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The Real Lessons Of
Dr. Deming’s Red Bead Factory
@MarkGraban markgraban.com/redbead
Why Are We Here?
“To learn… and
to have fun!”
Key Management Questions
• How are we performing?
– Are we getting better or worse?
• What action should we take?
Some rig...
Help Wanted – 6 Willing Workers
• Must be willing to put forth best efforts.
Continuation of job is dependent on
performan...
Help Wanted – Inspector
• Must be able to distinguish red from white;
able to count to 20. Experience not necessary.
Help Wanted – Inspector General
• Must be able to distinguish red from white;
able to count to 20 and have neat
handwritin...
Standardized Work
Account
Name:
White Bead Corporation CREATION DATE: 2/14/02
Process Location: Chicago IL CURRENT REVISIO...
Discussion Questions
• What did we observe & learn?
• Who is responsible for quality?
• How could you fix the bead “system...
Deming Said…
“The worker is not the
problem. The system is
the problem. If you
want to improve
performance, you must
work ...
Deming Said…
“Management should be
working with the
supplier to reduce the
number of red beads.
Reduce lot-by-lot
variatio...
Deming Said…
“94% of the
problems in
business are
systems driven
and only 6% are
people driven.”
X + [XY] = Red Beads
X = the worker effect
Y = the system effect
Deming Said…
“We have one equation
with two unknowns…
anyone who can solve a
single equation with two
unknowns is entitled...
Workplace Red Beads
• What are “red beads” in our workplace?
http://www.bbc.co.uk/news/magazine-10729380
BBC Online Simulation
• “…in the calculator, every patient in every
hospital has exactly the same chance of dying
and ever...
BBC Online Simulation
• The calculator shows 100 hospitals each
performing 100 operations
• The probability that a patient...
The Results
“The calculator seems
to show fatal
incompetence or
maybe even - let's
speculate what goes
through the public
...
Blaming the System
• 10. Eliminate slogans, exhortations, and targets for
the workforce asking for zero defects and new le...
Deming Said
“Management should be
working with the supplier
to reduce the number of
red beads. Reduce lot-by-
lot variatio...
“Disappointing Results”
An SPC Chart View
0
25
50
75
100
125
150
175
200
225
250
275
300
325
350
375
400
425
450
475
Oct-12
Nov-12
Dec-12
Jan-13
F...
The Wrong Questions
• “Why was performance bad yesterday?
• “Why were we worse than our goal
yesterday?”
• Don’t ask for a...
An SPC Chart View
0
25
50
75
100
125
150
175
200
225
250
275
300
325
350
375
400
425
450
475
Oct-12
Nov-12
Dec-12
Jan-13
F...
0
10
20
30
40
50
60 3/1/07
3/2/07
3/3/07
3/4/07
3/5/07
3/6/07
3/7/07
3/8/07
3/9/07
3/10/07
3/11/07
3/12/07
A Cycle of Blam...
Over Explaining a Stable System
• Above / below budget (but stable system)
– “Why are we over budget this month?”
• Daily ...
Were We Helping?
• This system was in control, but not meeting
management/customer specifications
• “Demanding” 30 minute ...
Can We Predict the Future?
Deming Said
“What is the purpose of
management? Not to play
games but to use numbers
so we can plan and predict
the future...
Improving a Stable System
• What went wrong yesterday or last month?
• Or… why is our system stable, yet not meeting
goals...
Red / Green Charts
http://www.leanblog.org/RYG
Red / Green Charts with SPC
http://www.leanblog.org/RYG
Red / Green / Yellow
http://www.leanblog.org/RYG
Two Kinds of Mistakes
1. To react to an outcome as if it came from a
special cause when actually it came from
common cause...
“Obviously overall, we’re doing quite well,
but this week, we were below our number.”
Reacting to Special Causes
• Can we identify what was different in that
time period?
– There’s a small chance there was no...
Deeper Thinking
• Is it fair to blame the bead game foreman?
• Where has application of “understanding
variation” not been...
W. E. Deming, The New Economics, p. 36
“Somehow the theory for transformation has been applied mostly on the shop floor.
E...
Quick Recap
• Don’t blame individuals for performance
variation that’s actually due to the system
• Don’t ask for “special...
Mark Graban, President, Constancy, Inc.
www.MarkGraban.com/redbead
mark@markgraban.com
Blog: www.LeanBlog.org
Twitter @Mar...
Mark Graban Deming Red Bead 2016 SHS
Mark Graban Deming Red Bead 2016 SHS
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Mark Graban Deming Red Bead 2016 SHS

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The Deming Red Bead Experiment

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Mark Graban Deming Red Bead 2016 SHS

  1. The Real Lessons Of Dr. Deming’s Red Bead Factory @MarkGraban markgraban.com/redbead
  2. Why Are We Here? “To learn… and to have fun!”
  3. Key Management Questions • How are we performing? – Are we getting better or worse? • What action should we take? Some rights reserved by Marco Bellucci
  4. Help Wanted – 6 Willing Workers • Must be willing to put forth best efforts. Continuation of job is dependent on performance. Educational requirements minimal. Experience in pouring beads is not necessary.
  5. Help Wanted – Inspector • Must be able to distinguish red from white; able to count to 20. Experience not necessary.
  6. Help Wanted – Inspector General • Must be able to distinguish red from white; able to count to 20 and have neat handwriting. Experience not necessary. • Must have a loud voice.
  7. Standardized Work Account Name: White Bead Corporation CREATION DATE: 2/14/02 Process Location: Chicago IL CURRENT REVISION LEVEL: 3.1 Operator Process Type: Producing White Beads PREVIOUS REVISION DATE: 9/15/15 JOB GUIDANCE SHEET PROCESS TYPE QUALITY/SAFETY ORDER OF PROCESS JOB STEP DESCRIPTION OF JOB CONTENT Analysis Information (Process Type & Estimated Time) DESCRIPTION OF KEY QUALITY ("Q") AND SAFETY("S") POINTS CODE ESTIMATE WHAT WHY 1 1 Ensure paddle holes are empty of all beads I 2 1 2 Grasp the paddle by the handle. TL 2 Ensure holes are oriented upwards. Necessary for proper capture of produced beads 1 3 Slide the paddle down into the beads until paddle is covered with beads. LD 4 1 4 Pick up paddle to 4 inches above the bead level. VA 5 1 5 Tilt paddle at a 47 degree angle to release excess beads. VA 5 Must be at precisely 47 degree angle. Best utilizes gravity. 1 6 Withdraw paddle from container UL 3 Make sure one bead is in each hole. Production quota 2 7 Walk to Quality Control WK 5 Be careful to not spill bead any beads. 2 8 Present to Quality Control for count of beads produced. I 10 3 9 Walk back to Production area. WK 5 4 10 Empty paddle back into bead container. RW 3
  8. Discussion Questions • What did we observe & learn? • Who is responsible for quality? • How could you fix the bead “system?” • What is the impact of labeling some as “below average?” • What are some forms of “tampering?”’ • What could you do with the red beads?
  9. Deming Said… “The worker is not the problem. The system is the problem. If you want to improve performance, you must work on the system.”
  10. Deming Said… “Management should be working with the supplier to reduce the number of red beads. Reduce lot-by-lot variation. That is how to get better numbers.”
  11. Deming Said… “94% of the problems in business are systems driven and only 6% are people driven.”
  12. X + [XY] = Red Beads X = the worker effect Y = the system effect
  13. Deming Said… “We have one equation with two unknowns… anyone who can solve a single equation with two unknowns is entitled to judge people"
  14. Workplace Red Beads • What are “red beads” in our workplace?
  15. http://www.bbc.co.uk/news/magazine-10729380
  16. BBC Online Simulation • “…in the calculator, every patient in every hospital has exactly the same chance of dying and every surgeon is equally good. This is to show what chance alone can do, even when the odds are the same all round.”
  17. BBC Online Simulation • The calculator shows 100 hospitals each performing 100 operations • The probability that a patient dies is initially fixed at five in 100 • The government, meanwhile, says death rates 60% worse than the norm are unacceptable (in red) • So any hospital which has eight deaths or more out of 100 ops - when the expected average is only five - is in trouble. • We've assigned one hospital to you, with a box around it - it could come out green or red.
  18. The Results “The calculator seems to show fatal incompetence or maybe even - let's speculate what goes through the public mind - murder at one, medical genius at another.”
  19. Blaming the System • 10. Eliminate slogans, exhortations, and targets for the workforce asking for zero defects and new levels of productivity. Such exhortations only create adversarial relationships, as the bulk of the causes of low quality and low productivity belong to the system and thus lie beyond the power of the workforce. – Deming’s “14 Points for the Transformation of Management”
  20. Deming Said “Management should be working with the supplier to reduce the number of red beads. Reduce lot-by- lot variation. That is how to get better numbers.”
  21. “Disappointing Results”
  22. An SPC Chart View 0 25 50 75 100 125 150 175 200 225 250 275 300 325 350 375 400 425 450 475 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Minutes ED Arrival to Admission CMS Top Decile = 175 minutes CMS Median = 277 then to 269 minutes
  23. The Wrong Questions • “Why was performance bad yesterday? • “Why were we worse than our goal yesterday?” • Don’t ask for a “special cause” explanation when you have common cause variation
  24. An SPC Chart View 0 25 50 75 100 125 150 175 200 225 250 275 300 325 350 375 400 425 450 475 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Minutes ED Arrival to Admission CMS Top Decile = 175 minutes CMS Median = 277 then to 269 minutes ? What was different this day?
  25. 0 10 20 30 40 50 60 3/1/07 3/2/07 3/3/07 3/4/07 3/5/07 3/6/07 3/7/07 3/8/07 3/9/07 3/10/07 3/11/07 3/12/07 A Cycle of Blame and Praise Kick Butt KB KB Praise Team PT PT GOAL Lab TAT – Daily Average
  26. Over Explaining a Stable System • Above / below budget (but stable system) – “Why are we over budget this month?” • Daily productivity – Lots of time wasted on 0.07% over goal • IMPROVE the SYSTEM – “Why is the system not meeting the goal?” – It’s not “what went wrong today?” • It’s the same things that went wrong other times
  27. Were We Helping? • This system was in control, but not meeting management/customer specifications • “Demanding” 30 minute performance will lead to: – Distorting the data – Distorting the system – Improving the system
  28. Can We Predict the Future?
  29. Deming Said “What is the purpose of management? Not to play games but to use numbers so we can plan and predict the future.”
  30. Improving a Stable System • What went wrong yesterday or last month? • Or… why is our system stable, yet not meeting goals? • What can we do to improve the system?
  31. Red / Green Charts http://www.leanblog.org/RYG
  32. Red / Green Charts with SPC http://www.leanblog.org/RYG
  33. Red / Green / Yellow http://www.leanblog.org/RYG
  34. Two Kinds of Mistakes 1. To react to an outcome as if it came from a special cause when actually it came from common causes of variation. 2. To treat an outcome as if it came from common causes of variation, when it actually came from a special cause
  35. “Obviously overall, we’re doing quite well, but this week, we were below our number.”
  36. Reacting to Special Causes • Can we identify what was different in that time period? – There’s a small chance there was no difference • Can we: – Prevent reoccurrence? (bad outlier) – Make that a permanent change? (good outlier)
  37. Deeper Thinking • Is it fair to blame the bead game foreman? • Where has application of “understanding variation” not been applied? • Other “real” lessons of the bead factory? • Understanding and managing variation when you don’t have figures (behaviors)
  38. W. E. Deming, The New Economics, p. 36 “Somehow the theory for transformation has been applied mostly on the shop floor. Everyone knows about the statistical control of quality. This is important, but the shop floor is only a small part of the total. The most important application of the principles of statistical control of quality, by which I mean knowledge about common causes and special causes, is in the management of people.”
  39. Quick Recap • Don’t blame individuals for performance variation that’s actually due to the system • Don’t ask for “special cause” explanations when the chart shows “common cause” variation
  40. Mark Graban, President, Constancy, Inc. www.MarkGraban.com/redbead mark@markgraban.com Blog: www.LeanBlog.org Twitter @MarkGraban Q&A

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