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11/28/2016
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Trends and Patterns(quantitative: run charts, statistical
analysis, qualitative study)
System Structure(pattern of interrelationship among key components of the system: hierarchy, process flows, attitudes and perceptions
Mental Models(key assumptions)
Leverage for Improvement
The Fifth Discipline FieldbookPage 97 - 103
Events
(crisis, anecdotes, problems)
®Butts-Dion, Crowe and Taylor 3
Listen. Really Listen!
“These terms — co-production, patient-centered care, what
matters to you — they’re encoding a new balance of power:
the authentic transfer of control over people’s lives to the
people themselves. That includes, and I have to say this,
above all, it has to include the voices of the poor, the
disadvantaged, the excluded, [the marginalized]. They
need our mission most.”
P4
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1990’s
The prevailing style of management must undergo transformation. A system can not understand itself. The transformation requires a view from the outside. The aim of this chapter is to provide an outside view—alens—that I call a system of profound knowledge. It provides a map of theory by which to understand the organization that we work in.
W.E. DemingNew Economics (1994) pg. 92
Appreciation for a System
Theory of Knowledge
Psychology
Knowledge about
variationProcess
®Butts-Dion, Crowe and Taylor 5
System of Profound Knowledge
Process
System
Variation
Knowledge
Psychology
®Butts-Dion, Crowe and Taylor 6
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Instructions1) We will show you a picture
or a cartoon
2) You will help identify the Lens component from the picture.
3) We will explore the Lens through large and small group discussion.
4) Each table group will capture the conversation and ideas on the flip chart at their table (World Café idea)
5) Hint: PDSA in your near future!
®Butts-Dion, Crowe and Taylor 7
first component
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®Butts-Dion, Crowe and Taylor 9
I am sure glad the hole is not in our end!
®Butts-Dion, Crowe and Taylor 10
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SYSTEMSWhat do we know or believe about systems?
What is in our system lens?
• A system is a network of interdependent components that work together to try to accomplish the aim of the system.
• The beginning of the system starts with the customer
• If each part of a system, considered separately, decides to operate as efficiently as possible, then the system as a whole will not operate to maximum effectiveness.
• The obligation of any component is to contribute its best to the system, not to maximize its own …measures.
• We should work on our processes, not the outcome of our processes….
Collection of thoughts and excerpts from variousW. Edwards Deming publications and teachings
1.6 Deming’s view of Production as a System (1994)
Design
and
Redesign
Consumer
researchSuppliers of
Raw MaterialsReceipt and
test of
Materials
Consumers
Distribution
Test of processes,
machines, methods,
costs
Production, assembly, finishing, inspection
A
B
C
D
E
F
G
Stage 0:
Generation of ideas
Deming and Ackoff (1.46)
®Butts-Dion, Crowe and Taylor 12
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Case study: Systems Thinking
• Optimization and Sub -optimization
• The simple story of blue pads
®Butts-Dion, Crowe and Taylor 13
Case study: Systems Thinking
• Optimization and Sub -optimization
• Your story
®Butts-Dion, Crowe and Taylor 14
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System Criteria
• Living systems are integrated wholes whose properties cannot be reduced to those of smaller parts.
• Shift attention back and forth between system levels– systems within systems
– with emerging properties at different levels
• There are no parts; there are patterns, an inseparable web of relationships, a network
Fritjof Capra
The Web of Life pp36-37
®Butts-Dion, Crowe and Taylor 15
Systems Thinking
• Is a language for learning and acting
• Helps us see how we create our reality
• Points to higher leverage solution to problems
• Helps us to understand and describe complex issues
• Is a discipline for seeing structures ( the patterns and connections) underlying seemingly diverse personal, organizational, societal issues
Leading Learning Organizations
Innovation Associates, Inc.
®Butts-Dion, Crowe and Taylor 16
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The first lesson is that blaming the fallibleindividuals at the sharp-end is universal, natural,emotionally satisfying, and legally convenient.
Unfortunately, it has little or no remedial value.
On the contrary, blame focuses our attention onthe last and probably the least remedial link in theaccident chain: the person at the sharp end.
James T. Reason
®Butts-Dion, Crowe and Taylor 17
second component
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VARIATION
• Variation Exists!
• Common cause variation is always present • Common causes tend to be numerous• Common cause variation is produced by the
aggregate of the variation in all the variables. It is also known as: random variation, chance variation, or un-assignable cause of variation
• Special causes are not present at all times• Special cause is in addition to common cause • Special cause is produced by a non-typical
variable. Special causes are also known as assignable and non-random
• Mistake 1. To react to an outcome as if it came from a special cause , when actually it came from a common cause.
• Mistake 2. To treat an outcome as if it came from common causes of variation, when actually it came from a special cause.
What do we know or believe about variation?
What is in our theory of variation lens?
Collection of thoughts and excerpts from various W. Edwards Deming publications and teachings
VARIATION
®Butts-Dion, Crowe and Taylor 22
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Variation can be a very revealing voice….. need to learn to listen! Some of my first Ahaa’s!
listening with my eyes.
®Butts-Dion, Crowe and Taylor
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THELEARN NGIIN TTIT U ESATQU UMRO
Global MeasureGlobal Measure
1 1.031.09
1.44
0.88 0.880.77
0.970.85
0.68 0.68
0.86
JanFeb
MarchApr
MayJun
JulAug
SepOct
NovDec
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
Infe
ctio
n R
ate
Median 0.93
Nosocomial Infection 1997Nosocomial Infection 1997
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THELEARN NGIIN TTIT U ESATQU UMRO
Intermediate MeasuresIntermediate Measures
1. 16
0. 74
1. 13
1. 73
1. 1
1. 39
1. 21 1. 26
1. 10. 98
1. 39
1. 1
Jan Feb Mar Apr May Jun Jul Aug Sept O ct Nov Dec
0
0. 5
1
1. 5
2
Median 1.19
Nosocomial Infections Unit C - 1997Nosocomial Infections Unit C - 1997
Infe
ctio
n R
ate
Infe
ctio
n R
ate
1. 02
0. 87
1. 12
0. 8
0. 22
0. 73
0. 62
1. 471. 31
0. 63
0. 33
1. 06
Jan Feb Mar Apr May Jun Jul Aug Sept O ct Nov Dec
0
0. 5
1
1. 5
Median 0.84
Nosocomial Infections Unit D - 1997Nosocomial Infections Unit D - 1997
Infe
ctio
n R
ate
Infe
ctio
n R
ate
0. 961. 08
0. 78
2. 07
1. 29
0. 370. 51
0. 34 0. 35
0. 530. 63
0. 54
Jan Feb Mar Apr May Jun Jul Aug Sept O ct Nov Dec
0
0. 5
1
1. 5
2
2. 5
Median 0.76
Nosocomial Infections Unit A - 1997Nosocomial Infections Unit A - 1997
Infe
ctio
n R
ate
Infe
ctio
n R
ate
0. 7
1. 79
1. 25
1. 56
1. 35
0. 94
0. 65
0. 43
0. 25
0. 46
0. 25
0. 48
Jan Feb Mar Apr May Jun Jul Aug Sept O ct Nov Dec
0
0. 5
1
1. 5
2
Median 0.85
Nosocomial Infections Unit B - 1997Nosocomial Infections Unit B - 1997
Infe
ctio
n R
ate
Infe
ctio
n R
ate
Variation exists in data and in
people
®Butts-Dion, Crowe and
Taylor
26
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®Butts-Dion, Crowe and Taylor
Burrhus Frederic Skinner (1904-1990)
Operant Conditioning
29
PSYCHOLOGY
What do we
know or believe
about
psychology?
What is in
our psychology
or human
interaction
lens?
• People are different from one another. A manager of people must be aware of these difference, and use them for optimization of everybody's abilities and inclinations. This is not ranking ..
• Merit awards and ranking are demoralizing. Rewards motivate people to work for rewards.
• Some extrinsic motivation helps to build self-esteem. But total submission to extrinsic motivation leads to destruction of the individual.
Collection of thoughts and excerpts from various W.
Edwards Deming publications and teachings
®Butts-Dion, Crowe and Taylor
30
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Forces of destructions (New Economics p.122)
Life begins Life ends
Extrinsic motivation
• Gradually replaces intrinsic motivation
• Competition and recognition drives actions
• Focus on the Individual not the System
• Problems attributed to Individuals not System
• Resignation to external pressure - demotivational
Intrinsic motivation
Curiosity Cooperation
Joy in Learning Self esteem Dignity
®Butts-Dion, Crowe and Taylor 31
®Butts-Dion, Crowe and Taylor 32
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Alphie Kohn
1. Pay is not a motivator
2. Rewards punish
3. Rewards rupture relationships
4. Rewards ignore reasons
5. Rewards discourage risk-taking
6. Rewards undermine interest
®Butts-Dion, Crowe and Taylor 33
®Butts-Dion, Crowe and Taylor 34
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When to Use Rewards: A Simple Flow Chart (Pink p. 69)
Use rewards, even “if-then” rewards, but
be sure to
Can you increase the task’s
challenge or variety, make it less routine, or connect it to a
larger purpose? Sure I can do
that
2. Acknowledge that the task is
boring
3. Allow people to complete the t
ask their own way
1. Offer a rationale for
why the task is necessary
That is pretty hard
YES
Is this task mostly
routine?
Start Here
No
Concentrate on building a healthy, long-term motivational environment that pays people
fairly and that fosters autonomy, mastery, and purpose. Avoid “if-
then” rewards in almost all circumstances. Consider
unexpected, noncontingent “now that” rewards. And remember
that those rewards will be more effective if:
1. They offer praise and feedback rather than things people can touch or spend
2. They provide useful information
rather than an attempt to control
®Butts-Dion, Crowe and Taylor 36
fourth component
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KNOWLEDGE
What do we know or believe about knowledge?
What is in our knowledge or learning lens?
KNOWLEDGE
What do we know or believe about knowledge?
And how does it guide our action?
Information • Information is not knowledge.
Knowledge• Knowledge is built on theory. • Without theory there are no questions:
Without questions there is no learning.• A statement devoid of rational
prediction does not convey knowledge
Learning from Failure• There is no such thing as a fact• No number of examples establishes a
theory, yet a single unexplained failure of a theory requires modification or even abandonment of the theory
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Rational behavior requires theory. Reactive behavior requires only reflex action
W. Edwards Deming
Profound Knowledge is a systematic way of learning that supports developing theory, knowledge and
informs action... tbc
Appreciation for a System
Theory of Knowledge
Psychology
Knowledge about
variationProcess Process
System
Variation
Knowledge
Psychology
®Butts-Dion, Crowe and Taylor 43
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Out of the Crisis W. Edwards Deming (1982, 1986, 1993)
®Butts-Dion, Crowe and Taylor 44
Break
®Butts-Dion, Crowe and Taylor 45
then PDSA
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Question……… ®Butts-Dion, Crowe and Taylor 46
Might using the System of Profound Knowledge facilitate asking more reflective
questions helping to better listen and understand... which would
support more effective change ideas?
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As our hearing trumpet…(project...?)P48
Model for Improvement* (MFI)
*Developed by the Associates in Process Improvement. Building on the work of W.E.Deming and Walter ShewhartLangley et al, The Improvement Guide, 1996, 2011®Butts-Dion, Crowe and Taylor 49
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ActAdapt?
Adopt ? Abandon?
Next cycle?
PlanObjectiveQuestions and predictions (why)Plan to carry out the cycle(who, what, where, when) Next cycle?
StudyComplete the
analysis of the dataCompare data to
predictionsSummarize what
was learned
DoCarry out the plan(on a small scale) Document problemsand unexpectedobservationsBegin analysis
The PDSA Cyclefor Learning and Improvement
W.E.Deming referred to this as the Shewhart Cycle
®Butts-Dion, Crowe and Taylor 50
Plan
The PDSA Cycle - cousins
DoStudy
Act
®Butts-Dion, Crowe and Taylor 51
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Objective for this PDSA Cycle: Date:
Is this cycle used to ___develop, ___test, or _____implement a change?
What question(s) do we want to answer with this PDSA cycle:
Plan:
Plan to answer questions: Who, What, When, Where
Plan for collection of data: Who, What, When, Where
Predictions (for questions above): .
Do: Report what happened, data; and begin analysis.
Study: Complete analysis of data. Compare the data to your predictions and summarize
the learning.
Act: Are we ready to make a change (adopt, adapt, abandon)?
Plan for the next cycle:
PDSA Tip
®Butts-Dion, Crowe and Taylor 52
PDSA(what predictions do we have?)
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®Butts-Dion, Crowe and Taylor 54
Lens of Profound Knowledge PDSAPlan: Develop 1 (or 2)Useful Questions for each of the four Lens.
Each person write down the questions
Appreciation for a System
Theory of Knowledge
Psychology
Knowledge about
variationProcess Process
System
Variation
Knowledge
Psychology
®Butts-Dion, Crowe and Taylor 55
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®Butts-Dion, Crowe and Taylor 56
TRIO PDSA
DO: TRIOSTwo test the questionsOne observer make notes
STUDY: ALLStudy the results per our predictions and plan. Review any incidental or unexpected events that happened.
Act: ALL Adapt, Adopt, Abandon Next Test?
®Butts-Dion, Crowe and Taylor 57
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Group Debrief
PDSA’s
Trends and Patterns(quantitative: run charts, statistical
analysis, qualitative study)
System Structure(pattern of interrelationship among key components of the system: hierarchy, process flows, attitudes and perceptions
Mental Models(key assumptions)
Leverage for Improvement
The Fifth Discipline FieldbookPage 97 - 103
Events
(crisis, anecdotes, problems)
®Butts-Dion, Crowe and Taylor 59
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For every complex problem, there is a
solution that is simple, neat, and wrong.
HL Mencken
®Butts-Dion, Crowe and Taylor 60