Tag Archives: continual improvement

Poor Results Should be Addressed by Improving the System Not Blaming Individuals

My response to: Where is the Deming study that asserts most errors are in organization or process?

There is no such study, it is based on Dr. Deming’s experience as I discuss in 94% Belongs to the System (improve the system, don’t blame the people in the system).

“I should estimate that in my experience most troubles and most possibilities for improvement add up to the proportions something like this: 94% belongs to the system (responsibility of management), 6% special.”

Page 315 of Out of the Crisis by W. Edwards Deming

Getting hung up on the figure 94% is a mistake. His point was that you improve performance going forward by improving the system not blaming people. His two books provide background and the thought process involved behind why we are failing to manage better. Changing the people, while leaving the system in place, most often doesn’t help.

Variation does confuse people sometimes. The same mistake as say yelling at someone any time results are really bad. Most likely results will get better. Not because yelling helps but essentially regression to the mean. So you can move people out after really bad results and things get better. Of course, most of the time they would have gotten better if you left the people there (and did nothing or yelled).

Even when the person did totally mess up, why did the system allow that? Why did the system put that person in a place where they were not qualified? Answering and fixing these types of questions would help improve the system and the results going forward.

Yes, occasionally the answer might be that Joel was hired sensibly, managed and coached sensibly but he just became a complete jerk and won’t respond to coaching and this is only his fault. But normally that won’t be the case, even when the person seems nearly totally to blame (and that isn’t even a very common situation) normally there are obvious weaknesses in the system that put them in the place to fail and will likely put anyone else in the same place in the future.

Jiro Dreams of Sushi

Jiro Dreams of Sushi is a documentary on a Japanese sushi restaurant, Sukiyabashi Jiro, that is full of great quotes for those interested in continual improvement. Throughout the film people discuss a never ending focus on doing better and better – never becoming complacent.

Quotes from Jiro Dreams of Sushi:

Jiro: “Once you decide on your occupation you must immerse yourself in your work. You have to fall in love with what you do… You must dedicate your life to mastering your skill. That is the secret of success and the key to being regarded honorably.”

Jiro: “There is always room for improvement.”

Jiro: “I do the same thing over and over, improving bit by bit.”

Jiro: “I feel ecstasy every day. I love making sushi.”

Fish seller: “When you think you know it all, you then realize you are just fooling yourself.”

Food critic ~ “when you work for Jiro he teaches you for free. But you have to endure years of training.

”‹Apprentice: “But there is only so much you can learn from words. I have to keep practicing.””‹

Jiro: ~ (paraphrased and changed a bit) “When the fish gets to me the sushi is 95% complete. I prepare it in front of the customer so get the credit but the truth is the person doing the least work gets most of the credit”

Jiro’s eldest son, Yoshikazu: “Always strive to elevate your craft.”

The focus is on the dining experience in total. The meal is composed of elements that are designed to work together with the focus on quality of the individual dishes but also on the interaction between the individual items and the complete experience.

The respect for suppliers is also seen in the film. Jiro’s eldest son says (approximately) “we are experts at sushi and we know a great deal but the tuna vendor we use knows more about tuna, the shrimp vendor knows more about shrimp… we trust them.” Later Jiro says (again from my memory), “we buy our rice from our vendor because Mr. ___ (I can’t remember the name) knows more about rice than anyone else, I trust him to provide what is best for us.”

They even touch on the bigger picture. Jiro’s son: “overfishing is the problem. Finding good fish is getting harder and harder… There should be regulations enforced on only catching bigger fish. Business should balance profit with preserving natural resources.”

As with any example there are particulars that you can learn from and specifics that don’t apply well to your situation. I know next to nothing about kitchens of world class restaurants but what I do know is they seem extremely dedicated to their work (much more so than many other organizations are interested in striving for). They also seem to be more autocratic than most other modern organizations. They also seem much more focused on perfecting the process to achieve the best result even if that requires a great deal more work than some alternative that produces very good results.

Resources for Using the PDSA Cycle to Improve Results

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:

Clearing Up Myths About the Deming Cycle by Ron Moen and Cliff Norman
The Importance of Concepts in Creativity and Improvement by Lloyd Provost and Gerald Langley
ASQ’s Accelerating Change Collaborative Series: A Challenge for Industry by Kevin Nolan
Evolution of the PDSA Cycle by Ron Moen and Cliff Norman
Understanding Variation by Thomas Nolan, Lloyd Provost

How to Sustain Long Term Enterprise Excellence

This month Paul Borawski asked ASQ’s Influential Voices to explore sustaining excellence for the long term.

There are several keys to pulling sustained long term excellence. Unfortunately, experience shows that it is much easier to explain what is needed than to build a management system that delivers these practices over the long term. The forces pulling an organization off target often lead organization astray.

Each of these concepts have great deal more behind them than one post can explain. I provide some direct links below, and from those there are many more links to more valuable information on the topics. I also believe my book provides valuable additional material on the subject – Management Matters: Building Enterprise Capability. Sustained long term excellence is the focus of the book. A system that consistently provides excellent performance is a result of building enterprise capability over the long term.

Viewing the organization as a system – to build long term improvement systems thinking is key. Without it divergent forces tear apart cohesive long term strategies.
Process thinking flows from viewing the organization as a system. Only by building a network of reliable processes is sustained excellence possible. To build those processes an understanding of process thinking is required (understanding variation, monitoring using in-process measures, visual management, continual improvement etc.).
Engaged and thinking people with the authority to act at the gemba are required for the robust, continually improving management system – which is required for sustaining excellence. Everyone must be focused on continual improvement and reacting when necessary (respect for people, visual management, standardized processes, proper training, coaching, trusting environment where fear doesn’t cripple improvement…).
Customer focus is also tied to long term success in a way that is often overlooked. Obviously building up a dedicated customer base is extremely valuable. But true customer focus, where the organization understands what problems the organization solves for customers, results in a forward looking organization that is constantly providing more and more value to customers. And this proactive focus is needed to to sustain long term excellence. Some related concepts: value stream mapping, outcome measures, visiting the user gemba…

You are a Fool if You Do What I Say

Guest post from Mark Graban

There’s an interesting quote from Taiichi Ohno in “Taiichi Ohno’s Workplace Management,” which I was re-reading today…

“You are a fool if you do what I say. You are a greater fool if you don’t do as I say. You should think for yourself and come up with better ideas than mine.”

The best examples of Lean in healthcare are examples where leaders and organizations learned, but did not blindly copy. Sami Bahri DDS (the “lean dentist”) read Deming, Shingo, Ohno, etc. and had to figure this out himself, rather than copying some other dentist.

ThedaCare is the first to say “don’t directly copy what we do.”

We can learn from others, run our own experiments to see what works, and keep improving to make it better than even Ohno or Shingo would have imagined.

Build Systems That Allow Quick Action – Don’t Just Try and Run Faster

This month Paul Borawski (CEO of ASQ) has asked the ASQ Influential Voices to share their thoughts on the cries for “faster, faster, faster” that so often is a refrain heard today.

I have long said that the measure of management improvement isn’t only about improving. It is the speed at which the management system and internal processes are being improved. Improvement is a given. If an organization is not improving every year the odds of long term success is low.

One of the common objections to a need for improvement is that we are doing fine and we are improving (so leave us alone we are already improving). That is better than not doing fine and not improving but it isn’t a reason to be complacent. Managers should be continually pushing the improvement acceleration higher.

The biggest problems I see with a focus on being faster are attempting move faster than the capability of the organization and falling back on working harder as a method to achieve the faster action. Really these are the same issue – working harder is just a tactic to cope with attempting to achieve better results than the system is capable of.

Agile software development has a principle, sustainable development, which is a reaction to the far too common attitude of management to just have software developers work longer and longer hours to meet targets. Any attempt to be faster internally or respond to a faster marketplace should first put the principle of sustainable workload as a requirement. And next build the capability of the enterprise to respond quickly and keep increasing how quickly it can respond effectively.

The well know management improvement concepts, practices and tools will lead an organization to improve that capability reliably, sustainable and continuously.

My new book, Management Matters: Building Enterprise Capability, delves into how to manage an enterprise based on the ideas needed to apply management improvement concepts, practices and tools to achieve results, including, but not limited to, faster.

Customer Focus

Customer Focus is at the core of a well managed company. Sadly many companies fail to serve their customers well. To serve customers, a thorough understanding of what problem you solve for customers is needed. The decisions at many companies, unfortunately, are far removed from this understanding.

It is hard to imagine, as you are forced to wind your way through the processes many companies squeeze you through that they have paid any attention to what it is like to be a customer of their processes. When you see companies that have put some effort into customer focus it is startling how refreshing it is (which is a sad statement for how poorly many companies are doing).

If the decision makers in a company are not experiencing the company’s products and services as a customer would that is a big weakness. You need to correct that or put a great amount of energy into overcoming that problems.

Another critical area of customer focus is to know how your customers use your products. It isn’t enough to know how you want your products to be used. Or to know the problems you intended people to use your products for. You need to know how people are actually using them. You need to know what they love, what they expect, what they hate, and what they wish for. This knowledge can help offset experiencing the products and services yourselves (in some cases getting that experience can be quite difficult – in which case you need to put extra effort into learning the actual experience of your customers).

You cannot rely on what people tell you in surveys. You need to have a deep understanding of customers use of the products. Innovation springs from this deep understanding and your expertise in the practice of delivering services and building products.

One of my favorite improvement tips is to: ask customers what 1 thing could we do better. It is very simple and gives you an easy way to capture what customers really care about. You shouldn’t rely only on this, but it is an extremely powerful tactic to use to aid continual improvement (with customer focus).

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Keys to the Effective Use of the PDSA Improvement Cycle

The PDSA improvement cycle was created by Walter Shewhart where Dr. Deming learned about it. An improvement process is now part of many management improvement methods (A3 for lean manufacturing, DMAIC for six sigma and many other modifications). They are fairly similar in many ways. The PDSA cycle (Plan, Do, Study, Act) has a few key pieces that are either absent in most others processes of greatly de-emphasized which is why I prefer it (A3 is my second favorite).

The PDSA cycle is a learning cycle based on experiments. When using the PDSA cycle, it is important to predict the results. This is important for several reasons but most notably due to an understanding of the theory of knowledge. We will learn much more if we write down our prediction. Otherwise we often just think (after the fact); yeah that is pretty much what I expected (even if it wasn’t). Also we often fail to think specifically enough at the start to even have a prediction. Forcing yourself to make a prediction gets you to think more carefully up front and can help you set better experiments.

An organization using PDSA well will turn the PDSA cycle several times on any topic and do so quickly. In a 3 month period turning it 5 times might be good. Often those organizations that struggle will only turn it once (if they are lucky and even reach the study stage). The biggest reason for effective PDSA cycles taking a bit longer is wanting more data than 2 weeks provides. Still it is better to turn it several times will less data – allowing yourself to learn and adjust than taking one long turn.

The plan stage may well take 80% (or even more) of the effort on the first turn of the PDSA cycle in a new series. The Do stage may well take 80% of of the time – it usually doesn’t take much effort (to just collect a bit of extra data) but it may take time for that data to be ready to collect. In the 2nd, 3rd… turns of the PDSA cycle the Plan stage often takes very little time. Basically you are just adjusting a bit from the first time and then moving forward to gather more data. Occasionally you may learn you missed some very important ideas up front; then the plan stage may again take some time (normally if you radically change your plans).

Remember to think of Do as doing-the-experiment. If you are “doing” a bunch of work (not running an experiment and collecting data) that probably isn’t “do” in the PDSA sense.

Study should not take much time. The plan should have already have laid out what data is important and an expectation of what results will be achieved and provide a good idea on next steps. Only if you are surprised (or in the not very common case that you really have no idea what should come next until you experiment) will the study phase take long.

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Dr. Deming in 1980 on Product Quality in Japan and the USA

I posted an interesting document to the Curious Cat Management Library: it includes Dr. Deming’s comments as part of a discussion organized by the Government Accounting Office in 1980 on Quality in Japan and the United States.

The document provides some interesting thoughts from Dr. Deming and others; Dr. Deming’s statements start on page 52 of the document. For those really interested in management improvement ideas it is a great read. I imagine most managers wouldn’t enjoy it though (it isn’t giving direct advice for today, but I found it very interesting).

Some selected quotes from the document follow. On his work with Japan in 1950:

This movement, I told them, will fail and nothing will happen unless management does their part. Management must know something about statistical techniques and know that if they are good one place, they will work in another. Management must see that they are used throughout the company.

Quality control must take root with simple statistical techniques that management and everyone in the company must learn. By these techniques, people begin to understand the different kinds of variation. Then quality control just grow with statistical theory and further experience. All this learning must be guided by a master. Remarkable results may come quick, but one has no right to expect results in a hurry. The learning period never ends.

The statistical control of quality is not for the timid and the halfhearted. There is no way to learn except to learn it and do it. You can read about swimming, but you might drown if you had to learn it that way!

One of the common themes at that time was Deming’s methods worked because Japanese people and culture were different. That wasn’t why the ideas worked, but it was an idea many people that wanted to keep doing things the old way liked to believe.

There may be a lot of difference, I made the statement on my first visit there that a Japanese man was never too old nor too successful to learn, and to wish to learn; to study and to learn. I know that people here also study and learn. I’ll be eighty next month in October. I study every day and learn every day. So you find studious people everywhere, but I think that you find in Japan the desire to learn, the willingness to learn.

You didn’t come to hear me on this; there are other people here much better qualified than I am to talk. But in Japan, a man works for the company; he doesn’t work to please somebody. He works for the company, he can argue for the company and stick with it when he has an idea because his position is secure. He doesn’t have to please somebody. It is so here in some companies, but only in a few. I think this is an important difference.

At the time the way QC circles worked in Japan was basically employee led kaizen. So companies that tried to copy Japan told workers: now go make things better like the workers we saw in Japan were doing. Well with management not changing (and understanding Deming’s ideas, lean thinking, variation, systems thinking…) and staff not given training to understand how to improve processes it didn’t work very well. We (those reading this blog) may all now understand the advantages one piece flow. I can’t imagine too many people would jump to that idea sitting in their QC circle without having been told about one piece flow (I know I wouldn’t have), and all the supporting knowledge needed to make that concept work.

QC circles can make tremendous contributions. But let me tell you this, Elmer. If it isn’t obvious to the workers that the managers are doing their part, which only they can do, I think that the workers just get fed up with trying in vain to improve their part of the work. Management must do their part: they must learn something about management.

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Psychology of Improvement

Even if ideas are good and have significant importance (high value to customers, reduce waste dramatically, improve safety…) implementing the ideas can be difficult. Getting people to make an effort to improve a situation by simply laying out the dry facts is not very effective. You need to engage in the management system to make your ideas something other people care about and want to do (you need to consider the psychology of getting things done in human systems).

Often a good way to do this is not to just think what is best for the performance of the system, but figure out what people want fixed/improved… and then figure out what I think could help. Then pick among various options to improve based upon the advantages to the performance of the organization, desires of decision makers and the ability of an improvement effort to build the capacity of the organization for customer focused continuous improvement.

Few places I have worked just want to adopt Deming’s ideas (which is my belief for what is the best way to improve performance). But they have things they care about – reducing the times people get mad at them, increasing cash flow… I find it much easier to help them with their desires and slowly get them to appreciate the benefit of Deming’s management ideas, lean thinking and quality tools. Though even this way it isn’t easy.

Even if the organization I am working with doesn’t think based on Deming’s ideas, I do. So I believe any effort to improve the management system must consider all 4 areas of Deming’s management system. In the beginning of an improvement effort psychology is very important for the change agent to consider and deal with. With an understanding of psychology and an understanding of the organization you can build appropriate strategies to improve and build the capacity of the organization to improve over the long term.

I also think about the long term as I am thinking of how to help. It is important to not just solve the current dilemma but to improve the organizational capacity to improve in the future. And for me that means increasing people’s understanding of the ideas I explore in the Curious Cat Management Improvement blog.