Ralph Soule, Senior Consultant, Spatial Integrated Systems. Inc.
Greg Thomas, Senior Consultant, Exeter Group, Inc.
Achieving Confidence in Fleet Readiness by Generating a
Quality Culture
ABSTRACT
Engineered standards are the foundation of the
high quality maintenance that supports
affordable fleet readiness. For the “system of
systems” that defines the fleet’s readiness for
tasking, consistently meeting standards is
essential. Adherence to engineered standards
results from a deep commitment at all levels of
an organization to meeting those standards.
Commitment to standards, which enables work
to meet customers’ requirements, requires an
organization to adopt and maintain a quality
culture. Building an environment that enables a
quality culture and a commitment to standards is
the responsibility of all levels of an
organization’s leadership.
This paper argues that a quality culture and the
learning that sustains it are rooted in an
organizations values and beliefs about the work
it does and the people that do it. A quality
culture is based on a work model consisting of a
trained and qualified workforce, operating
within an organization with well-defined and
communicated roles and responsibilities for
supervision, and relentless follow up, working
to clear, unambiguous, and readily updated
standards and processes, with leadership
engagement in and oversight of work. The
paper identifies the necessary characteristics,
roles, and responsibilities of leadership to ensure
the organization’s work model is understood,
balanced, and effective and provides practical
guidelines to enable an organization to measure
and achieve progress towards developing a
quality culture.
INTRODUCTION
Quality maintenance is an essential component
of fleet readiness. That readiness is a system of
systems that includes people, machines,
doctrine, and engineered standards. This paper
addresses maintenance, the people that do it, and
the engineered standards and support that
leaders need to provide to produce consistently
high quality outcomes.
Adherence to engineered standards results from
the commitment of all engaged with planning
and accomplishment of work performed to
meeting those standards. Commitment to
standards, which enables work to meet
customers’ requirements, requires an
organization to adopt and maintain a quality
culture. Building an environment that enables a
quality culture and a commitment to standards is
the responsibility of all levels of an
organization’s leadership and is accomplished
by: (1) fostering a sense of responsibility to
customers, measured by the quality outputs and
relentless effort to understand all results, “lockin” good results, and correct poor results, and (2)
maintaining the trust of the workforce by
making sure they have the tools and processes to
obtain quality results.
An organization with an effective quality culture
is one with a commitment to learning and a
strong degree of ownership for quality
demonstrated by all members the organization.
Learning and ownership can be fostered by
attributes included in some definitions of
quality. Commitment to continuous
improvement, a part of many definitions of
quality, is a commitment to continuous learning;
Commitment to elimination of waste, also a part
of many definitions of quality, communicates
ownership of all aspects of a process. A quality
and learning culture is rooted in an organizations
values and beliefs about the work it does and the
people that do it. A quality culture is based on a
work model consisting of a trained and qualified
workforce, operating within an organization
with well-defined and communicated roles and
responsibilities for supervision, and relentless
follow up, working to clear, unambiguous, and
readily updated standards and processes, with
leadership engagement in and oversight of work.
performed. An organization’s beliefs are the
foundation for its principles, and the attributes of
how an organization goes about accomplishing
its work are the manifestations of those
principles. A quality organization believes the
following:
1. It is the organization’s duty, obligation,
and calling to produce quality products
and services, free from defects, and
without waste.
2. The organization’s people want to
produce great products and services and
be connected to and recognized for that
greatness.
3. The organization owes its customers and
owners rigorous and visible application
of quality work principles regardless of
the type contract associate with the
work.
4. The organization is at its safest and most
cost effective operating point when it is
producing at its optimum quality point.1
ATTRIBUTES OF QUALITY
WORK
There are many different definitions of quality.
The working definition for the purposes of this
paper will be: quality is consistently delivering a
product or service that does exactly what your
customer wants and expects every single time.
While this is relatively simple to state clearly,
obtaining quality results is a multifaceted
challenge, especially in work as complex as
Navy ship repair and modernization.
Simply stated, quality is low variation from your
customers' expectations, every time. Special
consideration for this definition is due for
construction, modernization and repair of naval
warships. The readiness of the U.S. Navy’s
complex and high performance warships must
be based on engineered standards and processes
that produce consistent results because our
nation expects the ship, its crew, and associated
systems to perform effectively in combat. Some
customers for ship material readiness may feel
pressure from fiscal constraints to expect,
explicitly or implicitly, that quality standards are
goals and that meeting engineered standards for
performance should be based on affordability of
the means for achieving those standards. The
benchmarking an organization should do to
ensure its processes for achieving standards and
customer alignment about meeting those
standards are essential, but beyond the scope of
this paper.
High quality is the result of processes and a
culture that is supportive of achieving it, not an
aspiration unless it costs too much or something
that can be achieved through exhortation. It is
the result of focused attention by an organization
on deep knowledge of the work and how it is
An organization’s efforts to achieve its optimum
quality point are the way it produces consistent,
affordable results that meet engineered
standards. While this paper argues that
effectively achieving this result is based on
1
The Taguchi loss function is a depiction of a
process’s loss function. This figure, as shown in
M.W. Kim and W.M. Liao, “Estimating Hidden
Quality Costs With Quality Loss Functions”
((Accounting Horizons (March 1994): 8-18)
graphically portrays the loss function concept:
adherence to fundamental principles, there is no
single way to do so. Maintenance organizations
and their customers must be mindful of
performance incentives and constraints, real or
imagined, associated with the types of contracts
the U.S. Navy uses for ship construction,
modernization, and maintenance. Deciding the
definition that will be used to assess “optimum”
quality must be based on mutual, explicit, and
unequivocal understanding between
maintenance providers and customers, contract
type, and financial risks. The understanding
could be documented in some combination of
memoranda of agreement, contract provisions,
or policy statements.
Principles of quality assurance are founded on
these beliefs and these principles have been
delineated in various forms, from Department of
Energy directives to management textbooks.
These principles are2:
1. An organization’s quality program
policies and objectives must be
documented, understood and accepted.
2. Roles and responsibilities for quality
within the organization must be
specified, documented, understood and
accepted.
3. Expectations for quality must be
documented and communicated,
resources to achieve are identified and
allocated, and performance evaluation
and recognition systems are tied to
quality achievements.
4. The organization must continually strive
to improve, the essence of proactivity.
5. All members of the organization must
be learning to improve the work they do,
and afforded the support to do so.
6. Members of the organization must have
access to information that provides clear
data on the results of their performance.
7. The organization seeks and uses relevant
experience.
“Underlying Quality Principles “, developed by the
Department of Energy’s Office of Health, Safety, and
Security, http://www.hss.doe.gov/nuclear
safety/qa/principles.html
2
8. All work is planned and controlled
commensurate with the risks involved.
9. All members of the organization have
the right material, tools, and processes,
and any changes to them are
appropriately controlled.
10. Work and processes are frequently and
proactively assessed to ensure they meet
expectations and workers have the
support for executing them.
11. Risks and errors are proactively
identified, remedied, and shared without
punishing the workers that identify
report, and commit them.
12. Management Processes are reviewed
and assessed to sustain relevance and
improve effectiveness and efficiency.
The attributes of an organization grounded in
these quality program principles will be evident
during every engagement with the organization,
from visits to the organization’s work and
briefing sites, to attendance at its meetings, to
using its delivered products or service. Several
of the principles use the term proactively, as in
“essence of proactivity,” “proactively assessed”
and “proactively identified.” This is an
important note. It is not enough to have
documented processes, striving to improve, or
identify risks. Quality organizations go looking
for problems to identify error likely and poor
quality inducing situations before they cause
work problems. An example of the manifestation
of this principle for work procedures would be
for engineers or operations managers to
specifically consider where the workers might
stumble or could get confused by work
instructions and build appropriate measures into
the work document. Quality organizations also
look for processes they follow that are
consistently producing quality work, study these
processes, and apply what they learn to lock-in
the good results.
QUALITY WORK MODEL
One of the best tools a Quality organization has
to influence the distribution of work performed
is to give its members some simple mental
models and tools for understanding the key
elements of producing high quality work and
how those elements function as a system
Quality organizations have an operational work
model that supports producing quality products
and services. In Quality organizations this model
is understood and diligently used (figure 1). For
example, Naval Shipyards frequently refer to
this model in training on quality work (cf.,
Puget Sound Naval Shipyard Code 200Q
training material, “Event Investigation, Causal
Analysis, Corrective Actions”, April 2002)
Leaders must energetically, earnestly, and
persistently apply- and inspire application- of
this model to all forms of work. Thoughtful,
perseverant, and pervasive application of the
model is a precursor to becoming a quality
organization.
organization, and actions to minimize the size of
the deviations from expected behaviors and
standards (figure 2
In any kind of work environment, it is
reasonable to expect that the quality of work
output is produced within some normal
distribution. How narrow the distribution is
reflects the standards, processes, support, and
work ethic of the people doing the work.
Figure 2 Understanding normal behaviors
Figure 1. Quality work model
The quality work model communicates two
concepts: (1) all work is performed using a
balance among a trained and qualified
workforce, a work process, and supervision (the
three vertices of the triangle) and (2) work is
overseen, when and as appropriate, by agents not
directly involved with performing the work, i.e.,
quality assurance and safety inspectors. Leaders,
managers, and workers in Quality organizations
know that there is no substitution for direct
observation of in process work to understand the
state of “balance,” of their work models. These
observations enable re-balancing the model, a
determination of the “normal” behaviors of the
It is management’s responsibility to understand
the standard (the centerline of the distribution in
Figure 3), to understand the margin the standard
provides to the minimum acceptable
requirement, and to establish understanding on
the part of the workforce for their
responsibilities for maintaining standards.
Despite the presence of independent Safety and
Quality oversight, inherent in the work model is
the belief that workers have ownership and
responsibility for safe performance of quality
work. A key challenge for any organization
committed to producing high quality results is
attaining and sustaining commitment and desire
of the workforce to perform their responsibilities
as part of the work model. No two organizations
will accomplish the same way especially
because of differences in workforce
composition, experience, and training. Leaders
must address workforce acceptance and
understanding of the model to benefit from its
application.
A traditional characterization of the work model
shows the triangle at the center of figure 1.
Quality organizations treat the functions in the
vertices of the center triangle as work that is of
greater importance than the physical work
performed. They view supervision and
developing procedures as work, with an
analogous “work model” for that work that must
be understood and “balanced.” For example, in
Quality organizations, supervisors play a
leadership role in ensuring that the central work
model is balanced (e.g., processes are modified
as appropriate not only for the risk inherent in
the work but also to the skill level of the workers
and the conditions under which they are
working). Supervisors are not born knowing
how to make the important judgment calls
involved in balancing the work model, although
many do an amazing job of acquiring the
knowledge through trial and error. Organizations
that aspire to Quality need to decide how to
impart this knowledge to its supervisors since
gaining experience through critiques and errors
is not very efficient or cost-effective. Safely
performing the “work” of front-line supervision
with requisite quality requires supervisor
training and qualification requirements of
greater rigor than that of the workforce so
supervisors understand how to make the
important decisions necessary to balance the
work model for the situations they are likely to
encounter. There must be a set of processes for
supervisors to follow, with
engagement/supervision by managers to provide
support and ensure that the supervisory
contribution to the central work model is
appropriate and balanced with the processes
used by and skills of the workforce. In many
organizations struggling with quality, failure to
invest in supervisor development is a leading
cause of poor results. A 2010 review of a
shipyard struggling to meet standards revealed
that less than 10% of front-line supervisors had
completed the command’s first line supervisor
development program.
An example of the application of the work
model is provided as Appendix A.
In many situations, quality work is recognizable
when observed, but only if senior leaders
themselves have the experience and judgment
necessary to recognize it. Essential attributes of
quality work are:







Free from un-documented, un-adjudicated
defects when passed from production to
inspection and test.
Condition of inaccessible/not-visible
attributes are of equal or greater quality than
accessible/visible attributes.
Variability between completed products
produced to same standard is minimized,
and reduced over time.
Quantity of waste generated was accurately
forecasted, minimized, and plans for its
disposition upon work completion were
developed and executed.
All required in-process documentation was
generated in stride during job performance.
All unexpected events and conditions
encountered during production are
documented and receive appropriate review
and adjudication as they are uncovered.
Workers do not perform undocumented
rework or procedure modification because
they recognize this deprives the organization
of vital information necessary to improve
quality.
In quality organizations execution preparation is
treated as work just like changing the form, fit,
or function of a component, and receives
emphasis equal to that of the physical work.
Quality organizations strongly believe all its
workers intend to do a great job, that they want
and have the will “to win.” Just as no coach
enters a game without a game plan, Quality
work is consistently produced by organizations
with the “will to prepare to win.” Attributes of
“preparing to win” at Quality work are shown in
Appendix B. Attributes of winning at the
execution of Quality work are shown in
Appendix D.
The attributes delineated in the Appendices flow
directly from the most evident and pervasive
attribute of an organization committed to
quality: its overwhelming sense of purposeful
service. Purposeful service embodies two
principles3:
1. Purposeful4: The entire workforce
understands the, “whys”, behind the
work. Why must we do our work to
these standards? Why is our work
important? Why does this work need to
be done? The book, “Serving Leader”,
establishes ,“Run to Great Purpose”, as
the foundation of leadership.
2. Service: Service is subordinating one’s
own needs to the needs and
requirements of others and committing
to support these needs and requirements,
vice merely complying with them. For
naval ship work, the “others” are a
broad range of stakeholders, including
Sailors who serve on the ships,
taxpayers, and the environment.
Organizations with reputations for Quality are
committed to purposeful service. The Apple©
design philosophy,5 “Empathy, Focus, and
Impute,” communicates its commitment to
purposeful service.
POOR QUALITY IS EXPENSIVE
There may be a tendency for some experienced
personnel engaged in Navy maintenance to roll
their eyes during discussions of the principles of
high quality work and leadership behaviors to
support it. The source of this reaction is that all
the behaviors and processes supporting the
principles, engineer standards, maintain high
quality work procedures and documents, train
the workforce, conduct pre and post job briefs,
hold critiques and write reports, to name but a
few, sound like a lot of work. The authors are
“Understanding Purposeful Service”,
http://service.csumb.edu/understanding
purposeful_service.
4
“The Serving Leader”, Ken Jennings;
http://theshipcompany.com/products-andservices/the-serving-leader-a-practical-guide/.
5
Walter Isaacson, Steve Jobs (New York: Simon &
Schuster, 2011)
3
aware of a general feeling that only those with
deep pockets and responsibility for nuclear ships
can afford them. As will be noted in the section
on Practical Guidelines that follows, none of
these things have to be done in an expensive or
complex way (that is driven by the nature of and
risks associated with the actual work). Poor
quality that results in rework, personnel injury,
lost operational availability of Navy warships,
and work stoppages is enormously expensive in
terms of operational assignments missed, impact
on workers’ lives, impact to other work, and an
organization’s reputation. The authors suspect
one problem many people have in implementing
systematic processes for producing quality work,
especially when many of them are new to an
organization, is that they only think in terms of
the near-term costs to change what they are
doing and not the cost they are likely to pay if
they have a substantial quality incident.
LEADERSHIP MUST
COMMUNICATE THE COST OF
QUALITY
An organization’s leadership must establish
measures of the cost of quality to provide the
financial imperative for being a quality
organization. The foundations of a cost of
quality system are costs of conformance to
standards and costs of non-conformance to
standards. The costs of conformance can be
broken down into prevention costs and appraisal
costs and the costs of non-conformance into
internal failure costs and external failure costs.
Examples of each cost category are6:
Prevention Costs: Providing technical support
for vendors, preventive maintenance on tools,
and equipment, quality training of employees,
and process engineering.
Appraisal Costs: Inspection of materials,
processes, and machines, quality audits of
products and processes, vendor audits and
sample testing, and process risk analysis
6
Financial & Managerial Accounting, Needles,
Powers, and Crosson.
Internal Failure Costs: Scrap and rework, reinspection and retesting of rework, failure
analysis, and quality related downtime
External Failure Costs: Lost sales, restoration of
reputation, and investigation of defects.
Leadership must establish measures of quality
and communicate these to the organization. A
standard set are:
-
Total costs of quality as a percentage of
net sales
Ratio of costs of conformance to total
costs of quality
Ratio of costs of nonconformance to total
costs of quality
Costs of nonconformance as a percentage
of net sales
Without an understanding of measures of
quality, absent significant problems,
organizations tend to focus only on costs of
conformance. A healthy quality organization
measures and tracks costs of quality as outlined
above. For a detailed delineation of the four cost
categories, see Appendix C.
LEADERSHIP’S ROLE IN A
QUALITY CULTURE
For an organization to consistently produce
quality results, its leadership plays a crucial role
in creating a climate and infrastructure that
supports achieving consistently high quality
results. Leaders must model the principles of
quality assurance, must notice and reward the
behaviors that embody the principles of quality
assurance, must be engaged in how work is
actually done where it is done, must know their
workforce’s “red lines” for producing quality
work, must respond well to learning about
problems and getting bad news, and need to
relentlessly follow up on all performance, good
and below standard, to understand why it is
occurring and what has to be done to get more or
less of it, respectively.
An organization’s leaders are responsible for
ensuring high congruence between their
behaviors and the organization’s practices and
the principles espoused to produce quality
outcomes. Too often, an organization that
purports to produce quality work is run by
leaders that really want work done quickly and
cheaply above all else. This is not to say that
quality work is expensive or slow. In fact, high
quality work is faster and less expensive than
low quality work because no re-work, injuries,
or system failures result from high quality work,
all of which slow things down and cost
enormous amounts of time and money to
correct.
Workers are more attentive than leadership often
credits. They know perfectly well what is
important to an organization’s leaders because
of how bonuses, awards, and other forms of
recognition are distributed. Publicly praising or
awarding an abusive supervisor who gets results
despite cutting corners on safety and ignoring
the procedural problems encountered by those
working for him sends a strong signal that safety
and quality work are not as valuable to the
organization as “shipping the product” or
completing the work, regardless of quality, by
the deadline. On the contrary, leaders that praise
and single out workers that bring unsafe
situations to light, do not proceed with a
procedure because of a safety concern, or
identify deficient procedures that will make
accomplishing quality work more difficult, are
sending a much clearer signal to those on the
front line of producing quality outcomes of the
type of on-the-job behavior that they value.
[those on frontline need to understand why the
standard is appropriate to the job at hand,
embracing standard for the right reasons] The
organization’s workers will be “on their own” all
the time and facing dilemmas about how to
proceed. An organization may do work that is
too complex to be guided solely by the
Nordstrom’s dictate, “Do what’s right for the
customer,” but workers can be encouraged to
take sanctioned, equivalent action such as
“Sometimes, stop is good progress,” “Employ
thinking compliance,” and … Taking the time to
illustrate high quality behaviors and thought
processes in action is crucial to support the
workers in all the situations that leaders do not
see or cannot directly influence.
It may seem like an overstatement to say that an
organization’s leaders must be intimately
involved with and understand how work for
which they are responsible is actually done. It is
amazing to the authors how many times in their
careers they have seen leaders of organizations
producing low quality work or with poor safety
records shocked, just shocked at how far
workers have strayed from authorized
procedures while doing the work. Those familiar
with the Navy Nuclear Power Program know the
validity of the expression, “you get what you
inspect, not what you expect.” Leaders must
regularly get out of their offices or meetings or
other activities and take the time to actually go
to worksites and talk to workers, see what their
working conditions are, look at their work
documents, and assess their work practices. In
nearly every case that leaders do these things,
they are very likely to discover a gap between
work as they imagined it and how work is
actually done. How leaders act on this
information is crucially important to producing
quality work. If disciplining workers is the only
response for deviating from management’s
imagined work processes, leaders will likely
drive indications of similar disparities
“underground” so they are not as easy to
identify. Workers are likely to become less
forthcoming with managers conducting future
worksite surveillances. A better response to
significant gaps between work as performed and
work as imagined that is congruent with the
principles for producing quality work noted
above is to ask “why?” Leaders need to
understand why workers think what they are
doing is appropriate and acceptable and what
they, the leaders, have done, to send the signal
that cutting corners and taking safety risks will
be ignored or not noticed. Leaders need this kind
of insight to understand the situation and begin
to consider ways to change the signals the
workers are getting. Merely writing a safety
notice forbidding the discrepant practices,
disciplining the workers (except for the most
egregious kinds of safety or quality violations
and even then with great care), or changing
procedures will do little to impact the behavior
that is likely occurring in many other parts of the
organization unknown to leadership.
By regularly visiting the worksites and
understanding how work is actually performed,
leaders will gain insight into what is actually
needed by the workers to produce quality
results. This goes beyond work documents,
hospitable working environments, and job
briefings, all of which are important in their own
right. Do the workers have the training and
experience to conduct effective pre-job briefs?
Do the foremen know enough about teaching an
important skill to workers (fundamentals of
instruction)? Are the work documents clear and
unambiguous, not according to the engineer that
wrote them, but the foreman or mechanic
responsible for executing them? Does the
foreman or worker have enough time to
accomplish the task at his/her skill level? Do the
skills required for a particular job go beyond
what might be expected for the “average”
worker? Knowing the answers or range of
acceptable answers to questions like these will
help leaders develop organizational “red lines”
for producing quality work. A quality red line
can be thought of a limit beyond which workers
should not be expected to perform without some
form of additional support (more time, training,
resources, or modified procedures). If workers
struggle to produce quality outputs when
regularly pushed beyond their “red lines” or
leaderships have no idea what these red lines
might be, it is a failure of leadership and not
craftsmanship.
A corollary to the need to respond well when
they discover gaps between work as they have
imagined it and work as actually performed,
leaders that want to know what problems
workers are having producing quality outcomes
in order to have the information to correct them
must respond appropriately to receiving bad
news or learning from others about problems.
The first time a leader does not accept
information about a problem with grace,
aplomb, and determination to address it swiftly
and professional is the last time someone will
bring bad news to them. “Shooting the
messenger” may feel good or feed someone’s
ego, but it is completely antithetical to
producing quality results. This does not mean
that a leader has to be happy hearing bad news
or act as if nothing is wrong, far from it. They
need to resolve to effectively deal with the
problem. Similarly to responding professionally
and effectively to problems, leaders need to be
very responsive to requests for help from the
workforce. Help requests are opportunities to
evaluate and address assistance the workforce
needs before quality problems develop.
Leaders must relentlessly follow up and assess
the results of the organization and its work units.
Critiques and hot washes or after action reviews
are high pressure, complicated, and time
consuming and are only appropriate for
significant deviations or poor results. Many
other tools are available to leaders to understand
how and why work is or is not going as
expected. Simple conversations with workers at
their worksites or after completing jobs, small
group meetings at the end of a shift, or written
“fact sheets” from participants followed by a
brief training summary are all useful, low-cost,
informal ways to assess performance to identify
interventions to get more or less of it. Aviators
engage in post flight debriefs, informal dialog
among an aircrew about what went well and
what needed to be improved after flying nearly
every mission. The complex processes of ship
maintenance and construction produce
unexpected results all the time. No organization
can systematically improve its ability to achieve
the results that are important to it unless its
leaders are relentless in trying to understand why
they did obtained the results they did.
PRACTICAL GUIDELINES FOR
LEADERS AND WORKERS TO
SUSTAIN A QUALITY CULTURE
Taking concrete steps to influence an
organization’s quality culture, especially one
that is struggling to produce consistent quality,
is a daunting task. It may be more constructive
to think of improving an organization’s quality
culture as a journey, because getting on “the
path” is far more important than exactly which
path one takes.
There are many possible approaches an
organization’s leaders can take, but the authors’
view is that the most effective approach involves
more actions than words and these actions
should be directly associated with the work
being done. Tables 1 through 4 contain a list of
basic steps leaders can take with respect to
managing work for quality centered on:
 pre-job risk assessments,
 pre-job briefs,
 assessing work in progress, and
 post-action review and capture of
lessons learned.
The authors chose these activities for several
reasons:



they involve leadership engaging directly
with front line workers for mutual benefit,
they allow leaders to learn what the gap is
between work as imagined and work as
actually performed, and
they enable leaders to gage how effectively
their quality messages are permeating
through the organization.
These practical guidelines do not need to be
transformed into detailed, exhaustive checklists.
Recent literature7 suggests that the level of detail
provided in tables 1-4 is sufficient for the
majority of maintenance performed in the ship
repair industry.
CONCLUSION
The U.S. Navy’s ability to project its influence
wherever and whenever dictated by its National
Command Authority depends on the
effectiveness and quality of the Navy’s material
readiness activities, a key component of the
system of systems that support fleet readiness.
To achieve material readiness, the Navy needs
quality results from all facets of maintenance.
Because of the complexity of Navy ships and
their support systems, quality maintenance can
only be achieved through an engineered
approach to adhering to quality, worker support,
and learning. Achieving appropriate quality is
7
Atul Gawande, The Checklist Manifesto (
Metropolitan Books, Henry Holt and Company, LLC,
2009).
not simple, but it does not have to be high cost
either. An engineered approach to quality cannot
be sustained merely with checklists or slogans.
Rather, it must be deeply rooted in an
organization’s culture. Because culture is
resistant to overt, top-down intervention,
organizations aspiring to do quality work must
devote most of the attention to day to day
application of seemingly small, but very high
leverage activities on the part of workers and
leaders. that are grounded in a set of beliefs and
principles that communicate commitment to
quality. Leaders concern themselves with the
“details” of how work is done and relentlessly
follow up on results. Finally, leaders must help
their organization build and maintain a quality
culture to get consistently high quality results.
There are no shortcuts.
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AUTHOR BIOGRAPHIES
Ralph Soule is director of ship modernization
and maintenance for Spatial Integrated Systems,
Inc., and a retired Engineering Duty Officer. He
and his firm develop 3D data lifecycle
management solutions for the Navy. He
specialized in nuclear warship construction,
modernization, and overhaul. As commanding
Officer of Supervisor of Shipbuilding, Newport
News, his team oversaw construction or
overhaul and delivery of USS GEORGE HW
BUSH (CVN 77), USS NORTH CAROLINA
(SSN 779), USS NEW MEXICO (SSN 781),
USS CARL VINSON (CVN 70), and USS
ENTERPRISE (CVN 65). He hold the dubious
distinction of being the only Engineering Duty
Officer to have served as Carrier Type
Commander Ship Materiel Officer on both
coasts. He has a Bachelor of Science Degree
from the United States Naval Academy and
Masters of Science Degrees in Electrical and
Nuclear Engineering from the Massachusetts
Institute Technology. His currently enrolled in
the George Washington University’s Doctoral
Program in Human Organizational Learning.
Greg Thomas is currently a senior consultant at
the Exeter Group, Inc., in Cambridge, MA. A
retired Navy Captain, he served in a broad range
of submarine, submersible, and surface ship
design, construction, maintenance, and
modernization billets. Tours include Design
Manager for LSV-2 (CUTTHROAT), the
world’s largest unmanned autonomous
submersible, Repair Officer on the USS FRANK
CABLE (AS 40), Material Readiness Officer at
Commander Naval Submarine Forces,
Operations Officer at Portsmouth Naval
Shipyard, Shipyard Commander at Pearl Harbor
and Norfolk Naval Shipyards, and tours at the
Supervisor of Shipbuilding, Conversion and
Repair Offices in Groton and Newport News.
His educational background includes a Bachelor
of Science in Mechanical Engineering from the
United States Naval Academy and Master of
Science in Mechanical Engineering, Naval
Engineers, and PhD in Hydrodynamics from the
Massachusetts Institute Technology. Under his
command Pearl Harbor Naval Shipyard earned
the Robert T. Mason award in 2010 as the
Department of Defense top depot maintenance
facility, the first NAVSEA command to ever
win the award. His personal awards include the
NAVSEA Association of Scientists and
Engineers award for professional achievement,
the ASNE Brand Award for academic
excellence, and two Legions of Merit along with
other personal and unit commendations.
REFERENCES
Gawande, Atul. (2009). The Checklist Manifesto. New York: Metropolitan Books, Henry Holt and
Company, LLC.
Human Performance Improvement Handbook, Vol 1-Concepts and Principles. DOE-HPI-hdbk-1028,
U.S. Department of Energy, Washington, D.C. 20585, available on the Department of Energy Technical
Standards Program Web site at http://www.hss.energy.gov/nuclearsafety/ns/techstds/
Isaacson Walter. (2011), Steve Jobs. New York: Simon & Schuster
Jennings, Ken. (2004). The Serving Leader http://theshipcompany.com/products-and-services/theserving-leader-a-practical-guide/.
Kim, M.W. and Liao, W.M. (1994). Estimating Hidden Quality Costs With Quality Loss Functions
Kim, M.W. and Liao, W.M. (1994). Estimating Hidden Quality Costs With Quality Loss Functions
Accounting Horizons (March 1994)
Needles, Belverd, Powers, Marian, Crosson, Susan (2005). Financial & Managerial Accounting. Mason,
OH: South-Western, Cengage Learning.
Reason, James. (1997). Managing the Risks of Organizational Accidents. Burlington, VT: Ashgate
Publishing Company.
Underlying Quality Principles, developed by the Department of Energy’s Office of Health, Safety, and
Security. From DOEhttp://www.hss.doe.gov/nuclear safety/qa/principles.html
Understanding Purposeful Service, http://service.csumb.edu/understanding purposeful_service.
Table 1: Pre-job Risk Assessment
What does job success look like?
Job overview
How will workers recognize success?
Overview of the work and key points for success.
How does this job fit within the context of the
overall project? Why must this job be done now?
Review past performance
What happened the last time the job was done?
Job frequency
How long ago was "last time"? How often is this
work done?
Team Experience
Is this the first time this team has done the job or
just for some members?
Experience necessary/desirable
What qualifications and experience are necessary
for this work?
Adequacy of technical direction
How stable is the technical direction for the work?
Have there been recent changes that some might
not know?
Coordination challenges
What coordination challenges exist (who has to be
informed about what, when, to do what?)
Relevance/context of the task to the overall project
Why must this work be completed now? What are
the consequences of success/failure?
External pressures that might impact the work
What pressures exist to do the job faster or cut
corners?
Supervision planning
What is the role for enhanced supervision?
List of Human and equipment risks
What are some of the consequences for doing the
job badly? Safety, quality, etc.?
Most important risks to mitigate
What are the top 3-5 risks and what are the most
high leverage preventative measures?
Need for outside assistance
Does it make sense to ask for outside assistance?
e.g., the Original Equipment Manufacturer
Top 3 risks and the mitigation strategy
Use checklist, if possible
Workers understand the procedure, have the
qualifications, know the risks, sufficient experience
for the level of oversight, and can recognize
appropriate system response
Conditions for stopping and getting help as well as
making the job site safe when doing so
Tools, temporary services, documentation, safety
equipment, and materials on hand (and knowledge
of how to use them)
Risks and Safety
Additional applicable procedures
Worker readiness
Conditions for stopping
Tools and other job support aids
Table 2: Pre-job Brief
Review procedure
Conduct mutual introductions of all participants,
their roles, and identify the person in charge
Have man in charge or person doing the work
explain the work
Watch some or all of the work at the job site
Review past problems
Helpful if not familiar with the work, but not
mandatory
Explain why you are there, guides future
comments. Discuss relevance of the job and how it
fits into the overall project.
Identify what the most important steps, notable
risks (including safety that is task relevant), and
how workers will assess success, and
hold/stopping/check points- these points are not
solely quality checks mandated by the Quality
Organization.
Learn how work actually gets done
Ask about past problems workers have had so far in
the job, the engineering support to date, and how
they resolved any issues they have had
Table 3: Work In Progress Audit
Schedule
Procedure
Support
Safe stopping point
Surprises
Preparation adequacy
On, ahead, or behind schedule? Reasons for delays.
Is the mechanic using the procedure to do the
work? Can he show what he completed and what is
next?
Has the support by assist trades or technical
personnel been sufficient? How could it be
improved? Are enough people available to do the
work to meet the schedule? Has the supervisor been
informed?
What is the next safe stopping point? Is it before
shift change or after?
What were the surprises and how were they
identified? What do you know now that you wish
you had known earlier?
Brief ideas of what could be improved among prebriefs, procedure, training/qualifications.(save
details for Post-Action Review)
Table 4: Post-action review
Outcome Assessment
Things to do more often
Things not to do next time
Hazards caught
Assess work process tools
Surprises
Things to do differently next time
Was the desired outcome achieved?
Top things that went well that should be duplicated
next time
Top things that did not go well that should be
avoided next time
Note which are still open items
Assess effectiveness/utility of pre-briefs, procedure
(especially things not covered, but should be),
training/qualifications (sacred pact to follow up)
What were the surprises and how were they
identified?
List of what should be done differently next time
Applying the Work Model
Recent efforts to improve quality of naval ship maintenance highlight challenges in applying the work
model effectively. A persistent quality problem in ship maintenance is poor adherence to system
cleanliness standards. Recognition of a non-compliant condition is a key to maintaining system
cleanliness, and recognition is a function of worker experience, supervisor engagement, and the process
used to perform work. To assist a worker with understanding and enforcing requirements, work
procedures in shipyards will reference (using Naval Shipyards as an example) a Uniform Industrial
Process Instruction (UIPI), with the following standard statement, “Maintain Cleanliness In Accordance
With Reference (a)”, where reference (a) is the UIPI for cleanliness. The UIPI for cleanliness is
approximately 100 pages long and is subject to revisions on a frequent basis. On the basis of attendance at
more than150 pre-job/pre-shift briefs in three naval shipyards over the past 5 years, on greater than 50%
of the jobs where this UIPI was referenced, workers and supervisors were willing to proceed without
having consulted the UIPI, and on approximately 25% of those jobs when asked to explain the cleanliness
standards appropriate to the system to be worked, workers and supervisors guessed wrong on the
standards. Analysis of this problem revealed significant weaknesses application of the work model:
1. For a process to be an effective part of the model, the process must clearly and unambiguously
communicate requirements, e.g., cleanliness requirements. In the case of communicating
cleanliness requirements, the applicable system-specific cleanliness requirements within the naval
shipyards’ 100 page UIPI are typically 1 to 2 paragraphs in length and should be cut and pasted
into the document.
2. The number of reviewers of a procedure in development is not an indicator of process
accuracy/value. A recently reviewed cover sheet to an Enhanced Process Control Procedure
showed a total of 7 required signatures to issue the document to the trade supervisor. Despite the
number of reviewers, this procedure contained direction that would have resulted in significant
cleanliness control problems and potential component damage if executed as written.
3. Interaction between worker and supervisor prior to starting work must focus on relevant quality
issues and must include a discussion of the specific steps in the process that will be completed.
This dialogue will ensure standards intended to be met by the author of the governing procedure
are commonly understood by the supervisor and her/his worker. Supervisors require disciplined
training in the conduct of pre-shift/pre-job briefs and in developing meaningful dialogue and
relationships with workers; a sustaining/continuing training program must be part of this
program. Additionally, the use of deck-plate coaching of supervisors is an effective element of
supervisor development.
Appendix A
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Preparing for Conduct of Quality Work
:
Work is preceded by an interactive brief commensurate with the experience of the workers, the
complexity/risks of the job, the consequences of failure, and the local conditions led by the workers in
the presence of the supervisor. Attachment 1 is a representative example of a pre-shift brief checklist.
Interactive briefing areas are free from distracting clutter, well lighted, quiet enough to enable
productive dialogue, and enable review of process paperwork, tools, materials, and safety equipment.
The document that governs the work is used to guide the brief. Procedures contain minimal reference
to source documents; instead, the processes contain only the relevant extracts from the source
documents. Procedures provide relevant lessons learned and are always discussed, with the workers
leading the discussion on how they have integrated the lessons learned into their thought process.
Training and qualification status of workers and supervisors are confirmed prior to the brief and
validated as part of the brief (Note 1)
Safety hazards and risks relevant to the tasks to be performed are discussed by workers and the
supervisor. Personal Protective Equipment must be discussed as well as job specific hazards and risks
within the context of the work site conditions and other work/operations relevant to the tasks to be
performed. To achieve this, workers and supervisor must have visited the work site prior to starting
the brief.
All tools and materials are at brief site, staged at job site, or are staged between brief site and job site.
Use and risks of special tools are part of the brief.
Workers and supervisors agree on “pause” and “stopping” points, beyond those specified in the
procedure, to enable supervisor to worker dialogue at steps of shared concern.
A communication protocol between worker and supervisor for emergent concerns is established.
Expectations for progress are discussed along with remaining cost and duration budgets for the work.
Standards for work performance are discussed as quantitatively as appropriate for the task. Any
uncertainty uncovered during the interactive brief is resolved at the brief site with the author of the
technical work document (this implies that there will be some kind of pre-pre-job review by the
Supervisor and the worker for really complex/risky work).
Pre-job/pre-shift briefs are subjected to surveillances and audits by line management, senior leaders,
and oversight (i.e., Quality Assurance and Safety) organizations with as much rigor as other work.
Authors of technical work documents actively and formally participate in the audit and surveillance
program of pre-shift/pre-job briefs.
Note 1: Training programs in organizations with healthy quality conduct periodic “cross” or “joint”
training sessions, where members of the oversight groups, e.g., Quality and Safety, and the group
developing the work processes, e.g., Engineering and/or Planning Departments train alongside the
mechanics and supervisors responsible for the work.
Appendix B
Attachment 1 page 1 of 2
Attachment 1 page 2 of 2
From: Financial & Managerial Accounting, by Needles, Powers, and Crosson,
Appendix C
Performing Quality Work
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Work-sites are clean, well-lighted, comfortable (e.g., well-ventilated/cooled), and staged to maximize
worker performance.
The Technical Work Document governing the task is on-site and accessible, kept current with work in
process, and used during job performance to guide work and to record all required documentation.
Workers understand their responsibility for halting work when they identify unexpected conditions.
Workers are comfortable with stopping work when they have questions.
Quality inspectors and Supervisors do not merely reject incomplete work as “not inspection ready”
because they realize that it represents an important learning opportunity.
Supervisors visit work sites at agreed upon stopping points and at periodicities appropriate to the
inherent risk of the work and the workers’ and supervisors’ experience levels.
Inspectors assigned to view completed work will visit job sites at periodicity commensurate with risks
associated with the work, in addition to visiting work sites at designated inspection points.
Consistent with formal participation in audits and surveillance programs for pre-shift/pre-job briefs,
authors of technical work documents should participate formally in audits and surveillances of inprocess work and should, on an informal basis, visit job sites were work is being performed using
their process.
Appendix D