So you have a customer complaint. It’s not just any complaint, but a huge one from your biggest customer. The problem affects millions of dollars in business and threatens the survival of your company. Are you going to take action? Of course! You put together a team of top players and attack it head-on.
所以你收到了顾客抱怨。那可不是什么普通的抱怨，而是来自你最大的顾客的天大的抱怨。这个问题影响上百万美元的生意，也危险你公司的生存。你要采取行动吗？当然要行动了！你把各路大侠召集在一起，准备正面出击。
Team members investigate the problem and perform a detailed 5-Why analysis. They start with the problem statement and ask, “Why did that happen?” repeatedly, drilling down deeper with each iteration:
小组成员研究问题，并进行详细的5个为什么分析。他们开始反复问“为什么会发生呢？”，每重复一遍问题就深入一步。
Problem: There were seven data errors in reports issued to our largest customer in the last month
问题：上个月我们最大顾客发出的报告有7处数据错误。
• Why? Because lab reports are getting in the wrong project folders.
• 为什么呢？因为把实验室报告放错了文件夹。
• Why? Because the project numbers are written illegibly on the folders.
• 为什么呢？因为项目成员把文件夹的名称写错了。
• Why? Because the customer service representatives are rushed when preparing folders.
• 为什么呢？因为客服代表着在准备文件夹时着急了。
• Why? Because there are only two representatives taking calls for all divisions.
• 为什么呢？因为只有两个客服代表面对所有部门。
• Why? Because business expanded rapidly in the past year and management neglected to re-examine the work load of the customer service representatives.
• 为什么呢？因为去年公司业务增长太快，管理层忽略了重新检查客服代表的工作量。
After 5 Whys, the team has found what it believes to be the root cause of the problem: customer service representatives who are overworked. The team takes action to remove the root cause, which is the addition of a third customer service representative. A person is quickly transferred and trained, and the action is deemed effective by objective observers. A pizza lunch follows, including a congratulatory address by the president of the company. A week later, three more reports have data errors in them. Your company is dropped by its largest customer. Everybody was certain the problem solving was effective, but it obviously wasn’t. What happened?
经过5个为什么分析后，小组已经发现了他们认为是问题的根本原因：客服代表超负荷工作。小组采取行动消除这个根本原因，增加了第三名客服代表。这个人迅速到岗，并接受培训，而且小组采取的措施被一个客观的观察员认为是有效的。然后大家同进午餐，公司总裁还发表了祝词。一周后，三个以上的报告里带有错误的数据。你最大的顾客把你撂倒了。每个人都确定问题解决程序有效，当显然是无效的。为什么呢？
所以你收到了顾客抱怨。那可不是什么普通的抱怨，而是来自你最大的顾客的天大的抱怨。这个问题影响上百万美元的生意，也危险你公司的生存。你要采取行动吗？当然要行动了！你把各路大侠召集在一起，准备正面出击。
Team members investigate the problem and perform a detailed 5-Why analysis. They start with the problem statement and ask, “Why did that happen?” repeatedly, drilling down deeper with each iteration:
小组成员研究问题，并进行详细的5个为什么分析。他们开始反复问“为什么会发生呢？”，每重复一遍问题就深入一步。
Problem: There were seven data errors in reports issued to our largest customer in the last month
问题：上个月我们最大顾客发出的报告有7处数据错误。
• Why? Because lab reports are getting in the wrong project folders.
• 为什么呢？因为把实验室报告放错了文件夹。
• Why? Because the project numbers are written illegibly on the folders.
• 为什么呢？因为项目成员把文件夹的名称写错了。
• Why? Because the customer service representatives are rushed when preparing folders.
• 为什么呢？因为客服代表着在准备文件夹时着急了。
• Why? Because there are only two representatives taking calls for all divisions.
• 为什么呢？因为只有两个客服代表面对所有部门。
• Why? Because business expanded rapidly in the past year and management neglected to re-examine the work load of the customer service representatives.
• 为什么呢？因为去年公司业务增长太快，管理层忽略了重新检查客服代表的工作量。
After 5 Whys, the team has found what it believes to be the root cause of the problem: customer service representatives who are overworked. The team takes action to remove the root cause, which is the addition of a third customer service representative. A person is quickly transferred and trained, and the action is deemed effective by objective observers. A pizza lunch follows, including a congratulatory address by the president of the company. A week later, three more reports have data errors in them. Your company is dropped by its largest customer. Everybody was certain the problem solving was effective, but it obviously wasn’t. What happened?
经过5个为什么分析后，小组已经发现了他们认为是问题的根本原因：客服代表超负荷工作。小组采取行动消除这个根本原因，增加了第三名客服代表。这个人迅速到岗，并接受培训，而且小组采取的措施被一个客观的观察员认为是有效的。然后大家同进午餐，公司总裁还发表了祝词。一周后，三个以上的报告里带有错误的数据。你最大的顾客把你撂倒了。每个人都确定问题解决程序有效，当显然是无效的。为什么呢？
Why the 5 Whys alone don’t work 为什么5个为什么分析方法不好使呢？
Asking why one time after another assumes that the problem is perfectly linear, with one cause directly related to another. If we keep asking “why?” we’ll eventually get back to the root cause. However, real problems are much more complex than this. One cause does not always lead directly to another cause. There are contributing factors and hidden variables that mess up our ingenious chain of causes. If we try to treat every problem as nothing more than the result of a single chain of causes, we’ll miss the complexity that exists in the process.
连续不断地问为什么的前提假设是问题是纯线性的，一个原因直接导致另一个原因。如果我们不断的问“为什么呢？”我们会最终回到根本原因上来。但是，实际问题远比这复杂的多。一个原因并不经常直接导致另一个原因。还有影响因素和隐藏的变量绞合在我们富有创造性的原因分析链里。如果我们试图把每个问题都当作单一原因分析链，那么我们就遗漏了过程中存在的复杂性。
The other reason that the 5 Whys is ineffective is that it focuses only on today’s causes. People enter the problem-solving process by asking, “In this exact problem that occurred, what was the chain of causes that led to it?” The 5 Whys ignore the causes of tomorrow. For problem solving to be truly effective, we can’t only consider the causes we know about now. We’ve got to consider the potential causes of tomorrow. The 5 Whys will expose some of the current causes, but it will rarely reveal potential causes. We need to consider the entire universe of causes: actual and potential, present and future, large and small, obvious and elusive. The key to uncovering this is gaining an understanding of the process that produces the problem.
另一个5个为什么无效的原因是该方法关注今天的原因。人们通过询问切入问题解决过程，询问包括：“在这个发生的问题中，是什么原因链导致问题发生的？”。5个为什么忽略了明天的原因。要想使问题解决真正有效，我们不能仅仅考虑我们现在知道的原因。我们得考虑没有潜在的原因。5个为什么可以展示某些现行的原因，但很难展示潜在的原因。我们需要考虑全部原因，实际的和潜在的，现在的和未来的，大的和小的，明显的和隐含的。揭示的关键是获得对发生问题的过程的理解
Understand the process first, and then ask why 先了解过程，然后再问为什么
To address customer complaints in a thoughtful way, we must achieve an intimate understanding of our process. I don’t mean what the process should be; I mean what the process actually is. Whatever process is involved in the complaint must be described, step by step, as it is actually happening now. Existing procedures may not be much help to us in this regard. Procedures often describe how a process is supposed to operate, without any obstacles, surprises, errors, or creativity on the part of employees, but the world deals up all of these things on a regular basis.
要想贴切地表达顾客的抱怨，我们必须对过程的理解达到耳熟能详的程度。我不想要说过程应该是什么样子的；我的意思是过程实际是什么样子。无论抱怨涉及到那个过程，必须一步一步地描述出来，就像现在实际发生的一样。在这点上，现有的程序可能提供不了多大的帮助。程序经常在纯净的条件下描述一个过程，没有任何障碍、诧异、错误，或者员工部分的创造力也没问题，但通常情况下，现实世界得面对这些所有的问题。
Put away your procedure when investigating a complaint. Instead, assemble a team of people intimately knowledgeable about the process. The people you want are the ones who actually do the work and get their hands dirty. Utilize people from different perspectives: production, quality, engineering, logistics, and purchasing. Managers should be represented also, but their perspective is often woefully uninformed about the tasks and activities taking place.
在研究抱怨时，把程序仍到一边。诚然，得把对各个过程了解透彻的人员召集起来组成小组。你要的小组成员是那些做实际工作的，两手脏兮兮的人。利用具有不同背景的人：生产、质量、工程、物流和采购。各级经理也应该到场，但不告诉他们正在进行的任务和活动。
Explain to your team that you’re working to address a complaint and you need to understand the process that results in the complaint. The team will create a flowchart for the process as it actually exists. This will lead to an exploration of causes, but only after we’ve gained an understanding of the process from start to finish. Here are the supplies you’ll need to facilitate a session:
向小组解释你要表达抱怨，你需要理解导致抱怨的过程。小组按现有方式画出过程流程图。该图将用来探查原因，当只有在外面全面理解了该过程之后。以下方法可能对你的任务有帮助：
• Flip chart 活动挂图
• Markers 记号笔
• Large sticky notes 大号告示贴
Plan on keeping your flowchart exercise very simple. Fancy symbols won’t help you understand your process any better. In fact, the only “symbol” you’ll use will be large sticky notes. Also, avoid the temptation to use a laptop computer or other electronic device to help you construct the flowchart. Creating the flowchart on a flip chart will enable all team members to crowd around and personally contribute to the process. You don’t want to introduce any barriers to the creative process. Computers, by their nature, relegate the majority of team members to observers, which is the opposite of what you want.
要使流程图尽量简单。花里胡哨的符号对你理解过程没什么帮助。实际上，你使用的唯一“符号”是大号告示贴。同样，避免使用帮你画图的笔记本电脑或其它电子设备。在活动挂图上画出的流程图可以使全体成员聚集在一起发表个人意见。在画过程图时，你不要设置如何障碍。计算机排除了大多数人的观察，而这与你的愿望相反。
If possible, tell team members a day or two in advance that they’ll be making a flowchart for the process. Ask them to think about the various tasks, activities, and decisions that are part of the process. This way they’ll be well-prepared when the session begins and the team will use its time more efficiently.
如果可能的话，提前一二天告诉小组成员，他们要画出过程的流程图。让他们思考该过程的各种任务、活动和决策。这样他们在任务开始时就都准备好了，可以更有效地利用时间。
Here are the key steps to constructing a flowchart that we can use in problem solving:
以下是我们在问题解决中使用的构建流程图的关键步骤：
• Determine boundaries. Decide on starting and stopping points for the flowchart, and keep in mind that many problems originate on the periphery of the process. Make your starting point far enough upstream in the process to capture the early planning and logistics steps. Likewise, make the stopping point far enough downstream that you capture inspection, storage, and follow-up steps.
• 设定边界。确定流程图的起止点，并记住有许多问题是在过程的外围发生。让起点起始于过程上端足够远的地方，去了解早期策划和物流步骤。同样，让止点终止于过程下端足够远的地方，去了解检查、存储和下个步骤。【流程图的画法多为从上倒下，始于上部，结束于底部——jelly】
• Identify each step in the process. Beginning at our assigned starting point, identify the first step (task and decision) of the process. Write this on a large sticky note, writing only as many words as will fit. Continue doing this sequentially for each step in the process. Decide if each is a task or a decision, and put a “T” or a “D” in the lower right-hand corner of the sticky note to indicate this. It’s also helpful to write the decision steps in the form of a question to fully differentiate them from the task steps. Encourage participation and dynamic discussion of the process as a team. Anybody who attempts to dominate the process should be gently reminded to allow everyone to take part.
• 识别过程里的每一步。起始于起点，识别过程的第一步（任务和决定）。在大号告示贴上写上足可以描述清楚的文字。对每一个步骤都按照顺序重复上述工作。决定每一步是否是项任务或决定，在记号纸的右下角写上“T”或“D” 。按问题的方式写出决定步骤（有别于任务步骤）也同样很有帮助的。鼓励与会人员发表意见讨论。要提醒那些企图主导过程描述的人，以便让每个人都参与进来。
• Arrange the steps in order. Determine the sequential order of the tasks and begin placing them on the flip chart. The first step will go at the top, with subsequent steps flowing downward. As the team begins assembling the flowchart with the sticky notes, forgotten tasks and decisions almost always spring to mind. That’s the point of using sticky notes--they can be easily moved. Add new tasks as necessary and rearrange existing tasks until everybody agrees that the flowchart accurately represents the process.
• 将步骤排序。确定任务的连续次序，并将其写在活动挂图上。第一步写在最上面，然后一步一步写下去。在小组开始用告示贴勾画流程图时，被遗忘的任务和决定经常浮现出来。这就是使用告示贴的要点——可以很容易的挪走。尽可能的增加新任务并且重新对现有任务进行排序直至每个人都同意流程图准确的表达了过程。
• Connect the steps with arrows. Connect the tasks and decisions with arrows, indicating the flow of the process. Each task has a single arrow exiting it. Each decision has two arrows exiting it, with each arrow representing a different decision outcome. Make sure to label the arrows that exit the decision boxes indicating which answer to the decision outcome that they represent. The most common labels for decision arrows are yes and no, although they can be labeled with anything that makes sense in reference to the decision required by the decision box.
• 把步骤之间用箭头连起来。用箭头把任务和决定联系起来，表明过程的流动。每个任务有单一的流出箭头。每个决定有两个流出箭头，每个箭头表示不同的决定结果。保证流出决定框的箭头贴有标签，表明决定的结果。决定箭头最常见的标签是“是”和“否”，尽管也可以是任何可以表达关于决定框需要的决议。
• Check for accuracy. No matter what kinds of preparations are made or how smart the team members are, there are bound to be errors with a flowchart. When the team is finished constructing the flowchart, verify it by “walking the process.” Take your flowchart to where the work is actually being done and check that you haven’t forgotten any steps or made errors in sequencing. Make corrections as necessary.
• 经常其准确性。无论做了什么样的准备工作，小组成员多么优秀，流程图总会有错误。当小组画完流程图时，通过模拟过程演练的方式就是确认。把流程图拿到实际工作的地方，检查你们没落下任何步骤或者次序上有什么错误。必要时进行修改。
Identify causes 识别原因
The big benefit of starting with a flowchart is that it forces us to consider the entire process, not just the parts that we know best or are most likely to be involved. The team can now begin to identify the actual and potential causes that occur at each step of the process. Start at the top of the flow diagram and brainstorm what could possibly go wrong and lead to our customer complaint. Instruct the team members to think about the following possibilities at each step:
由流程图开始的最大益处是流程图使我们关注于考虑整个过程，而不是我们最了解的部分或最有可能涉及到部分。小组现在可以识别发生在过程里每一步的实际的和潜在的原因。从流程图最顶端开始，集体讨论什么地方可能做错惹得顾客抱怨。让小组成员考虑以下每一步骤的可能性：
• Mistakes that can be made 可以产生的错误
• Confusing tasks 不明确的任务
• Incomplete instructions 不完整的指示
• Conflicting goals 前后矛盾的目标
• Communication barriers 沟通障碍
• Anything else that can go wrong 其它可以做错的地方
Cast a wide net as you speculate on causes. Hunches are OK, and no proof is needed. The spirit of this is the same as brainstorming: All ideas are treated as potentially significant, without criticism. Write each of the potential causes on the flowchart next to the steps to which they apply.
在推测原因时思路要开阔。可以用直觉，不需要证据。这样做的精髓与头脑风暴法相同：把所有想法都当作潜在的可能性，没有批评。在流程图上可能发生的步骤边上写下每个潜在的原因。
Another way to think about causes is to call them failures. Ask the question, “What failures could lead to our customer complaint?” Whether they’re called causes or failures doesn’t really matter. The point is be to as inclusive as possible, taking a full inventory of what could go wrong at each step of the process as it actually exists. At the end of the exercise, your team will have identified dozens of potential causes. Now it’s time to narrow the field.
另一个思考原因的方法是将原因称之为失效。问“什么地方的失效导致顾客抱怨？”，无论将其称为原因或失效没什么关系。要点是尽可能包容一切，列出每一步骤全部可能做错的地方，就当实际这种错误存在一样。全部做完后，小组将识别出了大量的可能的原因。现在是开始缩小范围的时候了。
Narrow the causes to the most significant 缩小范围至最重要的原因
It’s unlikely that you have the resources to act on all the actual and potential causes. That’s why you have to narrow your focus. One of the easiest ways to do this is through a multiple-voting process. Each person on the team is assigned four votes to use for what he or she believes to be the most significant causes. Team members can cast their votes anyway they wish: placing one vote on each of four separate causes, placing two votes on two causes, whatever they decide. Choose a colored marker that is different from the ones used for constructing the flowchart and writing the causes. The votes can be cast as check marks beside the causes to which they relate.
有足够的资源来演化所有实际的和潜在的原因似乎不太可能。这就是为什么要缩小关注范围的原因。最简单的方法之一是投票。给小组每个成员四次投票机会决定他/她认为最有可能的原因。小组成员可以以他们希望的方式投票：在四个不同的原因上投票，在两个原因上投两次票，等等。选有别于画流程图的另一颜色的笔写下原因。在与之相关的原因边标注投票。
After all votes are cast, the facilitator will tally up the number of votes for each cause. You’re going to take action on not one root cause, but on a number of significant causes that contribute to the complaint in question. How many causes should the team act on? There’s no magic number, but taking action on five to seven causes for relatively obvious problems and 10 or more causes for complex problems seems to work well. List the top causes, as indicated by the number of votes they received, on a separate flip chart. It’s helpful at this point to allow a brief discussion on each of the top causes. The facilitator can begin this by saying, “Who would like to say a few words about this cause?” The point is to bring everyone up to speed on each of the top causes. This builds a richer understanding of the causes and creates a basis for taking action.
投完票，主持人累计每一原因的投票数。你就对不止一个原因采取措施。小组要对多少个原因采取行动呢？不确定，但对应问题明显一般针对7到10个原因采取行动，对复杂问题针对10个以上的原因采取行动看起来比较合理。在另一张活动挂图上列出主要原因并标注投票数。此时就主要原因进行一下讨论是很有帮助的。主持人宣布开始，说：“谁愿意对这一原因说点什么？”。其要点就是鼓动大家对每一个主要原因谈想法。这会对这些原因的理解更加深入并奠定采取行动的基础。
Plan and implement action 策划并实施行动
Now we come to the most important step of all--action. Each of our top causes must be matched with an action that will remove it or reduce it to an acceptable level. The team will consider each cause in turn and agree on an action for it. Here are the specific variables that should be identified:
现在我们到了最重要的步骤——行动。每个主要原因必须配以行动，使原因被消除或减少到可以接受的程度。小组将考虑依次考虑每个原因，并同意对其采取行动。以下是应该识别出来的变量：
• Action to be taken. Be as specific as possible in defining the action to be taken.
• 要采取的行动。在确定要采取的行动方面要尽可能的明确细节。
• Responsible party. Who will lead the implementation of the action? Preferably, each action should be assigned to someone who has participated in the problem-solving session. Team members are invested in the process, due to their involvement up to this point, and they have an understanding of the process variables.
• 责任方。谁领导行动的实施？最好每个行动的责任人为参加问题解决小组的成员。由于他们的参与，小组成员对过程变量有很好的理解。
• Required resources. List the money, people, supplies, time, and other resources that will be required to carry out each action.
• 所需资源。列出资金、人员、供应、时间和其它执行行动所需的资源。
• Expected completion date. State when the team believes that the action can be completed. Because you’re striving to assign actions to team members, you can get commitment from each responsible party on the completion date.
• 希望完成的日期。规定小组认为那个行动可以完成的时间。因为你力争把行动分配给小组成员，你就可以从责任方那里得到完成日期的承诺。
Agree on a date when the team will reconvene and review the progress on action items. Let it be known that top management will be present during the review meeting. This will highlight the importance of making progress on the assigned actions. Team members don’t want to appear remiss in front of their peers, but they’re mortified to appear remiss in front of top management. Visibility and accountability ensure that nobody drops the ball.
商定小组重新开会和评审行动进展的日期。让小组知道最高管理层将出席评审会议。这将强化行动取得进展的重要性。小组成员不想在他们同等人面前表现出玩忽职守，但在最高管理层面前表现出玩忽职守会让他们感到羞辱的。
Keep your customer abreast of the progress you’re making on the complaint. Because the actions were triggered by customer feedback, it only makes sense to provide some feedback of your own. “Here’s what we’re doing to improve our service to you,” sends a powerful message. It also cements the organization’s commitment to follow-through on the actions being implemented. The ultimate result of the entire process I’ve described is to create customer loyalty. Focusing on the entire process when attacking customer complaints, instead of just asking 5 Whys, will achieve this.
让顾客同步知道对抱怨所取得的进展。因为由顾客反馈信息所引发的行动，只有在你自己提供某些反馈时才有意义。“这是我们正在做的改善对你的服务”，发出一封强有力的信息。这也会强化组织对就正在实施的行动进行到底的承诺。我所描述的整个过程的最终结果产生顾客忠诚。当处理顾客抱怨时关注于整个过程，而不是仅仅问问5个为什么，就会达到顾客忠诚度提高的目的。
From Craig Cochran
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