There was an old woman who swallowed a fly

A Process Improvement Comedy of Errors

A friend was telling me of an unfolding story that was happing in his neighbourhood over the last 2 years.  His neighbour had kept chickens, but because they didn't control or store the chickenfeed properly, they started to get large numbers of rats and mice.  In order to deal with the rats and mice, they got a couple of female cats - but they didn't get the cats spayed and so quite soon male stray cats appeared and then so did several sets of kittens - so now there was a cat problem.   The mice and rats were gone, but large numbers of other wild animals and birds were being killed. Another neighbour got a dog to keep the cats off his land, but the (rescue) dog had a tendency to bark at anything and everything - annoying other neighbours - including my friend.  The chickens have long gone  - and so have the rats and mice, but the many cats and barking dog remain - I wonder what the solution to the barking dog will be!

As I listened to this story, I was reminded of the children's nonsense song about the old woman who swallowed a fly - she then successively swallowed a spider, a bird, a cat, a dog, a goat, a cow and finally a horse, each to catch the previous one and solve the problems created by the previous creature - and then she died - of course!  It's easy to think that this sort of song is ridiculous, but maybe it's not as far-fetched as you'd think.   And the 'process' it describes occurs time and again in the way organisations fix problems in order to keep things moving.

As humans, especially in fast moving organisations, it is our natural tendency to 'see an issue and fix an issue' so that we can move on. Unfortunately, as soon as we think we have understood the problem (and often we haven't fully appreciated it) we quickly progress onto coming up with a solution which itself  is often flawed or suboptimal in some way. Frequently, it will be a band-aid that seems to solve the immediate symptom, but does not address the real problem.  When that solution starts to cause problems, the cycle repeats -  and gradually, we lose sight of the original issue.

 Each cycle adds time, effort, and cost to a process, it reduces efficiency, impacts quality, and drains people. This effect occurs in just about every work environment; here are some of the things to look for that might indicate this effect is happening to you:

• Recurring problems that occur despite a lot of process improvement activity and initially seeming to fix the issue.
• Increasing complexity and bureaucracy as fixes to problems are implemented but add things like additional steps,  checks, and approvals etc.
• Decreasing efficiency and productivity as employees spend more time dealing with problems and navigating increasingly cumbersome processes.
• Rising costs due to the implementation of multiple fixes, increased labour costs, and additional resources required to manage recurring issues.
• Employee frustration and lowering morale resulting in turnover due to ongoing issues and the inability to resolve them effectively.
• Customer dissatisfaction despite efforts to resolve issues.
• Lack of innovation - innovation stalls as the organisation focuses on firefighting rather than strategic product or market development.
• Fragmented communication - communication breakdowns occur as different departments implement their own solutions without coordination.

So, what can you do if you recognise any of this, or if you just don't want this situation to arise in the first place:

• Implement Root Cause Analysis. Slow down to go faster. Invest time in conducting a thorough root cause analysis for any problem that arises. Use tools such as the “Five Whys,” and Pareto charts to drill down into the underlying issues rather than just addressing the symptoms.
• Encourage Open Communication. Encourage a working environment where employees feel comfortable sharing their observations and suggestions. Diverse perspectives can help identify and address root causes more effectively.
• Promote a Culture of Continuous Improvement.  There's a saying that "we're paid to do, not think'.  Encourage a culture where continuous improvement is valued over quick fixes. Give people permission, or set an expectation, to think more and seek out and address the root causes of problems proactively.
• Continuous Monitoring and Feedback. Constantly be on the lookout for the warning signs that trouble is brewing  - don't just wait for the next fire to emerge.  By continuously working at the root causes or issues, rather than just fighting the next fire, you gradually start to see improvement in all operational metrics.

 Approaches such as these can help break the escalating problem-fix cycles, and ensure your organisation remains efficient, innovative, and responsive to market needs. Addressing the root cause of a problem not only resolves the issue at hand but also prevents future complications, leading to a more resilient and healthier organisation, and happier people.

I wonder how much happier my friend and his neighbours would have been if they had just been able to meet and talk and share their collective wisdom.

Graham