Corrective Actions & Automatic Grace

Corrective Actions & Automatic Grace

(Because Quality Consultants suck at this stuff sometimes too!)

Background

We have a small farm with 2 horses. Our 17-year-old daughter Libby is a barrel racer. We buy grain 3 bags at a time because that’s how many fit in the container we keep grain in.

It’s common for us to almost run out of grain. We seem to hear from our daughter when we’re down to 1-2 meals left for the horses. That is stressful, because we feed a high quality grain that we have to get from a feed store that’s about 45 mins away. We can’t always drop everything to run and pick more up. On top of that, they don’t always have it in stock, so we call beforehand to make sure they have some. Then one of us makes the drive we weren’t planning on to pick up grain. It’s always worked out and we’ve never completely run out; that is until one rainy day in December 2022.

The problem

I had been traveling and got home late the night before. Our daughter Libby was sick so I decided I would go out to do the morning feeding for the horses. When I opened the feed container I found that it was completely empty. Not even enough to feed them breakfast.

Fortunately horses are happy as long as they have plenty of good quality hay, but they’re also creatures that need a routine, and our horses are barrel racing horses, which are athletes in the horse world, so they need a specific diet.

So I gave them hay and went back inside annoyed at our daughter’s irresponsibility. When I asked her about it, she said she forgot. (teenagers, right?!) My immediate reaction was anger at my teenager for not being responsible enough to get more grain before we ran out. I mean, is it too much to ask someone in my family (organization) to never forget about something I expect them to do? I’m the Dad (manager) and my daughter (employee) has failed to do something important!

Fortunately, my wife Lisa Rybolt who is usually quicker to extend grace than I am, (plus she’s also a QA consultant,) immediately pointed out to me that we have a broken process! We have almost run out of grain so many times that I can’t count, and we always just make it. Never once did we learn from those near misses and fix our system before we had completely run out. (quality escape) We failed to recognize the risk and mitigate it by putting in a preventive action.

Containment: what we do to make sure the problem doesn’t get worse while we figure out how to fix it

I gave the horses plenty of hay to keep their bellies full and their spirits high. An apple never hurts either.

Immediate Correction: what we do to fix the actual problem

I called the feed store and of course they were out of stock. But they said the delivery will be tomorrow and would call me when the truck arrived.

Root Cause: understanding why this happened. Where did the system fail?

We realized that our system was completely dependent on verbal communication between our teenager and us to organize a pickup at the feed store. We lacked any visual queues to tell us it was time to order, and that normally happened when we were desperately low.

Corrective Action: what we do to fix the root cause and make sure this cannot happen again

Instead of ordering 3 bags of grain, we now order 4 at a time. 3 bags will fit into our container, which means that the 4th bag is stored in our feed room unopened. We attach a brightly colored index card to the top of the bag (right where you have to open it) which says “Order Grain”. When the bin is empty and our daughter opens the 4th bag, she brings the index card inside and puts it on the refrigerator. Now we have a visual indication telling us to get grain which should appear about a week before we actually run out. (Kanban)

The Result

We don’t run out of grain anymore, and harmony in the house is improved because something that caused stress in the past has been eliminated. (employee morale) Plus our daughter has hopefully learned a lesson about how to rely on a system instead of our own memory which will fail us at times. Deming said “A bad system will beat a good person every time.” He was 100% right.

And for me, I am reminded that after 25 years of marriage, and almost that many years in quality management, Lisa usually has it more together than I do, and that I still sometimes don’t see the broken thing staring me right in the face. I can do better. We need to see the broken process, broken system, and broken person right in front of us. I am reminded that the people in our lives deserve grace as our immediate reaction. Our family & friends, our co-workers, our clients & vendors, our adversaries, and total strangers. It needs to be automatic. Not because it’s nice or even because it’s the right thing to do, but because grace is what was freely given to me at the Cross. I certainly didn’t deserve it. I deserve to be the one up there myself. So who am I to withhold it from others?

I know that’s a long way to go from a frustrating walk to the barn, but God sometimes uses little things to teach us big things. Merry Christmas.