Tag Archives: continual improvement

Rethinking or Moving Beyond Deming Often Just Means Applying More of What Dr. Deming Actually Said

Don Reinertsen – Is It Time to Rethink Deming? from AGILEMinds on Vimeo.

I feel very strongly about the value of Deming’s ideas. I am glad people challenge those ideas and try to push forward management thinking. Helping us manage organizations better (to get better results and allow people to better enjoy their jobs and lives) is why I value Deming’s ideas. To the extent we find better ideas I am very happy. I understand I will disagree with others on the best ways to manage, and believe healthy debate can be productive.

What Don Reinertsen discusses in the video, about special and common cause is not the best way to look at those ideas, in my opinion (though I would imagine it is the most common view). For data points that are common cause (within the control limits and not a special cause pattern) it is most effective to use common cause tools/thinking to improve. For indications of special cause (points outside the control limits or patterns in the data, such as continually increasing results that indicate a special cause) it is most effective to use special cause tools to improve.

This does not mean that a point outside the control limits is caused by a special cause (also know as assignable cause). It is just best to use special cause tools and thinking to address those data points (and the reason this is true is because it is most likely there is an assignable cause). The control limits do not define the nature of the point, they define the type of improvement strategy that should be used.

Don also says repeatedly that you don’t “respond to random variation” in Deming’s view. That is accurate. But then he implies this means you don’t address system performance, which is not. You work on improving systems (that are in control) by improving the system, not by responding to individual common cause data points (random variation) as if it were assignable cause variation.

The purpose of the control chart (that Shewhart developed) was to help you most effectively take action (knowing if special cause thinking, or system improvement, was the best improvement strategy). The control chart shows if the results are in control and tells you that the system is preforming consistently (and identifies a special cause so special cause tools can be used immediately, this is important because special cause improvement strategies are time sensitive). It tells you nothing about if the results are acceptable.

Continual improvement was also central to Deming’s management philosophy (based on the business value of the many improvement options available in every organization). For Deming this meant working on improving the system, if the results are in control, instead of trying to deal with finding a specific assignable cause for one data point and acting on that. If the issue is one of the system performance (no indication it is a special cause) the most effective strategy to get better results is to improve the system, rather than approach it as a special cause issue (examining individual data points, to find special items in that event to be improved). You can use special cause thinking, even where system improvement thinking would be better. It will work. It is just not very effective (improvement will be much slower) compared to focusing on system improvement.

I agree with Don that the United States mentality, not only in nuclear plants but everywhere, is to apply special cause thinking as the strategy for process improvement. This is one the areas Deming was trying to change. Deming, and I, think that setting your improvement strategy based on a common cause (system improvement) or assignable/special cause (learn what is special about that one instance) is the most effective way to achieve the best results. We believe in continual improvement. We believe that the effective way to improve, when a system is in statistical control, is by focusing on the whole systems (all the data) not assignable cause (special cause) thinking where you look at what is special about that bad (or good) individual result.

The economic consideration of whether the costs of improvements are worth the benefit is sensible (and I do not see Dr. Deming arguing against that). That is separate from the best method to improve. For Deming the best method to improve means using special cause thinking for assignable cause issues and common cause thinking for systems issues.

The idea of where to focus improvement efforts is not something Dr. Deming made as clear as he could have, in my opinion. So I see the argument of Deming not prioritizing where improvement should occur voiced occasionally. This is a weakness in Deming’s content, I believe, more than his philosophy (but I can understand it causing some confusion).
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Management Blog Posts From October 2006

I have selected a few posts from the Curious Cat Management Blog back in October 2006 for those of you who were not reading this blog then.

  • Why Pay Taxes or be Honest – “I don’t think acting illegally, immorally, unethically is excusable just because lots of other people are… It is sad how bad the behavior is that is considered acceptable.”
  • Hiring the Right Workers – “The job market is an inefficient market. There are many reasons for this including relying on specifications… Hiring is one of the area I think we could use some real innovation. I think much more flexibility would help.” I don’t feel as though any real progress has been made on better hiring in the last 4 years.
  • Righter Performance Appraisal – I know it is a silly title, but it is still one of my favorite blog post titles 🙂
  • photo of Longwood Gardens

    Longwood Gardens. Delaware by John Hunter.

  • Deming Institute Conference: Tom Nolan – there are many important elements to managing well. Turning the PDSA cycle quickly is close to the top of those elements.
  • Google Shifts Focus – “Now that they have a bunch of decent, but not really great products, adjusting and taking the opportunity to improve those product makes sense.” You might think this is about the new initiatives Google’s new CEO, Larry Page, has been discussing but it isn’t. It is about one of Google’s previous efforts to focus and eliminate less important “distractions.”
  • Simple Cell Phone – “I don’t think these features are only desired in poor countries, but I am not basing that on any market research just my opinion. Complex devices with many points of failure (both technical failure and user inability to figure it out) should not be the only option.

Engage in Improving the Management System

To actually improve management you need to engage in continual improvement of your management systems. This requires doing the hard work of challenging complacency. The job of those improving the practice of management is not to make everyone happy and just ignore that the words about improvement are not actually carrying through to changes in behavior.

Do Executives “Get It?”

So many times executives spout the importance of new initiatives like wellness programs, safety programs, or improvement projects like Lean, Six Sigma, etc. They talk about how great they are and how everyone should embrace them so the company can improve, but when push comes to shove, their actions indicate they really don’t believe in them.

If you are trying to bring about change you need in-process indications of actual success at improving the management system. Instead it seems to me, most of the time, the focus is on spinning what is being done to convince others that what is being done is good. This is not helpful and not useful.

Without in-process indications of how the movement to a better management system is performing the pattern is all too common. People want to show they are doing a good job (which often includes not being too negative – because if they criticize results they can be branded as negative). So instead we end up with actions that would be used if one assumed that while we had problems with the last 4 management fads we implemented, now we have this wonderful new idea it will avoid all the problems.

So we start our new process, and write up reports and presentations for meetings talking about our successes. We are careful to ignore any warning signs. Then, after 1, 2… years (in a good economy this can last quite a bit longer), the boss says the results are not improving, this isn’t working. Everyone quickly agrees and the improvement effort is dropped. Usually there will be a period of time taken until and a new fad is found that everyone agrees is wonderful for 2-5 years until they then all agree was a failure. Repeat for the rest of your career.

To break this cycle and actually continually improve we can’t go along with the in-process indications that the management improvement system is not really working. We need to seek out indications that it is not working and address those issues and build a strong continually improving management system.

Related: Management Advice Failuresflavors of management improvement effortsmanage what you can’t measureFederal Government Chief Performance Officer (a specific example of the repeated failure to improve), just pretending the failures in the past didn’t exist doesn’t help the current effort

Why Lean is Different


Why Lean is different by Operae_Partners

Short webcast by Michael Ballé discusses what makes lean manufacturing different: going to where the work is done, standardize processes (from the gemba view), practice respect for people and continually improve. Lean thinking focuses on achieving better results and through that process improves trust and teamwork internally, as well as better supplier and customer relationships.

Related: Non-technical Control Chart WebcastMihaly Csikszentmihalyi: Creativity, Fulfillment and Flowlean management, books, articles…

Quality is Made in the Board Room

Dr. Deming stated “Quality is made in the board room,” page 202 Dr. Deming: the American who taught the Japanese about quality. I believe, once the board and executive leadership has put in place the right management system (one that respects people, continual improves using a standardized improvement process (that itself is being improved), practices evidence based management, focuses on customer value, improves processes rather than blames people, builds the capacity of the organization over time…) then quality is everyone’s responsibility.

Executive leadership can’t do it themselves. Making it everyone’s responsibility after the system allows everyone to participate effectively is sensible. That does not, in any way, excuse blaming those stuck in a bad system for failures they didn’t heroically overcome.

Continuing from the quote from Deming above:

A worker can deliver lower quality, but she cannot deliver quality better than the system allows…
Exhortations not only have no long-term effect, but eventually they backfire

Related: The Two Pillar of the Toyota Way: continuous improvement and respect for peopleDr. Deming on ManagementBooks on Applying Deming’s ideas

Learn by Seeking Knowledge – Not Just from Mistakes

Being open to new ideas and new knowledge is what is needed to learn. Experimenting, seeking out new knowledge is even better.

You can be successful and see an even better way to do things and learn from it. This seems the best way to learn to me – not to just learn from mistakes. Of course this means your goal has to be improvement not just avoiding more mistakes than before.

Your actions are based on theories (often unconsciously): and learning involves improving those theories. Learning requires updating faulty ideas (or learning new ideas – in which case ignorance rather than a faulty theory may have lead to the mistake). Encouraging people to learn from mistakes is useful when it is about freeing them to make errors and learn from them. But you should be learning all the time – not just when you make mistakes.

You can be also be wrong and not learn (lots of people seem to do this). This is by far the biggest state I see. It isn’t an absence of people making mistakes (including carrying out processes based on faulty theories) that is slowing learning. People are very reluctant to make errors of commission (and errors of commission due to a change is avoided even more). This reluctance obviously makes learning (and improvement) more difficult. And the reluctance is often enhanced by fear created by the management system.

It is best to be open and seek out new knowledge and learn that way as much as possible. Now, you should also not be scared to be wrong. Taking the right risks is important to improving – encouraging creativity and innovation and risk taking is wise.

Experiment and be open to learn from what could be better and improve (PDSA is a great way to try things and evaluate how they work). And the idea is not to be so conservative that every turn of the PDSA cycle has no failures. In order to get significant successes it is likely you will try things that don’t always work.

The desire to improve understanding (and the desire to improve results provides focus to the learning) is what is valuable in learning – not being wrong. Creating a culture where being wrong needs to be avoided harms learning because people avoid risk and seek to distance themselves from failure instead of experimenting and digging into the details when something goes wrong. Instead of learning from mistakes people try to stay as far away from them and hide them from others. That is not helpful. But what is needed is more desire to continually learn – learning from mistakes is wise but hardly the only way to learn.

Related: The Illusion of Knowledgeconfirmation biasManagement is Prediction

How to Get a New Management Strategy, Tool or Concept Adopted

Often when learning about Deming’s ideas on management, lean manufacturing, design of experiments, PDSA… people become excited. They discover new ideas that show great promise to alleviate the troubles they have in their workplace and lead them to better results. But how to actually get their organization to adopt the ideas often confounds them. In fact, I believe most potential improvements efforts may well fail even before they start because people can’t get past this problem.

I believe the way to encourage adoption of management improvement tools, methods and ideas is to solve people’s problems (or give them new opportunities). Instead of trying to convince people by talking about why they need to adopt some new ideas, I think it is much better to show them. To encourage the adoption of whatever it is (a philosophy like Deming or a new tool) try to find projects that would be good candidates for visible success. And then build on those successes.

For adopting whole new ways of working (like lean thinking) you go through this process many times, adding more and more new ideas to the accepted way of doing things. It is a bit easier if you are the CEO, but I think the strategy is very similar whoever you are. For smaller efforts a boss can often just mandate it. But for something like a large improvement in the way work is done (adopting a lean management system, for example), the challenge is the same. You have to convince people that the new methods and ideas are valuable and that they can use the ideas to help improve results.

Start small, it is very helpful if initial efforts are fairly small and straight forward. You often will have limited resources (and limited time people are willing to invest) at first. so start by picking projects that can be accomplished easily and once people have seen success more resources (including what is normally the most important one – people’s time) should be available. Though, honestly getting people to commit will likely be a challenge for a long time.

It is a rare organization that adopts a continual improvement, long term focus, system thinking mindset initially. The tendency is often strong to focus on fire fighting, fear (am I taking a risk by doing x, if I spend time improving y – what about the monthly target my boss is measuring me on…) and maintaining the status quo. It is baffling to many hoping for improvement, when you have huge successes, and yet the old way of doing things retains a great hold. The inertia of organizations is huge.
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Good Process Improvement Practices

Good process improvement practices include:

  • standardized improvement process (pdsa, or whatever)
  • Going to the gemba – improvement is done where the work is done. You must go to the where the action is. Sitting in meeting rooms, or offices, reading reports and making decisions is not the way to improve effectively.
  • evidence based decision making, data guides decision making rather than HiPPO
  • broad participation (those working on the process should be the ones working on improving it and everyone in the organization should be improving their processes)
  • measurable results that are used to measure effectiveness
  • pilot improvement on a small scale, after results are shown to be improvements deploy standardized solutions more broadly
  • visual management
  • Standardized work instructions are used for processes
  • one of the aims of the improvement process should be improving peoples ability to improve over the long term (one outcome of the process should be a better process another should be that people learned and can apply what they learned in future improvements)
  • quality tools should be used, people should be trained on such tools. The tools are essentially standardized methods that have been shown to be effective. And most organization just ignore them and struggle to reinvent methods to achieve results instead of just applying methods already shown to be very effective.
  • the improvements are sustained. Changes are made to the system and they are adopted: this seems obvious but far too often process improvements are really just band-aids that fall off a few weeks later and nothing is done to sustain it.
  • goals, bonuses and extrinsic motivation are not part of the process
  • The improvement process itself should be continually improved

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Delighting Customers

If you have customers that see you as adequate you will keep customers based on inertia.

But you have several big problems awaiting you. Those trying to win your customers business only have to overcome inertia – which can be very low hurdle (saving a small bit of money, some minor additional feature). If your customers are delighted they won’t leave (by and large) without significant reasons to.

Also your attempts to increase price are very likely to lead to increased customer losses (than if customers are delighted). Delighted customers are willing to pay a premium which helps profits enormously (Apple has done this quite well).

Delighted customers will refer others to you – great free marketing.

Satisfied customers leave you very little leeway for error. If you cause satisfied customers some problem (which granted, hopefully you won’t but if you do) they are not likely to be forgiving. If they are delighted they may well stay even if you have a delay, provide less than stellar customer service for some request…

There are many ways to attempt to delight customers. One of the simplest powerful tools is to ask a very simple question: What Could we do Better?

Related: What Job Does Your Product Do?It Just WorksKano Model of customer satisfactioncustomer focus resources

The Toyota Way – Two Pillars

Toyota is receiving plenty of criticism now, much of it for good reason. There is also a large amount of psychology involved. From what I have seen, the insurance companies still see better claims history (fewer and lower cost claims) against Toyota than other manufacturers. And there is another strain that seems to enjoy criticizing what has been praised. Toyota does need to improve. But that is improvement of the existing management system, not a need to radically change the management of the company.

I think Toyota, even with the problems, is a fantastic example of a very well managed company. Yet even with all the study of lean manufacturing even basic ideas are overlooked. For example, the two main pillars of the Toyota way are “continuous improvement” and “respect for people.” For all of us, it is valuable to refocusing on core principles. We are too often looking for the next new idea.

This is one way of looking at the pillars of the Toyota Production System, from the Toyota Technical Center – Austrailia

Image of Toyota's pillars of management: respect for people and continuous improvement

Continuous Improvement means that we never perceive current success as our final achievement. We are never satisfied with where we are and always improve our business by putting forth our best ideas and efforts: we are keen to create better alternatives, question our accomplishments and investigate future definitions of success.

There are three building blocks shaping our commitment to Continuous Improvement:

1. Challenge – we form a long term vision, meeting challenges with courage and creativity to realize our dreams;
2. Kaizen – we improve our business operations continuously, always driving for innovation and evolution
3. Genchi Genbutsu – we go to the source to find the facts to make correct decisions, build consensus and achieve goals.

Respect For People refers to our own staff as well as the communities and stakeholder groups that surround us and we are part of. We respect our people and believe the success of our business is created by individual efforts and good teamwork.

Respect For People is translated in:

1. Respect – we respect others, make every effort to understand each other, take responsibility and do our best to build mutual trust
2. Teamwork – we stimulate personal and professional growth, share the opportunities of development and maximize individual and team performance.

These elements combined define our corporate DNA, provide a way of operating that is recognised by each and every Toyota-member around the globe and enables us to sustain our success in the future.

Back to Basics for Toyota by Akio Toyoda

When my grandfather brought Toyota into the auto business in 1937, he created a set of principles that has always guided how we operate. We call it the Toyota Way, and its pillars are “respect for people” and “continuous improvement.” I believe in these core principles. And I am convinced that the only way for Toyota to emerge stronger from this experience is to adhere more closely to them.

While recent events show Toyota obviously needs to improve, that has been true all along (it is just more obvious lately). Some may see this as an indication that these lean manufacturing ideas based on Toyota’s practices are no better than other management practices. I don’t believe this. I feel just as strongly about the value of lean management as ever. I think that the recent events show you that no matter how well an organization in managed there is plenty of room to improve. Toyota never was close to perfection. They have much to improve, but they are still one of the best managed companies in the world.

My comments in 2005:

I think the instances of such failures are just a sign that even Toyota still has quite a bit to improve. I think this announcement likely is a result of common cause variation (it is the natural result of the current system). The natural result (of the system) is not that they have this particular failure, but that this recall is consistent with the % of vehicles that required a recall of this general character. I believe they are getting better over time but they still have a long way to go. With a result based on common cause you want to look at the entire system when designing an improvement plan not at the root cause of the seat belt issue. See Responding to Variation online and the book, Forth Generation Management, by Brian Joiner.

Related: Toyota Stops Lines – Lots of LinesAkio Toyoda’s Message Shows Real LeadershipDeming CompaniesRespect for People Does Not Mean No Criticism

And my comments in 2007:

I don’t agree that they need to rethink their purpose in life (I have a feeling that is taken out of context). They need to maintain and maybe even increase their commitment to their purpose in life.

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Making Better Decisions

I think the most important thing you can do to make better decisions is to learn from the decisions you make. It sounds easy, but very few people do so effectively.

The best strategy to learn from decisions is to:

Helping Employees Improve

One aspect of managing people is to provide positive feedback and show appreciation. Doing so is important. People benefit from encouragement and reinforcement. In addition to just telling them, take action to show your appreciation.

The Dilbert workplace is alive and well. And even in above average management systems there is plenty of resistance faced by those looking to improve systems. For those employees that are making the attempt to improve the organization go beyond saying thanks: actually demonstrate your appreciation. Do what you can to help them achieve.

A manager should be enabling their employees to perform. That means taking positive steps that help them perform. This is even more appreciated than saying thanks. And has the added benefit of helping the organization by helping along their good idea. It is win, win, win. They win, you win and the organization wins.

Thoughts on: Rewards and Recognition

Related: Keeping Good EmployeesRespect for People Requires Understanding PsychologyPeople are Our Most Important AssetMotivationIncentive Programs are Ineffective

Checklists Save Lives

photo of surgery room

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

Eight hospitals reduced the number of deaths from surgery by more than 40% by using a checklist that helps doctors and nurses avoid errors, according to a report released online today in the New England Journal of Medicine.

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.

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 ImprovementThe Power of a ChecklistNew, Different, BetterManagement Improvement History and Health CareOpen Source Management TermsFast Company Interview with Jeff Immelt

Information Technology and Business Process Support

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 AroundInformation Technology and ManagementUsing Quality Management Principles to Develop an Internet Resource by John Hunter, Jun 1999 (pdf)

How to Improve

My management philosophy is guided by the idea of seeking methods that will be most effective.* There are many ways to improve. Good management systems are about seeking systemic adoption of the most effective solutions. What this amounts to is learning about the ideas of Deming, Ackoff, Ohno, Chirstensen, Scholtes, Womack… and then adopting those ideas. In doing so learning about management tools and concepts as they are applied to your work.

Here is a simple example. Continue reading

What Could we do Better?

At the Hunter Conference, years ago, a speaker (I forget who) talked about how to get useful feedback. He discussed how asking “how is everything” normally will get the response: “fine” (which is often that is exactly what the staff wants so they can move on without wasting any time). However, if you really want to improve that doesn’t help.

He explained how he worked with Disney to improve their restaurants. Using the “how is everything” question had not alerted the restaurant to any issues. So he visited the tables with the manager and asked – “What one thing could we do to improve?” Over 50% of the people said the rolls were stale: clear information that is actionable. And in fact they were able to adjust the system to remove that problem. A small thing, in this case, but a clear example of a good method to help target improvement.

To encourage useful feedback, specifically give the customer permission to mention something that could be improved. What one thing could we do better?

This post was sparked by Seth’s post: This must be hard. I think he was on the right track, but I think the results could be even better using a question like: what one thing could we do better?

Related: Usability FailuresCEO Flight Attendantcustomer focus blog posts

Change is not Improvement

In response to: Why executives order reorgs

“We trained hard… but it seemed that every time we were beginning to form up into teams we would be reorganized. I was to learn later in life that we tend to meet any new situation by reorganizing; and a wonderful method it can be for creating the illusion of progress while producing confusion; inefficiency, and demoralization.”

These lines, from the Satyricon of Petronius written 2,000 years ago…

Unfortunately it seems this quote is not actually his. Instead apparently someone attributed the quote to him to give it the weight of time. I think that the sentiment expressed rings true speaks to the experience of many.
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New Toyota CEO’s Views

The Man Driving Toyota from Business Week:

Toyota has grown in the past few years, but [there’s a risk] that a belief that the current status is satisfactory creeps into the minds of employees. That’s what I’m worried about.

We should never be satisfied with the current status. In each division, function, or region, we still have numerous problems to cope with. We need to identify each one of those tasks or problems and fully recognize them and pursue the causes. This needs to be done by all the people working for Toyota.

I think, this echoes my recent comment on post, Is Quality Foolproof? (unfortunately the link is broken, so I removed it. Luckily I posted my comments here so they are not gone), on the Vision Thing blog:
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