Ch2 JAD Breakthrough and Beyond.pdf - Juran Institute

36 CHAPTEH Two
THE BASIC TASK OF MANAGEMENT: THE JURAN TRILOGY 37
problem are designed to remove or go around the causes. No
remedies or improvements are even discussed, much less
designed and implemented, until the"root cause(s) of the problem
are scientifically established beyond doubt.
Effective quality improvement discovers root causes before
applying a remedy. Like peeling an onion, layer after layer of
causation is revealed until the root cause is visible. When
action is taken to remove or go around a root cause, many
improvements happen, because many problems or symptoms of
a problem have common cause(s). Extracting root causes
instead of more superficial causes pays off many times over by
reducing the time and effort the discovery journey takes and
eliminating the need for repeated iterations of searching.
EXAMPLE OF DISCOVERING ROOT CAUSES
Here's an example of what we mean. The stonework in the
Jefferson Memorial located in Washington, D.C. was crumbling
in places, especially inside the structure. A quality improvement
project team decided to go after the root cause of this.
NOTE: If we tell you at this point that the ultimate
remedy that stopped the stone from crumbling was to
turn on the outside illuminating lights after sunset,
instead of at dusk, would that sound crazy? It probably
would have to the project team, too, at the beginning of
the project, before it went beyond considering superficial
causes, and penetrated successive layers of causation
down to the root cause layer.
Let's follow the search for root cause, layer by layer. The
question was: "What is causing the stone to crumble?" Well, it
was the frequent washing with strong detergent that gradually
dissolved the stone.
So the next question was: "Why are there so many washings?"
Well, it was all the bird droppings that rapidly accumulated.
The next question was: "Why are there so many bird droppings?"
Well, it's because of all the birds that come into the
structure to eat the enormous number of succulent spiders
who have webs all over the place.
"Why are there so many spiders?" Well, it's because of the
almost endless supply of midges that the spiders eat.
"Why are there so many midges? Where do they come from,
and what are they doing here?" Well, at· dusk each night, the
midges hatch and emerge from the nearby water basin. The
bright lights that illuminate the monument attract them.
Root cause: These lights are turned on at dusk, just as the
midges emerge. When they approach the lights, they are
caught by the awaiting spiders.
So the root cause was the time when the lights were turned on.
Remedy: Turn the lights ona while after dusk. By then the
midges are dead or dying. The food chain is broken. The spiders
and the birds depart. No more washings. Problem solved.
Note that the problem would not have been solved by
removing the most superficial cause-the strong detergent. A
weaker detergent would probably lead to even more washings,
and no fewer midges.
The sequence goes further, to assure that breakthrough is
sustained. New controls, particularly on the remedial changes
made to the process being improved, are designed and implemented.
Periodic audits are performed to ascertain that the
controls are actually being applied.
INTERACTIONS OF ELEMENTS
OF THE TRILOGY
Recall that the output of any process has two aspects:
1. Product features
2. Product or process deficiencies
Product features come from quality planning. Quality planning
occurs when what is needed currently does not exist. It
must be created (such as designing a new product).
Freedom from deficiencies comes from breakthrough
improvement. Breakthrough improvement occurs when an
existing product or process fails to meet specific needs of spe­