Evolution to Perfection

Continuous Improvement to Zero Defects

Zero Faults, Errors and Losses (Six Sigma)
through identifying and eliminating the real causes of your quality defects

How to reach Zero Defect?

Triggers

All Loss Events are being triggered by several different faults and errors, working simultaneously. These triggering failures exist partly permanently, partly only in the very moment of the loss event. Nearly always at least one of these triggers is a human error.

Complex Systems

The risk of these faults and errors results from a number of different factors, frequently influencing each other. They are arranged in kind of a network (generally not hierarchically). With such “Complex Systems” you cannot precisely predict (as you could in “Linear Systems”) the results (e.g. number of future Loss Events) from changing one single factor. Therefore, for optimizing your organization you have to employ in an evolutionary way your “Learning Organization”.

Create Risk Profile

You pick a statistically representative number of Loss Events. You reconstruct the Fault  Tree depicting all chain reactions. You analyze extremely carefully all chains of reactions that had triggered the event. You identify their individual Basic Risk Factor.

This way you see your organization’s Risk Profile showing the dominating Basic Risk Factors.  And you plan the improvements that will eliminate these Basic Risk Factors.

Continuously you further measure the number of Loss Events and  check, whether you had taken the proper actions.

Step by step implementation of your “Zero Defect Management”

  1. Agree on some basic capacities of your system. Primarily it should work as a continuous control cycle
  • setting targets for the number of future Loss Events
  • planning and implementing improvement actions resulting from the Basic Risk Factors identified by this system to be dominating the events
  • furthermore permanently checking the results and meeting the target
  1. Define thekinds of Loss Events, the number of which you will be able to measure with this system as control parameter (don’t worry about the other kinds of Loss Events; they will as well profit from your actions).
  2. Record completely all Loss Eventsof these kinds; just date, time, some catchword, possibly period of time of event will suffice. Your system will, for the time being,  not require further details.
  3. Agree on abudgetin work hours required for analyzing the sampled events. Account for teams of four to five persons and one to two hours per analysis (with this amount you rarely can afford analyzing every single Loss Event.
  4. Considering this budget take on random the eventsto be analyzed.
  5. Analyze with your team these events looking into each individualchain of reaction. Identify for each chain theBasic Risk Factor, causing this reaction. File the results.
  6. As soon as you have collected a statistically representative number of reaction chains, identify theRisk Profile of your organization.
  7. Plan improvement actionseliminating the most important Basic Risk Factors

    Example

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