Tag Archives: Process improvement

Why Do People Fail to Adopt Better Management Methods?

It is confusing to know that better methods exist but to see those better methods being ignored. It seems that if there were better ways to manage, people would adopt those methods. But this just isn’t the case; sometimes better methods will be adopted but often they won’t. People can be very attached to the way things have always been done. Or they can just be uncomfortable with the prospect of trying something new.

In this post I will look at a very visible example of free throw shooting. A few details in this post might be a bit confusing if you are not familiar with basketball but I think the underlying idea can still be understood.

For shooting free throws the evidence seems pretty clear that results can be improved by using an underhand style of shooting. I won’t go into it here, the data is sparse so conclusion are perhaps not absolutely conclusive yet. In addition to the data, there are good explanations on the physics of why the underhand shot is more likely to be successful.

Personally, I just wish the Wisconsin Badgers would adopt the better method and everyone else can keep ignoring it. Rick Barry’s son can continue using the style (he plays for Florida Gators now and uses that style successfully – see video). His father was one of all time most accurate free throw shooters (using the underhand style). I believe, Chinanu Onuaku, a little used player, is the only current NBA player using the underhand style (he is 2 for 2 this year).

Sadly if Wisconsin did use this improved method, then others may copy them. But that isn’t certain, as you can see this better method has been known for decades without most people taking it up.

The reluctance to use better methods can be very strong. Just as the USA auto companies didn’t use known better methods until Japanese automakers were dominating them in the marketplace my guess is other teams will ignore adopting better free throw methods until a team, or even several teams, have most of their players using the better method. Often the reluctance is very similar to adopting the free throw improvement. It isn’t done just because it feels uncomfortable to do something in a new way (whether it is a different way to shoot a free throw or a different way to manage).

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Applying Toyota Kata to Agile Retrospectives

HÃ¥kan Forss, King (interactive entertainment games), presentation at the GOTO Copenhagen 2015 conference.

I strongly recommend Mike Rother’s book: Toyota Kata.

Description from Workshop description “The Toyota Kata Experience”

Kata means pattern, routine, habits or way of doing things. Kata is about creating a fast “muscle memory” of how to take action instantaneously in a situation without having to go through a slower logical procedure. A Kata is something that you practice over and over striving for perfection. If the Kata itself is relative static, the content of the Kata, as we execute it is modified based on the situation and context in real-time as it happens. A Kata as different from a routine in that it contains a continuous self-renewal process.

I think the great number of worthwhile conference presentations we can all now get sitting wherever we are provides us a great opportunity (and lets us avoid missing out of good ideas because “How could they know“).

A point made in the presentation that is very simple but still constantly the source of failure is that the current system isn’t supporting improvement. Retrospectives are a good method to help improve but if there is no time to think about the issues raised and come up with experiments to improve and review of whether those experiments worked or not and why failure to improve is the expected result.

Creating a culture where it is expected that any improvement ideas are tested and evaluated is one of the most important changes on the path to a company that will be able to continually improve. If not, what happens is some changes are good, many are not and soon people lose faith that any effort is worth it because they see how poor the results are. By taking care to evaluate what is working and what isn’t we create a process in which we don’t allow ad hoc and unsuccessful changes to demoralize everyone.

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Visual Management and Mistake-Proofing for Prescription Pills

Good ideas often just require some sensible thought to think of an improved approach. Management concepts can help guide such thinking, such as mistake-proofing and visual management.

To apply visual management requires giving a bit of thought to how to make visually obvious what is important for people to know. Mistake proofing is often really mistake-making-more-difficult (for some reason this term of mine hasn’t caught on).

prescription pills packaged together

Image from PillPack, they provide a service to deliver packages based on your prescriptions.

I believe mistake-proofing should put barriers in the process that make a mistake hard. Often what is called mistake-proofing doesn’t really fit that definition. The pill package shown above for example, doesn’t prevent you from continuing past the time on the package (Monday at 8AM) without taking the pills.

To call it mistake-proofing I would like to see something that makes it harder to make the mistake of failing to take the pills: something that blocks progress beyond that time without taking the pills.

Even something as simple as an alert to your smart phone that gets your attention and doesn’t allow the smart phone to be used without indicating you have taken the pills would reach the “mistake-proofing” level in my opinion (for someone that has their phone with them at all times). The Apple Watch could be a good tool to use in this case. Even so those wouldn’t make mistakes impossible (you can say you took the pills even if you didn’t, the phone/watch may lose power…). It would depend on the situation; this smart phone/watch solution is not going to be good for some people.

Another idea is that these pill packages should be tied to the room (in a hospital) and at home if a home care nurse (or even family or others) are responsible for assuring the pills are taken with a big display that perhaps 30 minutes before the pill is due posts a message that says “pills to be taken at 8 AM” and once that time is past it could become more obvious, perhaps after 15 minutes it produces an audio alert. The actual solutions are going to be better from those that know the actual situation than someone like me just thinking up stuff as I type.

But the idea is pretty simple: when you have processes that are important and at risk of failure, design processes with elements to make mistakes hard (and ideas such as mistake-proofing and visual management can help you guide your mind to ways to create better processes).

The entire process needs to be considered. The pill packages are nice, because even in failure modes they provide good feedback: you may still fail to take them at the right time, but you can look at the location where the pill packages are kept and see
if any have a time before right now (in which case you can follow the medical guidance – take the pills right now, contact the doctor, or whatever that advice is). Of course even that isn’t foolproof, you could have put the package into your purse and it is still sitting in their but you forgot.

Still the pill packages seem like a good mistake-making-more-difficult solution. And it seems to me that process has room to make mistakes even more difficult (using a smartphone addition, for example).

Continual improvement requires a continual focus on the process and the end user for ways to increase reliability and value. Each process in question should have engaged people with the proper skills and freedom to act using their knowledge to address weakness in the current process that are most critical.

Failure to take prescriptions as directed in a common problem in health care. Knowing this should make those involved in the process think of how they can use concepts, such as mistake-proofing, to improve the results of the system.

Too often to much focus is on making better pills compared to the effort is put into how to improve results with simple concepts such as visual management and mistake-proofing.

Each small improvement contributes to creating a more robust and effective process. And engaged people should continually access how the containing systems, new processes and new capabilities may allow more small steps to provide value to those relying on your products and services.

Related: Great Visual Instruction Example for Taking PillsVisual Management with Brown M&MsQuick Mistake Proofing Ideas for Preventing Date Entry Error

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The Value of Professional Conferences. Also Why Has There Been So Little Innovation?

In the most recent ASQ Influential Voices post, Julia McIntosh takes a look at the costs and benefits of professionals attending conferences.

I still remember being in high school and George Box talking about the primary value of conferences was talking to colleagues in the hallway. This seemed very odd to me, as it seemed that the reason for going to a conference was to learn from the talks.

I also didn’t really understand the value in catching up with people in person. I could see it would be somewhat useful but I didn’t really understand the benefits of personal communication. Pretty much all of my communication at that point was person to person. So I didn’t really see the huge loss of fidelity of any other communication (phone, email…).

At early conferences that I attended my main benefit was still in sitting in sessions and learning what people had to say. I did also benefit from discussions with other attendees. And I started to form relationships with others which grew over the years. And over time the networking benefits did exceed the learning from sessions benefits.

Part of this also occurs as your knowledge increases and you have less to learn from the average speaker. George was obviously well past this stage when I was talking to him. For me I still learned a lot from some of the speakers but also found I was learning much less and skipping sessions to talk to people I could learn more from was an increasing benefit. Still I have difficulty doing that and would focus more on networking at lunch, between sessions and in the evening.

The costs of attending conferences are easy for companies to calculate. The benefits they bring are very hard to calculate. I can see why companies often are very tight with budgets for conferences.

Egyptian carving of figures into a stone sarcophagus

A stone sarcophagus from ancient Egypt. I took this photo after presenting a Deming 2 1/2 day seminar in Boston (at the Boston Fine Arts Museum – see more photos).

I think the benefits of getting people outside the building and letting them interact with others to learn and think about new ideas is very valuable. I do think it is much less valuable in most companies than is should be because they have bad management systems that are atrophied with poor practices that are going to be extremely difficult to improve even if people have good ideas to try.

The organization really should focus on improving the management system so it isn’t such a barrier to improvement. But I think most organizations instead find it easy to just estimate a poor return on investments in conferences because those returning don’t actually make any improvements. Again, I think the cause of the failure to improve is more about the bad management system than the benefit of the conferences.

Of course, to some extent, the conferences should be focusing on how to improve given so many attendees organizations are crippled with a poor management system. But often people seem reluctant to acknowledge or discuss that. And those that point out problems often are seen as the problem (based on their actions – I can only conclude blaming the messenger makes sense to some people). And these factors are often even more pronounced in those the organization is willing to invest in (they are often more focused on making the bosses happy rather than something like improvement and change which often rubs people the wrong way).

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Root Cause, Interactions, Robustness and Design of Experiments

Eric Budd asked on The W. Edwards Deming Institute group (LinkedIn broke the link with a register wall so I removed the link):

If observed performance/behavior in a system is a result of the interactions between components–and variation exists in those components–the best root cause explanation we might hope for is a description of the interactions and variation at a moment in time. How can we make such an explanation useful?

A single root cause is rare. Normally you can look at the question a bit differently see the scope a bit differently and get a different “root cause.” In my opinion “root cause” is more a decision about what is an effective way to improve the system right now rather than finding a scientifically valid “root cause.”

Sometimes it might be obvious combination which is an issue so must be prevented. In such a case I don’t think interaction root cause is hard – just list out the conditions and then design something to prevent that in the future.

Often I think you may find that the results are not very robust and this time we caught the failure because of u = 11, x = 3, y = 4 and z =1. But those knowledge working on the process can tell the results are not reliable unless x = 5 or 6. And if z is under 3 things are likely to go wrong. and if u is above 8 and x is below 5 and y is below 5 things are in trouble…

To me this often amounts to designing systems to be robust and able to perform with the variation that is likely to happen. And for those areas where the system can’t be made robust for some variation then designing things so that variation doesn’t happen to the system (mistake proofing processes, for example).

In order to deal with interaction, learn about interaction and optimize results possible due to interactions I believe the best method is to use design of experiments (DoE) – factorial experiments.

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George Box Webcast on Statistical Design in Quality Improvement

George Box lecture on Statistical Design in Quality Improvement at the Second International Tampere Conference in Statistics, University of Tampere, Finland (1987).

Early on he shows a graph showing the problems with American cars steady over a 10 years period. Then he overlays the results for Japanese cars which show a steady and significant decline of the same period.

Those who didn’t get to see presentations before power point also get a chance to see old school, hand drawn, overhead slides.

He discusses how to improve the pace of improvement. To start with informative events (events we can learn from) have to be brought to the attention of informed observers. Otherwise only when those events happen to catch the attention of the right observer will we capture knowledge we can use to improve. This results in slow improvement.

A control chart is an example of highlighting that something worth studying happened. The chart will indicate when to pay attention. And we can then improve the pace of improvement.

Next we want to encourage directed experimentation. We intentionally induce informative events and pay close attention while doing so in order to learn.

Every process generates information that can be used to improve it.

He emphasis the point that this isn’t about only manufacturing but it true of any process (drafting, invoicing, computer service, checking into a hospital, booking an airline ticket etc.).

He then discussed an example from a class my father taught and where the students all when to a TV plant outside Chicago to visit. The plant had been run by Motorola. It was sold to a Japanese company that found there was a 146% defect rate (which meant most TVs were taken off the line to be fixed at least once and many twice) – this is just the defect rate before then even get off the line. After 5 years the same plant, with the same American workers but a Japanese management system had reduced the defect rate to 2%. Everyone, including managers, were from the USA they were just using quality improvement methods. We may forget now, but one of the many objections managers gave for why quality improvement wouldn’t work in their company was due to their bad workers (it might work in Japan but not here).

He references how Deming’s 14 points will get management to allow quality improvement to be done by the workforce. Because without management support quality improvement processes can’t be used.

With experimentation we are looking to find clues for what to experiment with next. Experimentation is an iterative process. This is very much the mindset of fast iteration and minimal viable product (say minimal viable experimentation as voiced in 1987).

There is great value in creating iterative processes with fast feedback to those attempting to design and improve. Box and Deming (with rapid turns of the PDSA cycle) and others promoted this 20, 30 and 40 years ago and now we get the same ideas tweaked for startups. The lean startup stuff is as closely related to Box’s ideas of experimentation as an iterative process as it is to anything else.

Related: Ishikawa’s seven quality control tools

He also provided a bit of history that I was not aware of saying the first application of orthogonal arrays (fractional factorial designs) in industry was by Tippett in 1933. And he then mentioned work by Finney in 1945, Plackett and Burman in 1946 and Rao in 1947.

Practicing Mistake-Promoting Instead of Mistake-Proofing at Apple

Mistake proofing is a wonderful management concept. Design systems not just to be effective when everything goes right but designing them so mistakes are prevented.

I have had several bad customer experiences in the short time I have had my iPad mini. One of the most pitiful is caused by mistake-promoting process design. As the name implies that isn’t a good idea. Mistake-proofing processes is a good practice to strive for; processes that create extra opportunities for failure impacting customers negatively are a bad idea.

My experience below is but one mistake-promoting practice that has caught me in its grips in the short time I have owned my iPad mini. I want to view books on the mini but can’t find any book reader. So I decide, fine I’ll just install the Kindle reader app.

I go to do so (run into additional issues but get through them) and then Apple decides for this free app, on an iPad I just bought with my credit card a week ago, to block me from getting what I need and force me to revalidate my credit card. This is lame enough, but I am used to companies not caring about the customer experience, so fine, what hoops does Apple want to force me through?

But guess what, the unnecessary steps Apple decided to force me through are broken so I can’t just waste my time to make them happy. No. They have created a failure point where they never should have forced the customer in the first place.

So they not only didn’t mistake-proof the process they mistake-promoted the process by creating a unnecessary step that created an error that could have been avoided if they cared about mistake proofing. But instead they use a mistake-promoting process. As a consumer it is annoying enough to cope with the failures companies force me through due to bad management systems that don’t mistake proof processes.

Companies creating extra opportunities to foist mistakes onto customers is really something we shouldn’t have to put up with. And when they then provide lousy and then even incomprehensible “support” such the “change your name” vision Apple decided to provide me now it is time to move on.

After 5 years of buying every computing device from Apple, they have lost my entire good will in one week of mess ups one after the other. I knew the reason I moved to Apple, the exceptional Macbook Air, was no longer the unmatched hardware it once was; but I was satisfied and was willing to pay a huge iPad premium to avoid the typical junk most companies foist on you. But with Apple choosing to make the process as bad as everyone else there isn’t a decent reason to pay them a huge premium.

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Interview on PDSA, Deming, Strategy and More

Bill Fox interviewed me and has posted part one of the interview on his web site: Predicting Results in the Planning Stage (sorry, the link has been hijacked to forward to an unrelated page [so obviously I removed the link], I have posted the interview which can now be reached here):

Bill: John, what is your best process improvement strategy or tactic that has worked well for you or your clients?

John: I would say the PDSA improvement cycle and a few key practices in using the PDSA properly like predicting the results in the plan stage—something that a lot of the times people do not do—to determine what would be done based on the results of that prediction.

People discover, especially when they’re new to this stuff, regarding the data that they’re collecting, that maybe even if they got the results they are predicting, they still don’t have enough data to take action. So you figure that even if that number is 30, they would need to know three other things before they make the change. So then, in the plan stage, you can figure that you need to address these other issues, too. At any time that people are collecting data is useful to figure out, for instance: “What do we need to do if the result is 30 or if the result is 3?” And if you don’t have any difference, why are you collecting the data?

Another important piece is the D in Plan, Do, Study, Act. It means “do the experiment”. A lot of times, people get confused into thinking that D means deploy the results or something like that, but thinking of D as ‘doing the experiment’ can be helpful.

A really big key between people that use PDSA successfully and those who don’t is that the ones that do it successfully turn the cycle quickly.

Another response:

Bill: What is the biggest misunderstanding about the Deming Management System you think people have?

John: I would say that there are a couple. The followers that want to pin everything to Deming tend to overlook the complexities and nuances and other things.

The other problem is that some of the critics latch on to a specific quote from Deming, something like a one-sentence long quote, and then they extrapolate from that one sentence-long quote what that means. And the problem is that Deming has lots of these one-sentence quotes that are very memorable and meaningful and useful, but they don’t capture every nuance and they don’t alone capture what it really means (you need to have the background knowledge to understand it completely).

They are sort of trying to oversimplify the message into these sound bites, and I find that frustrating. Because those individual quotes are wonderful, but they are limited to one little quote out of hours of videotape, books, articles, and when you don’t understand the context in which that resides, that’s a problem.

See the full interview for more details and other topics. I think it is worth reading, of course I am a bit biased.

Related: more interviews with John HunterInterviews with John Hunter on his book: Management MattersDeming and Software DevelopmentLean Blog Podcast with John Hunter

Steve Jobs on Quality, Business and Joseph Juran

This webcast shows an interesting interview with Steve Jobs when he was with NeXT computer. He discusses quality, business and the experience of working with Dr. Juran at NeXT computer. The video is likely from around 1991.

America’s in a tough spot right now, I think. I think we have forgotten the basics. We were so prosperous for so long that we took so many things for granted. And we forgot how much work it took to build and sustain those basic things that were supporting out prosperity. Things like a great education system. Things like great industry.

We are being out-planned, we are being out-strategized, we are being out-manufactured. It there is nothing that can’t be fixed but we are not going to fix it up here, we are going to fix it by getting back to the basics.

I agree with this thought, and while we have made some progress over the decades since this was recorded there is a long way to go (related: complacency about our contribution the USA has received from science and engineering excellencewhen you were as rich as the USA was in the 1950s and 1960s more and more people felt they deserved to be favored with economic gifts without effort (forgetting the basics as Jobs mentioned)Silicon Valley Shows Power of Global Science and Technology Workforce). After World War II the USA was able to coast on an economic bubble of extreme wealth compared to the rest of the world for several decades (and the economic success built during that period even still provides great advantages to the USA). That allowed wealthy living conditions even without very good management practices in our businesses.

Where we have to start is with our products and our services, not with our marketing department.

Quality isn’t just the product or service. Its having the right product. Knowing where the market is going and having the most innovative products is just as much a part of quality as the quality of the construction of the product. And I think what we are seeing the quality leaders of today have integrated that quality technology well beyond their manufacturing.

Now going well into their sales and marketing and out as far as they can to touch the customer. And trying to create super efficient processes back from the customer all the way through the delivery of the end product. So they can have the most innovative products, understand the customer needs fastest, etc..

The importance of customer focus is obvious at the companies Jobs led. It wasn’t a weak, mere claim of concern for the customer, it was a deep passionate drive to delight customers.

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Resources for Using the PDSA Cycle to Improve Results

graphic image showing the PDSA cycle

PDSA Improvement cycle graphic from my book – Management Matters

Using the PDSA cycle (plan-do-study-act) well is critical to building a effective management system. This post provides some resources to help use the improvement cycle well.

I have several posts on this blog about using the PDSA cycle to improve results including:

The authors and consultants with Associates for Process Improvement have the greatest collection of useful writing on the topic. They wrote two indispensable books on the process improvement through experimentation: The Improvement Guide and Quality Improvement Through Planned Experimentation. And they have written numerous excellent articles, including:

Related: Good Process Improvement PracticesThe Art of Discovery (George Box)Planning requires prediction. Prediction requires a theory. (Ron Moen)