Question from Lloyd S. Nelson, who worked with Deming -- This is a trick question!
Story from a reader of my blog… a story that illustrates this point perfectly. Management wastes too much time chasing every up and down (or wastes the time of people who are expected to give an “explanation” for each data point. Reacting to every data point usually INCREASES variation in a process and its results.
This book is so good, you should go online right now, download the Kindle version, leave my talk and spend 50 minutes reading it
We have one equation with two unknowns… anyone who can solve a single equation with two unknowns is entitled to judge people
Go from 5% to 12% on the slider – there’s fewer outliers on larger risk numbers, then down to 1%
Martin – via Cristal
Martin – via Cristal
Martin – via Cristal
https://www.youtube.com/watch?v=3dgi6EV0DRg They were at 12, the target was 20. He’s pointing at 12
Key Management Questions • How
are we performing? – Are we getting better or worse? • What action should we take? Some rights reserved by Marco Bellucci
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.
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.
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
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?
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.”
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.”
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.
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.”
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”
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
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
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?
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
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
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
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
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)
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)
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.”
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