The Quality Improvement Chain Reaction

 Dr. Deming's aptly named quality improvement chain reaction has been proven over and over since it was first established 70 years ago.

Here is a copy of his version of the chain reaction from his book Out of the Crisis.

This conceptual basis for improving quality can be reworded to fit any work process and it always rings true without question.

In my experience, if there were one enhancement to the wording, I would make sure the student of quality improvement recognized the connection between improving the process and improving quality.  So often, in discussions in the workplace, the focus on the process is lost in the zeal to focus on other aspects of this chain reaction.

It reminds me of the time I was meeting with Bill Conway of Conway Associates and in returning to my office with him and in the elevator, one of our employees asked me, in chit-chat fashion, what I was working on at the time.  Bill interjected with the comment that I was improving processes, exactly what I was paid to do.  Good thing the elevator only served three floors.

You might ask: does this mean that we continue to improve quality to the point of zero defects?  The answer is no because statistically zero defects are not reachable.

Process Engineer Looks at the School System

 

The purpose of this lengthy post is to provide an opportunity for local school boards and parents to become aware of a method for improvement used by most industries.  The methodology is simple, but the school system is complex, especially if one includes the hierarchy of the state and federal government's involvement in education.  Nevertheless, using the process improvement approach should reward local leaders with measurable improvement.

 

Important Concepts of Systems and Processes

Whenever a process engineer encounters a product quality problem, the reaction is to study the system that produced that product. Not just to study the system, but to then use the results of the study to identify projects for improvement.  Inspection to cull unacceptable products from the production line has been proven to be not only costly but ineffective. Ineffective because inspection always misses some defective product and therefore does not prevent poor quality products from reaching the customer.  Only a capable process can deliver quality products reliably.  Furthermore, capable, well-managed processes make work easier and promote a dedicated workforce.

Systems, such as the school system, are made up of a multitude of processes, each with inputs and outputs.  Systems are often complex due to the many processes involved and how these processes interact with each other.

Despite systems complexity, improvement must be directed at the process level.  This improvement effort is directed not only on the process but also on the influence of associated processes.  Systems are often more complex than realized at first.  The first step in developing improvement plans is to learn how processes of the system work together—or work against each other. Process engineers usually create a diagram showing how all the processes involved create the system. The purpose of this diagram is to communicate the makeup of the system so that everyone involved can see the whole picture and understand the complexity.

From an organizational viewpoint, processes have suppliers and customers, and processes also have owners.  Suppliers and customers are the most obvious simply because there must be raw materials provided by a supplier and a product output destined for the customer.  However, ownership of the process is often overlooked which is unfortunate because it is critical to identify owners as they play an important performance and control role. Owners are those individuals or leaders of organizations who have the responsibility to assure the performance of the process as intended, but they are also the sole authority to make any changes to the process.  Improvement of a process often requires a change to an associated process whose owner is not obvious.  That’s where complexity enters in.

Process outcome is improved by identifying and executing projects for improvement.  Slogans and urging of those who work in the process to work harder and/or work smarter are not improvement projects.  This kind of program only leads to the discontent of those who work in the process.

Customers and suppliers must be engaged to have an active improvement program.   An apathetic interest makes the identification of improvement projects nearly impossible.  Accordingly, customers and suppliers need special attention if they have become tolerant and apathetic to quality.  That special attention may mean special communications to get them involved.

Oftentimes, when those who take on the task of process and system improvement, find confusion about their role in the process being studied.  Clarification of this is a must before launching any study and identification of improvement projects.  This can only be done by the leader in charge of the process under study.  Without this leadership, it may be a waste of time to proceed.  It may also be difficult to find the leader in charge, but this must be the first step.

 

Applying the Concepts to the School System

In a macro system view, parents operate a process to provide the raw material (children) to the system. Then, the processes of the school (teaching) provide educational content.  There are other processes, including television, the internet, interactions with peers, and homelife all of which produces a product (an educated young adult) ready for the customer. These other processes have been found to have both a positive and negative effect on the education of children.

It would seem apparent that the education of young people should be viewed as a whole system beginning at the home, long before school age is reached, and extending beyond the hours spent in the classroom.  To attempt any improvement in the processes of the classroom and ignore all the other processes in the system would be shortsighted.

Reducing these thoughts to practice, parents should be seen as the supplier to the classroom teaching process as well as all the other processes involved in the education of their children. To be sure, parents do supply their children as input to the processes outside the classroom whether they think they do or not. The parents may not be thinking along these lines when they provide the access to social media or the internet.  Basically, the parents are saying to these processes, here is my child for you to use as an input.  More processes are in play to provide information to young people with information or to indoctrinate them on certain ideologies than just those in the classroom.  All of these associated processes compete with the processes of the teacher in the classroom.

Now to the output of the system, it is important to agree on the identity of the customer.  So, who is the customer of this system of processes, is it every parent, or is it society? Society did not provide input, nor is it accountable, but parents did provide the child as input to the system of education and have paid for the education process, so, logically, they are the customers.  But here is a test question:  can a customer be an effective customer if no demand for quality is apparent?  The answer is that without a demanding customer, the vigor for improvement is nil.

On the concept of supplier and customer, one sometimes encounters the argument that customers cannot be suppliers.  Metaphors are an interesting way to create understanding, so let’s find a co-op in the business world.  Cotton gins are often co-ops—that is, the suppliers are also the customers with the gin operating as a contract processor.  Sounds a lot like a school system.  The gin must accept all member’s field harvests of cotton bolls for processing, returning the processed cotton to the farmer in the form of a bale.   The costs are shared according to the volume processed.  The farmer accepts the processed baled cotton and sells it to the cordage maker who expects superb quality. 

Sometimes it works that way, sometimes not.  In this metaphor, the first sign of a problem is when the farmer receives a rejection of the baled product for being of unacceptable quality for making high-value cotton cordage. The complaint of poor quality works its way back in the process until the cause is determined as either a special cause or a system cause—a special cause would be due to an event that may have affected just one farmer’s bales.  A system cause problem may have been due to a malfunction in the gin and the quality of many farmers’ cotton would be affected.  Either way, a plan is devised to correct or improve the process.  In this metaphor, it is important to define the start and finish of the process of producing quality cotton.  Does it start in the field at planting time, or does it start at the conveyor feeding the harvested cotton to the gin?  This important question can’t be ignored as it will enter the topic of education later. Where are we to define the beginning of the education of children?  At birth with activities in the home or at the entrance door to the classroom?

Before we attempt to use the process approach to improvement, there is one detail that should be understood about the nature of processes.   Here it is:  As one defines a process in greater detail, it becomes obvious that most processes are made up of processes of smaller scope.  The metaphor example may be tiresome but think about the US Postal Service in their work to deliver a letter to your location from a few thousand miles away.  This overall process is made up of many processes where the letter is handed off from one part of the process to the next.  These so-called handoffs are the points where one process ends in a “product” and the new process takes over with that as an input.  Thus, a long process can have many supplier-to-customer interfaces within its end-to-end boundary.  This is the key point; processes are made up of smaller processes.

Let’s apply that idea to the school system.  Just in one day, the parent provides a child as an input to the teaching process in the classroom.  This teaching process ends at the close of the school day and a handoff occurs whereby the parent gets the child back from the teaching process.  Teaching continues after school, in the home, as it should, so the process of education is continuing. This handoff must meet the quality requirements of the parent, some of which are tested by the parents asking the child what they learned at school today.  That handoff must go smoothly, or the overall process is jeopardized.   Every day, day after day, these quality requirements must be met and if they are not, the teaching process stumbles and becomes discordant.   Just as with the US Postal Office, if every handoff does not go flawlessly, the result is delay or failure to deliver the mail.

Looking for Opportunities to Make Improvements

Assuming the readers are good students, we should take a test drive using the local school system, but before the start, one particular rule should be reviewed.  That rule is one of process ownership.  We can only expect to make improvements if we have the green light from the process owner.  That, in the school system usually implies that we work on local processes.  Got that?  Good, let’s proceed.

The first step in the evaluation of any process is to engage the customer, to determine if the parent is satisfied with the education that their child is receiving.  This should be done individually, not en masse, as you want a frank opinion.  Collect, discuss, and store the results.

The second step is to move backward in the process and ask the people working in the process for their views.  Ask questions that would delve into freedom to do their job, ease of delivery of their teaching, etc.---in so many words, are they able to do their job without hindrance or obstacles?  Again, collect, discuss, and store the results.

The third step is to determine the degree of freedom the process owner has to make improvements to advance the local system of education.  Without the ability to make any changes, the whole process of improvement is stymied.  But press forward as this is critical to get out in the open.

The fourth step is to determine the objectives for improvement efforts.  Oftentimes, we see printed statements made by organizations regarding goals and commitments to improvement.  Commitments are not measurable and serve mainly to buoy the spirit of the customers.  This is not negative, it’s also not productive.  Do as you might here but don’t expect much to come of these public relations types of statements.  Specific targets are needed. Setting targets is important as these targets define the energy needed to make improvements.  For example, if my industrial process is making 50 % of production that is unsaleable, and I set a target of increasing that to 55%, this will not energize an improvement program to any extent.  A target needs to be set that requires a vigorous effort of improvement.  In the school system, if a vigorous target is not realizable, then there exists another problem that will be discussed later.

By now, it is trusted that a question has arisen about who is to do this data gathering.  In general, the solicitation of data from the participants in the process is the process owner or an impartial designated person.  But be diligent with questions on process performance.  Here is an example of a designee asking about process performance:  At the local grocery store checkout, the checker often asks if “did you find everything you needed today?”  You provide the answer, but how often did the checker respond with the next step should you say that not everything went well with your shopping experience?  The question is asked without eye contact and while not hesitating to pass the items past the barcode scanner. The probability that your feedback would reach the process owner is unlikely.  Be real in your data gathering and be diligent with the use of the data.

 

Some nationwide observations of process problems with the big system of education

To illustrate how feedback, providing it is noticed by the process owner is helpful to guide improvement efforts, here are a few examples from the past.

In the 1970s teachers were beginning to show signs of losing control of children in the elementary grades.  This was the first of a series of signals that the input to the system of education was showing signs of a quality problem.  In a private enterprise commercial process, the supplier would have been rejected, and a new supplier meeting the needs of the process would have been selected.  But in the government school system, there is no way to reject a student who rebels against the education process.  As a result of having no alternative, the system modifies the process to accommodate the stress of bad behavior or a reluctance to learn by adding staff to fix the problem. The school system gets bigger and more bureaucratic.

Another observation: The U. S. Armed Forces finds that only 23 % of new applicants to the military are suitable, and businesses are reporting that their second most significant problem is the lack of education of the young person.  What do we mean by lack of education?  It’s usually an easy question to answer.  Many can’t form a complete sentence, they do not know government, and have trouble communicating face to face and, spend too much of their time on social media.  All solvable problems were created by faulty processes, some of which may be way outside of the classroom teaching process.

A Kickoff Question to the Process Owner

Keep in mind that the objective of any effort is to identify projects that can be implemented to improve the level of education of the children leaving the government school system.  Earlier it was discussed how to uncover some facts on how the process of education is working by asking the question of the customer, the supplier, and those who work in the process.

Also, discussed earlier was understanding the viewpoint of the process owner.  A proven way to do that is to ask the process owner to list the barriers (obstacles) to reaching breakthrough performance rather than incremental improvement.  Ask the owner why we cannot have a fully capable education process within two years.  Fully capable, of course, means meeting the state standards of competency.  The list should be obvious to the owner, or one should wonder if the owner is capable of understanding the barriers to process improvement.

Some Native Notes on Learning

Hesitant to make this declaration, but newborn children are probably not very different from newborn wild animals.  Both are born with survival instincts and not much more.  Food, water, contact with the mother, need to breathe, etc. are developed in the first hour after birth. Improper handling of this stage of development may show effects that last a lifetime.  

Keep in mind that instincts are not knowledge, knowledge is not wisdom, and neither is morality.  These come with education.  And then, there is also training, which is different from education.

A few years ago, I read a book titled Little Soldiers.  It was a story of an American mother who enrolled her children in an American School in China, where the enrollment was for children of Chinese parents and American parents.  The book described a routine in the school that was a stark contrast to that of a typical US school stateside. Most of the first year was devoted to training the children to conduct themselves in a manner that was conducive to learning.  That is, being obedient, having the self-control to sit in their seat for extended periods, and not being disruptive to the others in the class; all those attributes which if under control make the job of the teacher much easier and more effective.  The book describes the punishment for disobeying the rules, perhaps more suited to the Chinese culture rather than the American culture so I do not support some of the examples of severe treatment of young people.  Nonetheless, the book points out that training children to obey the rules from the start is critical to paying attention, which is critical to the learning process.  In finality, the teaching of obedience lies with the parents so that the teaching process is not burdened with the task.

Continuing with our preparation for the development of an improvement plan, let’s review some basic premises. This checklist applies when the Board is ready to develop an improvement plan.

(*   The Board of Directors must be sure that they have communicated their policy-making role of the ISD to the parents and the staff of the school.

(b)   The Superintendent and the School Board must come to a mutual understanding of the separate and distinct roles of the two organizations, one being policy making, and the other being operational.  Although some corporations do, the operational authority should not be the chair of policy making.

(c)   Even the best, most obvious improvement plans are not implemented without first testing them.  Testing has the purpose of assuring the plan is effective and prevents unintended consequences due to the implementation of misdirected improvement projects.

(d)  Diversity has its place in improvement work, but randomly selected diversity at this stage of plan development can produce stagnation of effort (the committee effect). Employ a diversity of expertise in plan evaluation when the team leaders report back to the main group.

(e)   Always keep in mind that there are education processes that are within the bounds of the school, but also an array of educational processes not within the four walls of the school. They often compete and interfere with the classroom process.

(f)    The school processes must assume a starting point regarding the knowledge of the incoming student.  It is extremely important to understand that starting point for every grade.  Not being ready to start school is a drag on those who are ready to proceed.  This may be the most important and difficult condition to meet.

Next, let’s imagine the kinds of responses to expect from the Superintendent to the question: what obstacles lie in the path to achieving 100 % compliance with the state standards?  In so many words, what stands in the way of meeting the target of 100% of students meeting state standards?  We are just imagining here as a warm-up exercise—it’s more productive than doodling while we wait for the real response.

Possible obstacles to breakthrough improvement inside the school system:

a)      The teachers lack the time to teach because of the administrative workload.

b)     Variability in teacher capabilities; some teachers are skilled at teaching but do not know the subject matter, some the reverse.

c)      Subject matter is handed down to the local school system and interferes with the basics of education.

d)     The classroom activity is cluttered with extraneous graphical and captivating screen material.

e)      Children are too active and mentally not ready to learn.  Processes do not exist to get them calmed down and ready to learn.

f)       There is a wide range of readiness to learn which requires individual tutoring, with group instruction almost worthless to both the advanced and the unadvanced child.  The classroom teaching methodology does not lend itself to individual or small group teaching.  Assignments and recitations do provide opportunities to teach subgroups.

g)     Some children are advanced and ready to move on to higher levels while others are not, all because of their lack of preparation by the parents to enter the government school system.  Social stigma often prevents this discussion with the community.

What’s next?

Initiate a private work session to practice the concepts without risking anything. After developing confidence in the approach to improvement planning and execution, then go back and make sure that the constituents of the process are involved and informed.

Remember, training wheels on a two-wheel bicycle do not help a child learn how to ride a bike. So, in this private work session, expect to get a bruised ego, and find some differences in viewpoint with cohorts.  It’s all part of learning how to make improvements to a system.

After practicing the art of improvement using a process viewpoint, consider experimenting.  Recall one of the principles:  Test your ideas on improvements by testing the change before implementing the change across the system.   This avoids unintended consequences.

 

 

Epilogue

Essays do not normally need or have epilogues, but this one requires one.

I think I have a good knowledge of process improvement methodology not only in theory but in industrial use, and in writing this essay, I chose to avoid any personal views on the performance of the government school system.

But in spending hours writing the essay and rewriting it to improve its utility, I began to form an opinion of the cause of educational problems.  Knowing but a smidgeon of what goes on in the educational system, I found myself posing the question to myself what would industrial leaders do if they encountered this environment?

Perhaps it was Yogi Berra who said this but if not, it sure fits his repertoire of sayings.  It goes something like this:  You can’t get there from here.  By using that thought, I sense that the local school board has a task that cannot be achieved without going outside their present system of teaching.  And that may be difficult.  It may even be impossible.

For I have become nearly convinced that the problem with the performance of the school system lies with the parents and not with the teachers and administrators. Consequentially, this lack of performance of the parents over decades in rearing their children has facilitated unintended changes in the government school system that will probably be an obstacle to making improvements.

Here’s my argument:

·         Too many parents take little interest in the education of their children.  Those that do, place their children in private schools or home-school them.  Home school parents are still a small percentage and not likely to grow to a greater number because it takes money and personal time. But that could change.

·         Those parents who do not put any effort into the education of their children are apparently not generally interested in children- as evidenced by one-parent families, abortion rates, use of daycare, embracement of pre-K schooling---the whole bit.  Parents today see children as a burden and not an asset.  The end game is Orwellian for sure.  Create children and turn them over to the government at birth to bring them to adulthood.  Raising a child probably costs more than $300,000 and many hours a day to bring each child to adulthood.

·         Parents themselves do not know what is important for their children to know or be able to do before entering the classroom.  The cause of this is that young parents of the current era have been brought up by the same system described above. The result is to defer to the government to fill the role of rearing their children.

And then, consequentially, on the school system:

·         Because of the lack of interest of the parents, the school system has rushed to fill the void with programs that edge out basic teaching of needed skills.  And, because of the wide variation in skills of 4 and 5-year-olds, it reduced whatever standards it once had in place to accommodate the variation.  It was the only response viable for the school system, so basically the standard is set by the lowest level achiever.   It’s like the cotton gin, it had to be redesigned to accommodate the farmers whose cotton was the most contaminated with field litter.

·         The school system has built a massive bureaucracy in response to filling the void created by the parents with classroom teachers, once the main employee of the school, now much less so.

·         The teaching methods that have been implemented preclude up-close instruction which allows teachers to assess comprehension of the subject matter.  Up-close instruction is especially important when the class has a wide range of capabilities.  Both homeschooling and the old one-room school system used the concept of study time in response to an assignment followed by up-close recitation.  For just a moment, sit back and think about the power of this approach to teaching.  Assignments followed by recitation are character building and it allows the teacher to assess the comprehension of every child directly.

·         The teacher’s unions are in control of not only the careers of teachers but also influential on the subject matter, allowing ideological indoctrination to enter the school system from organizations far removed from parents and even teachers.

·         Apparently, the administrative system makes it difficult to appraise teachers and terminate those who fall below standards.  The private industry would suffer badly if this were the case.

 

But like the song Raindrops Keep Falling on My Head, I will never stop the rain by complaining.  So, what to do?

The only way that the government school system can survive is to become competitive with the growing freedom of parents to remove their children from the system.  That shift may not be possible given the bureaucracy of the entire state and federal system of education.  But, let’s explore that anyway.

A simple answer comes to mind on how to do that.  Bring the homeschooling concepts into the government school system in a pilot program.

Key concepts of the pilot program within the school system:

·         Small group of children of a similar level of accomplishment and behavior.  No other screening for the selection of the student group.  It does not matter if the pilot group is ranked high or low.  The objective here is that the group is uniformly ready to learn.

·         Misfits in the pilot group are sent back to the general population of students and are replaced by the next candidate.

·         Teach classical topics in depth that the children can comprehend. 

·         Since the pilot group has the participation of the particular parents, avoid teaching those subjects which are reserved for parents.  Identify those subjects in agreement with the parents.

·         Teachers determine the degree of learning by personal assessment.

Freedom to carry it off?  Yes? Okay get started

Constrained in freedom to pilot the effort?  Well, that’s a problem.

 

A lifetime Story

 All petroleum companies’ laboratories were busy in the 1950s searching for ways to make unique products from oil.  Oil companies were also looking for ways to increase the consumption of oil as there was more oil than there was consumption.   This was an interesting new frontier because oil is composed of many different organic molecules which can be broken apart and reassembled into something quite different.  Common polymers like polyethylene or polyisobutylene are prominent examples.  The properties of these new products were unique at the time and the developers in the laboratory knew more about their potential use than anyone in the converter market. The developers of these new molecules had to instruct potential users on how to mold, cast, or fabricate end-user products. 

My first experience with quality came from the role I played to evaluate our first production of high-density polyethylene.  The plant struggled with the demonstration run, but large quantities of the polymer were produced, and I was provided with several hundred pounds for evaluation in the Products Research Laboratory.  The test samples failed all the tests of durability.  Production of that particular polymer was put on the back shelf for another 20 years. The process that was used in the test run failed to produce a viable product.

Quality in these early years had a very narrow definition and was usually defined as just one parameter. Jokingly, one said about polyethylene that if it's white and if it floats it must be polyethylene.

 

As could be expected, with evaluations of these new products for end uses, customers began to learn rapidly what raw material characteristics were important to them for their success in creating new end-use products.  The polymer characteristics required for making film were different from those required to make bottles.

 

Other suppliers developed related products and with growing customer interest, plants began to be built to supply commercial quantities.

Competition from other labs and their commercial plants plus the growth in customer knowledge caused a rapid rise in the demand for quality to be defined with additional parameters and measured by published test methods.  Once this change occurred, customers began to place limits on key variables and added these limits to their purchase requirements. At first, producers were very secretive about the limits to which they could produce products suggesting a disparity between what specifications were required and what the plant could meet.

 

Competition and customers’ needs drove specifications ranges to ever-narrower limits, so it often became necessary to inspect output to ensure quality requirements were being met. Some customers required tighter specifications than did others, so products were more carefully inspected for them to earmark product specially for them. Production that was out of range for most customers was re-manufactured by recycling with new production at the molecular level.  Recycling avoided losing off-specification production that would otherwise be scrapped, wasting raw material, and labor, and incurring disposal problems. It didn't take long before it became apparent that the chemical process required improvement to make it capable of routinely meeting specifications.  The need to inspect production before shipment ushered in the era of quality and continuous improvement.

 

Improving the process as a means to eliminate quality control by inspection became obvious but was also recognized as a difficult task due to a number of factors. The list of factors was long, consisting of process interruptions that compromised data collection,  employee errors, testing variability, lack of proper equipment for specific steps in the process, and the inadequacy of pneumatic controls for critical parts of the process. All the characteristics contribute to an out-of-control process.

 

Plant technical service engineers and chemists eagerly accepted the challenge to improve plant capability but were unsuccessful—the task was too large for the operating organization to handle.

 

Those who worked during this time said that it was as if there was an undefined struggle occurring between these few process engineers who were looking for a constructive way of overcoming the operating problems and two opposing forces; an operating organization that resisted change and a workforce that was antagonistic. The workforce viewed process engineers as agents of management and they were treated accordingly.

The few process engineers were trying to change how operating personnel were engaged in the process by shifting to a  focus on problem-solving, looking for root causes of operating problems.  The intent was to find some single cause and correct it to make the process run reliably, but the bulk of the management was ambivalent. It was apparent that they did not see any case for changing how the plant was managed. Their unspoken method for overcoming any of the operating problems was to increase accountability at all levels, stressing the need for more discipline in operations management.  It was not obvious at the time, but plant problems were generally understood to be the result of errors caused by careless operations employees, not by defects in the process itself. The solution to that was to put more pressure on the workforce—creating even more dysfunction.

The seed for this interest in solving problems came from reading about systematic problem-solving.  A training program for all engineers on systematic problem solving was conducted but that program was not effective because faulty data and unskilled treatment of the data did not support systematic problem-solving.  Furthermore, finding a root cause of a systematic problem was not in the cards.

One of the operations supervisors said, “it’s like a war zone out there,” referring to his morning control room review of overnight operating problems where the explanation of every upset in plant operations was referred to as a “process secret” by the workforce.  Key logbook entries were missing, and no one had any understanding of the events of the previous shift when the upsets occurred.  Upsets invariably produced scrap and off-specification production----these upsets were costly events, some presenting safety risks.  This antagonistic behavior of the operating crew served to reinforce the conviction of management that all the problems of the plant were due to operator performance either intentionally or unintentionally.

 

It was obvious that there were operating problems caused by the engineering design of the plant.  The process engineers suspected this additional likely cause because even they, with their knowledge of the process, had difficulty establishing stable operations.  Most of these design problems were assumed to be normal because the recurrence of the problems was part of the work of making the product for years.  The instability of the process was the cause of inspecting production before shipment, so it was clear that our objective was to improve the stability of the plant.  We all knew that inspection to ensure the quality of production never works 100% of the time.

 

This nearly unbearable situation lasted for several years during which time equipment sabotage, intentional errors in the execution of routine duties, management directives that were threatening, frequent customer complaints of poor quality, and a poor safety record were normal.  It’s a wonder that no one was seriously injured, and the plant was not destroyed.

During this time of conflict, someone had alerted the local newspaper of the plight of the shift worker and a full-page article based on a night shift interview with the operating personnel appeared in print, much to the surprise of local management. The featured article was like confidential information leaked to the press. The workforce saw success; management was embarrassed. The print copy even made it to the New York corporate offices.

The attempt by these few process engineers to tackle process improvement at the lowest level in the organization was not specifically blocked by management but was completely stalled by the war between management and the workforce. Neither side trusted the other. There was little time left in a full workday to improve anything when all efforts were devoted to repairing damage and reestablishing operations.  In addition, the ability of the organization to tackle a system problem of this magnitude was insufficient.

 

This contentious environment was nudged down the path of reconciliation by the change in a few mid-level plant management positions.  The new leadership had the philosophy of focusing on the process and not on personalities. This shift in management style happened by chance and definitely not by design.  Occasionally change that occurs by chance results in improvement, but don’t count on it.

The changes were timely as the plant was beginning to export products to locations where some customers were known for their attention to the use of process data for quality improvement by implementing projects to change the process.  Japan especially was getting to be known for its success in improving the quality of products in response to difficulties in world trade due to poor quality.   Japanese companies were leading the way in quality improvement using proven principles adopted from the teaching of Dr. Deming from the USA. That Japan was leading in adopting quality as a strategy was a paradox because the broad theory that an improvement in quality would lead to lower cost and higher productivity all the while increasing worker and customer satisfaction originated in the USA with leaders like Dr. Deming, along with Dr. Juran and others many years earlier. These methods were assumed to have been developed in Japan, not the United States because Japan popularized the use of these management techniques to improve quality and productivity.  At the time, our interest in these methods was increased from reading accounts of successes in process operations in Japan as the next level of thinking beyond systematic problem-solving.  We were gaining theoretical knowledge through our study but were not yet applying this knowledge to plant operations.

 

Still, few seemed interested in why the Japanese recognized a quality problem and those in our industry did not. The widespread interest in quality in manufacturing in Japan could be easily explained by noting that Japanese company top management viewed improvement as critical to their survival.  They adopted quality improvement as their main strategy as they were convinced of the relationship between improving quality and all the other outcomes of consisting of customer satisfaction, worker pride, cost, and productivity.  The apparent reason for their adoption of quality as a business strategy was that they had a case for action. When we saw little interest in this approach in our company, we asked ourselves could it be that management here did not sense a crisis because profitability was satisfactory, and they were comfortable with the status quo?  In the jargon of the time, there was no case for action here.

 

The attention to quality and process improvement received a boost from an unfortunate production error.^[1]  High product temperature at the time of packaging was known to have an adverse effect on product use by the customer. Lacking noninvasive temperature sensing tools,  dial thermometers were stuck in the solid product as it moved down the production line to determine if the temperature was acceptable to proceed with packaging the product.  This worked fine for a while, then, a customer in Japan received their shipment of product with a thermometer still stuck where the employee left it, having neglected to remove it.  Regrets were expressed in a response to their written complaint, but they were not satisfied with the response and replied by telling management that was not nearly as devastating as the product which they received that contained some worker’s coveralls.  Since the plant boasted that contamination of the product was at the parts per million level, both of these events were most embarrassing.

 

This product contamination with a worker’s coveralls could not occur by chance but had to occur from some prank, so it was viewed as an act of revenge even though relations between management and the workforce were improving at this time.

These contamination events caused two outcomes.  One is that the customer in Japan requested an in-person explanation of how this contamination was allowed to happen and then describe the process changes to prevent a recurrence. The operations manager traveled to Tokyo and met with the Japanese customer’s management to provide details on the cause of the product quality event, but unknown at the time, the presentation failed to adequately convince them that there was a process-based solution in place. The customer accurately perceived that a focus on the process was not yet an attribute of our organization.

The second outcome was the loan of a plant process engineer from a Japanese affiliate to help teach our plant process engineers to use basic statistical methods to improve the control of the process and the resultant quality. This was a clear example of management leadership assisting the plant’s technical organization in its efforts to improve the process. These two events were opportunities to learn what Japanese industry thought were important methods to manage production.  They were convinced that a focus on process improvement was a key strategy for their business.

Learning from these two outcomes occurred only in a few spots in the organization.

 

A few advances in quality and process improvement occurred at the workforce level, but some significant setbacks occurred at the same time.  Some employees voluntarily participated in quality improvement projects as a result of the leadership of three first-line supervisors and made notable contributions to quality improvement.  Much of this was lost over the next year due to personnel changes and organizational structure changes that did not support the need for quality improvement, confirming that there was still no case for action to improve and that command/control management methods were firmly entrenched.

 

The focus on operations by the Japanese engineer now on loan was on the statistical treatment of operating data.  The core of his influence was to use operating data to separate common causes of plant variability from special causes. His work showed that the process was often not in control. Many operations personnel were then trained in the practical use of statistical treatment of data demonstrating that the use of basic statistics to identify problems would not only create a more uniform product but also make their work easier.

 

As a shining outcome of this training, one shift operations employee brought to his workstation the software and his laptop computer from home to monitor one dimension of product quality and found that in the past, a large percentage of his time was spent adjusting the control settings on the equipment when in fact the process was not stable.  From his use of practical statistics, the process operator learned when to adjust the controls of the equipment and that making adjustments when not warranted would only create more variability. This was an example of using technology from outside our work sphere to improve operating stability, and voluntarily introduced as a new method of operations control.  This shift worker probably saw himself as an outlier among his peers, as he subsequently resigned from his position and left the company.

 

Work to establish the stability of the process by focusing on the equipment now took on more importance.  The quality advocates were pleased but not astonished with this worker’s efforts because they had high expectations that the talent of the workforce would be evident if allowed to develop; after all, the workforce hiring criteria was high.  However, once hired, there was no strategy for identifying the skills and talents of the individual and engaging that individual in the improvement in quality. 

Two major capital-intensive modifications were made to the plant significantly improving the stability of operations.  These two projects were the first major capital investments purposely aimed at improving stability in the long history of the plant.  One was computer control and the shift to electronic instrumentation and the other was a complete redesign of the packaging section of the plant. These two projects demonstrated process improvement and contributed to improving the capability of the process to meet specifications and lessen the dependence on inspection.

 

National interest in operating excellence ushered in an era of quality management under the guise of improving quality. The industry was flooded with written material from theorists on improvement techniques and philosophy.

Managers formed Quality Councils to focus on goals and their translation throughout the organization, accompanied by mission and vision statements,  change management programs, company-wide seminars, awards programs for waste reduction, etc.  Senior management made a bold move and formed a company-wide select team to identify key projects for improvement and to promote quality as a business strategy.  However, for the most part, the effect of these programs never made it to the operational level of the company.

One awards program that did make it to the workforce was to recognize work teams for the lowest level of scrap production; but that ended in total failure because to be the best at meeting the low scrap goal, those operating the process began to return the contaminated product to the prime product flow.  This generated both low scrap levels and as well as many customer complaints.  A principle was easily recognized from this program; be aware of unintended consequences coupled with the principle of testing a change before implementing a change, recognizing that not every change results in an improvement.

 

The company-wide spirit was notably increased but had little effect on identifying projects for improving the basic process capability of various processes.  Most of the energy in these management initiatives was created by well-worded inspirational writing on the subject of quality and operating excellence. These fashionable activities swept the industry. Those on the shop floor ignored most of this activity.

 

Meanwhile, a major example of a positive quality focus was the construction and staffing of a new plant apart and separate from the main facility, purposely planned, and executed in a manner that avoided carrying over any old customs of how to manage plant operations.  The new plant performance was better than anticipated.  The demonstrated performance of the new plant regarding safety, customer satisfaction, and cost of operations was recognized as outstanding.  The new plant’s success was so valued that the plant manager who promoted quality and process improvement from its inception, on his planning to retire, held off his retirement to be sure that his replacement had the right philosophy on employee involvement and the spirit of open management so that the plant would not see a setback.  This may have been the only time that an outgoing manager had any influence on choosing his successor.

This new plant brought to light several key principles on how a company can adopt quality improvement as one of its key strategies. One key principle was to view the company not only as a structure of authority but also as a structure of interdependent processes.  Even though the company business was based largely on processes in the plant, very few managers could relate to the processes involved at their level.  In this new, remotely located plant, employees were so tuned into the concept that processes exist at all levels in the organization, one technician said during a worksite meeting on quality,  “managers continue to urge us to study and improve the processes for which we are responsible, and someday, we will ask you, our managers, what processes you own and manage and what are you doing to improve them. You would be wise to have an answer ready for that day”. Many off-site managers did not get the point made by the technician, but a few did and were awakened by the comment.

This new installation demonstrated that all levels of the organization can and should be involved in continuous improvement of the process to satisfy customer needs, lower costs, and make work easier for everyone.  The role of management here is to lead the way for improvement work at all levels. 

 

This concept raised the question of the leadership for improvement at levels above that of the plant management.  The routine relationship between the plants and management levels above the plant was concentrated on reporting the operational problems of the process, including safety events.  During this time, the erratic operation of the process was deemed to be the result of incapable employees and their immediate supervision.  The net result of this relationship was frustration at the lack of expectation of a plan for correcting the systematic problems of the operations.  It appeared that the communication of plant performance to headquarters management was to assure that no manager was guilty of not knowing the performance of the plant, rather than not knowing how to improve the plant.  Still no case for action.

 

Leadership on quality at the top dropped dramatically with the next shift in assignments and the special quality development team structure was shifted with a change in personnel.

The quality development group which was formed to report to the management committee now reported to the executive vice president for a period of several years. As part of organizational changes, the development group was moved to report to one of the product vice presidents, and then, because none of the product vice presidents knew how to direct and lead what seemed to them like a controversial company-wide effort to improve manufacturing processes, the group was reassigned to the Human Resources Department where innocuity was assured.

 

Eventually and slowly, brick by brick, the dismantling of the quality thrust had begun.  The buildup of the philosophy of quality and continuous improvement to its modest extent after more than twenty-five years took less than one year to effectively dismantle the progress back to a state that existed many years earlier. The effort to add quality and continuous improvement to the strategy of the whole company ended when the development group was assigned projects unrelated to quality and continuous improvement. 

 

The decrease in attention to adding quality improvement as one of the business strategies now took on the characteristics of “just another program” in the eyes of the organization.

 

From the reporting of operations problems and the apparent lack of interest in process improvement to correct those problems, the next question focused on measurement.  The hypothetical question was asked, “what key measures of process performance were reported statistically to top management on a real-time basis?’ There were none. That’s because the measurement system at the working level consisted of events whereas the measurement system at the top level of the organization involved key parameters including money.  There was never a connection between the two systems of measurement, and we considered this to be a fault.

Another hypothetical question: What might the interest in quality and process improvement be if the top level of management had a real-time meter of the cost of poor quality in the operations? The emphasis on improved process stability would jump overnight, it was concluded.

 

The logic drove the thought processes right back to fundamentals.  If management wants to see improvement, measure the condition—but measure it at its source in terms of what matters---and that is the company’s key parameters including money.  Goals translation failed because it was translated down the organization and arrived on the workforce floor in terms that meant little to them. Performance measurement translated up to top management in the language of money would be a success. Measurement of the condition is critical because the leadership response to the need for process improvement is driven by the incentive to improve and without measurement the level of needed improvement is unknown.

 

Parallel thinking applied here: what might have been the interest in measurement if this dilemma of lack of measurement of performance was documented and leaked to the local newspaper? Just like twenty years before, the story might make it to the Corporate Offices.

 

Here’s what we learned from recalling the 25 years of effort, all condensed into a few items which describe the important and necessary conditions within an organization for it to function with quality as one of its organizational strategies---none can be ignored at the risk of others. But be aware, that the following are the necessary conditions for success but getting there still depends on management’s willingness and ability to provide the leadership.

Dr. Deming’s point about top management involvement was beginning to make sense.

Looking back over 25 years of effort in the field of quality and continuous improvement the structure and the capability of the organization were overlooked as contributing factors to the inefficacy to tackle process improvement projects.  Perhaps this is a common fault in that not much is known about the subtle effects of organizational structure on productivity.    Halfway through this journey of 25 years, the organization was restructured adopting a matrix design where the lead was given to product lines.  When this shift occurred, a major effect occurred: near minimization of process technology in the matrix structure coupled with a drift to avoid looking outside our industry for innovative solutions to process problems.  With this structural change, the new matrix management lacked process knowledge and interest, and the technology resources were lost.  The core process part of the organization was left in a stranded condition.

This distillation of the events would suggest the following conditions necessary for an organization to operate with one of the strategies being quality improvement.

 

·         All members of the organization must understand the operational definitions of a few keywords used in quality improvement.  New jargon should be minimized but some words must be defined---one such word is QUALITY.

·         Everyone in the organization must view their work as a component of an identified process. Thus,  the structure of the organization can be seen by all as a dynamic system of processes with defined controls and leadership, all of which are directed at achieving customer satisfaction and resulting in an improvement in productivity and pride in workmanship.

·         New processes introduced to the organization must be defined in their technical terms; input and output definitions and measurement methods, controls necessary, and services needed.  Process and design engineers must deliver a turnkey operation to the operations organization. Business specialists and staff groups must follow the same rigor in instituting new business processes.

 

·         The performance of processes must be measured. The units of measurement must be tailored to the part of the organization—such as process variance at the working level, and financial at the upper level. Without accurate measurement, there can be no organized effort to make improvements.  Measurement systems must be capable in and of themselves and have meaning at every level in the organization. Process performance measures must be able to be converted into relevant terms at any level in the organization thus assuring one language of measurement. The Information Technology function now has a more distinct role in process improvement, beyond that of mere automation.

 

·         Managers perofrming as leaders must formulate plans for improvement, develop projects for improvement and dedicate resources to improving process performance to achieve stable processes. In a large organization, this will require a shared process improvement function because of the many common processes.  Continuous improvement successes must be applied across the organization.

 

·         All members of the organization must know how to use the relevant tools and methodology for improving processes because their leader will expect them to participate in improving their process. The use of the tools of improvement includes the concept of testing a change before full implementation because not every proposed change will result in an improvement.  Everyone must be alert to the pitfalls of changes that could contribute to lowering performance.

 

·         There must be a constancy of purpose set by leaders at every level.  Assignments at every level must be consistent with the philosophy of constancy of purpose.  Leaders must be confident and able to demonstrate that constancy of purpose directed at the quality of output assures not only customer satisfaction but pride in workmanship both of which make other management programs unnecessary and avoids some which may be destructive. Especially think about safety, environmental control, and employee morale, all of which fall under the umbrella of quality and continuous improvement.

 

·         The organization must be capable of celebrating its successes and learning from its failures. This means that the whole organization can celebrate a success that occurred in another part of the organization because everyone sees value in system improvement no matter where it occurs.  Failures in one part of the organization must play a role in avoiding repetition in another part of the organization.

 

·         The structure of the organization must not, in its zeal to focus on the customer, neglect the focus on processes, for it is the effective process that best serves the customer.  Furthermore, the organization must not be complex and should not have more layers than necessary to manage the processes. The span of control can be increased with a better focus on the process and the customer.  Excessive layers in the organization lead to bureaucracy and add distance between leaders and workers.

 

If all this seems profound, why did we fail to develop the leadership in management to adopt quality and continuous improvement as one of the strategies of the company?

The simple answer may lie in the conversation with an associate recently.  We raised the question of why many governmental and industrial organizations appear to approach improvement haphazardly.   The answer from Ken was quick and to the point:  “It’s all about measurement; we engineers measure everything and measurement is a key component of the scientific method for making improvements.  This method drives action.”

We now conclude that we failed to develop and adopt a measurement system to reveal the cost of poor quality and make that measurement the driving force for leadership in process improvement.   We came close at one time about halfway through the journey, by developing manager’s quality stations where results were on display, but the measures were not relevant.  We chose the few measures that were acceptable because our quality stations were visible to visitors.  The cost of poor quality could not be on public display.

Alternatively, providing an internal weekly report to top management showing the costs of poor quality for the last week would have been effective.

 

The chapter on the history of a valiant effort on quality was opened and closed for the last time.

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[1] Anything that can go wrong will eventually go wrong, an adage dating back to 1866 turned out to be the case here.