The W. Edwards Deming Institute Blog

Using Checklists to Reduce Process Variation and Improve Results

image of the book cover for Checklist Manifesto

The Checklist Manifesto by Atul Gawande is a wonderful book about how to create systems that work.

At the core the Checklist Manifesto is about determining the critical process conditions and creating a system to assure that the those process items are properly handled.

In the book Atul Gawande paraphrases Daniel Boorman, veteran pilot who spent two decades developing checklists and flight deck controls for Boeing:

Good checklists… are precise. They are efficient, to the point, and easy to use even in the most difficult situations. They do not try to spell out everything – a checklist cannot fly a plane. Instead, they provide reminders of only the most critical and important steps – the ones that even highly skilled professionals using them could miss. Good checklists are, above all, practical.

Boorman stated when checklists are made by “desk jockeys with no awareness of the situations in which they are to be deployed. It is critical that checklists be developed at the gemba (where the real work is done) and that they are modified based on experience. A good checklist system integrates continual improvement to adjust checklists based on user experience.

As Atul Gawande states in the book, making a check on a piece of paper isn’t the important part (they even decided to skip doing it when that interfered with the process of work in a surgery environment). What matters is enforcing discipline to assure that the procedures deemed critical to success are followed.

The book also discusses the difficulty of successfully changing behavior. That is true even when that change to how things are done has documented evidence of success (it is usually easy to find excuses why that evidence doesn’t apply if you don’t want to change). Adopting a checklist manifesto is about creating a cultural change that prioritizes effectiveness and discipline.

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Updated W. Edwards Deming Institute Web Site

We have launched an updated web site for The W. Edwards Deming Institute.

The new site offers much better usability when using a smart phone and has an updated design. We have added several new features to the site to aid those seeking to apply Deming’s ideas.

Image of The W. Edwards Deming Institute website

The image shows our new design with the drop down menu for easy navigation.

I expect the new feature our readers will find the most useful is the new Deming Today section. That section will highlight applications of W. Edwards Deming’s ideas today by announcing blog posts, webcasts, podcasts, articles and events by the Deming Institute and by others that explore the application and extension of Dr. Deming’s ideas. You may subscribe to an RSS feed and stay current with news related to the application of Deming’s ideas. I expect it will be active, averaging 5 or more posts a week.

The site retains the content we had previously and we have updated the content where appropriate. So we still offer over 60 articles by Dr. Deming, show our upcoming events, provide a photo gallery (with a much improved design, in my opinion) and include information about the Deming Institute.

The most popular pages on our site detail some of the topics W. Edwards Deming is most well known for, including: The Deming System of Profound Knowledge® (SoPK), The PDSA Cycle, The Red Bead Experiment and Dr. Deming’s 14 Obligations for Management. On these pages and throughout the site we have provided links to let people delve further into the ideas being discussed. This aid to those seeking to learn about Dr. Deming’s ideas is another feature of the updated site that I expect to provide great value to those using our site.

We have added a few new pages of content including an online Deming management resource guide and several pages highlighting online video the Deming Institute makes available.

Another new feature of the site is an integrated search that lets you quickly search the content of our site to find what you are interested in.

There is much more on the new site than is discussed here: please visit and take a look for yourself. We hope you find the new website useful. Please comment below with your thoughts on the new site.

Related: New Website for The W. Edwards Deming Institute (May 2013)


Case Study: Adopting a Deming Management System in a Service Company

Total Quality Management in Logistics: a case study from the trucking industry by Harry Lehman, Jr. (a thesis at the Naval Postgraduate School). The thesis aims to

study the practical aspects of implementing a W. Edwards Deming-based quality program within a particular trucking company, Mason Transporters

I am thankful the Navy makes such documents available online. This document explores implementing these ideas in the service industry. Decades later we still hear people questioning if the ideas work outside manufacturing, which is sad.

Roadway established these goals for its quality teams: improve organizational productivity, improve employee satisfaction, develop employee capabilities through leadership and training, and improve communication by reducing frustration and conflicts.

I like that 2 of these focus directly on helping employees and seeing happier employees as a key to success. As with any stated aim or goal what matters is how it manifests in real decisions but it is a good start to acknowledge how important that is to a successful management improvement effort. And such an aim is required for any Deming based effort.

That culture can be seen further in

Quality training for warehouse workers extends well beyond lapel pins and pep talks. It includes training with pareto charts, fishboning, histograms and distribution of Corrective Action forms that encourage cause-and-effect reasoning, detailed explanation and precise communication. “We’re trying to break the old stigma where workers are paid for their strong backs, not their minds”

Once again this idea is commonly voiced. It is less commonly an active part of the management culture to train, nurture and value all the minds in the organization.

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Transforming the Management System of an Organization

In response to our request asking what topics readers would like to see addressed on our blog, Dan Bracewell said:

I’d like to see some posts about how to implement change in an organization. How does one get an organization to start looking at itself as a system? How does one get the organization to realize that the most important figures are unknown and unknowable? How does one convince an organization the importance of driving out fear? In short, how does one get an organization to listen to what Deming had to say?

I don’t think there are simple answers to the questions that take the form of “do this simple thing and you will have the results you wish to see.” This makes “selling” organizations on the idea of adopting the Deming management system more challenging. But I think it is a fundamental aspect of a good management system that cannot be avoided. Simplistic “solutions” may be easier to sell, but they don’t work. Managing an organization well just doesn’t allow for recipie solutions.

There are principles that can be fairly easily captured (respect people, improve using iterative experiments, use data to learn and test your understanding when possible but also realize that using data is not always possible…).

As W. Edwards Deming said in The New Economics

image with quote by W. Edwards Deming - The first step is transformation of the individual. This transformation is discontinuous. It comes from understanding of the system of profound knowledge. The individual, transformed, will perceive new meaning to his life, to events, to numbers, to interactions between people. Once the individual understands the system of profound knowledge, he will apply its principles in every kind of relationship with other people. He will have a basis for judgment of his own decisions and for transformation of the organizations that he belongs to.

That does not offer a simple recipe laying out what steps to take. But I do think it is a good explanation of the process. What should be implemented in your organization and what specific steps to take are not obvious, it requires apply the principles to your organization. And doing that also requires building the capability of your organization (including your people) to operate using those principles.

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Industrial Statistics – Research vs Practice

2013 American Statistical Association (ASA) Deming Lecture: Industrial Statistics – Research vs Practice by Vijay Nair, University of Michigan.

In his talk Dr. Nair referenced the article, W. Edwards Deming: The Story ofa Truly Remarkable Person, by Robert B. Austenfeld. He also referenced Dr. Deming becoming famous in the USA overnight, at the age of 80, after the broadcast of If Japan Can, Why Can’t We? in 1980.

This presentation is focused statistical process control (SPC) and some emerging statistics issues in industry. This presentation is probably of interest mainly to those very interested in more advanced statistical ideas. That isn’t a surprise for a presentation at ASA but I just want to mention this is likely of interest to a smaller sub-set of our blog readers than some of the other Deming Lectures.

At about 48 minutes of the webcast Dr. Nair discusses an interesting idea with processes failure examples (without watching this portion of the lecture this paragraph may be difficult to appreciate). Essentially there are various patterns that are indications of specific types of issue. So in his example a loose tie rod results in one pattern a warn bearing results in another pattern. His example is manufacturing but the same idea could be applied to any in-process measures.

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Applying Understanding of Variation to Large Datasets

Understanding Variation by Thomas Nolan, Rocco J. Perla and Lloyd Provost. There have been large changes in the use of data since the publication of Understanding Variation, by Thomas Nolan and Lloyd Provost. The new article discusses how to use an understanding of variation when working with large datasets (for example, government data).

From the current article:

Shewhart’s method is empirical and designed to minimize the risk of over and under-reacting to the data. “An assignable [special] cause of variation, as this term is used in quality control work, is one that can be found by experiment without costing more than it is worth to find it.”
In other words, if it costs more to find the problem than the value in addressing it, that is not economical.
In most applications, for points that fall outside of Shewhart’s three-sigma limits, it will be cost effective to search for a specific cause or to design a test to understand it.

This is one of the most fundamental points that is often not appreciated as clearly as it could be. An indication of a special cause is a signal that the most useful strategy to improve is to look for an assignable cause and fix that specific issue. The control chart is meant to help you identify those special causes in order to use an improvement strategy based on looking for an assignable cause – finding what was special about that result.

When results are not satisfactory but no indication of an assignable cause exists that doesn’t mean we have nothing to do. That means we have to focus on improving the system to improve all the results from the system. Seeking to find assignable causes and fix them for individual results that are within the control limits is just a poor strategy to use. The better strategy in such cases (with no indication of an assignable cause) is to use tools and thinking that address systemic fixes.

Most of the time we should be focusing on the entire systems and figuring out how to improve that. Unfortunately we often find ourselves focusing on one bad results and trying to assign blame for that to some specific thing (or person) and seeking to improve that way. That is isn’t a very effective way to improve.

Another important idea the article discusses is the use of stratifying your data in order to help understand the data. For example, looking at the high school dropout rate by low, medium and high family income.

charts of dropout rates by family income over time

Stratification of data is helpful when there are significant difference in different groups of data. You can think of these as results from different processes – where different solutions may be useful. It may be for example, that students from low income families benefit from certain improvements that have no impact on students from high income families. Stratifying the data helps you better understand your system and better measure the results of changes. It can be that without stratifying the data that improvements that are very significant are lost because the signal of that improvement is not strong enough when looking at all the data. But if you stratify the data then you can clearly see a change (for example to the system for students from low income families) was successful.

Related: What Role Does/Should The Deming System of Profound Knowledge Play in the World of “Big Data”?We Need to Understand Variation to Manage EffectivelySpecial Cause Signal Isn’t Proof A Special Cause ExistsHow to Create a Control Chart for Seasonal or Trending DataDeming Lecture by Dr. Jeff Wu on Quality Improvement from Autos to Nanotechnology


Optimize the Overall System Not the Individual Components

graphic of "A company could put a top man at every position and be swallowed by a competitor with people only half as good, but who are working together." quote by W. Edwards Deming

From Dr. Deming’s last interview; published in Industry Week magazine.

The results of a system must be managed by paying attention to the entire system. When we optimize sub-components of the system we don’t necessarily optimize the overall system. This is true when looking at the people as Dr. Deming mentions. It is also true when optimizing say one department or one process.

Optimizing the results for one process is not the same as operating that process in the way that leads to the most benefit for the overall system.

It is a lot easier within an organization that doesn’t view the organization as a system to assign responsibility to achieve specific results to specific individuals and components of the organization. Which is likely why most organization manage themselves this way. Even they see the risks of such behavior and so most often there are requirements to consult with those who are impacted.

But most often these efforts to have people cooperate outside of what they are held accountable for are weak and the primary focus is on optimizing what they are accountable for. And the organization suffers even while improving results of components because the most significant gains are to be made in managing the organization as a system not in optimizing components within the system.

The management system will nearly always determine how the individuals working within it manage. The lack of teamwork is not something that the individuals bring to the workplace that failure to work together is the result of how the organization has been setup. To change behavior the management system must be changed.

Related: Break Down Barriers Between DepartmentsWhy do you hire dead wood? Or why do you hire live wood and kill it?Dr. Russell Ackoff Webcast on Systems ThinkingWhere There is Fear You Do Not Get Honest FiguresDistorting the System, Distorting the Data or Improving the System


Change the Situation – Get a Different Result

David Langford’s presentation at the 2015 Deming in Education conference starts with a clip from Clare Crawford Mason’s PBS presentation on Mt. Edgecumbe High School, in Sitka, Alaska.

Deming was a champion of the individual. He would go into companies and he would just berate management, but he loved the workers…
He would say things like “people have the right to joy in their work.”

So why was Dr. Deming so tough on management (and especially executives)? He believed in their right to joy in work also. But Dr. Deming understood the critical role executives and managers played in creating work environments that destroyed the ability for people to experience joy in work. Dr. Deming felt, and I agree, that those people with great responsibility had to be challenged given the consequences of the current management practices have on so many others.

At the very end of the webcast their is a video of Dr. Deming and he says:

Management must know these things. There is no excuse, well, there is an excuse for ignorance but there is a penalty for ignorance and we all pay it.

He was talking about the ignorance of executives and executives about better management practices. The interviewer asks what we can do and Dr. Deming says

To help, optimize, don’t judge. We need to develop self esteem, dignity, joy and pride in work so that people can innovate and contribute their best to the job. If we destroy them they are humiliated. Ranking them, destroys them.

David Langford:

Change the system – watch how behavior changes. Rather than what we have been taught to do: leave the system alone and manage the behavior it is producing – behavior management systems.

In education, often we blame students for poor data (poor test scores, being late to class…) and then try to force the student to change (manage their behavior). That is also fairly similar to how most organizations manage themselves. What Dr. Deming sought to do is to get us to focus on the organization as a system and when we have results that we think should be better to think about how the system could be changed to improve results.

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Toyota’s Management History

One of the items Toyota highlights on their web site is winning the Deming Prize in 1965.

photo of Professor Deming and Toyota President Fukio Nakagawa

Professor Deming and Toyota President Fukio Nakagawa at the Deming Prize award ceremony (1965)

From the Toyota website:

Receiving the Deming Application Prize strengthened Toyota Motor Co., Ltd.’s resolve to push ahead with further TQC initiatives, and based on the points cited by the Deming Prize judges the company set the following policies:

  1. To promote all-around quality control, including at affiliated companies such as suppliers and dealerships.
  2. To establish simple and effective management systems without being preoccupied by form, paying particular attention to ensuring checks and actions, and rotating the management cycle rapidly.
  3. To enhance overall planning and, from a long-term perspective, achieve swift and precise decision making and execution through coordination among management structures.

Under this policy, in February 1966 an eight-company QC Liaison Committee was established among Toyota-related companies, creating a framework for deliberating specific measures to involve all Toyota-related entities in quality assurance actions.

Toyota continued their efforts and became the first company awarded the Japan Quality Medal in 1970 (a company is eligible 5 years after winning the Deming Prize).

From Toyota’s Japan Quality Medal page, 1970 Basic Toyota Corporate Policy:

  1. Harness resources in and outside the company to grow and become a Global Toyota
  2. Practice ‘Good Thinking, Good Products’ at all times to raise the reputation of Toyota as a maker of quality products
  3. Establish mass production systems, achieve low prices, and contribute to the growth of the Japanese economy
  4. Be aware of the public nature of the automotive industry and contribute to the welfare of society

Note: Items 1 through 3 were formulated in fiscal 1963 (ended June 1964). Item 4 was added in fiscal 1970 (ended June 1971).

The Toyota history website includes a view into Toyota’s learning and continual improvement of their management system. In 1979:

A two-year management capability improvement program was implemented with the department and section managers specifying topics for operational improvement. Compared to the improvements being made at manufacturing sites, increases in the efficiency of management and administrative departments was lagging and the number of managers who had not experienced the Deming Prize screening was increasing, resulting in a rising sense of a need for improvement of the management skills of department and section managers.

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Developing Software Using Deming’s Ideas

Deming Institute podcast with TJ Gokcen, CEO of Acquate on “Joy in Software Development” (download the podcast).

Describing the importance of creating software using Deming’s ideas as expressed in agile software development, TJ says

so it is a set of methods and practices that is more catered to change. So you do not have a big document, specifications document, at the front, what you do is instead you just go and develop whatever is the first value you need

This method allows for users (and project owners, etc.) to respond to what they actually see in practice instead of trying to imagine an entire system and then express that at the beginning in a large specification document laying out every detail of the software.

In practice this creates short iteration cycles and quick delivery of working software. And such processes result in much better results for software projects.

Scrum, scrum, agile they are great methodologies and they certainly have a place in software development as methodologies themselves. But applying the System of Profound Knowledge for software development with regards to the whole system give you much more benefit than what you can get just from them alone. But when we say that we also advocate that you must learn what the System of Profound Knowledge is not copy.

Don’t copy… learn the underlying principles, get the knowledge, create your own way.

Kanban for Developers presentation by TJ Gokcen:

Related: What’s Deming Got to Do With Agile Software Development and Kanban (2013)Software Process and Measurement Podcast With John HunterJim Benson on Applying Deming’s Ideas to Knowledge WorkInvolve IT Staff in Business Process Improvement (2010)