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Recommended Posts: Standardized Work Instructions - Cease Mass Inspection for Quality - Visible Data - Evolution of the PDSA Cycle
Related: Management Improvement Tools Explained - 7 basic quality tools - PDSA - Control Chart - 5s - Kanban - Flowchart...
Verify your work with checklists
If a checklist so simple can save so many lives, I thought the technique could surely help us do better as well. So after reading about this study and their checklist, I’ve been pushing us to create checklists for all the common procedures at 37signals.
We now have checklists in Backpack for confirming that a feature is complete, we have a checklist for preparing the feature for deployment and for executing the deployment, and finally for verifying that the feature is working as expected in the wild.
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It’s the kind of stuff that we all know, but that we’ll often forget if we’re not being reminded about it in the moment. Thinking back to the mistakes we’ve made in the past, there are plenty of those that could have been avoided or caught much earlier if we had been using checklists.
This is a great reminder of two things: using checklists and adopting good ideas. Checklists are a simple and effective quality management tool. We use them for our software development (I have been a bit slow at getting them in place but we have been making progress recently). Also this shows how management improvement should work. You get good ideas from others and adapt them for use in your systems. Copying what others do, doesn’t work well. But understanding the concepts they use to improve performance and then adapting those concepts to your organization is the path to improved performance.
Related: Checklists Save Lives - Find Joy and Success in Business - Lean, Toyota and Deming for Software Development - The Power of a Checklist - Most Meetings are Muda
Combinatorial testing of software is very similar to the design of experiments work my father was involved in, and which I have a special interest in. Combinatorial testing looks at binary interaction effects (success or failure), since it is seeking to find bugs in software, while design of experiments captures the magnitude of interaction effects on performance. In the last several years my brother, Justin Hunter, has been working on using combinatorial testing to improve software development practices. He visited me this week and we discussed the potential value of increasing the adoption of combinatorial testing, which is similar to the value of increasing the adoption of the use of design of experiments: both offer great opportunities for large improvements in current practices.
Automated Combinatorial Testing for Software
Practical Combinatorial Testing: Beyond Pairwise by Rick Kuhn, US National Institute of Standards and Technology; Yu Lei, University of Texas, Arlington; and Raghu Kacker, US National Institute of Standards and Technology.
Related: Future Directions for Agile Management - The Defect Black Market - Metrics and Software Development - Full and Fractional Factorial Test Design - Google Website Optimizer
Lynda Finn, President of Statistical Insight, has written an article on how to create a control chart for seasonal or trending data (where there is an underlying structural variation in the data). Essentially you need to account for the structural variation to create the control limits for the control chart. She also provides a Minitab project file. Both are available for download from the Curious Cat Management Improvement Library.
Related: Control Charts in Health Care - Common Cause Variation - Managing with Control Charts - Measurement and Data Collection - Fourth Generation Management
The popular ER TV show highlighted the importance of using checklists in surgery yesterday.
Such powerful quality tools, like the checklist, are just waiting to be used. But far too many fail to use these simple improvement tools. And in health care those failures are potentially critical.
Related: Checklists Save Lives - The Power of a Checklist - management improvement dictionary - Articles on Improving the Health Care System
Jeff Bezos and Root Cause Analysis by Pete Abilla
Using quality tools really works. Lots of people don’t use them. Improving is often not any more difficult than just applying tools that have been used for decades. Improving does not require rocket science. Just do the simple things and you are well on your way to great success. Of the 10 stocks in my original 10 stocks for 10 years post Amazon is one of 4 that are up.
Related: Bezos on Lean Thinking - Amazon Innovation - Bezos Webcast on the Internet Boom - Improvement Tools and Improving Management - Root Cause Analysis - European Blackout is Not “Human Error”
Checklists are a simple quality tool that have been used widely for decades. Pilots use them, without fail, to save lives. Some surgeons have been using them and the evidence is mounting that checklists can save many more lives if more in health care use them. Studies Show Surgeons Could Save Lives, $20B by Using Checklists
If all hospitals used the same checklist, they could save tens of thousands of lives and $20 billion in medical costs each year, says author Atul Gawande, a surgeon and associate professor at the Harvard School of Public Health.
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In his study, which was funded by the World Health Organization, hospitals reduced their rate of death after surgery from 1.5% to 0.8%. They also trimmed the number of complications from 11% to 7%.
The study shows that an operation’s success depends far more on teamwork and clear communication than the brilliance of individual doctors, says co-author Alex Haynes, also of Harvard. And that’s good news, he says, because it means hospitals everywhere can improve.
Researchers modeled the checklist, which takes only two minutes to go through, after ones used by the aviation industry, which has dramatically reduced the number of crashes in recent years.
This is more great evidence of the value of applying simple management tools that are already well known. The idea that improvement takes brand new breakthrough ideas is just plain wrong.
Related: Using Books to Ignite Improvement - The Power of a Checklist - New, Different, Better - Management Improvement History and Health Care - Open Source Management Terms - Fast Company Interview with Jeff Immelt
I moved from management improvement work into information technology work (where I continue to practice management improvement). Many IT practices follow quality management guidelines well (agile software development for one).
I have found it far easier to design and provide software solutions than convince people to change their processes directly. I found it funny that as I delivered new IT solutions, in which was embedded a redesign of the process, those changes were often accepted without any significant debate. But the same changes that I tried to implement without a new IT solution had been impossible to make progress on (all sorts of reasons why it couldn’t be done were raised).
I strove, and believe I succeeded, to implement software solutions in a manner consistent with management improvement concepts. I started doing so in areas where I had been working and I was designing software tools based on my intimate knowledge of the system. And in doing so I tried to use an iterative approach (and the concepts of PDSA, though not really formally doing PDSA) involving those who were actually working in the business system. So I am not talking about just plastering in some IT solution from headquarters on the other side of the continent.
Too often organizations fail to invest enough in IT. The IT department is staffed merely to do what others request (and often not even provided the resources to do that). So then the executives can get what they need from IT. Others can get IT to respond if the manager can elevate the issue and explain how important it is that they get some support. But in general, all sorts of obvious improvement opportunities are wasted because the resources to carry them out are just not available.
In my opinion many organizations would benefit from increasing the resources to IT and shifting the focus from passive supplier to active participant in using information technology to meet business needs. This requires staffing IT with some people that are able to work with others to determine business needs and then determine the best IT solutions and then deliver those solutions. I have found many IT people are well suited to this role (though not all - which is fine those that prefer to focus on technical implementation can do so).
Another reason this often makes sense is how integral IT is to the functioning of the company. Expertise is technology is often very important today (and it is often missing). And getting your proactive quality experts working closing with IT will help them provide more value.
This post presents some thoughts in response to: Does anyone see value in merging Quality and Information Technology departments into a Business Process Management department?
Related: Software Supporting Processes Not the Other Way Around - Information Technology and Management - Using Quality Management Principles to Develop an Internet Resource by John Hunter, Jun 1999 (pdf)
Response to LinkedIn question: “Whether Six Sigma as a quality tool really delivers the benefits ? How does it makes difference from a common sense approach ? (Where the process wastes and the required solution is known / can be easily identified just by applying common sense)”
Six sigma (or another management improvement method) can help in several ways. First, lots of things that are sensible are not done. A method to assure that more sensible things are done is useful.
Second, many things are sensible, but are not sensible when looked at in isolation (sub-optimization). Six sigma can (not does, can - sometime this won’t happen) assist those in the organization to evaluate from a larger context than they normally do. So instead of say the IT department forcing everyone to use some poorly designed software because it is the cheapest thing for the IT department to support the added costs to the rest of the organization are more fully considered.
Third, many things that are sensible are not evaluated based on their sense but instead based on internal politics… A standard methodology can help focus people on the merits of a proposal instead of who said it (again six sigma can do this, often it fails as the organization continues to cling to old patterns of power over sense).
Fourth, many of the tools, go beyond what sensible people alone see (design of experiments, understanding variation, PDSA, systems thinking, root cause analysis). Using the tools can often lead to valuable discoveries that were not obvious without using the tools.
If the solutions were obvious why were they not done last year? It is true that there are often plenty of simple improvements waiting to be adopted because management has done such a poor job that obvious improvement are left undone. But once sensible management is in place, eventually those obvious improvement will be done and a more structured approach to finding improvement is valuable. Even simple concepts like letting those that work on the process improve the process are often ignored by organizations (even those saying they are doing six sigma, unfortunately). So I see a strong value in adopting management improvement principles and tools.
Related: Management Advice Failures - Improvement Tools and Improving Management - Six Sigma Pitfalls - Why Isn’t Work Standard? - European Blackout: Not “Human Error”
Illustration of how 2-Bin Systems work, by Bill Hanover.
Related: Overall Equipment Effectiveness (OEE) video by Bill Hanover - Messiness is Bad - Drum-Buffer-Rope Example - lean manufacturing resources
ValuMetrix Services provides some really nice lean six sigma case studies. Simple short but still with enough detail to actually provide some sense of what is going on.
While on the topic of online case studies let me plug the Curious Cat management improvement library. I think it is one of the more valuable resources for management improvement offered on the Curious Cat sites. Library shelves: health care articles, lean manufacturing articles, six sigma articles, newly added articles…
via: Daily Kaizen
Related: Curious Cat Management Search - Management Consulting, what does the web site show? - Lean Management Case Study
I am reading a fascinating book by Jessica Snyder Sachs: Good Germs, Bad Germs. From page 108:
This is a great example of a positive special cause. How would you identify this? First you would have to stratify the data. It also shows that sometimes looking at the who is important (the problem is just that we far too often look at who instead of the system so at times some get the idea that it is not ok to stratify data based on who - it is just be careful because we often do that when it is not the right approach and we can get fooled by random variation into thinking there is a cause - see the red bead experiment for an example); that it is possible to stratify the data by person to good effect.
The following 20 pages in the book are littered with very interesting details many of which tie to thinking systemically and the perils of optimizing part of the system (both when considering the system to be one person and also when viewing it as society).
I have recently taken to reading more and more about viruses, bacteria, cells, microbiology etc.: it is fascinating stuff.
Related: Science Books by topic - Data Can’t Lie - Understanding Data
Does Your Product Or Service “Just Work”? By Jim Kukral
There is truth to that statement. I think largely due to how bad so many products are - that they don’t actually work. The Kano model of customer satisfaction is an excellent way to view customer expectations.
The Kano model states that you have expected quality - it just does what it needs to (what is expected). Then more is better type - give me more at the same price and I am happier. But where you really want to get as a company is products and services that delight customers.
When you are delighted you are not easy prey to other companies. When you are satisfied you are ready for offers that say we will give it to you a bit cheaper or give you a bit more. But if you are delighted you don’t want to leave and instead are telling everyone you know how great this product or service is.
I think it might be that in many cases now people are delighted if things just work. Perhaps they have become so disillusioned that something actually working is delightful - I think there is real truth here. Which shows how much room there is to improve. It is such a huge bother to deal with junk that doesn’t work and the thought of dealing with the lousy service on such failures is enough to drive them to tears.
Related: What Job Does Your Product Do? - Quality Customer Focus - Ritz Carlton and Home Depot - Good Customer Service Example - Seven Steps to Remarkable Customer Service - More Bad Customer Service Examples 
This does a great job of explaining what you need to know clearly. While this presentation for Azithromycin doesn’t prevent a mistake it sure makes it much more likely that the process can be completed successfully. We need more effort in creating such clear instructions.
Visual clarity is more important than lots of words. Applying that concept is not as easy as it sounds but it is a very important idea for instructions to end use and instructions for processes in your organization. Expecting people to read much is just setting yourself up for failure when they don’t bother (you should consider psychology, and how people will actually use your instructions not how you want them to).
via: Prescription UI
Related: Using Design to Reduce Medical Errors - Visual Instructions Example - Visual Work Instructions - Standardized Work Instructions - Health Care Pictographs - 5s - Edward Tufte’s: Envisioning Information
Great article on The Checklist - If something so simple can transform intensive care, what else can it do? by Atul Gawande
Related: Why Isn’t Work Standard? - Visual Work Instructions - posts on quality tools - European Blackout not Human Error-Not
Edwards looks toward future of testing
In a recent Benefield Anechoic Facility test, the 412th Electronic Warfare Group used Design of Experiments methodology to cut a two-month program to three weeks. This schedule reduction translated directly into savings and helped reduce the concept-to-fielding cycle time while still ensuring the system was thoroughly tested. While building these capabilities is critical, the most critical piece of the puzzle is our people. We must continue to develop engineers, pilots, navigators, program managers and maintainers to test these systems and “find stuff so the warfighter doesn’t.”
It is hard to tell if they really are using Design of Experiments or just using the term but it seem possible they are really using it. As I have said a number of times it is a powerful and under-utilized tool for improvement. Related: Using Design of Experiments - design of experiments articles - posts on public sector management - Why Use Designed Factorial Experiments?
The Toyota Secret: Constant Change And Growth by Norman Bodek
Great article. Kaikaku by Bodek. via New Norman Bodek Article
Related: Lean Podcast with Bodek - Change is not Improvement - What Is Muda? - lean management resources - Curious Cat management articles
Tools are just tools by Lee Fried
Great post. Great goal; and quite a challenge. My personal belief is while you are trying to make this change (which takes years) to become an organization that acts as a system you must balance education (an investment - one of the best forms of investment often) and improvements gains today (both are needed). And just applying tools effectively can often provide nice gains today (with the right guidance and proper restraint).
Often the two go hand in hand - there is little more educational than actually participating in using quality/lean/improvement tools and concepts to solve your own problems. That is the best way for managers to learn about lean thinking. But I think when you see this dual role of current improvement efforts it changes your measure of success - not just measuring improvement for today (or improvements in the value stream that will pay dividends for years) but also valuing the new knowledge gained by the participants. I have never been able to quantify the benefit of the education but that doesn’t bother me.
Related: Systemic Improvement - Encourage Improvement Action by Everyone - Keeping Track of Improvement Opportunities - Search management improvement sites selected by Curious Cat
From lean tools to lean management by Jim Womack:
Only management by science through constant experimentation to answer questions can produce sustainable improvements in value streams. ( Toyota’s A3 is a wonderful management tool for putting science to work.)
He is right. The tools are useful. The much more significant changes are in the management suite not on the shop floor (or cubicle farm). Even on the shop floor there is room for huge amounts of improvement. In the c-suite I don’t know how to explain the amount of work left to do. Lets say this - there is much much much more improvement left to do than has been done so far.
Related: articles by Jim Womack - Deming on Management
IRA Toyota - Milford; Great Service
The slickest part of the wizard was the capability to pick a service and schedule a date. Depending upon what service you picked, the calendar changed. This wasn’t any old calendar. This was dynamic. Clearly, they had predefined the capability of handling some number of services per day. It was likely also interactive depending upon what was already scheduled for that day. This all makes wonderful sense but I had not seen this before.
I went ahead and scheduled the service for Monday AM planning to drop the car off Sunday night. Saturday, we received an email reminding us of the service scheduled for the car. Sunday, Allison and I drive over to their location, pull into the lot following the “Service” sign and find lanes specially marked for night drop off. There were already some cars in the lanes so we found a spot. The box on the wall had a pen and several forms. We filled out one and put the keys in the envelop through the clearly marked “key drop” slot. This group has figured out service and seems to have thought of everything. The drive home continued the conversation on how well they have planned for service; web site wizard, email reminders, lanes for drop off, etc. Well done!
I think the lean folks will like the level loading the dynamic calendar facilitates (and all the other ways the process provided value to the customer). This strategy levels the load by pushing around demand a bit (rather than just accommodating whatever demand exists - real world conditions can make this the correct strategy). For example, if special machines are needed for certain jobs and the long term demand supports one of each such machine and if you can adjust the flow to level out the demand doing so is a good strategy. As this example shows, customers have flexibility in scheduling preventative maintenance; therefore take advantage of that in your system design.
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Every so often an article appears discussing the need to change focus from process improvement to innovation (and recently they are followed with quite a bit of blog talk). I disagree on several grounds. First you have needed to focus on both all the time. Second, it is not an either or choice. Third, the process of innovation should be improved.
I do not believe process improvement is bad for innovation. Bad process changes can be bad for innovation. But if we are looking at a research and development organization where the output is new products then process improvement would be focused on improving the processes to make that happen. The type of process improvement would be different than those made to manufacturing a product better.
Some six sigma efforts are little more than cost cutting efforts. And those efforts might claim a “process improvement” that is really just cutting costs in R&D. But we should not confuse bad management with the good practice of process improvement. Yes, cutting costs for the sake of cutting costs often leads to problems. Waste should be eliminated (which can reduces cost). Focus on eliminating waste. Eliminating waste in innovation activities is no worse than eliminating it anywhere. It might be more difficult to determine what is waste (that is where management skill and knowledge come into play) but the idea that process improvement (including eliminating waste is bad for innovation is something that should be rejected). And process improvement in innovation should not be limited to eliminating waste.
A good example of process improvement in innovation activities: Fast Cycle Change in Knowledge-Based Organizations (pdf format) by Ian Hau and Ford Calhoun, published by the Center for Quality and Productivity Improvement, University of Wisconsin - Madison.
Related: Better and Different - New Rules for Management? No! - Quality and Innovation - “New” Management Needs - Management Advice Failures
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