Why is There a Scrap of Paper with “5S = Failure Pls address” on My Desk?


Mark's Note: Today's guest post is by Paul Critchley and while it shares a story from a manufacturing company, I could see a situation like this taking place in healthcare or in any large organization that doesn't quite get what Lean is about.

By Paul Critchley:

Part of my messy deskLean can be many things to many people; a way to earn more profits, a way to improve quality, or even a way to change a company's culture for the better. For as many different reasons there are for people to start practicing Lean, there are ten times as many ways people misuse it, and wind up doing more harm than good.

Such was the case at a major aerospace manufacturer in Connecticut. As many companies had done, they took the Toyota Production System and morphed it into their own branded program, complete with a tiered accreditation structure for employees, core group of experts, and functional area certification goals. With much fanfare, they rolled out this new program to the masses, touting the benefits it would pay us all in increased efficiency, greater throughput and better employee engagement.

It didn't take long before the whole thing turned into a competition amongst the Directors and VPs. As part of the roll-out, they had been given metrics for their respective groups to achieve. For instance, a percentage of their employees had to complete training and get certified by a certain date. Similarly, their groups' areas had to pass audits and achieve a certification “level” within a given timeframe. Rumor had it that their bonuses were tied to achieving these goals, and as many studies have shown – people will do what you pay them to do. Couple that with some good ol' competitive spirit, and the race was on.

One of the (many) problems with this system was that the people at the top didn't really understand how to implement it, which is an essential part of Lean. In truth, Lean is about engaging the workforce in the matter of completing the work of the company, and if implemented correctly, it will yield the positive results it has become famous for. In this regard, though, the company failed – big time. Upper-level managers started going on half-cocked Gemba walks through their areas, using them as audits instead of a method to go out and learn something from their people.

During this time, I shared a cubicle with three other employees. They were all good people -hard workers who really cared about the company and what it did. One of my cube-mates was a design engineer who'd been with the company for more than 10 years. Over that time he had come to personalize his desk area. He had a picture of his wife, some small company nick-knacks, and several small figurines of medieval knights and witches. Admittedly, it was a little much for my taste. The number of items he had on his desk was perhaps a little over the top, and most of them had nothing to do with work, but it wasn't my desk, so it didn't really bother me.

It did apparently bother the VP of Engineering though, because one morning he came through on one of his audit-walks (I won't call it a Gemba walk because that's not what it was). He left a note with the somewhat cryptic message “5S=Failure Pls address” on my cube-mate's desk, and signed it with his initials. He was too busy, apparently, to spell out the word “please.”

None of us were in the cubicle at the time the note was left, but I happened to return before anyone else did and noticed it on his desk. I was stunned. The message was wrong, and so poorly delivered, I considered taking it and going to see my manager before my cube-mate found it. Before I could decide what to do, though, he returned.

What unfolded in the following weeks was a testament to how badly the whole program was being implemented. My cube-mate, upon finding the note, was of course angry and insulted. He sought counsel from his manager on what to do. But, not getting anywhere, it led him to eventually clear his desk of everything personal and he turned into a straight 8-to-5 guy. Gone was the creative genius; replaced by a neutered automaton. When I left that company years later, he remained, but only as a mere shadow of his former self. Similarly, the implementation of Lean principles had become stagnant, and was reduced to being referred to as a “check in the box” by most of the employees. The phrase was so widely used that our president actually issued a company-wide letter denouncing the moniker

Many companies make this mistake when trying adopt a Lean culture, and they inevitably fail at implementing it. They mistakenly believe that it takes oversight and enforcement because “people don't like change, so therefore must be required to do so”. In fact, the contrary is true when it comes to Lean. The workforce must be involved from the start, and continuously encouraged to participate through learning and being rewarded for their efforts – not punished for failure. To do so is not only short-sighted, it misses the entire point. Lean is all about building an environment of collaboration and empowerment, not forcing people into a standard method of behavior. In short, the only way to successfully implement Lean, and hence realize the benefits of doing so, is to start with those who will eventually determine its fate – the front line employees.


What do you think? Please scroll down (or click) to post a comment. Or please share the post with your thoughts on LinkedIn – and follow me or connect with me there.

Did you like this post? Make sure you don't miss a post or podcast — Subscribe to get notified about posts via email daily or weekly.

Check out my latest book, The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation:

Get New Posts Sent To You

Select list(s):
Previous articlePodcast #228 – Zeynep Ton, “The Good Jobs Strategy”
Next articleHappy Labor Day 2015: Good Jobs, Safe Jobs
Paul Critchley
Paul W. Critchley founded New England Lean Consulting after enjoying a successful career implementing Lean Principles throughout the Automotive, Medical Device and Aerospace industries. He is co-author of “The Whole Professional, A Collection of Essays to Help You Achieve a Full and Satisfying Life”. He can be reached at http://www.newenglandleanconsulting.com.


  1. Hi Bob,
    Not sure I’ve seen that one..!
    It always surprises me how badly our senior leaders fail at implemention. You’d think that people at that level would understand that it’s not about the “what”, but about the “who”. In this case, the manager eventually got compliance, but lost so much more for the company that I consider it a failure.


Please enter your comment!
Please enter your name here

This site uses Akismet to reduce spam. Learn how your comment data is processed.