Tag Archives: process thinking

Add Constraints to Processes Carefully

Take great care in adding constraints to processes to avoid doing so needlessly.

Online you will frequently find forms that have required fields that needn’t be. Certainly if you were designing with focus on what is best for customers those requirements rarely make sense. Occasionally a required field is a sensible constraint on an online form but so often they add unnecessary constraints.

I frequently find those forms even requiring a false answer since a response is required and none of the options are true. Often this is because the organization is thinking of the boxes they expect users to fit themselves into rather than thinking how to create the best user experience.

I wrote previously about a company representative that suggested a customer change their name because the computer system didn’t accept names with 2 characters. Constraints on creating a secure password are a frequent failure of web sites for the last 10 years.

Man without arms denied housing loan due to inability to provide fingerprints

because Wu Jianping has no arms, creditors claimed they could not give him a loan since he was unable to be fingerprinted.

After the case was publicized and there was a great deal of negative publicity on social media the banks modified their process and approved the loan. But your organization shouldn’t have as the mistake-proofing (obviously not mistake-proofing at all) that when the process doesn’t quite work well then rely on a massive social media outcry which is a signal to us to straighten out the issue.

Frequently I see unnecessary constraints creating the edge case excuse. By burdening your process with unnecessary constraints you create edge cases that fail and then use the excuse that each of the edge cases is rare and therefore you can’t justify the expense of fixing them.

But if you designed the process sensibly in the first place the edge case never would have failed and you wouldn’t need special work arounds for such “edge cases.” A simple example of this is unnecessarily complex web page code that fails if to submit a button without javascript. Yes, a small number of users won’t have enabled all javascript to run (today anyway) so it is an “edge case” to deal with if you don’t have the form work without javascript. But there is no decent reason to have it fail in most cases.

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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).

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.

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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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Peter Drucker Discussing The Work of Juran, Deming and Himself

In this clip Peter Drucker talks about Japan and his work there as well as the work of W. Edwards Deming and Joseph Juran.

His discussion highlights how he remembers the Japanese were so willing to take new ideas and implement them immediately. There was not a reluctance to try things that “were not invested here.” They were also ready to abandon ideas if they were tried and didn’t work.

Drucker talked about the shared importance he, Deming and Juran put on the importance of valuing all employees and creating management systems that capture all the value they can offer. He spoke of all 3 of them tilted against those that believed in command and control business organizations. Sadly the lack of respect for all workers is still common today; but it is much better than is was due to the work of these 3 management experts.

In this clip Drucker mentions Just-In-Time works well for Toyota but companies trying to copy it find it doesn’t work for them because they are trying to install it on top of a system that doesn’t support it. The exact same point was made in a clip I posted in my post on Monday to the Deming Institute blog.

Peter Drucker speaking of Juran’s ideas on quality

You don’t start with putting in machines. You start with looking at the work process… You start with engineering the work, not engineering the machines and not engineering the material flow

In the clip, from the early 1990’s, Drucker says

GM wouldn’t be in the pickle its in if it hadn’t pour $40 billion in automation before, without, analyzing the work process which is just wasting $40 billion. Thats why GM is in trouble today.

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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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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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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.

Bad Weather is Part of the Transportation System

The job of managers is to create a robust system that delivers value to customers. A system that fails constantly (fails during the continual variation the system faces) is a failed system. Bad weather is part of the variation airlines face. Any management system has to cope with the variation that it faces. The management system must be designed and managed so that the organization successfully delivers value to customers under the conditions the organization will face.

The air travel system in the USA is a disgrace for so many reasons it is hard to catalogue them all. One, of many, is how fragile the system is; causing massive (nation-wide) customer harm multiple times a year due to weather. Weather is sometimes bad. If your organization fails when there is bad weather, fix that problem (make your system robust in the face of bad weather), because you are not going to be able to fix the weather to let your un-robust system be effective as it is.

Instead airlines only response seems to be to get their friends in government to approve anti-competitive mergers to eliminate competition and allow failed organizations to become even larger and harm even more people. Airlines should design robust systems that work in the environment they will face (which they don’t do now).

Their planes don’t fall out the sky when they face bad weather. The engineers behind designing planes have made them very robust. Pilots have been trained to handle variation they will face. And yes, the system has been designed with adjustments to avoid flying into conditions that are risky.

The safety of the air transportation system is very good. The management of airlines in most every other aspect is pitiful, and has been for decades.

The managers running the airlines have done amazingly bad job of creating robust organizations capable of delivering given the variation they know they will face (weather, mechanical problems, IT problems, etc.) for decades. Poor management is the cause of these failures that result in harm to customers. Weather is not the cause. Poor management, over decades, resulting in incredible fragile systems that constantly punish customers is the responsibility of the airlines. And they have done an incredibly bad job at creating a robust system to deliver value to customers.

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Epidemic of Diagnoses

What’s Making Us Sick Is an Epidemic of Diagnoses by Dr. Welch, Dr. Schwartz and Dr. Woloshin:

For most Americans, the biggest health threat is not avian flu, West Nile or mad cow disease. It’s our health-care system.

True, and probably the biggest economic threat too. See: Deming’s Seven Deadly Diseases and Health Insurance Premiums Soar Again.

But it also leads to more diagnoses, a trend that has become an epidemic.
This epidemic is a threat to your health. It has two distinct sources. One is the medicalization of everyday life. Most of us experience physical or emotional sensations we don’t like, and in the past, this was considered a part of life. Increasingly, however, such sensations are considered symptoms of disease.

Lack of understanding systems and understanding variation? To me this is a very similar idea to seeing everything as a special cause and addressing each problem with special cause thinking (find the one special cause). Instead, often (97+% according to Dr. Deming) the most effective improvement strategy is to examine the whole system (use common cause thinking). This view in itself, might be a sign that I have “Demingitis” – the propensity to see the excessive focus on special cause thinking everywhere I look.
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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. Years ago, my boss was frustrated because an award was sent to the Director’s office to be signed and the awardee’s name was spelled wrong (the third time an awardee’s name had been spelled wrong in a short period). After the first attempts my boss suggested these be checked and double checked… Which they already were but…

I was assisting with efforts to adopt TQM and the time and when she told me the problem and I asked if the names were in the automated spell checker? They were not. I suggested we add them and use the system (automatic spell checking) designed to check for incorrect spelling to do the job. Shift from first looking to blame the worker to first seeing if there is way to improve the system is a simple but very helpful change to make.

This example is simple but it points to a nearly universal truth: if an improvement amounts to telling people to do their job better (pay attention more, don’t be careless, some useless slogan…) that is not likely to be as effective as improving the process. The example includes ideas such as poka-yoke (mistake proofing), respect for people and root cause thinking. I find it most effective to apply tools within an system that has some understand of the management concepts of Deming, lean, six sigma…

The tools by themselves can be useful but it is much easier for them to be misapplied when there is not a more comprehensive understanding. If an organization wants to commit to a serious effort to improve that does not mean that improvement must wait for this education. But it does mean the most effect way forward is to initially strive to improve performance and at the same time build the capacity of the organization by building a broad understand of these ideas. Building that capacity is an investment that will pay off over the long term (and can be “funded” using the gains made using the tools and concepts).

* Update – in re-reading this my first sentence strikes me as a bit obvious, to the point that it is meaningless. Let me state it another way. I am not focused on getting the best result this minute, I am focused on finding the best methods that will produce the best results over the long term (predictable, repeatable system performance). I do not believe that the best management system is one that relies on heroic effort (fire fighting, large sacrifices…). That is most often the sign of failed management not successful management. CMMI covers this idea well.