Improvement process with the Kaizen

Working better is what I endeavour. I am allergic to disorganised work and process of rediscovering the wheel. Whenever I recognise a situation when the work is complex, not defined and can go sideways, I put some structure to it so that we can improve.

My approach for doing it originates in Lean and Kaizen steps.
The steps go:

  1. Identify an opportunity for improvement.
  2. Analyze the current work method.
  3. Develop an optimal solution by investigating ideas.
  4. Propose and implement the solution.
  5. Track results of the change.
  6. Standardize the solution for the scale.
  7. Plan for the future and sustain the change

In one of my previous projects, I faced such a situation. That project was my first assignment in the department. This is where the journey begins.

1. Identify an opportunity for improvement.

Organizational requirements

I learned that every project needs to meet organizational requirements. The list had dozen or so security and quality-related requirements. You must meet all the relevant if you wanted to promote your project to production.

2. Analyze the current work method.

When I get familiarized with the process there were not many things that I could refer to. The expected result was vague defined. It could differ from case to case. From department to department. It was defined on the organizational level and suppose to fit to all the projects.
Everyone was running project-based his/her way. It was built on the previous experience, but no one documented it. Everyone working on the project had to clarify almost everything. Prepare document template, figure out who deliver what and when. Sometimes you worked on the process with someone who has as little experience as you. Then you could get in the thought of war mode as everyone tried to do as little as possible.
I realized that the current way of defining actions and people responsible was unclear. Different people gave me different answers: PO, BA, QA Manager. They all have their own opinion who should do what and how the result should be delivered. The only clear thing was that document preparation is the responsibility of a QA specialist. The person who did not have access to the required artefacts and was a middleman in the whole process.
Of course, going this way we could not improve anyhow. If we do not measure it we cannot improve it.

3. Develop an optimal solution.

At the end of my first project and all the meetings and clarifications, I decided to take an initiative and put some structure on this process. I collected relevant data and prepare a process improvement initiative. Following benefits were foreseen:

  • Remove ambiguity for the team and project members,
  • Simplification of knowledge sharing with the new team members,
  • Transparency of the process; clear and sharable with Confluence link,
  • Professionalism, it is always good to know that responsible people know what needs to be done

Before the meeting with the Sponsor, I have prepared two artifacts.

  1. Table with the time needed for the process & time I have spent with other participants just in meetings.
  2. Process outline in the BPMN notation
How oftenWhoWhatTime invested (minutes)
one timeChange TeamStakeholders meetings150
one time Change Team Change proposal60
one time SponsorApproval5
1/projectChange Team Requirements data delivery15
1/project Change Team Tacit knowledge gathering15
1/project RafalData analysis 10
1/project RafalData consolidation 10
1/project RafalNew process design60
The time needed for the process to keep on rolling
Time invested for the meetings during reference projectDate
BPMN process improvement
BPMN process definition

Change team

The first step was to find a Sponsor for the initiative and have his buy-in. It was not easy from the beginning. I analyzed data based on my project and estimated potential time-saving in the long go. My estimation for the first noticeable benefits was set to 6 months.
I have held a few meetings with the key stakeholders and process participants. Based on the data collected I proposed following solution.

4. Propose and implement the solution.

The process had 3 key phases:

Phase1: Data collection

As we had 14 different cases and depends on the project approach. Data gathering could differ from project to project. At the end of the project, QA expert shared with me all the relevant documents. At this point in time, all the pieces of evidence landed in one Word document. It didn’t help in analyzing it and drawing conclusions. I decided to split it per requirement.
Next step was to have a quick meeting with the person to gain tacit knowledge:

  • who provided key data,
  • when in the project cycle the data was available,
  • key elements of the evidence,
  • required action from the person creating the document.

Phase2: Data analysis and process definition

Once we had enough data for the given requirement first version of the process was created using BPMN notation. How much data is enough? Based on the observation. In our case, it was when we start recognizing emerging patterns. On average it was after five projects. Based on the input I have created a document defining end to end process. It covered:

  • gathering relevant data,
  • communication flow,
  • store it on Confluence.
    Each process was reviewed and accepted by the team members and relevant stakeholders. After that, it becomes the first version of the working process.

Phase 3: Execute

It took us 7 months to have process created for the 12 out of 14 requirements. At that point, we knew that the most important parts are covered.
As of then at the beginning of the project:

  1. the person responsible for quality identify relevant requirements
  2. reviewed project needs
  3. communicated the approach using defined processes to start building transparency with relevant stakeholders.

5. Track results of the change.

We have worked together on improving processes. It happened whenever someone encountered an edge case. This could be situations that were not covered or adjustment to the flow. Depend on the scope of the change we could have to actions:

  1. The person in charge updated the process and communicate it or if the change was bigger
  2. We gather together to ideate on the best approach to incorporate it in the current flow.

7. Plan for the future and sustain the change

During the next 12 months after finalizing the process, in the team, we didn’t experience any tension or will to get back to old habits. The change was successful. Accepted by the team and organization. Once per while we experienced some tension on the flow, but it never happens more than once or twice. Whenever the situation happened we reviewed current approach adjust and formalize it in the process.

Final thought

In the end, our department got all the expected benefits. The time wasted for the clarification of the responsibilities and managing expectations was gone. Other expected benefit of this approach was knowledge transfer needs. As it was clearly defined:

who do what by when in the project cycle.

It was also easy to ask for help. When any of us was swamped with the project work less busy colleague could help. And these things happen as the whole task was independent and encapsulated. New joiners were able to work on it without any additional guidance. All the actions and already collected evidence were accessible via Confluence for the reference.

Take away

What can you take with you? Whenever you work on:

  • the repetitive task,
  • you have dependencies,
  • it’s not clear what should be done start with:
  1. Identify the current situation – how the work is done? What are the good things? Where are the bottlenecks? Try to collect some data. It’s always good to have a conversation based on the data and not assumptions (or emotions). Visualize it – it helps in fostering conversation.
  2. Ideate ideal state – what are the perfect conditions for this situation. Consider organizational possibilities and limitations. In the best case, you will organize a meeting with all the stakeholders. Listen and write down their struggles and concerns. Bring a common understanding of the possibilities and challenges.
  3. The gap – identify first possible steps that could be taken to close the gap moving you closer to the ideal state. Very often you will be able to identify quick wins. There without much effort, you can get quick improvements and results. Things like checklists or any other quality gates can help here.

And last but not least. Do it together – as a team. It helps to boost morale and bounds within the team. There are not many better ways for team building. Solving problems together and see it working, benefit from it is one of the most profound experiences as a team.

Problem-solving and continuous learning with 5 whys.

Problem-solving and continuous learning with 5 whys.

Problem statement

“[…] in this world nothing can be said to be certain, except death and taxes.”

-Benjamin Franklin (1789)

I will extend that quote and add problems. If you want it or not problems are part of our life. Daily, weekly we face a different kind of problems. According to the survey solving skill is one of the most important for success in your professional and personal life. Let’s start with the basics.

What is a problem?

Oxford dictionary defines a problem as:

“a thing that is difficult to deal with or to understand”

You can visualize problems like an onion. They are built with multiple layers. When we are firefighting providing solutions, we tackle the most outer layer. The core of the problem remains intact.

Considering these facts, we must have a good and easy to apply the problem-solving approach, but do you have one?

What happens generally is that we solve symptoms – outer layer- and not the core of it. Are you among them?

Below I’m going to give you a method I’m using that will rocket your problem-solving capacity. It’s simple and easy to use as food to go! That’s why it’s so good. It’s called “Five Whys”. It comes from Toyota Production System, so it must be good J


Five Whys method was introduced in the 1930s by the founder of Toyota Industries – Sakichi Toyoda.

It got famous thanks to Taiichi Ohno (father of Kanban) and his book 1950 “Toyota Production System: Beyond Large-Scale Production” where he stated:

“the basis of Toyota’s scientific approach […] by repeating why five times, the nature of the problem as well as the solution becomes clear.”

In 2008 & 2009 Eric Rice author of Lean Startup (book and methodology) remained us about it in his blog posts.

Currently, Five Whys is part of:

  • Kaizen,
  • Lean manufacturing,
  • Lean Startup
  • Six Sigma



  • Anyone can use it; kids are using it already!
  • You don’t need fancy tools or statistical analysis


  • You can use it as a standalone technique
  • You can combine it with other techniques


  • It’s a pen & paper solution
  • No additional costs


  • Quick learned
  • In 15 minutes, you can get to the root cause of your problem

When to use it?

Whenever you face a problem you want to solve. Think about situations:

  • You have a process that doesn’t work,
  • You have a process in place, but it doesn’t deliver the expected result,
  • Despite taken actions, unwanted circumstances happened repeatedly,
  • You have anything you want to improve on?

I will provide you with the tool to help you tackle these problems. You can apply it to improve any aspect of a product, work or process quality. To be effective the technique requires the involvement of the people who are part of the process under investigation. You will need stakeholders as well as people who work on and with the process.

Five whys tool is super simple and easy to use… In the business world listen for:

  • “We’ve always done it this way….”
  • “No matter what nothing will change here”
  • “We don’t document our best practices”

There you go! On a white horse with your newly gather skill.

As stated earlier “Five whys” come from Toyota manufactures, where it was used to find human error behind any technical problem. What is very important to mention here – you never stop on a person. Your destination for the root cause is process, procedure, but never a person. You need to jump over the symptoms to get to the root cause of the problem. The best results you can achieve with problems that have a single root cause – but not only. I will show you that later.

How to use it

The quick answer is to ask five times why starting with “Why did it happen?” and with the fifth answer will give you the root cause of the problem. As simple as that. Period.

Though the method is Five whys there are no strict rules. Sometimes you can reach the root cause with 3rd why (make sure it’s not a symptom) whilst in other cases, you will need to ask why 9 times or more.

This tool will work well as a standalone problem-solving approach or in combination with other techniques like:

  • Fishbone diagram,
  • Lovebug diagram,
  • Causal tree diagrams,
  • Fault Tree Analysis,
  • Causal Analysis based on System Theory (CAST),
  • The prospective risk assessment approach

If you want to use it as part of continuous improvement process or element of your learning organization… there goes your recipe!


Organize your space. Use pen & paper with a whiteboard of the flip chart. If you can’t – go for a digital option. Ensure strong facilitator. Outcomes depend on this person. It doesn’t have to be senior in position or organization, rather someone with a curious mind. Someone who will ensure the quality of the process and outcomes of it. Form a good team and this is where you start your problem-solving journey.


1. Form a team

Anyone who was involved or care about the problem. That could be stakeholders, process owners, any other people affected by it or ones who will create the solution. A cross-functional team with 360 views of the problem will deliver better input and ideas for problem-solving.

2. State the problem

Problem Wellstated is Halfsolved”

Charles Kettering.

Write it down. Make it visible to all the participants. Make sure you all agree on the problem to you want to solve. Prepare all the fact and figures you can to show the severity of it. Do not work with assumptions and feelings.

3. Ask the first “why?”

Start with “Why do you think it happens?” or “Why did it happen?”

4. Collect and record all the answers

Depends on the team size you might need to divide the group. You can create 3-5 teams (you can use 1-2-4-All group process), to challenge each other and bring the best ideas from the team. Record results as a brief meaty statement – nothing verbose.

5. Validate the answers together

This is a very important step. Build the following questions on the previous answers. Team select the most probable problem statement to go forward. As the process goes from “why” to “why” with the invalid reason you will go in totally off track. Wrongly chosen problems at this point can put the team off track (benefits of having diversified team).

6. Ask second “why”, and… so on and so on… till you get to the actionable item.

This is where you get to the root cause. Five why is only a suggestion. If you need more questions, go for it! Start a conversation with your problem. You form questions based on the answer you form preceding “Why”.

How do you know you are the root cause of the problem? There are a few ways how can you check.

  • You can apply SMART to it.
    • It is simply stated,
    • You can measure progress on it,
    • It’s actionable for the team,
    • Relevant to the problem,
    • And the action points will be time-bound.
  • You are at the process or tool level
    • The penultimate stage might point to the person who based on wrong/missing process, not accurate instruction or wrongly-placed cause the problem
  • Answers are not useful anymore.

What to do when answers to the “Why” are outside the room? You have to go and bring it. It means:

  • Do the research,
  • Investigate,
  • Bring someone who has missing knowledge.

You can also decide to end the meeting and continue when you cover the knowledge gap. To create valuable output you must ensure quality on input. It means you need to rely on data and facts and not on opinions and assumptions.

7. Generate countermeasures

It’s time to create some action points. We call them countermeasures and not solutions. Countermeasures will protect you against reoccurring of the problem. The solution will firefight the symptoms.

8. Record & Communicate

This is the key step for you to embrace the continuous learning and learning organization concepts. You need to record the results of the session a communicate it openly. It can have a form of list, mind map, fishbone diagram whatever fits you. Save it in the SharePoint of a wiki page. By making it accessible you let others learn from your case (continuous learning). Communicating it broadly you promote learning & innovation culture.

Finally, create an action plan. Who will do what by when?

9. Follow up

Create a sense of urgency. Pick the relevant date and stick with it. 30, 60, 90 days? Set up the meeting then and verify if the positive change did happen. Nothing visibly positive happen? Not a problem. You are smarter, you have learned something, you have a new data set. Use it and relaunch the process.

Result of the process depends on the two factors:

  • Quality of the input data
  • People involved

Remember, you are aiming for one of these items:

  • Process,
  • Procedure,
  • Tool,
  • Documentation,
  • Communication,
  • Exception

Never stop on a person!


Titanic cause map

There is also one especially good example when in 2004 the author of the blog post experienced how Jeff Bezos applied this technique.

Why did the associate damage his thumb?

Because his thumb got caught in the conveyor.

Why did his thumb get caught in the conveyor?

Because he was chasing his bag, which was on a running conveyor.

Why did he chase his bag?

Because he had placed his bag on the conveyor, which had then started unexpectedly.

Why was his bag on the conveyor?

Because he was using the conveyor as a table.

And so, the root cause of the associate’s damaged thumb is that he simply needed a table. There wasn’t one around and he had used the conveyor as a table. To eliminate further safety incidences, needs to provide tables the appropriate stations and update safety training. It must also look into preventative maintenance standard work.

Source: Adapted from Shmula. 2008. Available:

Different flavours

5 why tree

To address more complex problems, you can use 5 why tree. It is a game-changer.

Here you don’t limit your options to only one path. You can create on any level numerous branches of the possible causes, to find the multiple reasons behind each why.

In such a tree you can see the steam of the tree as a problem, roots are causes (root cause 😉 and leaves are observable results)

During the problem-solving journey, you should not spend too much time developing all the possible branches. Though this activity is good for the risk assessment.

For the root cause analysis focus on the one most probable cause. Always finish work on one (higher) level before moving to the next (lower) one. Decide together with the team what is the most probable cause a continue exploring it further.

Multiple causes can result in one observation. Like burned food on the pane can be a result of too high temperature and not stirring the food at the same time. If you do either of these you will not burn it.

(For And we use different graphical representation) .

“And” gate has a different presentation.

As it is a free form you can adapt it to your need. Colours, symbols, shapes as you wish.

Every node branch from the AND gate can result in its own Why tree to be investigated further down.

Tips and best practices

You can use also 5Why tree to uncover not only your problems but also strengths.

Scale up your strengths.

You can use 5why for this purpose as well. Instead of a problem, you focus on the behaviour you want to embrace. You work on this with 5why and at the end of the process, you have your home-grown recipe for success.

Continuous innovation – keep documents form the 5whys sessions easily reachable and available to the audience.

You will promote a learning culture and help others learn -even many years after the decision- what makes someone buy a license for that software we all have (and love or hate it). Build a culture with “bring your problems” mindset. Countermeasures you will find together.

Why countermeasures and not solutions?

Solutions by nature are targeting the symptoms (firefighting) whilst countermeasures are preventive and targeting root causes.

You might know the people skilled with firefighting. When you smell the fire, you will see they are coming with their solutions. Fire brings them money.

What do you need for the effective 5 why session?

  • Ensure trust and openness
  • Work with the key stakeholders,
  • Use pen & paper if you can
  • Confirm with participants understanding of the problem
  • At the end of session read answers in the reverse order adding “and therefore” at the end
  • Don’t jump too quickly to the conclusions
  • Focus on facts, knowledge and data
  • Assess the process not people
  • Never settle for the human error
  • Works best with the teams

Why not?

5 Whys it’s no silver bullet. It’s not a perfect tool. Among critical opinions are:

  • It’s just a basic tool,
  • Mentioned very often: Different group of people can get to different results
  • You settle on the symptoms; not getting deep enough to reach the root cause
  • The team is limited with their knowledge
  • It’s confirmation bias – “I already told you before we started”
  • Not able to deliver answers on the “why?” – We don’t know what we don’t know
  • Focus on one root cause leaving out other causes (not applicable for the tree approach)
  • With multiple roots causes prioritization challenge. (tree related)
  • Assuming the solution delivered with 5th why is the best one.
  • The inexperienced facilitator can direct the conversation to the wrong path
  • Targeting the most distal cause while the best use will be on a proximate one.
    • Many why’s might go through it

Counter measurements

·Get yourself good facilitator (at least). The one who will include everyone, ask good/right supporting questions. When you have problems with asking good questions probably you are on the wrong problem. When we work on wrong problems, we asked wrong questions

  • Use 5 why tree diagram
  • Verify each answer on the current “why” before going forward
  • Focus of the positive aspects/strengths (if you have) instead of asking “why something doesn’t happen” ask “why something happens?” It can be sells, processes, meeting.
  • Use it with combination with other techniques focusing on data collection.
  • Use 3 whose to help with 5 whys (Reg Revans)
    • Who knows?
      • The situation is best informed about how to solve it.
    • Who cares?
      • About the problem
    • Who can?
      • Act on the solution
  • Ensure you have all these people in the facilitation area.
  • Keep an eye on the answers that are not providing quality and value especially starting with not enough (time/money/manpower)



Have you heard that we should deliver solutions, not the problems? How many of these you’ve seen these solutions delivered and acted on?

With this technique, you can change this situation by changing your approach. Ask for problems and deliver solutions. Deliver solution as a team. This part alone promotes a culture of continuous improvement. The team will feel empowered and will build self-trust. It’s one of the strongest bound for the team building. Solve the problem together, deliver fix together, and improve on that together. 5 why technique gives your team tool they can trust. Together you will have confidence that from now on you can improve processes daily.

5 Whys with all these flavours are one of my favourite problems solving techniques. It’s easy to explain, easy to understand and easy to apply. The best part of it is that the result very often is bigger than initial expectations. Every method has its limitations.

To get the best from the tool:

  • work on it with the cross-functional team,
  • work on it with the cross-functional team,
  • collaborate on the problem and bring 360 views on it.

When you apply the steps, mentioned you will bring a solution to every problem you will tackle.

This is the simplest way how can you encourage continuous improvement within your team without blaming each other. By bringing it to the team you give them a tool they can trust to boost their confidence in the daily improvement process. And it’s fun to use 😊 Now it’s yours. Take it with you and start using. You won’t be disappointed.