The W. Edwards Deming Institute Blog

What is a system?

Guest post by Keith Sparkjoy, vice president of the Sparkjoy Foundation, originally featured as a post at  Follow this link to listen to our first podcast with Keith.

Dictionary definition: “a collection of parts that make up a whole”.

Deming took this one step further by postulating that every system must have an aim.

Many systems evolve without their “designers” consciously thinking about an aim, but you can often reverse-engineer the aim of a system by studying its makeup and the outcomes it’s producing.

In nature we see many examples of systems, and the aim there seems to be sustainability. Nature tends to balance itself so that only the necessary parts in the system remain, and unnecessary parts die out.

Wetlands are a great example of a sustainable system. Fish eat plants and produce ammonia as waste. If this ammonia were allowed to build up, it would eventually become toxic. Certain types of bacteria treat this ammonia as “food” and convert it into nitrites and ultimately into nitrates, which is “food” for plants. The plants remove the nitrates from the water, effectively cleaning it so the fish can thrive. All of the parts work together to contribute to the aim of the system, and the aim is sustainability – that all of the parts may thrive. Fish, bacteria, and plants, ultimately live together in harmony.

Humans create systems all the time. A business is a system. A school is a system. A home is a system. How well any of these systems function, how effective and efficient they are, often comes down to how well the parts cooperate to support the aim.

Complex systems are fractal in nature. Take a school, for example. If the aim of the school is to serve the students so they develop into mature, contributing adults in a democratic society, then every part of the school must contribute in some way to that aim. For example, a necessary part of a school is facility maintenance, which creates a physical environment conducive to achieving the aim of the school.

One part of a system can become selfish, no longer concerned with the aim of the overall system. Think about what would happen if the fish in a wetland were to multiply so much that it was out of balance. The entire system could be destroyed this way. Nature takes care of this by eliminating the excess fish – they starve if there’s not enough food, and the system restores its balance.

What about human-engineered systems such as schools, business, and government? It’s remarkable how these systems survive as long as they do given the amount of selfishness present in the parts. Take departmental goal setting as an example in business. Each department is out for itself, trying to be number one by hitting its goals, versus thinking about what’s right for the overall system of which it is a part.

When a part of a system becomes selfish, it weakens the overall system, which ultimately harms all of the parts. When a part of a system makes a sacrifice that helps the overall system, all of the parts of the system are rewarded because the whole system thrives.

The Most Popular Posts on The W. Edwards Deming Institute® Blog in 2018

Guest post by John Hunter, who founded (in 1996)

As our blog ages new readers often don’t go back and read through the previous posts. But those past posts include many thoughts that age well. And while many new readers might not read back through the posts from previous years, many people do read them (following links from other articles or posts and following their online searches that link to the posts from previous years). In fact the 20 most popular posts were all originally published before 2017.

The 20 most popular post on our blog this year (by page views reported by our analytic tool):

image of Deming quote: A leader is a coach not a judge

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A Brief History of Quality, Part 1 – “Time has no divisions to mark its passage…”

Post by Bill Bellows, Deputy Director, The Deming Institute

On several occasions in my 33+ years of employment in the aerospace industry, I witnessed industrial chemicals in full use right up to their respective expiration dates, and then banned from use and tagged for immediate disposal with the passing of the expiration date.   Only moments before, the “good” quality chemicals were freely used.  While they may rapidly sour, is it likely they instantly expire to “bad” quality, with a big bang, all in keeping with the sentiment of German novelist Thomas Mann’s observation about New Year’s Eve, “Time has no divisions to mark its passage, there is never a thunderstorm or blare of trumpets to announce the beginning of a new month or year. Even when a new century begins it is only we mere mortals who rings bells and fire off pistols.”?   

What is the thinking which drives one to act upon the belief that the quality of industrial chemicals expires instantly, with a seeming blare of trumpets, on their implied expiration date?   As such, the expiration date represents a real line across which a change occurs suddenly, not gradually, as when the Fairy Godmother’s spell over Cinderella was broken at the stroke of midnight.   For two possible conditions, we could call it “binary thinking.”   As simple as good or bad, black or white, one side or the other.  Legally, as well as mathematically, such a line of separation between these two sides has no width.   In other words, it has zero thickness.   For example, if the expiration date is indeed midnight, the quality of the “material” associated with the expiration date is considered to be “good” all the way until the clock strikes 12:00am.    Not only “good,” but equally “good,” without variation, until exactly 12:00am.

Faster than a speeding bullet, the passage of the expiration date implies that the “material” under review is no longer in the quality status of “good.”    It has now shifted to the quality status of “bad,” beginning with the smallest increment of time one can imagine.  In the world of mathematics, as revealed in the figure below, a material which is subject to this shift in quality, from steadily “good” to steadily “bad” is said to have undergone a “step-change.”   Coupled to this thinking of step-changes, and the associated action of step-changes, consider the abilities of those who have collected the requisite data to know where to place the expiration date.

Far removed from children’s stories about magical and imaginary beings and lands of the likes of Cinderella, with spells terminating at midnight, we are well accustomed to coupons having an expiration date.   Legally, they become useless at a nano-second past this date.   Yet, does the science of chemistry have an equivalent quality property, rendering a useable chemical unusable, across a line of zero thickness?    Likewise, in the legal world, we are accustomed to the ownership of a piece of land shifting from one owner to another, also across a line of zero thickness, precisely placed by a surveyor.

As a prelude to a series of blogs on the topic of “A Brief History of Quality,” let me now transition from expiration dates and step-changes and begin this exploration with three questions, for which readers are encouraged to make a record of your answers, as they will provide a foundation for continuing to think about, if not rethink about, quality.

  1. First, what do you call the person who graduates last in his or her class in medical school?
  2. On to the second question, one involving numbers. Which two of these three numbers, 5.001, 5.999, and 6.001, is closest to being the same? While these values need not represent anything other than three rational numbers, they could also represent the measured values of hole diameters in an aluminum casting, the “0 to 100 kilometers per hour” acceleration times of a car, or the bacteria levels in a soap solution.
  3. For the third question, I offer a well-practiced thought experiment. Imagine a can of a fizzy drink (soda), filled with to the top, but without a closing cover. Now, imagine a small flavor probe in the can, wirelessly connected to a pen in your hand, used to record a flavor profile on a sheet of paper, using flavor as the vertical scale and time on the horizontal scale. At the moment the can is sealed, Time equals 0, the probe provides an initial reading of the flavor of the fizzy drink. From this starting point on the vertical axis, what is the expected flavor of the drink over time? Use the format of the figure below to record your answer.

For the past 20 years, I have used audiences’ answers to questions such as these to reveal basic assumptions about how we think, and thereupon learn and act, both individually and collectively.   In subsequent episodes of this “Brief History of Quality” series, I will share my experience with collecting answers to these questions and how this feedback has continually shaped my interest in and explanations of Dr. Deming’s remarkably distinct views on management in any organization.

Happy New Year and thanks for reading, as you experience the blare of trumpets!

Dr. Deming’s work lauded by world famous philosopher, Alasdair MacIntyre

Guest post by Michael Godfried: planner and policy analyst in Washington State and Bill Bellows, Deputy Director, The Deming Institute

Alasdair MacIntyre is one of the most pre-eminent philosophers in the world. At 89, he continues to teach and write and learn. Like Dr. Deming, age is no barrier to his continued intellectual vigor. In his 2016 book, Ethics in the Conflicts with Modernity, MacIntyre cites Dr. Deming at length:

“Deming agreed with [Wendell] Berry that short-term profitability is the enemy of good productive work…Note that neither ignores the need to be productive, the fact that it is the production of worthwhile goods that gives productive work its point and purpose, but both take it that such work serves a common good to which the worker contributes.” (p171)

MacIntyre is what is called a ‘virtue ethicist.’ He is deeply informed by the work of the great Greek philosopher, Aristotle, who believed that a flourishing life was only possible by following the classical virtues that include wisdom, justice, courage and temperance. Aristotle also held that a flourishing life desires some ‘good’ and seeks to achieve excellence:

“Every art and every inquiry, and similarly every action and human pursuit, is thought to aim at some good; and for this reason the good has rightly been declared to be that which things aim.” (Nicomachean Ethics 1094a1-3)

Dr. Deming believed that organizations should seek excellence both in their outcomes and processes. At the same time, he valued employees as human beings and believed strongly in seeking their input and developing their abilities. Whereas modern economic theory sees people as isolated individuals only seeking pure economic gain, Deming saw employees as having diverse goals and desiring to make a contribution at work. In The New Economics, Dr. Deming declares ‘We must restore the individual…’ Later, in that same chapter, he discusses the role of the manager:

“A manager of people understands that people are different than each other. He tries to create for everybody interest and challenge, and joy in work. He tries to optimize the family background, education, skills, hopes, and abilities of everyone.” (The New Economics, p86)

As MacIntyre recognized, Dr. Deming excoriated how a focus on quarterly earnings distracts companies from long-term goals of achieving quality products and services and a quality workplace. In the recent bankruptcy filing for the ailing Sears company, there is yet another sad example of siphoning off the assets of a company while leaving stakeholders, such as employees and communities, out to hang. As Russell Ackoff comments:

“A corporation that fails to see itself as an instrument of all its stakeholders will probably fail to use them, and be used by them, effectively enough to survive in the emerging environment.” (Recreating the Corporation, p289)

There is no mistaking the ethical dimensions of organizational life. This is a point that Dr. Deming makes again and again in all his writings. It is likely one of the passions that drove him to work incessantly up until his death at the age of 93 to promote organizational renewal and the restoration of the individual.  This is a quality that MacIntyre recognized and celebrated in his most recent book.

Additional references:

A lecture by MacIntyre

Excellent, free lectures on Aristotle by Professor Gregory Sadler (who also studied with MacIntyre)

Break the Cycle

Post by Bill Bellows, Deputy Director, The Deming Institute

Russell Ackoff had a profound capacity for using stories to educate his audiences about the basic concepts of managing systems, both in his lectures and in his books. He also had a profound way with words. One of my favorites is his warning that “it’s better to do the right thing wrong, than the wrong thing right”, a concept he claimed to have borrowed from his good friend, Peter Drucker. The challenge, of course, is determining what is right to do, for such a label is far too easy to apply. Yet, the outcomes are far too hard to see, especially when one is confident in the direction of apparently independent action, and when the system is open to both familiar and unfamiliar unknowns. Should the system be small enough, the actions would always seem right. Only with expansion of the system, in time and/or in space, could there be doubt as once unknowns become known.

I offer these comments as feedback on efforts to apply improvement principles, including the Toyota Production System, to turnaround situations. In appreciation of systems, Ackoff offered advice on how to steer past the time-honored traps that prevail in our traditional mechanistic thinking, which can lead us to narrowly judge efforts as either wasteful or non-value-added.  And, with what context or system is such a judgment made?  Instead, he encouraged us to shift our focus from managing actions, such as parts, tasks, modules, components, departments, divisions, and program elements, to managing the interdependence (interactions) between these (connected) entities, being ever mindful of the value proposition of shifting our thinking to seeing ever-larger systems. Such thinking embodies the “production viewed as a system” advice that W. Edwards Deming offered his many audiences in Japan, including students such as Shoichiro Toyoda, whose humble beginnings led to Toyota’s far reaching Total Quality Control efforts and the eventual appreciation of Toyota’s “Just in Time” (JIT) advocate, Taiichi Ohno.

In a recent conversation with a friend who serves as both a management consultant and leadership coach, he shared a few lessons he’s learned in 30 plus years of engagement in turnaround efforts. He commented on the self-described qualities and skills of the senior managers he has guided. When the topic of our conversation turned to questioning skills, he shared that curiosity is rarely acknowledged by senior managers as a leadership trait. As such, how could these leaders suspect that the pending turnaround is but a left hand turn around a racetrack, leading left turn after left turn to the starting point of a need for another turnaround? From where will the cycle end and the right hand turn emerge with a vision for managing interactions and not the actions taken separately?

In his first book on management, Quality, Productivity, and Competitive Position, Dr. Deming summarized a list of interactions (interdependent actions) for senior managers, which he defined as his “14 Points for Management,” which later evolved into his System of Profound Knowledge.   Whether prompted by a crisis and the subsequent need for a turnaround, or an essential effort in an organization’s continued success, these points (and a deepening appreciation of the System of Profound Knowledge) are well worth studying and adopting if one desires to turn right and break the cycle of left hand turns.

Rethinking Statistics for Quality Control with George Box

Guest post by John Hunter, author of the Curious Cat Management Improvement Blog (since 2004).

George Box shared a presentation on Rethinking Statistics for Quality Control at our 2008 Deming Institute Conference in Madison, Wisconsin.

In the presentation George discusses how to look at data from a process. He mentions why it was so important to understand what Shewhart understood about process data: the order of the data is extremely important; which is why run charts and control (process behavior) charts are plotted in time order.

The talk captures George’s humor as did what I think is a very entertaining and interesting autobiography: An Accidental Statistician.

At points the talk does get into statistics beyond what many of those reading this blog are likely to need, but if that is true for you it is easy enough to ignore those sections. I liked George’s comment during one of those forays:

Look George, I know how to calculate an average, but this is all very complicated and I don’t like it much.

My guess is if you are feeling that way when you reach this point in the talk you might want to skip the next 10 minutes of the presentation. I find it interesting but it is getting into statistics that is far beyond what is normally needed. For complex processes (large chemical plants, complex manufacturing processes…) these ideas are important but most of us will not need to get into these complex statistical engineering ideas.

The discussions at the end are interesting. George talks of adjustments (in the talk and the questions and answers) which I can imagine many with an understanding of Deming’s ideas would think of as tampering. I do see that risk in the actions he discusses. But I also think we should be open to thinking about alternative strategies; not to just ignore the risks of tampering, but consider alternatives with understanding of those risk while looking to most effectively manage existing processes.

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The Ethics of Quality

Guest blog by Dennis Sergent, Principal Consultant, Sergent Results Group  (Follow this link to find Dennis’ previous guest blog)

There is a strong correlation between quality and ethics. Leadership’s demonstration of their philosophy and practice of ethical behavior impacts the whole organization in education, government or commercial enterprises.  In the June 1994 issue of ASQ Quality Progress, Marion Steeples offered these definitions that I ask you to consider:

“Quality is the standard by which Americans measure the goods and services they value.”

“Ethics is the standard by which Americans measure their own behavior and that of institutions.”

Leadership’s example is critical. Yet, we have some leaders and practitioners who focus on only a few aspects of quality, to the detriment of the whole system. Focus on only some of the principles, practices, methods and tools cause us to miss the aim and purpose of an ethical system to deliver quality. When we lose sight of the big picture, we do not think of the sustainable impact on the system, such as a focus on schemes such as cost cutting, headcount reduction or “driving efficiency throughout the organization”.

A system that values cost cutting, headcount reduction or efficiency over quality devalues the ethical behaviors of quality. We only need to look at the recent news media to see examples like Wells Fargo, Takata, Enron, Volkswagen, the Veteran’s Administration, WorldCom, numerous auto-maker recalls.  In these examples we can see the effects of unethical manipulation of the numbers or manipulation of the system, instead of improving the system in an ethical way by focusing first on quality in the system.

Local events in Flint, Michigan illustrate that this problem cuts across our culture. In the state’s task force report of causes for the long-lasting damage to its citizens, there was a system of causes driven by a focus on balancing the books for Flint. All parts of the system were acting to be efficient with the financial issues that caused Flint to change the water supply, starting with the legislators, through every political office and onto the people who worked directly on the changeover. With a few exceptions, the players and the leaders were simply trying to fulfill their role in efficiently reducing the cost of water and balancing Flint’s balance sheet.

Managers who value efficiency first – do so to the detriment of the organization’s beneficiaries, stakeholders and the sustainability of their system. Yet, this is a flaw we are all susceptible to as human beings. Who does not take some pride in completing all of today’s action items? Who doesn’t feel good at handing some problem quickly and getting it into someone else’s hands to care for? Who is immune to the fear of not doing their “part” of the process right?

Ethical managers and leaders can pay attention to the philosophy of quality, and try to understand that the efficiency of their system is an outcome of the causes, beginning with making ethical behavior and quality of the whole system a core value. Dr. W. Edwards Deming said “Quality is made in the boardroom,” and his lifetime of teachings about the practice of learning and improvement with knowledge provide us with examples of his approach to ethics and quality.

Modern systems are extremely complex, and no one person is smart enough to know all the interrelationships. Causes and effects in our systems are distant in space and time. The modern history of a focus on cost savings as the starting point optimizes only part of the system that delivers value to the customer and the stakeholders in the system. This focus on efficiency ahead of effectiveness makes it less than our best ethical thinking. Russell L. Ackoff used efficiency as an operational definition as “doing things right” and effectiveness as “doing the right things.”  Is it not effective to do the right things and also do them right?

Great leaders put ethics, quality, effectiveness and “respect for people” first to eliminate fear in the system and look in the mirror often to see if our own thinking is ethical and a cause of quality throughout our system. The evidence is ample that this offers a way for leaders of people and organizations to link their values to the value they provide to their system, their stakeholders and their customers.

Dr. Deming addressed both efficiency and effectiveness with this statement from the first paragraph of his classic article, “Code of Professional Conduct”:

“(iii) to improve efficiency, uniformity, quality, service, and performance of product; or (iv) to achieve smoother operation and more effective administration and management in industry and in government.”

In this same document, he goes on to describe a number of points that emphasize his ethics and expectations of the customer in details that also define a set of ethics for the relationship and responsibilities between customer and supplier, in his case, the statistician and his clients and customers.  I think this defines the “win-win” he referred to in both Out of the Crisis and The New Economics.

Customer Satisfaction is Not Enough

Guest post by John Hunter, author of Management Matters: Building Enterprise Capability

quote image with text: 'It will not suffice to have customers that are merely satisfied. An unhappy customer will switch. Unfortunately, a satisfied customer may also switch, on the theory that he could not lose much, and might gain.'

To succeed over the long term organizations must seek not to satisfy customers but to delight customers.

Employees need to understand how customers actually use their product or service. And then they need to use this knowledge to continually improve the value delivered to customers.

No customer asked for electric lights… No customer asked for photography… No customer asked for an automobile… No customer asked for an integrated circuit.

W. Edward Deming, page 7 of The New Economics

Companies that understand what their customers needs and desires are and deliver solutions that customers didn’t even know they wanted will delight customers. And in that process make those delighted customers more loyal over the long term and gain new customers. Doing so also contributes to the Deming Chain Reaction (adding more and more jobs over time).

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What we see…

Post by Bill Bellows, Deputy Director, The Deming Institute

In reflecting on the popularity of lean, I offer a proposal to those who provide both educational resources and qualifications to lean practitioners.   While using the educational foundation established in The Machine That Changed the World, I suggest being ever mindful of the influence of our respective paradigms in filtering out data that doesn’t fit our own paradigms.   If we share the vision of James Womack to see “the spread of lean thinking far beyond the factory and far beyond the high wage economies to every corner of the world,” wouldn’t it be prudent to improve the thinking of lean thinking and thereby improve lean doing.   As advised by author and futurist Joel Barker, “if we want to lead successfully to the future, we must become aware of our present paradigms, and then be unafraid to replace them.”

A few years ago, I read an account of the Airbus Quality Lean Academy, with an inspiring image of students entering a lean temple, where students are coached and developed “with the basis they need to become self-reliant problem solvers and spread the word around the business.”   Maintaining an investment in such a dedicated learning environment for 15+ years is no small feat, especially with the challenges of the idiosyncrasies of the partner nations.   While “Standards are everything at Airbus: from cleaning up the table in the canteen after eating to operating a machine, they influence every part of the employees’ working day.”  Yet, what can be said of the limits to standardization?   Should everything be standardized, including language?  Or, should advancements in the implementation of lean, coming from a proposal for a chartered Lean Institute, include a suggestions for a context for advocating standardization?   At times, multiple languages and multiple software systems, assisted by translators, might provide a more systemic solution.   That is, a more economically viable solution, in which the investment is off-set by the systemic savings.  The same could be said for a quality goal of 6.3 defects per million opportunities, the standard for Six Sigma Quality, or zero defects, the highly acclaimed quality standard of Philip Crosby.

Before leading to the future, I’d like to focus on events of the not too distant year of 1989 and provide a context for my remarks.   In January, U.S. President Ronald Reagan delivered his farewell address.    In November, the Berlin Wall fell and German unification began.   In between, Motorola was working to unveil its Six Sigma Quality efforts and James Womack, Daniel Roos, and Daniel Jones were in the 4th year of a highly productive 5-year study on the future of the automobile.   At home, we purchased our first Toyota product, a pick-up truck, after growing disappointment with 2 U.S. brands and one European brand.   I also began a self-study effort to explore all things quality, from Philip Crosby and Zero Defects to Genichi Taguchi and Robust Design to Six Sigma Quality and aspirations of process capability indices of 2.0 and the critical desire to reduce defect rates to 6.3 per million opportunities.  I also took advantage of an opportunity to meet Dr. Deming during his February 1990 lectures at Western Connecticut State University.  In a career change away from engineering R&D for gas turbine engines, my interest was to develop an expertise in the tools and techniques of continual quality improvement.

Twenty-nine years later, our family continues to own and drive Toyota products.   I also continue to refine my thinking about continual improvement, including a theory of how Toyota operates.   In doing so, I’m reminded of a cautionary comment from Myron Tribus, who offered that “There is no such thing as an immaculate perception.   What we see depends on what we thought before we looked.”    In this spirit, I am often reminded that historians are guided by how they are trained to interpret.   As opposed to being objective, with the ambitious credence of a journalist, the contrary implication is that historians who are trained differently to look at a multitude of events in our world will likely arrive at distinctly different conclusions.   Systems theorist and educator Russell Ackoff also offered an explanation of this phenomenon.  His reasoning was that the adjective in front of the word problem, as in economic problem, education problem, medical problem, design problem, or social problem, told us a great deal about the vantage point and training of the observer.  That is, doctors and nurses are prone to seeing (specific “problem”) events as uniquely medical problems while sociologists are prone to seeing (these very same problem) events as uniquely social problems, rather than as a composite of a multitude of problems, with the opportunity for solutions stemming from one or more of these disciplines.

I offer these comments as an explanation for why my interpretation of the Toyota Production System, including 29 years of generally happy ownership of 5 Toyota products, differs significantly from explanations included in The Machine That Changed the World.   As with reformed cost-accountant H. Thomas Johnson, author of Profit Beyond Measure, I interpret Toyota’s success as the ability to manage resources, both efficiently and effectively, far better than their competitors have been able to accomplish.  We both view Toyota’s highly prized resource management results through a lens of interdependencies that is guided by W. Edward Deming’s System of Profound Knowledge.   In this regard, we both believe there’s much to be learned by Shoichiro Toyoda’s acknowledgment in 2004, when the Chairman and former president of Toyota accepted the American Society for Quality’s Deming Medal, and remarked that “Every day I think about what he meant to us. Deming is the core of our management.”  

Had I been trained as an Industrial Engineer, I would likely have interpreted Toyota’s success as the result of a focus on principles that include the elimination of waste and non-value added work.    Had I been trained at Philip Crosby’s Quality College, I would likely have interpreted Toyota’s success as the result of a relentless focus on achieving Zero Defects.   Had I been trained as a Master Black Belt, I would likely have interpreted Toyota’s success as the result of efforts to reduce variability to zero.   Instead, my lens has been colored by the influences of Dr. Deming, Russell Ackoff, Genichi Taguchi, and others, to be sure.

In consideration of the economics of quality improvement, are defect goals of either 6.3 per million, or zero red beads, always a worthy process improvement outcome?   Should variation, waste, and non-value added efforts always driven to zero?   At what cost?   For what benefit?    With a focus on achieving zero variation, waste, and non-value added efforts, what is the likelihood that the accumulated benefits will exceed the accumulated costs?   Furthermore, should determinations on whether activities add value be guided by “what the customer is willing to pay for?”  Or, should the context of a greater system be a consideration?  While standards are even a standard with 5S and even 6S efforts, why not include System as a new “S”?   Such an addition could be presented as “5S+1” or “6S+1” to advocate the value proposition of contextual considerations, inspired by the mindful advances in lean that are continually fostered by a Lean Institute.

While lean academies such as Airbus’s train new generations of practitioners, the research investments coordinated by a proposed chartered Lean Institute could focus on advancing the contextual excellence of lean thinking, building upon a “Deming Foundation” in Profound Knowledge.  For, as Myron Tribus espoused, “what we see depends on what we thought before we looked.”

Change Management – Post Change Evaluation and Action

Guest post by John Hunter, who founded in 1996.

Change is difficult in most organizations. It is easiest to just keep doing what has been done. Once something has reached a point where the need for change has been acknowledged how the organization proceeds is important.

The first part of the process isn’t in the scope for this post; but most often the process should start by using the PDSA cycle to understand the current situation, decide what to try, test improvements and iterate over those improvements until an improvement has been deemed worthy of being deployed widely.

The PDSA cycle process automatically includes studying the results of a possible change as part of the process. And it includes collecting evidence on the results of deploying an improvement widely and studying those results. That evidence will most importantly show if the expected results are achieved (it is far more common for changes to fail when put into action than most people acknowledge). If the expected results are not achieved learn why not, what happened?

image of the PDSA cycle

PDSA cycle image from Management Matters.

Even though the plan is to create an improvement that can be deployed more broadly it is very possible for that to fail for some reason. A common reasons for failing is failing to understand the necessary conditions for success. Yes, the PDSA test worked, but maybe you didn’t realize that result was really dependent on the special knowledge and skill of a critical person involved in the PDSA process, or the location where the test was run was different enough from alternative sites that the improvement wasn’t robust enough to be deployed more broadly.

There are many reasons the change may need to be iterated over to adapt it to different conditions. The important factor, that is far too often overlooked, is to collect evidence on the result of the change as it is deployed and to study that evidence to determine if the improvement is able to be deployed more broadly without modification. It may be that you learn more PDSA is needed as part of the process to deploy it more broadly.

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