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?

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Dr. Deming’s Red Bead Game

Let’s Get Started!

See Notes & More:MarkGraban.com/redbead

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

• 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 handwriting. Experience not necessary.

• Must have a loud voice.

Standardized WorkAccount 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 OFJOB 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    

Dr. Deming’s Red Bead Game

Game Debrief

See Notes & More:MarkGraban.com/redbead

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.”

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.”

Deming Said…

“94% of the problems in business are systems driven and only 6% are people driven.”

X + [XY] = Red Beads

X = the worker effectY = the system effect

Deming Said…

“We have one equation with two unknowns… anyone who can solve a single equation with two unknowns is entitled to judge people"

Workplace Red Beads

• What are “red beads” in our workplace?

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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”

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.”

“Disappointing Results”

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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

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What was different this day?

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A Cycle of Blame and Praise

Kick Butt

KB KB

Praise Team

PT PTGOAL

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

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?

• What can we do to improve the system?

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 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

“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 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 theshop floor is only a small part of the total. The most important application of theprinciples of statistical control of quality, by which I mean knowledge about commoncauses 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

Mark Graban, President, Constancy, Inc.www.MarkGraban.com/redbeadmark@markgraban.com Blog: www.LeanBlog.org Twitter @MarkGraban

Q&A