Yesterday I posted a blog about my new book being delayed to the customers who ordered it. The good news is, the problem has been found and the books will not be significantly delayed. So what happened? Coincidentally (I think), in the afternoon after the blog was posted, I received an email from my publisher apologizing and attempting to explain the reason why. In my publishers own words, "Our printer shipped the wrong books to our warehouse. The outside of the boxes have the correct bar code and ISBN number, but the books inside were for another publisher. Some of those books were sent to Amazon and we are straightening it out. Customers will not get the wrong book because they match orders with ISBN's so Amazon will return those books to us. We have located your books and they are being redirected to our warehouse where the orders will be expedited. It took me a while to figure out what was going on. I couldn't give you any info because I didn't have it - and was completely baffled and confused as to how this could happen....nothing like this has ever happened before. I am so sorry. I will keep you posted and please know that this is being straightened out."
Needless to say, I felt much better and sent a thank you email to my publisher for finding out what had happened and taking actions to correct the problem. So if you were the publisher, in this case, is this the end of your actions? I mean you solved the problem....right? Or did you? If I'm the publisher, the actions taken so far simply fall under the heading of corrective action...don't they? Isn't there another side to this dilemma which, of course, involves a complete root cause analysis to determine why this happened and then to determine how to prevent a recurrence. Isn't that what great companies do? My belief is that, if it truly has never happened before as my publisher stated, then something in their printing and delivery process changed and unless and until they identify the source of the change, this same scenario will happen again. Not "might happen," it will happen!
If you stop and think about problems of this nature, I refer to them as "change related problems" simply because according to the publisher, this event has never occurred before. If it were me, there are probably two tools that I would use in the next step of this investigation. The first tool is a causal chain analysis, often referred to as a why-why analysis or the 5-whys. I've used this many times and it's always worked for me. Here's an example of one I used to determine why a cotter pin hole was off location:
Working from right to left, I continue asking the question "Why?" until I arrive at the most probably root cause. The other tool that I would be using would be the Process Failure Mode and Effect's Analysis (PFMEA). The PFMEA is an incredible tool which can be used to analyze existing processes to identify potential problems. Obviously the FMEA is best used in the design stage of a process, but since this process already existed, I would use this tool to scrutinize the existing process to look for other issues that could result in the same outcome......late deliveries.
The point of this posting is that if you simply stop at the corrective action stage of a problem, you're missing a golden opportunity to improve and avoid the same or different problems.
Bob Sproull
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