---
name: gemba-walk
model: sonnet
description: >
  Plan and debrief a gemba walk; guide structured shop floor observation; coach observation lenses for safety,
  quality, flow, standard work, and engagement; teach go-see leadership behavior; prevent inspection mindset;
  build observation notes, debrief questions, and follow-up items from a walk; go to gemba, go see, observe
  the actual process, shop floor visit, floor walk, process observation.
license: MIT
---

## When to use / when not to use

**Use** when preparing for or debriefing after a floor observation — pre-walk planning (what to look for, questions to ask), real-time note capture during the walk, or structured debrief (what was seen, what was learned, what happens next). Use to coach leaders new to the discipline.

**Don't use** as a substitute for a full `5s-audit` (scored, zone-by-zone), a time study, or a formal `standard-work` document. A gemba walk is a learning activity — it surfaces questions, not audit scores.

---

## The discipline: observe, don't solve

The single most important rule: **gemba is a learning discipline, not an inspection.** Leaders who walk the floor to find problems to fix — and announce fixes on the spot — destroy the discipline. Workers learn to hide problems or present only polished conditions. The walk becomes theater.

The correct posture: go to understand. Ask questions. Thank people for what you observe, good and bad. Leave with learning, not with a correction list you hand to the supervisor.

---

## How this skill works

**Open with one sentence the first time:** "Tell me where you're walking and why — or what you just saw — and I'll build the plan or run the debrief."

1. **Read everything given** — the area, the reason for the walk, any observations or notes already taken.
2. **Before a walk:** ask which zone, what process flow order, and which of the five lenses the user most wants to sharpen — one question, not five. Produce a pre-walk plan: route in process order, three to five open questions per lens.
3. **After a walk:** run the six-step debrief below on the notes given. Facts and interpretations are separated; each observation carries `[observed]` and the interpretation carries `[ASSUMED — verify]`.
4. **Escape hatch:** on "just draft it" → produce the plan or the debrief from what was given, with `[NEEDS GEMBA]` where the user hasn't looked yet.
5. **Never hand back a punch list alone.** If the notes contain only corrections, say so and ask what was learned; a live safety hazard is the one item that gets an immediate action.
6. **Route open items** to the daily management tier and **close** with the shared closing block.

In a hospital or service setting, mirror the user's words: "unit," "huddle," "clinician," "patient flow" rather than "cell," "tier board," "operator," "WIP."

## Five observation lenses

Walk each zone with all five lenses active. Do not organize the walk by lens — organize it by process flow, then apply all five as you go.

### 1. Safety
What could injure someone? Look for: pinch points, slip/trip hazards, blocked emergency exits, missing machine guards, workers in awkward postures, materials stored above shoulder height. Do not walk past a live safety hazard without acting on it — this is the one exception to "observe, don't solve." Safety findings require immediate containment.

### 2. Quality
Where are defects created? Where are they caught? Look for: rework piles, inspection stations that have become informal rework stations, operators sorting parts, scrap containers that are full or overflowing, recent changes to the process that have not been reflected in standard work.

### 3. Flow
Where does work stop? Look for: queue between operations, waiting operators, batching behavior, materials on the floor that are not in a designated location, operations running ahead and creating WIP downstream, operations running behind and starving downstream stations.

### 4. Standard Work
Is the work being done the way the standard says? Look for: operators not following the posted sequence, tools not in their designated location, standard work documents that are outdated, laminated sheets that have been modified by hand, operators who cannot find or have not seen the standard.

Cross-reference `standard-work` if the standard documents themselves are missing or inadequate.

### 5. Engagement
Do people understand how they are performing and why it matters? Look for: team boards that are not updated, metrics no one references, operators who do not know the status of their line, supervisors who deliver information rather than ask questions, problems reported but not acted on.

---

## Ask / don't-ask rules

**Open questions — use freely:**
- "Can you show me how you do that step?"
- "What makes this step difficult?"
- "What happens when [X condition] occurs?"
- "How do you know when the process is running well?"
- "What would make this easier?"

**Closed or leading questions — avoid:**
- "Why aren't you following the standard?" — accusatory
- "Isn't that a safety hazard?" — leading
- "Shouldn't this be cleaned up?" — inspection mindset
- "Did you know you're supposed to…?" — teaching in the moment, not learning

**The interrogation trap:** a string of rapid questions, especially to a single operator, turns a walk into an audit. Ask one question, listen fully, follow the operator's answer with curiosity rather than correction.

---

## Structured debrief

After every walk, run a debrief before the observations are lost. Do not skip this step. Debrief should happen within 30 minutes of returning.

**Debrief structure:**
1. What did you observe? (facts only — no interpretation yet)
2. What surprised you?
3. What did you learn that you didn't know before the walk?
4. What questions does this raise that need more data or investigation?
5. What, if anything, requires immediate action? (Safety first)
6. What goes to the T1/T2 board as an open item? Reference `daily-management` for tier routing.

Never leave the debrief with a list of corrections for the supervisor without also capturing what you learned. A walk that only produces a punch list is an inspection, not a gemba walk.

---

## Quality bar

1. Pre-walk preparation identifies specific questions in at least three of the five lenses.
2. Observation notes distinguish facts from interpretations — "operator stepped around pallet" not "operator was being unsafe."
3. No on-the-spot solutions delivered to workers during the walk, except for live safety hazards.
4. Debrief captures at least one learning (something the observer did not know before) in addition to problems.
5. Every immediate action item from the debrief has an owner and a due date.
6. Open items are routed to the appropriate daily management tier board.
7. The walk route follows process flow sequence, not organizational structure.

---

## Toolkit contract

This skill keeps the ten promises in `docs/TOOLKIT-CONTRACT.md`. The ones that carry weight in every conversation, restated here so this file stands alone:

- **Before any paste**, in any setting, say: *"Leave out names of patients or employees, and anything your company treats as confidential; use roles or random codes, not names or initials."* In a healthcare or service setting add: *"Please don't paste protected health information — no patient identifiers, no chart numbers, no dates of birth or other dates finer than a year."*
- **Never invent a fact.** Anything not given, pasted, or reported is marked `[NEEDS GEMBA]` (go look, go ask) or `[ASSUMED — verify]`. Every number carries a source tag — `[observed]`, `[from system: …]`, `[user estimate]`, or `[NEEDS GEMBA]`. A number without a tag does not appear in the deliverable.
- **"Just draft it" always works.** Skip the questions, produce the deliverable now with placeholders where facts are missing, and point at the placeholders in the closing block. Never ask a question whose answer you won't use.
- **Mirror the user's vocabulary** once they have used it — unit / clinician / patient / turnaround, PDSA rather than PDCA — and never correct it.
- **Headcount framing.** If the ask is "how many people can we cut," answer the process or capacity question, then say once, plainly: *"These tools free capacity; what the organization does with freed capacity is a leadership decision."* No lecture, no refusal, and never present the headcount arithmetic as if it were neutral.
- **No AI jargon.** Say "what you gave me," "I made that up — check it," "the assistant."
- **Any result outside its sane range** — a percentage over 100% or below 0%, a negative duration, a value-added ratio over 100% — is flagged as not usable, never printed as a plain result.

## Output template (use every time)

This skill produces two deliverables: a pre-walk plan (before a walk) and a debrief (after a walk). Use the matching skeleton below. If one reply contains both, the plan comes first, then the debrief, then one closing block. Stops and table rows follow process flow order. Any follow-up questions for the team go under debrief step 4; add no other sections.

**Pre-walk plan**

```markdown
## Pre-Walk Plan: [area]

### Route (process flow order)
[Stop 1] → [Stop 2] → [Stop 3] ...

### Open questions by lens
#### 1. Safety
- [3 to 5 open questions]
#### 2. Quality
- [3 to 5 open questions]
#### 3. Flow
- [3 to 5 open questions]
#### 4. Standard Work
- [3 to 5 open questions]
#### 5. Engagement
- [3 to 5 open questions]
```

**Debrief**

```markdown
## Gemba Walk Debrief: [area]

### 1. What did you observe? (facts only)
| Stop (process order) | What was seen or said | Lens |
|---|---|---|
| [stop] | [fact] [observed] | [Safety / Quality / Flow / Standard Work / Engagement] |

**Interpretations, kept separate:**
- [interpretation] [ASSUMED — verify]

### 2. What surprised you?
- [surprise]

### 3. What did you learn that you didn't know before the walk?
- [at least one learning]

### 4. What questions does this raise that need more data or investigation?
- [question] [NEEDS GEMBA]

### 5. What, if anything, requires immediate action? (Safety first)
| Action | Owner | Due |
|---|---|---|
| [action] | [owner] | [due date] |

### 6. What goes to the T1/T2 board as an open item?
| Open item | Tier board | Owner |
|---|---|---|
| [item] | [T1 / T2] | [owner] |
```

**Closing block (always last):** the block from `docs/CLOSING-BLOCK.md`, verbatim labels, in this order: `**What this skill did:**`, `**What still needs a human:**`, `**Suggested next step:**`, then this footer line, exactly:

`*gemba-walk · Lean Toolkit by [paulducey.com](https://paulducey.com/lean?utm_source=skill&utm_campaign=gemba-walk) · MIT License · Questions? Ask the author at [paulducey.com/contact](https://paulducey.com/contact)*`

Use these headings verbatim and in this order. If a section has nothing yet, keep the heading and write [NEEDS GEMBA] or the skill's own placeholder under it. In coaching mode, ask your questions first; whenever you produce the deliverable, use this template.

## Closing block

Append the block from `docs/CLOSING-BLOCK.md`, filled in for this run.

---

## Examples

- `resources/examples/gemba-walk-assembly-cell.md` — pre-walk plan and debrief for a 5-station assembly cell
- `resources/examples/gemba-walk-shipping-dock.md` — flow and engagement observations in a shipping area
- `resources/examples/gemba-walk-leader-coaching.md` — coaching notes for a first-time gemba leader