"Find Leverage Points"

Terminei a leitura da primeira parte de Reset: How to Change What's Not Working.

Podemos dizer que Reset é um livro sobre técnicas de melhoria da qualidade - mesmo que não seja apresentado como tal. Traduz conceitos profundos e eficazes de melhoria contínua e mudança organizacional para um público mais vasto, sem recorrer ao jargão técnico habitual da qualidade.

Na primeira parte do livro, intitulada "Find Leverage Points", Dan Heath apresenta estratégias para identificar áreas onde intervenções mínimas podem gerar resultados significativos. Estes pontos de alavancagem são fundamentais para promover mudanças eficazes em sistemas e processos. Os principais conceitos abordados incluem:

1. Go and see the work: Enfatiza a importância de observar directamente o trabalho no local onde ele ocorre, permitindo uma compreensão realista dos processos e desafios enfrentados.
2. Consider the goal of the goal: Incentiva a reflexão sobre o propósito final das actividades, permitindo a identificação de caminhos alternativos para alcançar os resultados desejados.
3. Study the bright spots: Foca na análise de casos de sucesso dentro da organização para replicar práticas eficazes em outras áreas.
4. Target the constraint: Destaca a necessidade de identificar e abordar o principal obstáculo que impede o progresso, concentrando esforços na sua resolução.
5. Map the system: Envolve a criação de uma representação visual dos componentes e interacções dentro de um sistema, facilitando a identificação de pontos de intervenção eficazes.

Por exemplo: Uma empresa de logística tem recebido reclamações frequentes de clientes por causa de entregas atrasadas. A direcção pensa inicialmente que o problema está nos trabalhadores do armazém — “falta de atenção” ou “falta de compromisso”.

Go and see the work - Em vez de decidir a partir do escritório, um gestor vai ao armazém observar como decorre o processo de preparação de encomendas. Descobre que os operadores passam muito tempo à procura de produtos porque os locais de armazenamento mudam frequentemente e não estão devidamente registados.

Study the bright spots - Numa das equipas do turno da manhã, os tempos de preparação são consistentemente mais baixos. Ao observar essa equipa, percebe-se que um dos operadores criou um sistema informal de organização por cores nas prateleiras — simples, mas eficaz.

Map the system - O gestor desenha, com a equipa, um mapa do processo desde a recepção da encomenda até à expedição. Identificam-se pontos de espera, redundâncias e falhas na comunicação entre o sistema informático e o armazém.

Target the constraint - Percebe-se que o gargalo principal é a falta de um método padrão para localizar rapidamente os produtos. É decidido implementar uma etiquetagem sistemática e formar todos os turnos com base no modelo usado pela equipa mais eficiente.

Consider the goal of the goal - O objectivo não é "acelerar o operador", mas sim "garantir entregas a tempo e horas" — o que só se consegue com previsibilidade e organização. Isso muda o foco da solução: não se trata de "trabalhar mais depressa", mas de melhorar o sistema de suporte ao trabalho.

Vamos para a segunda parte.

Gargalos de tarefas

Em "Acerca de gargalos e "políticos"" comentámos a diferença entre gargalos de tarefas e gargalos de recursos. Quando se enfrenta um gargalo de tarefas, atirar mais recursos sobre o problema não o resolverá. O verdadeiro desafio está na forma como o trabalho é organizado, não na quantidade de pessoas ou materiais disponíveis.

Agora ao ler a introdução a de "Reset: How to Change What's Not Working" de Dan Heath encontro um exemplo de gargalo de tarefas.

No hospital Northwestern Memorial, a área de receção tinha sérios problemas: levava em média três dias para entregar encomendas internas, gerando desperdício, atrasos, medicamentos estragados e custos adicionais. 

"Just to linger on the absurdity: A nurse might order some vials of medicine, and FedEx might fly that medicine across the country in one day, and then getting that medicine from the receiving dock to, say, the third floor of the same building would take another three days."

Quando se resolve que o desempenho não serve, o mundo muda:

"Every system is perfectly designed to get the results it gets.” Meaning that once you change your aspiration—when you set your sights on different results—the system you have is wrong, by definition. Because the system is designed, intentionally or not, to yield the results you got yesterday."

Paul Suett, o novo gestor, envolveu a equipa numa mudança, começando por escutar as suas queixas, melhorar equipamentos simples (como carrinhos), e promover uma análise profunda dos processos. Juntos, identificaram desperdícios, como chamadas telefónicas constantes e repetição desnecessária de tarefas. 

A equipa percebeu então um factor crítico: a forma como trabalhavam estava a gerar o problema. A prática de processamento em batch (acumular encomendas para entregar várias de uma vez) estava a atrasar as entregas. Ao mudar para um fluxo contínuo, reduziram drasticamente o tempo de entrega: passaram de três dias para apenas um, aumentando a eficiência, a satisfação dos colaboradores e a qualidade do serviço. Isto fez-me lembrar a Zappos ... 

"But we're not trying to maximize picking efficiency. We're trying to maximize the customer experience"

Acerca de gargalos e "políticos"

A revista MIT SMR do Inverno de 2025 traz um pequeno artigo, "Improve Workflows by Managing Bottlenecks", que à partida parece não trazer nada de novo, mas depois percebe-se que afinal tem algo de interessante.

Há poucos dias, numa reunião numa empresa, este tema surgiu de forma muito pertinente — um desafio que, curiosamente, também atormenta políticos e gestores públicos. Perante um problema, a solução mais tentadora costuma ser atirar dinheiro para cima dele, na esperança de que os recursos financeiros resolvam tudo. O que frequentemente acontece é o cenário clássico: o dinheiro gasta-se, mas o problema persiste — e, em muitos casos, agrava-se.

O ponto crucial é que muitos dos problemas enfrentados, seja em empresas ou na política, não têm origem na falta de recursos, mas sim nos procedimentos e sistemas implementados. No entanto, mudar processos, embora seja a solução mais eficaz, é muitas vezes politicamente sensível e delicado. Por isso, optar por "fazer de conta" que se está a agir ao despejar mais dinheiro no problema é a saída fácil. Mas fácil não significa eficaz.

A reflexão aqui é simples, mas poderosa: antes de alocar mais recursos, é essencial analisar se o verdadeiro estrangulamento não está na estrutura ou nos procedimentos existentes. Por vezes, mudanças estratégicas no desenho do sistema ou na descentralização de tarefas podem ser a chave para resultados muito melhores.

"Bottlenecks are a common source of frustration in organizations. ... When leaders encounter a bottleneck, they may dedicate resources to addressing it only to find that the process in question is still stalled by other bottlenecks.

...

Bottlenecks manifest as tasks that are stalled for one of two reasons: because they depend on the output of other tasks that have not been completed, or because the resources required to complete the task are not available. 

Task bottlenecks frequently occur as teams wait for approvals from legal or compliance departments, for example. Resource bottlenecks happen when there is a lack of resources necessary to complete a task or process - say, if a construction project has only one crane available and there are competing demands to use the crane.

Task bottlenecks may emerge when more time is needed to complete the activity than has been budgeted, even if all necessary resources are available. While resource bottlenecks can be solved by investing in more resources, task bottlenecks cannot necessarily be solved by simply throwing more resources at the problem. [Moi ici: Atirar dinheiro para cima de problemas, uma solução demasiado frequente. Depois, o dinheiro gasta-se e o problema cresceu. Recordo um postal de Maio de 2020 - "Quando tem um problema, saca da carteira e compra uma máquina!"]

...

Task bottlenecks are dependent on two factors in a work system: centralization and complexity. Centralization refers to the degree to which a work system contains tasks that serve as connecting mechanisms between other tasks in a sequence, creating dependencies between activities, or, more specifically, the extent to which many activities within a system flow into or out of a few other tasks in the system.

...

Although centralization tends to create more bottlenecks, it can have benefits such as the ability to deploy resources efficiently, ensure consistency in quality, and coordinate efforts across multiple groups to achieve a shared goal. To evaluate these trade-offs and choose the appropriate level of centralization, managers also need to take the complexity of the activity system into consideration.

Complexity is determined by the number of tasks in a work sequence before it repeats. [Moi ici: Ainda esta semana li algures haver uma correlação entre a frequência de monitorização de um projecto e a sua propensão para atrasos. Periodicidades maiores levam a desvios maiores e mais frequentes. Algo que também recordo do livro "How Big Things Get Done" de Bent Flyvbjerg e Dan Gardner, quando falam em módulos menores e independentes] ... As sequences become longer, there is a greater chance that any given task in the cycle may fail to be completed, resulting in a greater ripple effect that will impact the entire cycle of activities by lengthening the time it will take to restart the cycle. Complexity rises when there is more variability in the tasks within the cycle, with some more difficult than others, resulting in a varied likelihood of task completion."

Resumindo:

Para gargalos de processo:

• Tarefas de alta complexidade: Quando o trabalho é complexo e envolve muitas tarefas semelhantes, a descentralização permite maior eficiência. 
• Tarefas de baixa complexidade: Para tarefas simples e repetitivas, é mais eficiente centralizar o trabalho, reduzindo custos operacionais e evitando redundâncias desnecessárias.

Para gargalos de recursos:

• Fungibilidade: Refere-se à capacidade de um recurso ser usado para diferentes tarefas. 
• Slack (margem de recurso, buffer): Representa a disponibilidade de recursos prontos para uso em momentos de necessidade. 
• Combinação necessária: A melhor performance ocorre quando uma empresa tem simultaneamente recursos fungíveis e slack suficiente.
• Custo de recursos inactivos: Ter muitos recursos inactivos aumenta os custos, pelo que é crucial equilibrar a disponibilidade com a aplicabilidade prática.

E agora? Pense nos seus próprios desafios, na sua empresa ou na sua área de responsabilidade. Há estrangulamentos que podem ser resolvidos sem mais investimento, apenas com uma reformulação inteligente dos processos? O convite é claro: antes de recorrer a soluções rápidas e dispendiosas, desafie o status quo, questione os procedimentos e procure alternativas que abordem o cerne do problema. O impacte pode ser transformador.

O artigo inclui ainda esta figura:

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.
.
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 ...
.
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 ...
.
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:
.
What should we do to meet these targets (metas in Portuguese)?
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Kaplan and Norton's advice was ...
.
.
.
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.