, no upstream causes, they represent root causes, they are root causes. In our example we have (see the yellow sticky notes):

Let us also identify sticky notes that include "no(t)", things we don't have or don't do:

Strategic initiatives will be projects, action plans, dedicated to surgically eliminating root causes and the various "no(t)".
Remember the figure of the monstrous earthmoving machine in part III?

I use it to get here and to highlight the specificity of what is going to be proposed, the degree of detail, as well as the authorship of these proposals, people who suffer from these problems and who are involved, challenged to give their opinion. People with tremendous motivation to perform, because it is their everyday work and they were the creators of the action plan.

Going back to the sticky notes, now of another color, we can place over each root cause or no(t), one or more elementary actions to eliminate these causes.

"Streamline staffing" (we often don't need to hire more people, we just need to transfer people from some sectors to others) to eliminate "The staff number is very restricted"
First "Update job descriptions and competence requirements", then "Train staff" to eliminate "We do not train staff"
"Allow time for training" (be creative, you don't need to do training seated in a room, on-job-training? games? films?) to eliminate "No time available for training"
"Design and implement safety protection systems" to eliminate "We have no safety accident protection systems"

If we impleent those actions what will, most likely,  happen? See the green sticky notes

But ...
If we no longer have lack of human resources... staff no longer needs to systematically extend working hours... Do you know what that means?


The chain of effects downstream no longer happens!!!

So, what do we need to do?

How to turn this into an action plan, a strategic initiative?
We have to answer the questions:

Who? When? Sequence? Time? Cost?

Et voilá!
We come to a detailed action plan arising from the strategy described in the strategy map.

Normally a team of 6 or 7 can generate 3 to 5 pages like this one:

Using the technique of sticky notes with different colors (gray is action; green is something you cannot change)

Then we list all gray sticky notes ...

... and start to make groups of gray sticky notes around a common theme. For example:

• marketing and brand
• production and efficiency
• innovation and interested parties
• marketing and influencers.

What do you think about this technique?
Would you like to try it?

Practicing the noble art of cheating (part IV)

Parte I, Parte II and Parte III.

We have a strategy map and we assigned indicators to each strategic objective. For each indicator we can measure current performance, the today's results, and we settle targets for future performance.

As we wrote before in Part III, today's organization generates today's results in a perfectly normal way. More demanding future desired results have to be generated by a different organization, the desired future's organization. So, to get that performance improvement we need to tramsform the current organization.

There is no chance. Sustainable performance improvements don't happen by accident.

Normally, we set a time frame between today's result and meeting the target. For example, we say that in the next 12 months the organization will increase its productive capacity utilization rate from 55,9 to 85%.

And I question you: Why 12 months? Why not tomorrow or next month?
And you answer: Because we are not yet the organization of the desired future, the one able to generate the desired performance.
Then I add: the strategy map is a theory, a hypothesis about how the organization will improve its performance, but the present organization is still not there.

So I ask: where are the weak spots that prevent us today from having the desired future performance? Concentrate on them, they are what restricts us, what constrains us from achieving our goals.

Let us look into the gap between today's results and desired future results as a perfectly normal and legitimate product of our current set of processes (that's how we work, how we manage, how we train, how we learn, ...)
Those current processes include within, a set of systemic structures that conspire (I use this word here because it seems perfect for what I want to communicate) so that today's results differ from desired future's results. Those systemic structures generate behavior patterns that quite naturally are behind today's results.

To eliminate the gap between today and the desired future we need to identify and eliminate the root causes behind those systemic structures through a set of action plans, strategic initiatives, which will transform today's organization into the desired future's organization and that way generate the set of processes of the future.

We will use a trick to identify the systemic structures: compare current performance with desired future performance. So, plunge into that gap and identify a negative fact. A fact is a fact. A fact cannot be denied. A fact is no theory. Everyone can see that fact. Be as specific as possible.

Gather a diverse group of people who together know the organization at several levels and from different perspectives. Ideally most of them were present when the strategy map was drawn. Remember to all the strategy map, the importance of the cause effect relationships and highlight the fact that the organization is still not the organization of the desired future, highlight the gaps in performance and give everyone a generous amount of sticky notes. Then ask them to individually and anonymously write a negative fact per sticky note and record as many negative facts as anyone can.

An example of a negative fact can be:

1. The machines have been down for a long time (x hours or y%)

When everybody finishes with the negative facts ask them to keep their facts secret and ask them to speculate. Ask them to give their opinion. Ask them to write down the causes that they think are behind each of the negative facts.
One cause per sticky note
For example:

A1. We do not perform preventive maintenance

B1. We have no critical spare parts

When everybody finishes with the causes ask them to give a final step and ask them to write down their opinion about why each negative fact is important for our strategy execution. One reason for importance per sticky note.
Example:

a1. Lost production capacity

This is what we are doing:

In this way we draw a cause-effect relationship anchored in reality, in a negative fact, something that no one can deny.

Negative facts are real but they can have no impact in the organization's strategy. 

I always use the example:

The company's last Christmas party was a failure.

Truth? Yes!

Relevant to the strategy? Most likely not!

So, we must test the importance criteria and check if they have any connection with strategy. Check if the importance criteria violates any promise from the strategy map:

In this example: Lost production capacity clearly goes against complying with prodution plans and maximizing usage capacity.

This way of working with facts, causes and importance criteria make us look into the organization at different levels of abstraction:

The following table can represent the contribution of one person:

Imagine that your team has 7 persons. 

Imagine that each person records 5 negative facts. So, you will have 35 cause effect relationships.

Imagine that 5 are similar to others. So, you will have 30 cause effect relationships.

Test all those negative facts to check if they are really relevant for strategy:

Now, look into the set of 30 cause-effect relationships and see if you can find new relationships among two of them. For example:

The effect "a1.Lost production capacity" acts as the cause that generates the effect "A3.We have stock shortages". And then A3 becomes the cause that generates "3.We carry unmatured product"

Go back to the remaining 28 cause-effect relationships and see if you can find one that relates very well with this two. Normally, people find more and more relationships. After some they will start to write new sticky notes because seeing all these at a wall make them find new relationships (that is why I use a codification for each individual negative fact, the new ones have no code, they are a product of team interaction)

After some iterations we can get a picture like this:

That is why I like to use the word "conspiracy".

Can you see how many feedback loops we have acting on the system?

If we want to improve we have to break this self-reinforcing cycles.

This post is already too long, in Part V I will present my technique to go from the conspiracy cycles into a set of very focused action plans, the strategic initiatives.

Other examples of conspiracy cycles (in Portuguese) here, here and here.

Practicing the noble art of cheating (part III)

Parte I and Parte II.

So, instead of starting to draw a strategy map based on abstract concepts such as mission and vision, we showed in Part II how we do the other way around and start with an example of organization-customer fit and do the exercise of going from the concrete to the abstract.

In this post "Opportunities are not just out there, ready to be plucked" one can read about the "Shaping Ability":

"Opportunities are not just out there, ready to be plucked. Courses of action that can be superior often require proactive efforts to shape selection criteria for their potential to be expressed."

Yesterday, during a morning walk I read "Crossing the chasm: Leadership nudges to help transition from strategy formulation to strategy implementation", from Alex Tawse, Vanessa M. Patrick, and Dusya Vera, and published by ScienceDirect. I think this article can be used as an introduction to the challenge of developing an approach to implement a strategy.

"The issue of crossing the chasm from planning to implementation is particularly germane to top managers and other business leaders who bear primary responsibility for strategy formulation and must engage in the implementation process for it to be successful.
...
In this article, we argue that successful strategy implementation should stem from within the organization and needs to garner total organizational effort, including the leadership and active participation of top-level and mid-level managers."

This reminds me why I use so many times this picture to joke about implementing a strategy:

 Normally, organizations ask outsiders to prepare a paper about what needs to be done to execute the strategy: Easy! Raze everything and build from scratch!

Let me go back to high school and to Descartes.

With Kaplan and Norton I started with BSC 1.0 and BSC 2.0, but when I got there I felt some dissatisfaction.
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When I tell this story I always use this analogy: When I studied Philosophy in high school, I loved Descartes's statement "I think, therefore I am" was so powerful ... everything else could be a lie, but I existed because I am a thinking being, because I was aware of myself ...
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After this brilliant corner stone for his building we learned Descartes's justification for the existence of God ... God is a perfect idea. Man is an imperfect being. An imperfect being cannot generate a perfect idea. Therefore, God must exist a priori, cannot be a human creation.
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I didn't like this justification ... a man who had laid such a powerful foundation for his worldview ... stood for this ...
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When I was working with BSC at the beginning and coming up with BSC 2.0, a strategy map and indicators and looking at the goals:

The question soon arose:
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What should we do to meet these targets (metas in Portuguese)?
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Kaplan and Norton's advice was ...
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No, it can't be
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A brainstorming ...
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What?! After all the intellectual rigor to build the strategy map and indicators, build a set of strategic initiatives based on well-intentioned brainstorming? !!!!!!!
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I never liked this solution until I discovered William Dettmer's book, "Strategic Navigation", that operationalized the ideas of a guy called Goldratt and his Theory of Constraints, and it was based on what I learned from them that I started using these cause-effect  relationships:

as the basis for formulating strategic initiatives.

Let us start with this picture:

Thus, if the current system performance is a natural consequence of the current system functioning (today), and if the organization aspires to a different future performance then the current system must be transformed into the future (desired future) system, the only one capable of generating the desired future performance in a natural, systematic manner.

When we compare today's business with the desired future business, we find that there is a gap (the today's performance versus the targets). That gap does not happen by chance but it is the product of a system that conspires to produce today's results rather than the desired future results.

Well this introduction took me more space than I thought. In Part IV we will show how to describe the conspiring system and from there how to develop strategic initiatives capable of executing a strategy.

É nestes momentos de mudança ... (parte IX)

Parte I, parte II, parte III, parte IV, parte V, parte VI, parte VII e parte VIII.

O mapa da estratégia descreve a lógica de sucesso do negócio com base na estratégia.

O mapa de processos descreve o como a empresa funciona hoje:

A empresa de hoje ainda não é a empresa do futuro desejado, ou futuro imaginado, a empresa capaz de funcionar de acordo com a lógica do mapa da estratégia. Os indicadores são a prova provada que existe uma diferença entre as duas empresas (a actual e a do futuro desejado)

Portanto, a empresa de hoje tem de ser transformada numa empresa diferente, a empresa do futuro desejado. 

No último balanced scorecard que ajudei a desenvolver numa empresa  usamos, contra minha vontade, a técnica do brainstorming para determinar o que tinha de ser mudado para conseguir a transformação da empresa na empresa do futuro desejado. 

Tenho de reconhecer que a coisa correu melhor do que eu estava à espera. Identificaram 2 grandes vectores de actuação para promover a mudança: melhorar a capacidade inovadora da empresa; e melhorar a formação de operadores nas linhas de fabrico.

Normalmente, prefiro seguir outra abordagem. Ao olhar para a diferença de desempenho entre o Hoje e a Meta, peço que se veja cada um desses resultados como algo de perfeitamente normal. Afinal, não há acasos. Lembram-se de Artur Jorge no Benfica?

Peço para olhar para os resultados actuais como a consequência de uma ou mais limitações que têm de ser colmatadas e que, enquanto existirem, conspirarão para impedir a empresa de atingir o desempenho futuro desejado de forma sustentável. A minha ferramenta predilecta é a Teoria das Restrições.

Acerca do papel da estratégia (parte III)

Parte II e Parte I.

Voltemos ao texto, "If Your Business Strategy Looks Too Complicated, It Probably Is. Here's Why":

"2. Set a clear definition of success and a timeline.
Beyond direction, a good strategy needs a clear desired outcome and definition of success. Too many strategies stop at big ideas without nailing down specifics. The devil lies in the details. Too often, I see a team of people agree to a high level strategic priority, only to discover they are on vastly different pages when the details are fleshed out.
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For each strategic direction, create a set of specific goals that are both measurable and time bound. It should be clear to everyone what constitutes completion, and it ideally should include a handful of objective criteria. I generally suggest a simple checklist or short description of the outcome or product."

Na Parte II listamos acções a desenvolver para executar a estratégia e dúvidas ainda por resolver.

A propósito de "For each strategic direction, create a set of specific goals that are both measurable and time bound." a minha técnica preferida ganhei-a ao estudar a Teoria das Restrições, e está descrita na série "Transformar uma empresa de forma alinhada com a estratégia", na apresentação:

O que começar a fazer na próxima segunda-feira para executar a estratégia? from Carlos da Cruz

O importante é não esquecer que uma estratégia começa por ser uma narrativa. Uma narrativa que tem de ser implementada, que tem de ser executada. Executar uma estratégia significa transformar uma organização de forma alinhada e focada. O que precisa de ser transformado? Que projectos desenvolver?

Transformar uma empresa de forma alinhada com a estratégia (parte VIII)

Parte I, parte II, parte III, parte IV, parte V, parte VI e parte VII.

Como programar as transformações que decidimos fazer para criar a organização do futuro desejado de forma alinhada com a estratégia?

Eu proponho a criação do que chamo fichas de missão por cada projecto ou iniciativa.

A origem e como medir a eficácia.

A seguir, where the rubber meets the road, o que é que vai ser feito por quem, até quando para criar a empresa do futuro desejado:

Não tentar marcar o 2º golo antes do 1º!!!

Pensar em acções que sejam adequadas ao estádio de desenvolvimento da organização em particular. Esquecer os bonitos o fogo de vista.

Pensar em eficácia.

Agora só falta implementar o plano de acção, monitorizar a implementação no terreno e as consequências a nível de indicadores.

E não esquecer, o que conta são os resultados medidos pelos indicadores.