Quality and Innovation

Today’s Op-Ed section in the Washington Post has a piece by Philip K. Howard called “Health Reform’s Taboo Topic”. The problem?

Health-care reform is bogged down because none of the bills before Congress deals with the staggering waste of the current system, estimated to be $700 billion to $1 trillion annually. The waste flows from a culture of health care in which every incentive is to do more — that’s how doctors make money and that’s how they protect themselves from lawsuits.

The article goes on to talk about “defensive medicine,” the practice of ordering tons of diagnostic tests to refine a diagnosis or a treatment plan for the purpose of avoiding malpractice suits. Howard suggests that physicians are cultured into this way of doing business as a defense against potential risks and potential malpractice cases – he even mentions one case where a doctor reacted to a lawsuit by changing his behavior in favor of defensive medicine. A solution, however, is possible:

Containing costs, as Rep. Jim Cooper (D-Tenn.) noted on “Face the Nation” recently, requires overhauling the culture of health-care delivery. Incentives need to be realigned. That requires a legal framework that, instead of encouraging waste, encourages doctors to focus on what’s really needed. One pillar in a new legal framework is a system of justice that is trusted to reliably distinguish between good care and bad care. Reliable justice would protect doctors against unreasonable claims and would expeditiously compensate injured patients. The key is reliability.

The culture of a system – in this case the U.S. health care system – influences the behavior of individuals within the system. This behavior can be waste-producing. When it is, we need to look towards the cultural influences or the structure of the incentives that drive that behavior, and examine ways to address the root cause(s).

It reminds me of the requirements gathering phase of a software development project. Stakeholders spend hours trying to hash out what functions and behavior they expect from their software, and how reliable they want it to be. It is always a challenge to avoid designing the system (that is, how it will look or act) when the essence of what you need to know is what the system needs to do.

I see evidence in the growing national healthcare debate that many people have opinions on the design of the system (e.g. who gets coverage, how pre-existing conditions are handled, how much it costs, who pays), whereas most citizens and Congressmen aren’t even touching the requirements for a successful system (e.g. what scenarios it should support, what behaviors it should provide incentives for, or its reliability/requirements for how much waste the system can and should generate).

In my opinion, one requirement for a successful health care system is that it provides incentives for you to remain healthy and stay out of doctors’ offices and hospitals. A tax credit for a health Body Mass Index (BMI), or maybe lower interest rates? I’d go for that… it would even stimulate me to boost the economy a little more by buying rollerblades or something.

This is the fourth and final installment of my collaboration with John Hunter and friends on the Year-End Management Improvement Carnival, where we review the best management improvement blogs and share which posts we found to be the most insightful or helpful. Today I have the privilege of bringing you a few gems from the iSixSigma blogosphere.

PART 4 of 4 – The iSixSigma blogs are written by a cast of columnists who share their experiences with the practice of quality improvement. The favorites I’ve picked out here are only the tip of the iceberg… there are many more on the site.

Innovation and Six Sigma (5/9/2008) – This article aims to answer the question “Does Six Sigma kill innovation?” In addition to being a thought-provoking article, the collection of comments is worth reading as well. I particularly liked this perspective: “I’m reminded of a story I was once told about an author who decided to write an entire novel without using the letter E. You’d think this would be incredibly limiting, but in fact the author ended up learning many, many new words and taking his writing in entirely new directions. The structure forced him to break old habits and think in new ways.”

The iPod Did Not Come From a Focus Group (3/3/2008) – Development of the iPod is an example of customer and market-driven innovation. The author of this article notes that “your company probably knows more about what is possible than most of your customers; but the lesson I take away from the Apple example is this: some of our customers know a lot more than we do, and we ignore them at our peril.” There’s also a pointer to an excellent 2002 article in the Harvard Business Review.

Six Sigma: The Laissez-Faire of Politics (1/28/2008) – In this article, the author explores how to solve a real public policy issue using Six Sigma: reducing the consumption of plastic bags (like the ones you get at the grocery store) on the national level. “If there is one area in society that definitely needs an injection of Six Sigma, it’s politics. Just like the working world of business, people want a silver bullet quick fix that sounds good and will make people feel good. Politicians often open their mouths without performing due diligence and as a result only partially address an issue.”

What You Measure is What You Get (12/22/2008) – This post reflected on the role and meaning of measurement (one of my favorite issues). “Perhaps what you measure is what you get. More likely, what you measure is all you’ll get. What you don’t (or can’t) measure is lost” – H. Thomas Johnson

Six Sigma Project Failure (7/28/2008) – What’s required for a Six Sigma project to fail? Conflicting definitions are explored in these survey results. (This is somewhat related to Eight Reasons Why Projects Fail (4/24/2008), another good post.)

Return to Part 1 of 4 –>

Return to John Hunter’s Management Improvement Carnival: 2008 Year in Review –>

This is the third installment of my collaboration with John Hunter and friends on the Year-End Management Improvement Carnival, where we review the best management improvement blogs and share which posts we found to be the most insightful or helpful.

PART 3 of 4 – Clarke Ching’s stream-of-consciousness blog covers random musings, cartoons, links to useful articles, recipes, mathematical puzzles and games, and thoughts about quality-related techniques including Theory of Constraints and software development.

Testers – the worst thing that happened to software development? (5/30/2008) – This story describes a first-person view of how software quality can be achieved more easily – by studying the successful approaches used by good maintenance teams. “There’s a huge amount that development managers (i.e. those that work on bigger projects) could learn from the way good maintenance teams work. The first would be to break down their work into smaller chunks.” (Again, this reminds me of “stackless thinking”which really appeals to me.)

Critical Chain Scheduling (8/22/2008)- Clarke wrote an article, published over at stickyminds.com, covering how to use the critical chain method to improve scheduling in agile development environments. “Critical Chain, as I’ve described, is a great way of rebuilding trust between managers and their staff. In fact, it is THE best way I’ve found. It’s also sorely needed, judging by some of the comments.”

Lord Kelvin (9/13/2008) – Why measure things? On a trip to Scotland, Clarke reflected on this question as he pondered the intro to Douglas Hubbard’s book, How to Measure Anything: “When you can measure what you are speaking about, and express it in numbers, you know something about it; but when you cannot express it in numbers, your knowledge is of a meagre and unsatisfactory kind; it may be the beginning of knowledge, but you have scarcely in your thoughts advanced to the state of science.”

Go to Part 4 of 4 –>

This is the next installment of my collaboration with John Hunter and friends on the Year-End Management Improvement Carnival, where we review the best management improvement blogs and share which posts we found to be the most insightful or helpful.

PART 2 of 4 – Europe’s ”#1 Blog for Software Development Managers” has posted an excellent review of the most popular 2008 articles from their site, based on the site traffic throughout 2008. Here are my personal favorites.

A Theory of Everything for Software Development (8/7/2008) – Physicists pursue the grand unified theory to explain space, time and everything in between… while noop.nl attempts to reconcile the myriad of approaches to software development by reminding us of context-dependent approaches. Here’s a sample: “Unix and Windows are both proper solutions, though each in its own limited cultural context. And they cannot both be the best solution at the same time and place. (And might I suggest that, in the case of operating systems, a Theory of Everything has already been found with the invention of virtual machines? Just a wild thought.)”

Simple vs. Complicated vs. Complex vs. Chaotic (8/20/2008) – You can have predictable, complex, and chaotic systems that are simple – or, you can have predictable, complex and chaotic systems that are complicated. This is the best description (and collection of online references) I’ve seen to explaining the differences between these concepts. “My computer is complicated. My software project is complex. My house is complicated. My household is complex. My blog is complicated. My thoughts are complex. Your dinner is complicated. Your dog is complex.”

Thank You, Stupid Americans (4/23/2008) – This is an interesting blend of software development insights and politics! Although I don’t personally equate simplicity with stupidity, and I realize there are plenty of smart Americans too, I found this to be a lighthearted and stimulating read.

How to Handle Many Simultaneous Projects (9/30/2008) is also an excellent commentary. I don’t know any manager who doesn’t have this issue – whether they are a quality manager, a technology manager, a construction manager, or a manager of software development.

Go to Part 3 of 4 –>

I’m privileged to be partnering with John Hunter and friends to produce the Year-End Management Improvement Carnival. Our goal is to review the best management improvement blogs out there, and find out what gems were posted during 2008 – then take you on a guided tour of the past year’s most intriguing management insights.

PART 1 of 4 - The first three favorites on my list come from David Anderson’s http://www.agilemanagement.net, a blog that focuses on effective and productive implementation of agile methods in software development and management.

Providing Value with Lean (3/31/2008) – One of the most important considerations while implementing a quality program or process improvement initiative is that you focus on the right aspects of the problem at the right times. This is much easier said than done, especially since the problem solving environment is socio-technical – and as a result, complex. But David makes the excellent point that “doing lean” means more than just eliminating waste. You have to take a systems perspective, and first consider how value is to be added, then analyze the process for flow, and then work on eliminating waste. Sometimes, to get a better process, you have to add waste before the improvements can be realized in a sustainable fashion.

Recipe for Success (9/5/2008) – David says: “This is the mechanism I use to achieve sustainable pace and to implement a pull system which provides a nice mechanism for simple prioritization. Prioritizing becomes easier when you have demand balanced against throughput of work items.” In addition to the two variants on the recipe he presents, another reason I like this post is that it reminds me of how the concept of “stackless” programming languages can inform efficient workflow.

Personal Hedgehog (11/2/2008) – What are you uniquely good at? What are you passionate about? What motivates you economically? The most productive people are in roles that fit them well, and the Personal Hedgehog concept can help you find your niche. (Might also be good for managers who want to help their team members find a good fit.)

(I’m also intrigued by David’s concept of an unconference.)

Go to Part 2 of 4 –>

Quality experts and practitioners alike know that a solution should be designed for a particular context of use. The complete environment of the problem should be considered, and political, economic, social and technical ramifications should be examined before investing in a costly project.

This wasn’t the case for the $260 million construction of a cruise terminal in Shanghai along the Huangpu River which was recently opened. The building is ultra-modern, environmentally friendly and a model for sustainable development. But to get to the terminal, ships have to sail underneath the Yangpu Bridge, which has such low clearance that a third of the world’s ships can’t fit (and the trip is risky for many of the others, who have to wait until low tide to navigate it).

An architect or designer should have recognized that for the terminal to achieve “fitness for use” as defined by Juran, the traffic pattern to bring ships to the building would play an important role. The situation is a little more striking when you consider the question of siting airports – how useful would it be to build an airport in the center of a metropolis where airplanes couldn’t find a clear path to the runway? Building the terminal without consideration for traffic patterns was wasteful: the city will miss opportunities to serve many customers, blocking out the possibility to drive passenger revenue to the city, extra time will be needed for captains to successfully steer their ships in, and extra fuel will be expended in the process. (Not to mention that the only solution now would be to raise the bridge, which would cost several tens of millions more.)

These types of problems are not limited to examples in transportation. I remember several years ago I went to a meeting where a group of highly skilled, senior engineers were discussing how to deploy a sensitive piece of research equipment they’d been working on for years. It had been a long, hard road, and they were finally ready to see the fruits of their labor in use. A concrete monument had been poured to keep the instrument level, and they were discussing in excruciating detail how to get the instrument onto the pad.

“Hold on,” somebody asked. “How many pounds can that monument hold?”

Another engineer quickly replied. “We used some really high-grade concrete. It can hold up to ten thousand pounds.”

“Yeah, but our instrument is almost twice that weight!”

Ten scientists and engineers looked around the room, pensively. Some wrinkled their brows and others started furiously scribbling notes on paper, but no one said a word. After a few uncomfortable minutes, the leader of the meeting said “Well, we’ve come to the end of the hour. Let’s talk about that next time.”

I don’t think the instrument ever got deployed. Remember: think about the whole system! Quality depends on fitness for use in a particular context.

The seven types of waste are a foundational concept in lean manufacturing, all forms of muda as described by Taichi Ohno of Toyota. Reducing waste systematically can help you achieve flow in your processes. Waste can result from:

• Overproduction – making too much of something that goes unused, spoils, or collects dust.
• Inventory – keeping too much of something that goes unused, and costs time or money to store.
• Extra Processing – wasting time or effort on steps that are unnecessary.
• Motion – exerting energy to do something that doesn’t create value.
• Defects – products or processes that don’t conform to their specifications.
• Waiting – time spent being unproductive could be used in other ways to create value.
• Transportation – moving things over long distances costs time, effort and money.

In addition to muda, mura (unevenness in production) and muri (overburdening of people and equipment) are also recognized as characteristics of a process that impede flow. Overburdening either people or machines can lead to burnout, which can result in a high repair or replacement cost!