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Instructor: â€¦ testing. So what can we do different? Well, let’s take this in an ISMS context. This is ISMS, after all. This is the five core functions of ISMS. Now, for the five core functions, we start with defining the work scope. Let’s work the procedure as it is. What’s the work scope?
All: [inaudible, 00:20]
Instructor: Make white beads, very straight forward. What are the hazards?
All: Red beads.
Instructor: Red beads. Boy, we got this licked, don’t we? We’re ISMS. What do we do for hazard control?
Well, we told you about it. We gave you a procedure. You got a set of tools. We performed the work, right? We gave lots of feedback, didn’t we? Wrong way, did somebody say? One-way feedback, ah, very interesting, one-way feedback from management to the workforce, but it was very accurate and fair feedback, was it not? Nothing could be more fair than how many red beads did you make? But did we use that to change anything? No.
Well, okay. Let’s talk about ISMS as it should be and how we do it in the Department of Energy. Do we need to change our definition of the work scope? It’s a pretty good work scope, make white beads. Are there any hazards other than there’s some red beads there? No. I suppose not, but what about hazard control? Anybody got some ideas on hazard control?
Male: [inaudible, 01:35]
Instructor: Don’t put the red beads back in the thing. That would eliminate that. I assume you want to put the white beads back in but not the reds. As we do it we can not only have the QA count them, but remove them. Now, what was the purpose of QA, by the way? Make sure how to count but they certainly weren’t helping, like they could have removed the red beads. I probably wouldn’t have let them but they could have. Did I hear another comment? There’s some other things we can do.
Male: Take the red beads out.
Instructor: Take the red beads out. Now, that would be a lot more productive probably. You get rid of them at the source. I mean, we can get rid of them as we produce them but we could get rid of them at the source. Go through here, get rid of those red beads. Sounds good to me. That’s a good hazard control.
How should we do that as we perform the work though? What’s that?
Male: First article.
Instructor: First article. Meaning?
Male: Inspection [inaudible, 02:26]
Instructor: Inspect the incoming product. Very good idea, or work with the supplier of the product so his outgoing product doesn’t have any red beads. That’s very good. We can certainly allow you to pick the white beads out by hand, but it’s probably more effective to get rid of the red beads in the first place.
Now what about feedback? Now I gave you a good example of feedback here which is what we are doing. We are using this thing called control charting. See, the problem is in the old days with the former contractor, any month when the safety injury rate was less than average, there was an article in our local paper. Safety’s better than average this month. We’re getting better.
Of course, the next month it’d be above average. You didn’t hear anything though. The following month it’d be below average and it’d be, â€œSafety’s getting better. We’re better than average.â€ Every time we were lucky and were below average you get the message, safety is improving. Didn’t work.
There’s people out there believe, â€œOh, I just got to motivate the work force. I’ve got to convince them they’re doing good.â€ Of course, if you come to a person, say, â€œCliff, you’re doing great. Very proud of you. Great job.â€ Now are you going to do anything different?
Instructor: No. As any sane person is not going to do anything different which means we just keep making nine red beads every time, plus or minus nine. We have to fix the process. How about that stop, think, act, review? That’s a real program out there, by the way. It can work if, as part of thinking, the worker is allowed to get involved. Remember, a key of ISMS is involvement. Was the worker involved as part of any of that STAR?
A worker made the beads, but yes, we have to look at how do we utilize the good ideas of the workforce. Management does own the process. Management is not the bad guys here. Management is helping to coordinate things and focusing the workers input so we can fix these processes. Then the goal becomes, achieve a statistically significant improvement.
For example, I mentioned seven in a row below average would be a sign of an improvement. We don’t set a numerical goal. We run these charts and say, â€œWhat do we need to do?â€ When we get that significant improvement, that’s our feedback that we had an effect. So we’re not just saying, â€œWe came in below average this month. We must be good.â€
That takes some patience because you just can’t say, I have changed today and see the effect tomorrow. We all know it takes longer than that. Don’t we? I’d like to turn the mic over to Steve and a few other thoughts and we’ll get some input from the audience.
Male: Just a couple of comments and I will build on the one thing that you mentioned earlier which was, when he asked if there was a CAMS or DTS representative in the audience, this chart and the idea of variation and how you approach correcting the variation or reducing the variation has a lot of important impact to how we do corrective action management on the site.
If you look at this chart, you realize that it is stable, as Steve described and how you approach improving this process is different than if the dots or the points were outside the control limits. If you have something extraordinary happen that’s outside the control limit, that’s probably an easily identified cause. You can go and fix it. Get rid of it. It’s not part of the process. But the variation here, the problems that you’re looking at here are part of the process and they are not going to go away unless you change something very fundamental in the process, as Steve has been discussing, by changing the feedstock or perhaps the procedure by which you select the beads.
It’s important then, in deciding your strategy of how you’re going to approach corrective action. If you take a fire fighting or special cause approach and try to apply it to the inherent variation here, you’re not going to achieve lasting improvement. We do that, at least in my experience here in the last three and a half years, that is our consistent approach.
The fire fighting approach is applied to almost every problem. Those are the people that are recognized. Those are the people that are promoted and so on, because fire fighting is something that’s visible. However, to really achieve lasting improvement, you have to look at the inherent process variation and tackle that. That’s a lot harder work, but that’s what needs to be done.
Instructor: One more comment on procedures. What was the purpose of the four inches and the 47 degrees? Not much purpose to it in this case, was it? It did not help the hazard, did it? So an overly prescriptive procedure can cause us trouble.
Now if this is, when I was in the navy I worked in a torpedo maintenance facility and if you work with those torpedoes the wrong way they could go boom. Kind of ruin your day if they went boom. We had procedures that sometimes had the equivalent of, â€œDon’t lift this more than four inches, and you tilt it exactly 47 degrees.â€ Sometimes that is important, called the graded approach in ISMS.
If I’m dealing with an explosive or a nuclear hazard, I may end up with some four-inch criteria there. If I’m dealing with red beads, fairly low risk evolution, although it costs us our contract, the 47 degrees didn’t make any sense, now did it?
What we want you to do as part of this, we’ve put this in an ISMS context, when you leave this conference, we are depending on you because what makes a difference is you. Think about the red beads at your workplace. How many times are you reacting to just the latest thing? Doing the fire fighting, trying to treat a consistent event with, ‘I got to find out why that happened?’ Why did you get 11 beads, or where is my worker of the day? Where’s my stellar worker of the day?
Male: [inaudible, 08:23]
Instructor: There were two. What did you guys do different? Nothing. You were lucky. How did you feel about that? Are you ready to go home and post that plaque on your wall? You got your candy. At least we gave you something tangible, but rewards can be negative. Rewards can actually hurt if people don’t understand what they did different to get the reward. I would like to ask for any comments from the audience. Other than that, no comments? I think we kind of incorporated everything as we went.
Would like to wrap this up. I’d like to thank Steve. Thank you for coming. I certainly appreciate the invitation to come and do this and hopefully now with a video record we can expose some more people to this. Thank you very much for attending.