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  • Mason Neck State Park Photos
  • How to Improve

    Good management systems are about seeking systemic adoption of the most effective solutions.

    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.

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  • Customer Focus at Ritz Carlton and Home Depot

    Ritz-Carlton’s motto is “We are ladies and gentlemen serving ladies and gentlemen.” And they actually turn those words into reality. They are not platitudes with no action. The system is guided toward achieving that vision.

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  • Common Cause Variation

    Every system has variation. Common cause variation is the variation due to the current system. Dr. Deming increased his estimate of variation due to the system (common cause variation) to 97% (earlier in his life he cited figures around 80%). Special cause variation is that due to some special (not part of the system) cause.

    ...

    To take action against a special cause, that isolated special cause can be examined. Unfortunately that approach (the one we tend to use almost all the time) is the wrong approach for systemic problems (which Deming estimated at 97% of the problems).

    That doesn’t mean it is not possible to improve results by treating all problems as some special event. Examining each failure in isolation is just is not as effective. Instead examine the system that produced those results is the best method.

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  • What one thing could we do to improve?

    Asking “how is everything” normally will get the response: “fine” (which is often that is exactly what the staff wants so they can move on without wasting any time). However, if you really want to improve that doesn’t help.

    To encourage useful feedback, specifically give the customer permission to mention something that could be improved. What one thing could we do better?

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  • The Illusion of Understanding

    It is important to understand the systemic weaknesses in how we think in order to improve our thought process. We must question (more often than we believe we need to) especially when looking to improve on how things are done.

    If we question our beliefs and attempt to provide evidence supporting them we will find it difficult to do for many things that we believe. That should give us pause. We should realize the risk of relying on beliefs without evidence, and when warrented look into getting evidence of what is actually happening.

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  • European Blackout: Human Error-Not

    The focus seems to be that we didn’t do anything wrong, just some “human” made an error, which seems to be implied is out of their control. Why would the organization not be responsible for the people and the system working together? Management needs to create systems that works. That system includes people and equipment and process management and suppliers

    If management tries to claim a failure was due to "human error" they have to provide me a great deal more evidence on why the system was designed to allow that error (given that they say the error is "human" implies that they believe the system should have been able to cope with the situation). Requesting that evidence is the first thing reporters should ask any time they are given such excuses. At which time I imagine the response options are:

    1. no comment
    2.  we had considered this situation and looked at the likelihood of such an event, the cost of protecting against it (mistake proofing) and the cost of failure meant and decided that it wasn't worth the cost of preventing such failures
    3. we didn't think about it
    4. we think it is best not to design systems to be robust and mistake proof but rather rely on people to never make any mistakes

    What they will likely say is we have these 3 procedures in place to prevent that error.
    Are they every followed? You have something written on paper, big deal? What actually happens?
    Yes they are always followed by everybody, this one time was the only time ever that it was not followed. Why?
    This person made a mistake.
    Why did the system allow that mistake to be made?
    What? You can't expect us to design systems that prevent mistakes from being made.
    Yes I can. That is much more sensible than expecting people never to make a mistake.

    continue reading: European Blackout: Human Error-Not

  • Sub-optimize a Part to Optimize the Whole

    ...choosing to sub optimize a part to optimize the whole. One of management’s roles is to determine when to trade a loss to one part of the system for the sake of the overall system. One of the big losses for software development is interruptions which distract developers.

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  • Ackoff’s F-laws: Common Sins of Management

    Managers who don’t know how to measure what they want settle for wanting what they can measure.

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  • Amazon Innovation

    In my view Amazon is doing some very interesting innovation...

    I continue to believe they have a good shot at doing so going forward (and their core business is doing very well I think). Innovation often involves taking risks. Bezos is willing to do so and willing to pursue his beliefs even if many question those beliefs. That means he has the potential to truly innovate, and also means he has to potential to fail dramatically.

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  • Creating and Sustaining Great Management Systems

    It is hard enough to create and sustain great management systems without adding more challenges to achieving success. When the management system results in having credit for each success fought over (to allocate credit to whoever convinces others they deserve the credit) it is much harder.

    This is one of the many ways Performance appraisals schemes (where people have to claim responsibility for successes in order to get more cash) create problems.

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  • Simple Cell Phone

    Complex devices with many points of failure (both technical failure and user inability to figure it out) should not be the only option. Simple, easy to use, reliable devices would have a big market. Creativity is not just about more complex devices.

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  • Turning The PDSA Cycle Rapidly (Iteration)

    One point he made was that he often finds that organizations fail to properly “turn” the PDSA cycle (by running through it 5-15 times quickly and instead to one huge run through the PDSA cycle). One slow turn is much less effective then using it as intended to quickly test and adapt and test and adapt…

    In my experience people have difficulty articulating a theory to test (which limits the learning that can be gained). He offered a strategy to help with this: write down the key outcome that is desired. Then list the main drivers that impact that outcome. Then list design changes for each outcome to be tested with the PDSA cycle. 

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  • Designing In Errors

    When you design products that create more possibilities for more errors you create products that will in fact fail more often.

    Related: The Edge-case Excuse

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  • Righter Performance Appraisal

    Just because it would be nice for performance appraisal to work doesn’t mean it does work. As Deming said some numbers are unknown and unknowable and the wish that it is possible to quantify the contributions of people doesn’t mean you can. People cling to the idea that performance appraisal is the only tool we have to manage performance so we must use it. Even if most people realize it is just a game that accomplishes little, if anything positive, and causes great frustration and animosity they persist. Hopefully performance appraisal will be seen as “artifact of the past” sometime soon.

    continue reading: Righter Performance Appraisal