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Demonstrating the Problem is in the System

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Process improvement opportunities are everywhere. Even in the steps in the New York City subway.

That’s the case of a remarkable story reported by NBC:

[The] video shows person after person tripping on the seemingly innocuous step in the middle of the staircase. Some catch themselves instantly; others fall straight to their knees.

In one worrying instance, a man carrying a baby jerks forward as his foot catches the offending step. He is able to regain his balance by grabbing on to another step in front of him with his free hand.

The dangerous step, it turns out, is a half-inch higher than the others. Stairway design guidelines call for risers to be a minimum of 6 inches and a maximum of 7 inches, according to MTA spokesman Kevin Ortiz. The allowable variance is 3/8 of an inch.

Crews went to the station Wednesday to block off the staircase in preparation for repairs. The MTA said Thursday that the work had begun and involves the replacement of the entire stairway.

“The repair cannot be limited to one stair riser; the entire stairway will need to be refurbished,” Ortiz said in an email to NBC 4 New York.

How is that a half-inch makes all the difference? Watch the video for yourself to see:

At first glance, it’s amazing to think that the MTA could make this kind of mistake. Surely every part of construction is checked and double checked. And certainly once a station is completed, officials doing a final inspection would notice a step that wasn’t quite right.

But if you watch the clip closely, it’s obvious why the problem wasn’t caught sooner. Every person who trips blames themselves. No matter how sure-footed they’ve been before, no one assumed that stairs were messed up. If someone did, they probably would have been called crazy. But they would’ve been right. They weren’t the problem. In fact, this may be the most fundamental challenge with any business process improvement effort: we tend to think that we are the problem and don’t look for problems in the system.


© Flickr user Matthew Robinson

Long before you can improve workflow in your own organization, you have to find out what is not working right. And before you can address those issues in a meaningful way, you must try to demonstrate that the problem is not the people, but the system. Sure, from time to time it could be the people, but more often than not, if you’re surrounded by a talented and dedicated team, most issues could be coming from ineffective processes.

Another important thing to note here is that just the one stair couldn’t be fixed. The entire stairway has to be refurbished. Sometimes a very minor issue can cause huge problems. If you have a small process problem, things may not be as easy as simply focusing in on that one issue and sorting it out. Perhaps that is affecting something else. Perhaps by changing things, you’ll create more problems. That’s why it’s important to always be looking for things that should be improved. If you can catch them early, then it may be easy to fix. If you wait too long, the ideas and processes become ingrained, and the change may be all the more painful for that.

That’s the secret of process improvement: focus on the process, not the employees. People make mistakes. Are you setting them up to make more by giving them uneven steps?

For more information on how you can create and maintain effective processes while improving productivity, contact our business process implementation consultants today! We love to help organizations like yours become more productive and avoid slip-ups like this!

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