Tag Archives: Quality tools

Improving Management with Tools and Knowledge

Too often today I hear people disparaging management tools/concepts (PDSA cycle, mistake proofing, flowcharts, design of experiments, gemba…). The frequently voiced notion is that tools are being applied and not helping improve management in the organization.

But it seems to me using these tools re-enforce the best practices of management improvement. Yes, ignoring the underlying principles (while applying tools and concepts) drastically limits how successful an organization will be in improving management practices (and limits the results the organization will achieve). But using the tools is not the problem. Using the tools is a necessary but not sufficient part of the process to improve.

What is needed is to use the tools with engaged people that are continually learning and adjusting the management system based on their increase understanding of the organization as a system. Using management tools effectively (if you are unsure of what those tools are, read the posts on this blog discussing many management improvement tools) supports gaining insight into the underlying management improvement principles.

It is important to understand there are fundamental concepts that connect and reinforce each other. And those organizations that are successful are using management tools and continually building their understanding of the underlying principles.

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Applying Improvement Concepts and Tools to Your Daily Life

This month the ASQ Influential Voices is taking a bit different approach. This month we are looking at applying quality tools in our personal life based on the post from other influential voice, Sunil Kaushik: How Lean Helped Me Travel To Egypt With Just $500.

Sunil is on a nomadic trip around the world to learn and enjoy the experience while also helping others applying lean thinking.

I just returned from my own nomadic adventure.

John Hunter at Marble Mountain - Buddha  statue in background

John Hunter, in a cave at Marble Mountain, Da nang, Vietnam. This is one of my last stops before returning home. See more of my travel photos

I have experience applying quality tools since I was a kid being guided by my father. Another influential voices author, that I met in Hong Kong when I presented a a Deming seminar, included a mention of that connection in his post: Quality Life and Succession.

In this blog I write about using management improvement thinking in my personal life. That extends from management concepts such as optimizing the entire system and not getting trapped by habit or convention, for example in: The Aim Should be the Best Life – Not Work v. Life Balance.

My father applied these ideas in our family life and so naturally they formed my way of thinking. At the core was a focus on experimentation and focusing on what was important. It is easy to spend a lot of time on things that really are not that important and questioning if the actions we are taking is really what we should be doing based on the most important aims was a natural part of how we thought growing up. In order to experiment effectively you need to be able to understand data and draw appropriate conclusions (post on an experience with my father as a child: Playing Dice and Children’s Numeracy).

Also we would look at what wasn’t giving the results we desired and experiment on how to improve. I include in “results” the happiness or frustration the process causes (so as a kid this was often the frustration my brother and I had in doing some task we didn’t want to do – cleaning our room, doing homework etc. and the frustration our parents felt at having to continually bring us back onto task). Much of this effort amount to setting the understanding and incentives and process to get better results (both the end results and increasing happiness and reducing frustration of all of us in the family).

A concept I use a good deal in my personal thinking on a more concrete level is mistake proofing (or at least mistake making less easy). Many people do this, without really thinking that is what they are doing. But by thinking of it consciously I find it helps you design processes to be most effective.

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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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Magnetic White-Board Kanban Card Options

Just some quick ideas for Kanban whiteboard magnetic card options from a question I answered on Reddit.

Here is the best lean solution: Trying Out My Agile Kanban Board from Jon Miller.

kanban board with magnetic whiteboad  cards

Magnetic kanban board from Jon Miller.

Why, well mainly I am kidding about it being the best, but if you don’t read his Gemba Panta Rei blog you should! Go add it to your RSS feed reader, before you continue with this post.

Ok, welcome back. In addition to thinking his blog is great the solution from his blog is very flexible and easy – though it isn’t quite a packaged solution (as asked for on Reddit). Also that post provides some good insight into the thinking behind the board (as well as how to create your own).

More links with kanban board options: Magnetic whiteboard cards (50-pack)Physical TaskboardsI think just magnetic symbols (not magnetic white board card) but could use magnet with icon to stick paper to the board

Another silly site, that sells some sort of solution, blocked my access because they don’t sell in the country my computer reported being located in. So I didn’t give them a free plug (assuming their product was decent which it might be?). Very dumb design if you ask me; well even though you didn’t ask, I told you anyway.

Localization that impedes users rather than helping them seems far far too common in my experience. Mapping (and related – find closest…) uses are about the only localization stuff I find useful – country based localization I nearly always find annoying or crippling. And showing my location on a map is totally awesome (especially as I travel around as a tourist – or really in whatever capacity). Such bad design and poor usability decisions cost companies money.

Related: Visual Management with Brown M&MsMaking Data VisibleDeming and Software Development

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.

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

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)

Jeff Bezos: Innovation, Experiments and Long Term Thinking

Jeff Bezos, bought the Washington Post. He has long showed a willingness to take a long term view at Amazon. He is taking that same thinking to the Washington Post:

In my experience, the way invention, innovation and change happen is [through] team effort. There’s no lone genius who figures it all out and sends down the magic formula. You study, you debate, you brainstorm and the answers start to emerge. It takes time. Nothing happens quickly in this mode. You develop theories and hypotheses, but you don’t know if readers will respond. You do as many experiments as rapidly as possible. ‘Quickly’ in my mind would be years.”

The newspaper business is certainly a tough one today – one that doesn’t seem to have a business model that is working well (for large, national papers). I figured the answer might be that a few (of the caliber of Washington Post, New York Times…) would be owed by foundations and supported largely by a few wealthy people that believed in the value of a strong free press and journalism. Maybe Bezos will find a business model that works. Or maybe he will just run it essentially as a foundation without needing a market return on his investment.

The Guardian (where the article with the quote was published) is an example of good journalism by a foundation. ProPublica is another (though I guess it is really a non-profit but most of the funding seems to be via foundations).

Related: Jeff Bezos and Root Cause Analysis (2009)Amazon Innovation (2006)Jeff Bezos on Lean Thinking (2005)Jeff Bezos Spends a Week Working in Amazon’s Kentucky Distribution Center (2009)

Design of Experiments: The Process of Discovery is Iterative

This video is another excerpt on the design of experiments videos by George Box, see previous posts: Introduction to Fractional Factorial Designed Experiments and The Art of Discovery. This video looks at learning about experimental design using paper helicopters (the paper linked there may be of interest to you also).

In this example a screening experiment was done first to find those factors that have the largest impact on results. Once the most important factors are determined more care can be put into studying those factors in greater detail.

The video was posted by Wiley (with the permission of George’s family), Wiley is the publisher of George’s recent autobiography, An Accidental Statistician, and many of his other books.

The importance of keeping the scope (in dollars and time) of initial experiments down was emphasized in the video.

George Box: “Always remember the process of discovery is iterative. The results of each stage of investigation generating new questions to answered during the next.”

Soren Bisgaard and Conrad Fung also appear in this except of the video.

The end of the video includes several suggested resources including: Statistics for Experimenters, Out of the Crisis and The Scientific Context of Quality Improvement.

Related: Introductory Videos on Using Design of Experiments to Improve Results (with Stu Hunter)Why Use Designed Factorial Experiments?brainstormingWhat Can You Find Out From 12 Experimental Runs?