The W. Edwards Deming Institute Blog

Systems Thinking: Feedback Loops

Appreciation for a system is one of the four components of Deming’s management system. In this context the most common item to think of is Deming’s diagram of an organization as a system. That is a powerful diagram.

When thinking of appreciation for a system within the Deming context the view of the organization as a system is the most common concept to consider. But systems thinking has an entire body of knowledge that is useful. Going into this area was much more common in the Deming community decades ago (when W. Edwards Deming was with us) than it is now.

Feedback loops are a part of systems thinking.

Reinforcing Loops

A reinforcing loop encourage the system to continue in that direction (e.g. a damn starting to leak, as water flows over the damn wall it will further erode the wall which leads to more water flowing over causing more erosion).

When the reinforcing loop is undesirable it can be referred to as a viscous cycle. This would be something that you would want to avoid if possible. Designing the system to avoid reinforcing loops that push results into an area you wish to avoid. When you can’t design that away having processes that provide notice when things are moving in the wrong direction so you can institute countermeasures to avoid the natural result of leaving the reinforcing loop to move against your desires.

Sometimes you can design the process to have countermeasures automatically take place if conditions start moving in the wrong direction.

When the reinforcing loop is a desired result then we want to design system to encourage things to move in that direction. Sometimes it can be useful to think of it as having a bit of inertia but as you put in some effort to get things going then it gathers momentum and can produce more and more benefit for very little effort (like rolling something down a hill).

An example of a positive reinforcing loop is building trust in an organization. As people gain trust (and fear reduces) people are more willing to be trusting and cooperate, that behavior then encourages more of that behavior and so on. A positive reinforcing loop are often called a virtuous cycle.

Balancing loops

Balancing loops will encourage the system to stay in balance (e.g. eating will cause you to feel full and stop eating while not eating will cause you to feel hungry and start eating).

If you have a specific desired result if you can design a system to include natural balancing loops that achieve the desired result that is making good use of systems thinking. This is often how balancing loops are portrayed but they can also be stubborn resistance to improvement. It can be that the balancing loop is balanced not at a desired state but at a less than desired state.

Organizations in fire-fighting mode can often fall into this trap. When there is a crisis, direct resources to address that crisis and return results to at least a non-crisis level. At that point, what an organization based on Deming management system would want to do is consider if that crisis is an indication of a bad system that we should spend resources to examine and improve. Often people say this is what they do, but it isn’t, normally, at best they slap on band-aids and more on.

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The Intellectual Foundation of Modern Improvement

The video above shows Don Berwick’s presentation at the IHI/BMJ International Forum on Quality and Safety in Health Care, 13 April 2016. He starts the presentation with the Red Bead Game (see related posts on our blog: Lessons From the Red Bead Experiment with Dr. Deming, The Red Bead Experiment with Dr. W. Edwards Deming).

Quoting Shewhart, Berwick said:

When you inspect you are conceding the to the system.

This is a nice short quote to emphasis the weakness of relying on inspection. What we want to do is improve the system to reduce the instance of poor results, not to inspect our unreliable process to remove bad results. This is even more true in services where often you can’t inspect to catch errors before the customer is disappointed (think of call centers for example). If the customer service representative gives a poor response you can’t inspect it before it reaches the customer. You need to improve the system to avoid producing poor results. (See: Inspection does not improve the quality, nor guarantee quality. Inspection is too late.)

Tampering is responding to random variation as if it were informative.

This is very common. When you don’t understand variation you react to data points as if they mean something other than what they do mean. See our posts of understanding variation. Evidence-based decision making is good, but just because you use data doesn’t mean it is effective (for example, the read bead experiment). You must know how to understand what data is telling you.

Deming’s proposal was this. He said, you used to think, before Stewart, before Deming, before Juran, that if you want to get better at something you needed to understand the subject. You want to get better at surgery study surgery, if you want to get better at nursing study nursing, if you want to be better at pharmacy study medicines. Thats right, thats subject matter knowledge, you better know it. I don’t want a surgeon to operate on me that doesn’t know anatomy. And that he says will produce traditional improvement.

But, he said we are not after traditional improvement, we are after total system transformation. He said there is another set of knowledge we need, in fact he said there are really four kinds of knowledge.

Those 4 areas are appreciation for a system, knowledge of variation, theory of knowledge (in the talk Dr. Berwick sometimes lists this as PDSA) and psychology.

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The Deming in Education Initiative

In this Deming Institute podcast (download the podcast) Kevin Cahill and David Langford share how The Deming in Education Initiative was conceived, the impact of the Deming Philosophy on education, and where the Initiative is going in the future.

Kevin Cahill and David Langford

Kevin Cahill and David Langford

The initiative first began many years ago when David joined the Deming Institute Advisory Board to help with their efforts to apply the Deming philosophy in education. But the roots of Deming in Education go even further back. As David explains, improving education was “a great love” of Dr. Deming, as an educator who taught at NY University for 40 years. Many of Dr. Deming’s theories and teachings are directly focused on the education system. After working with Dr. Deming from 1986 to 1993, David began implementing the concepts in his own education system, finding that students easily took to the new approach.

Over the last 25 years, David has seen the Deming teachings make a profound and lasting impact on improving school culture and the learning process in the US and around the world. It is the only philosophy that improves all aspects of the education system. That impact has inspired Kevin, David and The Deming Institute to commit a deeper focus on developing a long term, sustainable, systems approach to improving education for all students, through The Deming in Education Initiative.

The Institute is trying to create a critical mass in regions by focusing the efforts on a specific region of the USA each year (with multiple seminars and a conference). David alludes to the problem of short term thinking and the common failure of a conference to actually result in change. It takes a long term commitment (constancy of purpose) and something beyond occasional conferences are needed.

There is also international interest and the Deming Institute is considering how to address the international interest.

Upcoming Deming Education Initiative events:

Seminars will be scheduled in the Atlanta region in 2017.

Related: Deming Inspired Innovation in Education (David Langford’s presentation at our 2014 annual conference)Deming in Education: Education as a SystemThe W. Edward Deming Institute Launches a New Podcast Series (with Kevin Cahill in the 1st episode)


Bill Scherkenbach Interview with Dr. Deming

This is a very interesting interview with W. Edwards Deming by Bill Scherkenbach (recording in February 1984, during this time Bill Scherkenbach worked at Ford and Deming was consulting with Ford). The interview provides many insightful quotes from Deming and shows his concern for the widespread failures of American management and the suffering caused by executives and senior managers.

This video also provides a view of his personality. He repeatedly expresses the importance of changing the management of our organization to let those doing the work use their brains, which far too often American management represses due to heirarchacal management systems.

Maagement can face almost every problem, except for problems of people. Some live in constant fear of their jobs… when it comes to problems of people they turn the job over to somebody else… Factory workers the world over has always been interested in quality… They tell me they are the only ones interested in quality. All they ask for is a chance to take pride in their work.

It is not what management says, it is perception and rumor that runs a company.

As with so many quotes of Deming, this short segment is packed with ideas (in this post I barely scratch the surface of a very small number of the ideas he raises). Also, this video, as with many similar ones, can be a bit of a challenge as he dips into dozens of ideas and flips from one to another, often without finishing the thoughts on the first. Still it is filled with powerful ideas.

This quote again shows Dr. Deming’s focus on the importance of letting those doing the work guide the organization. Instead we often have those far removed formthe work setting policies and guidelines and frustrating the ability of those doing the work from doing the best job. Deming believed we need to focus managers and executives on managing the organization as a system. And to do so they needed to provide the training and organizational framework (policies, practices etc.) to let them do so.

And as he started off the video those most in need of training are senior managers and executives. That is where the transformation is needed. And sadly it is still at that level where training is most needed. To some extent executives in some organizations have learned to treat employees with more respect and focus on creating the proper systems to allow people to take pride in their work and delight customers. But there is still a huge amount of work to be done in this area.

The last line I included in the quote above is so powerful but so overlooked. What matters isn’t what manaagement says. What matters is what management does. People know saying cusotmer service matters while forcing customers to deal with impenatrable burocracy when they need support. Employees don’t focus on rumor and guesses about what really matters because that is how they naturally would act.

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Using Deming’s System of Profound Knowledge to Gain Insight into Data Collection

Guest post by Kim Melton

When many of the ads on the final round of the Masters Golf Tournament are about using data to make decisions, you know that data has become big business! In ads IBM touched on the use of data in transportation, healthcare, manufacturing, crime, love, education, farming, pollution, weather, energy, and many other areas!

The ability to collect large amounts of data is increasing daily, and organizations are attempting to use analytics to transform this data into usable information to help them gain better knowledge about their products, services, and customers. Successful transformation from data to information and knowledge touches on all four components of Deming’s System of Profound Knowledge (and the interactions among the components).

Unfortunately, there is no such thing as (truly) objective data. All data are subjective! Also, Deming’s System of Profound Knowledge can help us understand and improve the collection and analysis of data. The theory of knowledge helps us recognize that someone decides what data to collect and what operational definitions to use. Knowledge about variation helps us recognize that obtaining data (measurements) is a process and that variation is present in all processes.

As such, we must acknowledge that each individual measurement is actually an estimate of an unknowable value. Theory of a system leads us to see that collecting data is just one component of a larger system—that the measurements are intended to help us understand characteristics of the item or process that produced the data. Psychology influences what data individuals see as important to collect, how individuals react to the collection and analysis of data, and can influence the actual measurements obtained when data are collected.

Consider data collection in education. Data are collected to assess student learning, to evaluate teaching, to make decisions about college admissions, for budget allocations and financial aid decisions, and for many additional purposes. But, these uses of data are not independent. Measures used to assess student learning are often used as part of the evaluation of teachers, as input into making decisions about college admission, allocation of budgets, and financial aid decisions for academically based scholarships. And, the implications are not limited to one direction. For example, how a teacher is going to be evaluated may influence the timing and methods of assessing student learning as well as content coverage in courses.

Image with students asking "will that be on the test," "will the test be multiple choice"... and the teacher thinking "I want my students to look good, so..."

Consider the events that occurred in the Atlanta Public Schools (APS) during the last decade. Over multiple years, student learning (as measured by the CRCT Exam) had increased at rates that were bringing national attention to the school system. This case provides an example where psychology, a failure to understand systems, and lack of knowledge about how the data were actually created interacted to create results that were inaccurate.

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Upcoming Deming Institute Seminars and Conferences

We have several events scheduled throughout 2016 for those interested in applying Dr. Deming’s ideas today.

Deming Management Method for Owners and Executives

May 23-25, 2016 in Hauppauge, New York

2 1/2 day seminar with Kelly Allan and Lynda Finn. This seminar is aimed at those interested in implementing Deming’s System of Profound Knowledge (a.k.a. The Deming Management Method) to lead a professionally managed organization.

Deming in Education Seminar

July 19-22, 2016 in Seatac, Washington

The Deming in Education Seminar is a four-day, interactive learning event and hands-on approach to the Deming Method with David P. Langford. It delves deep into the Quality Learning Principles and Tools that are necessary to gain the vision, purpose and capacity for quality implementation and to overcome the challenges and behavior problems you may face in your classrooms.

participants engaged in discussion around table and flipchart with postits

Participants at the Deming in Education conference, 2015

I Make No Apologies For Learning

September 16-18, 2016 in Lansing, Michigan

More details will be available soon on our annual conference.

2nd Annual Deming in Education Conference

November 4 – 6, 2016 in Atlanta, Georgia

The Deming In Education Conference will shatter the existing beliefs that are perpetuating our education crisis. Hear the stories of leaders who are challenging the status quo to create exceptional learning environments that preserves our children’s natural curiosity and “yearning for learning”. Learn how the systems approach of Dr. W. Edwards Deming will liberate fear and ignite passion in students and educators alike. Come discover the true potential and future of education in our country.

Our calendar of events on our web site lets you stay updated on The W. Edwards Deming Institute events.

Related: Deming Instute podcast with Ron Moen and Cliff Norman of Associates in Process Improvement (API) – “I Make No Apologies for Learning”The W. Edwards Deming Institute 2015 Fall Conference, Sep 18-20


Eliminate Slogans, Exhortations and Targets

Point 10 on W. Edwards Deming’s list of 14 points for western management:

Eliminate slogans, exhortations, and targets for the work force 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 work force.

Slogans are a way to say you care about quality without actually demonstrating you care. To improve results the system needs to be improved. Slapping up a slogan doesn’t improve the system. Noramally all a slogan does is result in blaming people for not delivering what the slogan promises.

The reason that the organization failed is because the systems are producing what they will produce (along with the expected variation) not because an employee isn’t doing their part. To change results change the system.

Nearly everyone knows slogans and exhortations are pointless. If you listen to what people say outside of the meeting all you will hear is derision. Inside a meeting often no-one will object. If so, you should examine your management system. Why do people allow bad practices to go officially unquestioned? It is a bad sign and points to serious management problems. And it is also a common condition.

Targets are less universally seen as pointless. But Dr. Deming understood the damage targets cause.

if management sets quantitative targets and makes people’s job depend on meeting them, “they will likely meet the targets – even if they have to destroy the enterprise to do it.

W. Edwards Deming, quotes in Profits Beyond Measure by H. Thomas Johnson (in the forward to the book).

I achieved my goal by not my aim. That happens a lot, we honestly translate aims to goals. And then we do stupid things in the name of the goal get it the way of the aim. We forget the aim sometimes and put the goal in its place.

Mike Tveite, Achieving goals but failing to achieve the aim. Watch this short video for a great story illustrating this problem in action:

There may be cases in which incentives work only as intended, but I suspect they are relatively rare. The trouble is that we are usually dealing with complex systems (people and organizations) that may behave not at all like our myths would predict. The best policy may be to avoid incentives altogether and focus instead on creating systems in which intrinsic motivation, cooperation, ethical behavior, trust, creativity, and joy in work can flourish.

Gipsie Ranney, The Trouble with Incentives: They Work

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Inquiring Minds: Improving Elementary Science by Linda Lippe

Linda Lippe’s presentation, Inquiring Minds: Improving Elementary Science in Leander ISD, Texas at our 2015 Deming in Education Conference. The 2nd annual Deming in Education conference will be held November 4-6, 2016 Atlanta, Georgia

One of the first tools they used in 2003 to determine what they should focus on to make their students successful in elementary science was the cause and effect diagram (fishbone diagram). Linda says that was a very useful tool to get them to understand the system and where to focus to improve student learning. She also discussed their use of other quality tools: force field analysis, multi-voting, interrelationship diagraph.

Their aim (“what we desired”) was

student learning and loving that learning of science. And we thought that would come through hands on, and not just hands on, not just doing it, but minds on experiences.

One of the nice things about having presentations and podcasts from Leander school districts over the years is that you can see how the continued focus on engaging students and creating systems that allow students to continue to love learning drives Leander. It is easy to say that cultivating the love of learning in students is the goal but it very different to actually make decisions based on this aim. You can read our blog posts and view the presentations and listen to podcasts from Leander and really see how they focus on student learning.

This presentation also makes it obvious how well Leander ISD intergrates the use of quality tools into their efforts. Quality tools alone are not sufficient but the effective use of quality tools is extremely important to long term success of efforts to improve the system. And most organizations use quality tools far too infrequently.

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“Our Problems Are Different” – Not Really

image of quote by Dr. Deming; "A common disease that afflicts management and government administration the world over is the impression that 'Our problems are different.' They are different, to be sure, but the principles that will help to improve quality of product and of service are universal in nature."

It is very common for people to see their situation as special and so different that they can only learn about management from some situation identical to the one they face. But this is a misunderstanding of what learning about better management practices is about. It isn’t an effort to find practices to copy. It is an effort to learn about managing organizations made up of people so that you can apply those ideas to your specific situation.

It is easier to explain why you cannot learn and improve than to put in the effort to learn and improve. But that isn’t a good reason for accepting excuses.

What are the best practices for your organization will differ a bit from another organization. But the principles are the same. No having a recipie to copy is why the iterative nature of the management improvement theory and stratgy Dr. Deming provided is so important.

We must test improvements on a small scale in our organization and adjust and adapt to make it work within our organization. We use the ideas to create a management system that is best for our organization. The principles will be similar across various organization but the details will vary. What we need to learn are the principles and how to iteratively apply those priciples to improve the management of our organization.

Related: Do We Need to Find Management Ideas from Our Industry? No.Deming’s ideas are focused on principles and knowledgeThere is No Instant Pudding, You have to Show Up to Disrupt


True North Can Really Be “Management by Results” in Disguise

Guest post by Mike Stoecklein

I hear a lot of talk in healthcare about the importance of defining “true north” for the organization. If you search the internet, you’ll find many definitions of true north and examples from organizations. Here are a few (all are from healthcare organizations):

  • The company’s governing objective. Example given: deliver double-digit returns to our investors.
  • The company’s shared objectives and values. Example: provide the best customer service in our industry.
  • The core of what the organization is in business to do. Example: meeting budget, achieving 95% performance in the country on all quality indicators and, having all our staff members on Kaizen events.

Will these definitions help to create “constancy of purpose?” In many cases, the answer seems to be “no.” True North should help everyone in the organization to understand the common direction (the what), and see how they play an active role in supporting that direction. True North should also speak to the hearts and minds so that everyone understands why (the organization’s purpose).

True North is also commonly associated with results. What shall we measure? How will we know we are getting closer to our True North? The common categories of results usually include:

  • Quality (sometimes including “safety”)
  • Financial (usually including revenue, expense and productivity)
  • Delivery (timeliness or throughput)
  • Engagement (of staff)
  • Satisfaction (of customers)

This usually reveals an “explosion” of the many measures that healthcare organizations typically try to track. Many times this is due to requirements from outside agencies (the government or payers) but many times the additional KPIs (Key Performance Indicators) are due to requirements from upper management. Jim Womack, former CEO of the Lean Enterprise Institute, described it this way when he spoke at the 6th Annual Lean Healthcare Transformation Summit, “The more MBAs who produce more KPIs will only result in the ‘triple M’ – more, meaningless measures).”

To handle the volume of measures, it’s not uncommon for organizations to adopt a scorecard (balanced of course) approach. One example of such a chart is shown below. Color coding is intended to help identify where the parts of the organization are “off track.”

color coded (red and green) measure scorecard sheet

This approach typically does not lead to improvement, but rather to fear. Are the changes due to random variation or are they due to a special cause? How would they know? Viewing the organization as a set of parts, and then managing those parts separately will not lead to constancy of purpose. How could it?

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