Sooner or later we all realize that nothing happens of its own accord. I am because of all of you. For that I am grateful.
Thank you for being patient with me when I was restless and impulsive; when I got on my high horse; when I chose poorly; when my actions caused upset and hurt. I know how trying I can be. And if it weren’t for your calm steady presence I wouldn’t have been able to focus on what needed to get done. I’ve done what I’ve done, and have what I have, because you enabled me to.
Thank you for being there. I don’t ask for help, but you gave when I needed it–just enough to lift me over my hurdle; without imposing; without expectation; just because. My life wouldn’t be the joy it is without you in it. We may not have talked in ages, but you’re in my memories, just as real. For all our silly disagreements, I share a precious bond with each of you.
My Thanksgiving Day is wonderful for the relationships I am fortunate to have. I wish yours is wonderful, too!
Mark Graban’s blog post, “What Do We Learn from Charting a Reduction in CLABSI Rates in Different Ways?”, provides a great example of how to plot and analyze data.
Here I present my analysis, observations, and comments.
The data, which appears to be a count of central line associated blood stream infections (CLABSI) for each year starting 2005 and on through 2017, is shown in Table 1. According to Mark, it was presented by some leaders from a children’s hospital.
Table 1. Data for neonatal intensive care unit (NICU) central line associated blood stream infections (CLABSI) for 2005-2017
The simplest analysis that provides insight is the best analysis to perform. So, let’s plot the data (Figure 1).
Figure 1. Plot of count of central line associated blood stream infections (CLABSI) for 2005-2017
It is obvious just from the plot in Figure 1 that the performance of the system has changed; it has improved. It has dropped from ~40 NICU CLABSIs for 2005-2007 to ~6 NICU CLABSIs for 2009-2017. Mark writes that a process change was made around 2008. However, no other details are available as to the nature of the change. Without further context all we can say is that the effect of the change made in 2008 in subsequent years is obvious and dramatic—evidence of effectiveness of action. No calculations were necessary to make this observation.
Still, we could add a center line to the plot (Figure 2) to gain further insight.
Figure 2. The addition of the center line (average of all 13 points), clearly shows two distinct runs: a run of four points for 2005-2008, and a run of nine points for 2009-2017. The run of nine points is unusual, and signals a process shift.
The center line is the mean, calculated using all 13 points. It is ~14. From the plot we see a run of four points above the mean and a run of nine points below the mean. The second run is unusual and signals a process shift. It supports the claim that a process change was made around 2008-2009. With a single calculation, the mean, we have corroborated our original observation.
If we want to predict the performance of the system in 2018 or 2019 or 2020, we need to construct an XmR chart. Knowing that there was a process change around 2008, we should focus on the system’s performance after that i.e. 2009 and beyond. Table 2 shows the calculations for the XmR chart.
Table 2. Calculations are shown for attributes necessary to plot an XmR chart. The calculations are shown just for the process thought to currently exist i.e. 2009-2017
The moving range (mR) is calculated as the absolute value of the difference between the current and previous year e.g. mR for 2010 is calculated as |X2010 – X2009| = |0 – 9|, which is 9.
The mean value is calculate for just those points after the process change, i.e. 2009-2017, as (9+0+0+3+8+2+3+10+2)/9 = 37/9 = 4.1
The mean moving range is calculate as the average of all the calculated moving range values as (9+0+3+5+6+1+7+8)/8 = 39/8 = 4.9
The upper natural limit (UNL) is calculated as the mean + 2.66*mean range i.e. 4.1 + 2.66*4.9 = 17
The lower natural limit (LNL) is calculate as the mean – 2.66*mean range i.e. 4.1 – 2.66*4.9 = -9. However, because you cannot have negative count, the LNL is set to zero on the chart.
The upper range limit (URL) is calculated as 3.268*mean range i.e. 3.268*4.9 = 15.9
The lower range limit (LRL) is zero.
The XmR chart is shown in Figure 3.
Figure 3. The natural process limits are shown for the current system with the UNL = 17, mean = 4.1, and LNL = 0. If the system continued to perform without change, we can expect between 0 and 17 CLABSIs in the next years.
From the XmR chart we can make the following predictions:
Provided the system continues to operate as it has the past few years, we can expect an average of ~4 CLABSIs in future years. There may be years where we could see up to ~17 CLABSIs. There may be years where there are none. Further more we can expect the counts to vary by ~5 on average from one year to the next. Some years may vary by as much as 16 counts. Others may not vary at all.
Management must decide whether this is adequate performance. If further reduction in NICU CLABSIs is wanted, new actions to improve the current system will need to be taken.
 Graban, Mark. What Do We Learn from Charting a Reduction in CLABSI Rates in Different Ways?. Retrieved on 2017.11.01 from https://www.leanblog.org/2017/11/learn-charting-reduction-clabsi-rates-different-ways/
Writers and readers are in a relationship. Each has responsibilities. The writer is responsible for the structural quality of his writing such as spelling, grammar, punctuation, and vocabulary. (The language should be invisible in high quality writing so that the reader can focus on the content i.e. the writer’s message.) The reader is responsible for being fluent in the language to understand high quality writing.
This book should never have been published just for its atrocious quality of writing. It is filled with spelling mistakes, terrible grammar, and horrid punctuation. These issues, in addition to needless Japanese jargon, car jargon, and undefined acronyms, interrupted reading so often that I had to put the book away every few pages. This is especially frustrating as the book is fundamentally about building quality in into a product! There is no indication that this was done in the production of this book.
I am deeply interested in the product development process. Experience with several companies has shown me that their respective product development process, if it exists as such, is poorly designed, poorly defined, and not effective in operation. So I have been studying—I’ve read Stuart Pugh’s “Total Design”, Don Clausing’s “Total Quality Development”, and Ulrich/Eppinger’s “Product Design and Development”, among other books and papers. Given that Toyota excels at bringing great products to market quickly, I really wanted to learn and understand its approach. So it was with this intent, and Jeffrey Liker’s reputation, that I picked up “The Toyota Product Development System”.
The book does not deliver what its title promises. The authors do not provide a model of the product development process, instead discussing the sociotechnical system (STS) at Toyota, the V-Comm communication system, and PDVSM—product development value stream mapping to improve the product development process. This is already superbly detailed in Jeffrey Liker’s “The Toyota Way”. We get it—the product development process at Toyota is grounded in its world leading STS, but what is the process specifically? The authors don’t detail the product development process as I’ve come to expect from reading Pugh, Clausing, Ulrich/Eppinger. Perhaps that is a failure on my part.
How are design inputs collected and/or developed? How are those inputs converted into engineering terminology? If Toyota doesn’t use the House of Quality, what does it use? How are engineering requirements converted into sets of concepts? There is no usable explanation of set-based concurrent engineering. For crying out loud, Jeffrey Liker wrote several papers on this! What is the method for vetting various concepts? How does detailed engineering happen i.e. converting requirements into drawings? How are those concepts verified and/or validated? What type of testing is performed or skipped? When is it done? None of the things that would help a design and development engineer to understand the design and development process at Toyota is covered in any useful way.
When these questions are touched upon, they are done so piecemeal and superficially; disconnected from one another. The authors make the reader work very hard to extract nuggets from their writing. The discussion often happens in the context of an example, but the examples require you to know car terminology! So if you don’t have experience in the automobile industry, good luck trying to figure out what the authors are trying to communicate. (Thank you Google & Wikipedia for helping me see what is meant.) The matter is made worse by the fact that an example doesn’t carry through between discussion of topics.
One final note, there is a ridiculous amount of adoration of Toyota’s results that borders on worship. I didn’t care for that, especially when what I was looking for—the description of process—was missing. I didn’t buy the book for the authors to tell me how good Toyota is and how bad everybody else is. I already know this. It is unfortunate that several masters in lean wrote rave reviews for the book. I wonder if they bothered to actually read it. I am now less inclined to be guided by their reviews and recommendations. My suggestion to you is you skip this book. It isn’t worth anyone’s time.
 Pugh, Stuart. Total Design. Addison-Wesley Publishers Ltd. 1991. ISBN 0-201-41639-5
 Clausing, Don. Total Quality Development. ASME Press: New York, NY. 1993. ISBN 0-7918-0035-0
 Ulrich, Karl T., and Steven D. Eppinger. Product Design and Development. New York, NY: McGraw Hill Education. 2012. Print. ISBN 978-93-5260-185-1
 Morgan, Kames M., and Jeffrey K. Liker. The Toyota Product Development System. New York, NY: Productivity Press. 2006. Print. ISBN 1-56327-282-2
 Liker, Jeffrey K. The Toyota Way. New York, NY: McGraw Hill. 2004. Print. ISBN 0-07-139231-9
Now, today I’m going to go into the very fundamental…the guts of Hinduism. But what I want to do is to begin with certain documents that are known as the Upanishads. And these documents constitute what is called Vedanta. V-E-D-A-N-T-A. And that is compounded of two words: Veda, Anta. Anta means end or completion or summation. Veda, of course is related to the Latin video—to see. Veda is the fundamental revelation of the Hindu way of life contained in its earliest scriptural documents which are generally dated in the period between 15 and 1200 BC.
The Upanishads has, being the summation of the Veda, are from…found from over a long period of time. Beginning perhaps as early as 800 BC. Some of the Upanishads are much much later than that. And the basic position of the Upanishads is that the Self is the one and only reality without a second—that all this universe is finally Brahman—and appears to be a multiplicity of different things and different events only by reason of Maya, which is illusion, magic, art, creative power. So then it is basic to the Vedanta that Brahman—this intangible non-objective ground of everything that exists—is identical with the ground of you. And this is put in the formula: tat tvam asi. T-A-T, tat, same as our word ‘that’; tvam, T-V-A-M, same as the Latin tuus—thou; asi—art. We should translate that into a modern American idiom as “You’re it.”
This, of course, is a doctrine which is very difficult for those brought up in the Judeo-Christian traditions to accept because it is fundamental to Christian and Jewish theology that whatever you are, you are surely not the Lord God. And Christians feel about the Hindu doctrine—that we are all fundamentally masks of God—that it’s pantheism, and that’s a dirty word in Christian theological circles because of the feeling that if everything is God, then all moral standards are blown to hell; because it means that everything is as good as everything else; everything that happens is really God and this must include the good things and the bad things. And that seems to them a very dangerous idea. Actually all religious doctrines contain very very dangerous ideas.
However, we won’t worry about that for the moment because what the Hindu means by God when he says Brahman is not at all the same thing as a Jew means by the Lord Adonai; because the Jew and the Christian means ‘the boss’ to whom divine honors are due as above all others. The Hindu, on the other hand, does not mean ‘the boss.’ He doesn’t mean the king, the Lord, the political ruler of the universe. He means the inmost energy, which, as it were, dances this whole universe, without, as it were, the idea of authority, of governing some intractable element that resists his or its power.
So if a Christian, or a person in a Christian culture, announces that he has discovered that he is God, we put him in the loony bin, because it is unfashionable to burn people for heresy anymore. But in India if you announce that you’re the Lord God, they say “Well, of course. How nice that you found out,” because everybody is.
So then why, the great problem arises, does it appear that we are not, why do we think, why do we have the sensory impression that this whole universe consists of a vast multiplicity of different things and we don’t see it all as one? Well, what would you think it would be like to see it all as one? I know a lot of people who study oriental philosophy hear about attaining these great states of consciousness: nirvana, moksha—which the Hindus use…liberation, satori—Zen Buddhist word for enlightenment or awakening. What would it be like to have that? What…how would you feel if you saw everything is really one basic reality?
Well a lot of people think that it would be as if all the outlines and differentiations in the field of vision suddenly became vague, melted, and we saw only a kind of luminous sea of light. But rather advisedly the Vedanta philosophy does not really seriously use the word “one” of the supreme Self. Because the word and idea “one” has an opposite, “many,” on one side, and another opposite “none,” on the other. And it is fundamental to Vedanta that the supreme Self is neither one nor many, but as they say non-dual. And they express that in this word advaita—a, is a negative word like non, dvaita is from dva, same as the Latin duo, two. So advaita is non-dual.
And this at first for westerners is a difficult conception, because you naturally as a western logician would say, “But the non-dual is the opposite of the dual! Therefore it has an opposite.” True, but the Hindu is using this term in a special sense. It’s like this, on a flat surface I have only two dimensions in which to operate, so that everything drawn in two dimensions has only two dimensions. How, therefore, on a two dimensional level can I draw anything but two dimensions? How in logic in human rationality can I possibly think except in terms of opposites?
All rational discourse is talk about classification. The classification of experiences, of sensations, of notions. And the nature of a class is that it’s a box. And if a box has an inside, it has to have an outside. “Is you is, or is you ain’t?” is fundamental to all classification. And we can’t get out of it. It’s almost as if, you see, whatever we see to be different is an explicit difference on the surface covering an implicit unity. Only it’s very difficult to talk about what it is that unifies black and white. Of course, in a way, the eyes do. Sound and silence are unified by the ears. So, you…you can see, can’t you, that if you can’t have one without the other…it’s like the poles of a magnet, North pole and South pole. You can’t have a one pole magnet. True the poles are quite different, one’s North and the other’s South, but it’s all one magnet. And some such idea is that is what the Hindu is moving into when he’s speaking of the real basis or ground of the universe as being non-dual.
Take it the fundamental opposition that I suppose all of us feel between self and other. I and thou. I and it. There is something that is me. There’s an area of my experience that I call myself, and there’s an other area of my experience which I call not myself. But you will immediately see that neither one could be realized without the other. You wouldn’t know what you meant by self unless you experience something other than self. You wouldn’t know what you meant by other unless you understood self. They go together. They arise at the same time. You don’t have first self and then other or first other and then self. They come together. And that shows, you see, the sneaky conspiracy underneath the two, like the magnet between the two different poles. And so more or less that sort of what isn’t classifiable but which lies between all classes, the class of elephants opposite the class of non-elephants, has as it were the walls of the box joining the two together, just as your skin is an osmotic membrane that joins you to the external world by virtue of all the tubes in it and the nerve ends and the way in which the external energies flow through your skin into your inside, and vice versa.
But, we do, don’t we, see and feel and sense, or we think we do, the world as divided into a great multiplicity. A lot of people would think of the universe as a collection of different things, a kind of cosmic flotsam and jetsam washed together in this particular area of space, and prefer to take a pluralistic attitude and don’t see anything underlying. In fact, in contemporary logical philosophy the notion of any basic ground or continuum in which all events occur would be considered meaningless, for obvious reasons. If I say that everybody in this universe, every star, every planet, is moving in a certain direction at a uniform speed, that will be saying nothing at all unless I can point out some other object with respect to which they are so moving. But since I said the universe that includes all objects whatsoever. Therefore, I cannot make a meaningful statement about the uniform behavior of everything that is going on.
True, but on the other hand every sound you hear on the radio, whether it be a honking horn, a Bach sonata, or a newscast is the vibration of the diaphragm in your loudspeaker. The radio doesn’t tell us this. The announcer doesn’t come on first thing in the morning and say “Ladies and gentlemen, from now until closing time all the sounds you will hear will be vibrations of the diaphragm in your speaker.” That is taken for granted and ignored. So in the same way your eardrum is basic to all that you hear, your lens of the eye and retina is basic to all that you see. What is the color of the lens of the eye? We say it is no color. It is transparent in the same way as a mirror has no color of its own. But the mirror is very definitely there, colorless as it may be. The eardrum, unheard as it may be, is very definitely basic to all hearing. The eye, transparent as it may be, is very definitely basic to all seeing.
So, therefore, if there were some continuum in which everything that is going on and everything that we experience occurs we would not notice it. We would not be able, really, to say very much about it, except, perhaps, that it was there. It wouldn’t make any difference to anything except the one all-important difference that if it wasn’t there there wouldn’t be any differences. But you see philosophers nowadays don’t like to think about things like that. It stretches their heads and they would rather preoccupy themselves with more pedestrian matters. But still you can’t help it, if you are a human being, you wonder about things like that. What is it in which everything is happening? What is the ground? Well you say obviously it’s not a what because a thing that is a what is a…is a classifiable thing. And so very often the Hindu and the Buddhist will refer to the ultimate reality as no thing. Not nothing, but no special thing. Unclassifiable. Can’t put your finger on it, but it’s you. It’s what you basically are. What everything basically is. Just as the sound of an automobile horn on the radio is in one way an automobile horn but basically it is a vibration of the diaphragm.
Okay. So you are all, in the Hindu view, vibrations of the entire cosmic diaphragm. Put it like that. That’s an analogy and I’m using sublunar language or cataphatic language from the point of Christianity. The best language is to say nothing but to experience it. How could you experience it? Well, that’s the whole thing as I pointed out last time. The nub of all these oriental philosophies is not an idea, not a theory, not even a way of behaving. But it’s basically a way of experiencing a transformation of everyday consciousness, so that it becomes quite apparent to us that that’s the way things are. But you…but when it happens to you it’s very difficult to explain it. So in exactly the same way, when somebody has that sort of breakthrough which transforms his consciousness, and it happens all over the world, it’s not just a Hindu phenomenon, somebody suddenly realizes it’s all one or technically non-dual. And really always coming and going and all this frantic living and dying, grabbing, struggling to…, fighting, suffering…all this is a fantastic phantasmagoria. He sees that! But when he tries to explain it he finds his mouth isn’t big enough because he can’t get the words out of their dualistic pattern to explain something non-dualistic.
Why is this so? Why are we under this great magnificent hallucination? Well, the Hindus explain this in Saguna language as follows. It’s a very nice explanation. A child can understand it. The fact of the matter is the world is a game of hide-and-seek. Peekaboo. Now you see it, now you don’t. Because, very obviously, if you were the supreme Self what would you do? I mean, would you just sit there and be blissfully one and forever and ever and ever? No, obviously not. You would play games. You would, in other words, for the very nature of the fact that I said no energy system is an energy system unless it lets go of itself. So you would let go of yourself. And you’d get lost. And you’d get involved in all sorts of adventures. And you would forget who you were. Just as when you play a game, playing poker. And although you’re only playing for dimes or for chips, you get absorbed in the game. And nothing really important to win, nothing really important to lose, and yet it becomes fantastically interesting. Who wins and who loses?
So in the same way it is said that the supreme Self gets absorbed through ever so many different channels, which we call all the different beings, in the plot, just like an artist or a writer gets completely absorbed in the artistic creation that he is doing or an actor gets absorbed in the part in the drama. At first we know it’s a drama. We go to a play and we say, “It’s only a play.” And the proscenium arch tells us that what happens behind that arch is not for real; just a show. But the great actor, he is going to make you forget it’s just a show. He’s going to have you sitting on the edge of your chair. He’s going to have you crying. He’s going to have you trembling because he almost persuades you that it’s real. And what would happen if the very best actor was confronted by the very best audience? Why they’d be taken in completely, and the one would confirm the other. So this is the idea of the Universe as drama. That the fundamental self, the Saguna Brahman, plays this game, gets involved in being all of us, and does it so damn well, the…the…it’s so superbly acted that the thing appears to be real. And we’re not only sitting on the edge of our chair, but we start to get up and throw things. We join in the drama and it all becomes whatever it is that is going on here, you see.
Then, of course, at the end of the drama, because all things have to have an end that have a beginning, the curtain goes down and the actors retire to the greenroom. And there, the villain and the hero cease to be villain and hero and they’re just that: the actor. And then they come out in front of the curtain and they stand in a row and the audience applauds the villain along with the hero. The villain, for having been a good villain. The hero for having been a great hero. The play is over. And everybody heaves a sigh of relief, “Well, that was a great show, wasn’t it?”
So the same idea, the greenroom, is the Nirguna Brahman. That, behind the whole show, where there are no differentiations of I and thou, subject and object, good and evil, light and darkness, life and death. But within the sphere of the Saguna Brahman all these differentiations appear because that’s out in front, that’s on the stage. And, no good actor, when on the stage, performs his own personality. That’s what’s wrong with movie stars. They try to cast the person to act a role which corresponds to his alleged personality. But a great actor can assume any kind of personality; male or female; can suddenly convert himself, right in front of the audience, into somebody who takes you in entirely. But in the greenroom he’s his usual self.
So Hinduism has the idea then, you see, it’s all the conventions of drama, you’re right along with it; that all this world is a big act. Lila, the play of the supreme Self. And it’s therefore compared to a dream, to a passing illusion, and you should not therefore take it seriously. You may take it sincerely, perhaps, as an actor may be sincere in his acting. But not serious, because that means it throws you for a loop. Although that of course is involved. We do take it seriously. But you see one of the great questions you have to ask yourself when you really get down to the nitty-gritty about your own inmost core is “Are you serious?” Or do you know deep within you that you’re a put-on.
In the last session of this particular course, which is an introduction to Oriental philosophy, I tried to condense the fundamental principles of what you can call the central viewpoint of Hinduism—Vedanta. The…not some much the doctrine as the experiential realization that what you are basically is the same as the root and ground of the universe. In other words in the formula atman, the self, is Brahman, the ground of being.
Now, today I want to relate this way of playing hide-and-seek with the very design of Hindu society. Because Hinduism is difficult to characterize as a religion. Especially because we belong to a religion where in its institutionalized form it can very well degenerate into a religion that’s for Sundays only; that doesn’t apply to every detail of life. In other words, when a Hindu brushes his teeth it’s a religious act. There is not such a way as a Christian way of brushing your teeth. But in Hindu life all the details of life are Hinduism.
So then, underneath all the presuppositions of Hinduism can be found a transition from one kind of culture to another: from a hunting culture to an agrarian culture. This explains a great deal about this way of life. Now, in a hunting culture, which is a culture on the move—nomadic, every man knows the whole culture. In other words, you do not get a high specialization—division of labor. A man who is a hunter has to know how to make clothes, how to skin animals, how to cook them, how to shoot them, how to trail them. He has to know every kind of skill because he’s often alone. And in a hunting culture you do not get a special division of priesthood from ordinary people. Every man in his own way is capable of being a priest, but some more so than others. Not by virtue of any ordination or schooling that they’ve received, but by their receptivity. Because the priest or holy man of a hunting culture is called a shaman.
A shaman is an individual who separates himself from for a certain period and goes alone into forests or mountains to commune with what he will usually call the ancestors. That is to say with his basic origins. And he will find something, by way of a spiritual experience, for himself. Not through any teacher, not through any previous authority. He finds it genuinely on his own. And the shaman, therefore, goes into solitude to find out who he really is. Because in society everybody is busy telling you who you are. And you rely on others to see yourself. But to find himself, in other words, to find out what all this really is all about, the spiritually minded man of the hunting culture goes alone. And so the culture of the American Indians is to a very large extent hunting culture and you will find the spiritual man of the American Indians is a shaman.
However, when a hunting culture becomes settled, it becomes agrarian, there arises farming, looking after the land. And then you get a completely different kind of society. Let me suggest that it is something like this. Where do agrarian communities settle? Where do they build a village? Usually at a crossroads. Especially if roads be crossed with water, a river. And where the crossing meets the agrarian village settles itself and protects itself by building a pale. We say, “a person is beyond the pale.” That means he’s an outcast. He lives outside the village. He’s a pariah. But in the village, notice that the pale, having been built around the crossroads, it divides the village into four sections. And oddly enough there are four divisions of labor in all fundamental agrarian societies. And these consist of one, the priests. You know the word “clever,” “clerk,” “cleric,” and “clear,” are all the same word. It meant someone who’s literate. Clever. Also clear—“put it down clearly”. You can’t do that unless you’re literate. And so if you’re a literate person you’re a cleric. And “clergy,” is the same word as “clever,” in old English. “Much conceit of clergy,” is an old English phrase meaning he’s intellectually snobbish. So that’s your caste number one. Caste number two: warrior, or incidentally, ruler. Three, merchant or craftsman. And four, laborer; unskilled.
So now what’re these? They’re four castes or four roles. And so…in society where there’s a division of labor, because an agricultural society is more complex than a hunting culture, we immediately get division of labor and we all play different roles. That is to say, assume different masks for purposes of living in this kind of community. All of you, you see, are essentially…we are essentially clerics. You are what the Hindus would call Brahmins, as you’re all being trained in the university. So the Hindu name for this caste Brahmana; for this caste Kshatriya; for this caste Vaishya, and for this caste Shudra. So those are the basics of the four castes. And…so if you are in the pale, if you belong to the community, you have to be typified. They say, “Is you is, or is you aint?” Into which of these do you fit? And you must fit into one of these.
Now caste is something, of course, which has got a very bad name. From a modern point of view, both modern point of view with us and with the modern India. Because they say once you get into a caste, you’re stuck. If you are born to a laborer, a laborer you must be. If you are born to a warrior you must be a warrior or a ruler. You could never become a cleric. And we think that’s pretty terrible. Because in our culture we work under the assumption that you as an individual are free to choose whatever occupation you will follow. But unfortunately this involves going to school. And for certain purposes, going to school is one of the worst things you can do.
For example, if you want to become a completely fantastic expert carpenter you have to begin the trade at the age of seven at the latest. And your father, if he is a carpenter, is obviously the best teacher you can have. In a very ancient form of agrarian culture as in India or as in Japan or China, a young man who was son of a carpenter would become fascinated with his father’s occupation. And that would mean a very special relationship would grow up between him and his father, which does not grow up in our culture because most of us do not know what our fathers are doing. They go away to a mysterious office or factory where they do something called making money as an inciden… as a…the main reason for the incidental occupation which they pursue there, but the children and the wife have no active part in that occupation whatsoever. They know papa only as a kind of clown who returns home in the evening having made money. And one dad’s money is the same as another dad’s money. It makes no difference, except that everybody wants more. They don’t give a damn how he gets it so long as he doesn’t complain too much.
So the child, instead of learning and participating in his close father relationship, in learning an occupation or a trade or an art is sent off to an impersonalized institution to be taught to be everything and nothing. And therefore, doesn’t learn early enough any craft so as to become a true master of it. What is happening for example in Japan, where a father can no longer apprentice his son at seven years old to become a carpenter because he has to send him away to school to learn to be an insurance salesman. He can’t teach his child and then comes high school. And then when the kid gets our of high school, he’s interested in girls. And it takes him until he’s about twenty-two to be able to settle down to learn carpentry. And it’s too late. Too late to attain real mastery. Because a great Japanese carpenter never uses a plan. He doesn’t need a drawing. Does it all by eye. And can fit the most complicated joinery together by eye. And it’s the same with the arts of weaving textiles, of making superb ceramics, jewelry. Any kind of gorgeous craftsmanship depends on beginning as a child.
And so, all right. We can’t buy it anymore, in this country. There is not on any kind of commercial basis great craftsmanship available here. We have to go abroad to get it, to so called primitive societies. We must be content with plastic simulation. So there is something to be said, you see, for the caste system. I just wanted to present the other side of it.
Now, however, in going through this system there are certain stages, whatever caste you’re in. There are three stages of life which are called ashramas. Ashram, means really an abode; a center for spiritual study; for practicing yoga, will be called an ashram. But an ashram also means an abode in the sense of a stage of life. And the three stages are one called Brahmacharya—that means the stage of being a student, two, Grihasta—household, and the third stage, Vanaprasta—that means forest dweller. Isn’t that funny? Grihasta, householder. Vanaprasta, forest dweller.
Because, you see, in this order of society you come into society and you go through one of its acts as a Grihasta or householder. But when you arrive at the point in life where you have got a son by birth from yourself or by the marriage of your oldest daughter, a son who will take over your work, you give up being a householder and you become a forest dweller. In other words, you go outside the pale and back to the forest with the idea of finding out who you really are. While you were in the community you were playing a role; one of the four roles or its subdivisions, and you came on as tinker, tailor, soldier, sailor, rich man, poor man, beggar man, thief. But that wasn’t the real you. That was one of the masks of the Brahman, the true self behind everything. To find out the Brahman, who you really are, in order to get ready to die, you become Vanaprasta. Go back to the jungle having fulfilled your work to the world.
Now in practice in India this means the head of the house often moves to a cottage in the backyard. You know, in the course of time, everything becomes sort of going through the motions. But the original idea was that he became, what do they call it in Sanskrit, Shramana. It’s almost the word “Shaman”. A shraman is a person who has gone back to live in the forest. And therefore, he is in regard to society an upper outcast. There are also lower outcasts. Those are the Aborigines—the people living in India before the Aryan invasion, who later became the Untouchables. They are not even Shudra. They are outside caste altogether, like the Indians in the United States. They are true Untouchables in our caste system. Their plight is so much worse than the Negroes. It’s unbelievable. But they are outcasts. So in the same thing happened in India.
But the upper outcast is a man who goes wild. And in Hindu society you have a right to do that. You are respected if you voluntarily abandon caste. And of course, in doing so you give up your name and you take another name. Now taking a new name is taking a new identity. An Indian in society may be Mr. Mukhophadaya. And that would be a family name indicating membership in a family. When he becomes a shramana, however, he will take a name such as Brahmananda—bliss of God. He takes a divine name. And the original idea of a Christian name, when you were baptized, is that you gave up the name Julius, as you might be a Roman, and took on instead the name Matthew, one of the apostles, one of the divine beings of the Christian religion. Or you might take the name of an angel, Michael. Or in Spain or Mexico, even Jesus (Hay-soos)–Jesus. Jesus Maria would be a perfectly reasonable name for a man in Spanish culture. But you take on a divine name to indicate a transformation of the…your identity.
But in this case when you give up caste, you see, and return to the forest you become a nobody. And therefore, you take one of the names of that which is no one. Namely the Brahman—the supreme Self. Because it’s no one in the sense that it’s all ones, and therefore, in itself no one. So you abandon caste and you abandon name; you give up property; you give up both the responsibility and society is allowed to give up responsibility for you. If they give you alms, if they support you, that’s for gravy. They don’t have to do it, and you don’t figure that they owe it to you.
But this…this kind of society has a profound respect for people who leave it. And they feel that a society cannot be healthy unless it somehow pays respect to people outside the pale, to non-joiners and outsiders, who have indeed fulfilled some responsibility within society and then abandoned it. They would, I think, be a little uptight about hippies who would abandon society before having fulfilled a responsibility in it. But in a sense every shramana is a sort of elderly hippie. Now, of course, our hippies have a different problem in that they are critical of the very structure of the society in which they are asked to enter because they feel that it is a rat race, a game which has lost its quality. They might even prefer a caste like society of this kind in that it might have a bit more quality, because, you see, in our society one works not as a vocation.
In this scheme of things every vocation you perform is called a swadharma. And this word: the word “dharma” has many meanings. Dharma. It means a function in one sense. It means the thing that is right for you. Here swa is the same as the Latin suus. And so it is one’s own. Your own function. What we would call your vocation in life. Swadharma. As we say, “doing your own thing.” That’s swadharma. And so, you have to find, as it were, your own thing. Now, a job, which you do purely for money can never be called a swadharma because you are doing it for another end—to make money, which has a purely symbolic value. But when you do a certain work because that is what is your thing to do—you want to be a doctor because you are fascinated with medicine and all its problems, and you just…you like people so much that you want to heal them from their diseases or for the same reason you might want to be a nurse or you might be fascinated with problems of law and so become a lawyer or fascinated with religion and so become a minister—then you’ve got a vocation because you would do that thing whether it paid you very much or whether it didn’t because that’s the one thing you have to do. If you’re a painter, you have to paint. If you’re a writer, you’re one of those crazy people who just has to write. I’m a writer. I have to write. Whether it makes me money or whether it doesn’t I would still have to be a writer. That’s a swadharma. And every person’s vocation in caste is supposed to be your thing, your swadharma. But we feel in our culture, you see, that we have such a tremendous choice of swadharma that sometimes it’s what the French call embarras de richesse. It’s like embarrassment of riches when you’re confronted with one of those enormous menus in a restaurant which has so many things on it you can’t make up your mind which to pick.
Well now then, you see, as a person passes out of this he gives up the social order and becomes a nobody, he then, in that sense, he goes back to the forest. He goes back from the organization, the role playing of the agrarian culture to the solitude of the hunting culture to find out who he is alone all by himself. And so he becomes, in that sense, the upper outcast. The man who is respected by those people who are still in caste because they say without this kind of person we should lose our sanity. We should become confused with our roles unless there’s always the hermit in the forest to remind us that man is not his role, that he’s something deeper than that. And that they true end of man is to play the game of hide-and-seek for a while and to get lost in these roles. But then to return back to nature, back to the way of the forest. And in later life, as distinct from infancy, with all that experience behind him, find out again who you really are. So that when death comes, what a funny thing will happen. Death comes and will find no one to kill. For while you are identified with your role, with your name, with your ego, there’s someone to kill. But when you’re identified with the whole universe death finds you already annihilated. And there’s no one to kill.
Coffee shops provide a great opportunity to observe the flow of product from customer order and collection of cash to the delivery of the order and order pickup by the customer.
The coffee shop I sit at has the entrance for its order queue close to the entrance to the store. So, when customers walk into the store they immediately find themselves in queue to place their order. The customers place their order at one of two cash registers that are set side by side along the path of the flow. They then walk further to the end of the line where their order is delivered. In a relative measure, the exit of the queue is much farther from the store entrance than the entrance of the queue.
Recently I made a couple of observations:
1. Some customers order specialty coffee products (e.g. espressos, lattes, etc.), while others order brewed coffee. Specialty coffee products takes time to make while brewed coffee is ready to serve on demand.
Customers who order specialty coffee products move to the end of line and wait there for their order. Almost all of them wait right at exit of the queue. During a surge a cluster of people forms there essentially blocking the exit.
Customers who order brewed coffee have their coffee delivered to them right at the cash registers. Their order is not delivered at the end of line. So these customers, almost exclusively, exit the queue through the entrance of the queue instead of taking their order and following the line and exiting at its end. I suspect two contributing factors: the exit to the store is closer to the entrance of the queue, and the exit of the queue is blocked by the cluster of people waiting to pick up their order.
2. Many customers after picking up their order from the end of line still do not exit from there. They instead move back through the queue and exit through the queue entrance and then on through the store exit. I suspect that is because there is no direct way to exit the store from the exit of the queue. The customer has to navigate through the seating area.
As I made my observations on how people were behaving, I found myself getting irritated. Why couldn’t these customers, who had a brain and the ability to sense their environment, follow the line from the queue entrance to the queue exit and then out of the store? It’s not hard! Stop creating back-flows! How inconsiderate! So selfish! So oblivious! Ugh! I’m sure my disgust was plainly apparent on my face. I recall my many sanctimonious conversations with friends and colleagues on the thoughtless behavior of people.
Then I experienced an epiphany. My mind, without my conscious awareness, flipped its perspective and answered the question, “What is it about the design of the space that led people to use it in the way they were?” It shifted from blaming the human to accepting human behavior as an uncontrollable factor and addressing the inadequacy of the design of the space that enabled humans to behave in an undesirable way. That released my mind from being stuck and frustrated to feeling creative. With that one realization, my mind started working on redesigning the space.
Still, I wanted to continue observing the activity to understand it a little more deeply. But what happened caught me by surprise. Even though I had had the epiphany that the design of the space was the problem, and that people were responding to the design, I still found myself getting irritated with them for what I ascribed to them as their conscious decisions. That triggered my second epiphany, that unless I consciously focused on the first epiphany, my mind will naturally shift to blaming people for their behavior instead of the design of the space that enables it.
Postscript: Our brain evolved in an environment to notice activity that signaled potential danger: movement, sound, smell, etc. So it is biased to see this foreground. So much so that most times it doesn’t even see the background; the relatively unchanging environment. People and their behavior are always in the foreground. The context for their behavior, the design of the space, is in the background. When we are faced with behavior problems, our mind instinctively focuses on the human, rather than his environment. It takes conscious awareness to not do that.
We call a human being an individual. But is he really? Consider what the word “individual” means. It is derived from the Latin “in-,” which means not, and “dividere” which means divide. So the word “individual” means not divided or undivided. But even a cursory look reveals that the human being is totally fragmented!
We have created a society where each of us plays different roles in the course of our daily life, each distinct from the other. We go further and purposely try hard to keep them separate, switching from one role to another as we move from environment to environment. These roles are nothing more than images we have constructed in our mind, built by the thoughts that fill it. If we observe our thoughts, pay attention to them, we become aware of the great variety of them appearing and disappearing in our mind: fragments from memory with no discernible relationship between them.
Even as I define myself as an individual, I am really not undivided. I am not whole. I am an unintegrated collection of thought fragments, memories. And because these fragments of thought have no relationship to one another, they are often contradictory and in conflict with each other. So the prevailing state of my mind is chaotic! When I, an individual, am not whole, how can my world be? After all, the chaos in my mind I act out in the world.
The problem of fragmentation and disorder affects both the common man and our so-called leaders. Thus, we all behave in contradictory ways, engage in conflict and hypocrisy. It is critical that each of us work to transform ourselves from fragmented beings, disordered and divisive, into whole beings, ordered and unified. This has real world implications on how we relate to one another in conflict and cooperation. It determines whether our change efforts succeed, whether we will live in harmony or discord.
External systems of rules and regulations can coerce behavior, but they cannot integrate the fragmentation inside the human mind. That work must be done by the individual. It can only be done by the individual. Even the gurus, priests, imams, psychologists, are fragmented beings. How can they guide you to becoming an integrated whole? No one can. Thus, as the Buddha said, “be a light unto yourself.” If the human being transforms himself, he transforms everything, i.e. if he changes, his world changes. If he does not, nothing changes.
Early on in my career my thoughts about the world and work were fragmentary. They often conflicted with one another. These conflicting disorganized thoughts were the source of a lot of confusion and frustration.
Then I read W. Edwards Deming’s Out of the Crisis. On page 4, Fig. 1 shows a diagram of “Production viewed as a system”. It instantly reshaped my perspective. I had an “Aha!” moment. It gave me the context to understand my differentiated knowledge and experience. I understood where and how I fit in.
I sense that most people suffer from confusion and frustration from a lack of context for what they do. While I believe everyone should buy and read Out of the Crisis, it is not an easy read for the new worker.
This year I discovered two books that I feel are more accessible: Improving Performance Through Statistical Thinking and Statistical Thinking: Improving Business Performance. Both provide the worker a frame for understanding their job, how it fits within an organization, and how to work better, both individually and together.
These books aren’t just for quality people. In fact I think they are more helpful to everyone else–Marketing, R&D, Design & Development, Manufacturing, Sales, Accounting, Finance, Legal, and any other department I might have missed. I think every worker who reads them will have an “Aha!” moment, and can immediately benefit from them.
Dr. Deming pointed out, “It is not enough to do your best; you must know what to do, and then do your best.” You already do your best, but with confusing and frustrating results. These books are wonderful resources to help you understand what you should do so that your best efforts produce satisfying results; ones that make you feel good and proud.
I feel it’s important for me to say this: Don’t let the reference to Statistics in their titles scare you off. You don’t need to know any Statistics to read them. In fact, I feel you will benefit more if you didn’t know any Statistics. You will learn three important lessons from these books:
- All work occurs in a system of interconnected processes
- Variation exists in all processes, and
- Understanding and reducing variation are keys to success
 Deming, W. Edwards. Out of the Crisis. Cambridge, MA: Center for Advanced Engineering Study, MIT. 1991. Print. ISBN 0-911379-01-0
 Britz, Galen C., Donald W. Emerling, Lynne B. Hare, Roger W. Hoerl, Stuart J. Janis, and Janice E. Shade. Improving Performance Through Statistical Thinking. Milwaukee, WI: ASQ Quality Press. 2000. Print. ISBN 0-87389-467-7
 Hoerl, Roger, and Ronald D. Snee. Statistical Thinking: Improving Business Performance. Pacific Grove, CA: Duxbury, Thomson Learning. 2002. Print. ISBN 0-534-38158-8
Yesterday I had an interview with the Human Resources Director of the company. He asked me what I was looking for in my next job. I shared that I was looking for a good group of people to work with. I was looking to build relationships with my coworkers wherein I could help them feel good about the work they were doing. I was looking for a company where I could reduce wasted effort, boost productivity, and build pride in personal craftsmanship.
This was music to his ears, and he said as much. He said that the company wanted to be an employer of choice. He shared the effort made by the company to improve its culture to that end. Like many of my previous employers, they had surveyed their employees to find out what management could do. Employees, while happy with the cafeteria, had said the food was too expensive. So the company decided to subsidize it with $20 per employee. They also started making people take their birthdays off.
Sounds good, doesn’t it? It makes it appear as if management was listening and responding to employees, that it cares for their well-being.
The trouble is that such actions do nothing to improve an individual work process or the system within which workers work. And we all know by now that the bulk of the problems workers deal with reside in the process or system. Workers are powerless to affect them. What does subsidizing the cost of a meal do for improving the way work gets done? How does making people take their birthdays off boost productivity? Will installing an espresso machine help with reducing rework?
The assumption going into providing such fringe benefits (perks) is that problems are the result of workers holding back. That workers do not give their all or that they do not do their best. If only management rewarded them more, then workers would work better. Much has been written about the negative impact of boosting extrinsic rewards without changing the work process or system. Rather than feeling better, workers become more stressed, make more mistakes, take more time.
Management’s diagnosis of the cause of productivity problems is fundamentally flawed. Worse, management knows it. But working on the system to improve it requires management to work in ways they are not prepared to. Effects of changes to the system are not immediate nor are they easily perceived. But providing fringe benefits makes a real splash, however short-lived it might be. So here’s to hoping the pizza and beer will stop all of you workers from whining!
Virtually every component is made to be assembled with its counterpart(s) into sub-assemblies and final assemblies.
If individual pieces of a given component could be made identical to one another, then they would either all conform or all fail to conform to the component’s design requirements. If they conform, then we could pick a piece at random for use in a sub- or final-assembly. It would fit and function without fail, as intended.
But material varies, machine operation varies, the work method varies, workers vary, measurement varies, as does the environment. Such variation, especially in combination, makes it impossible to produce anything identical. Variation is a fundamental principle of nature. All things vary.
Variation affects the fit, the form and the function of a component. And, it is propagated along the assembly line such that the final product is at times a mixed bag of conforming and nonconforming widgets.
Material Consider 316 Stainless Steel. It is used to make medical devices. Manufacturers buy it from metal producers in sheet stock or bar stock.
If we measured the dimensional attributes of the received stock, e.g. its diameter or length, for several different purchase orders, we would see that they were not identical between orders. They vary. If we measured these attributes for pieces received in a single order, we would see that they were not identical between pieces of that order either. If we measured these attributes for a single piece at different points in its cross-section, we would see that they, too, were not identical. If we then zoomed in to investigate the crystalline structure of the stainless steel, we would see that the crystals were not identical in shape or size.
The elemental composition, in percent by weight, of 316 Stainless Steel is: 0.08% Carbon, 2.00% Manganese, 0.75% Silicon, 16.00-18.00% Chromium, 10.00-14.00% Nickel, 2.00-3.00% Molybdenum, 0.045% Phosphorous, 0.030% Sulfur, 0.10% Nitrogen, and the balance is Iron. We see that the amount of Chromium, Nickel, Molybdenum and Iron are specified as ranges i.e. they are expected to vary within them by design!
These are some of the ways a specific raw material used in the production of medical devices varies. Keep in mind that a medical device isn’t a single component but an assembly of several components likely made of different materials that will vary in just such ways as well. All this variation affects the processing (i.e. machining, cleaning, passivation, etc.) of the material during manufacturing, as well as the device performance in use.
Machine One piece of equipment used in the production of medical device components is the CNC (Computer Numerical Control) machine. Its condition, as with all production equipment, varies with use.
Take the quality of the lubricating fluid: it changes properties (e.g. its viscosity) with temperature thus affecting its effectiveness. The sharpness of the cutting tool deteriorates with use. A component made with a brand new cutting tool will not be identical to one made from a used cutting tool whose cutting edges have dulled. The cutting is also affected by both the feed-rate and the rotation-rate of the cutting tool. Neither of which remain perfectly constant at a particular setting.
What’s more, no two machines perform in identical ways even when they are the same make and model made by the same manufacturer. In use, they will almost never be in the same state as each other, with one being used more or less than the other, and consumables like cutting tools in different states of wear. Such variability will contribute to the variability between the individual pieces of the component.
Method Unless there is standardized work, we would all do the work in the best way we know how. Each worker will have a best way slightly different from another. Variation in best ways will find its way into the pieces made using them.
These days a production tool like a CNC machine offers customized operation. The user can specify the settings for a large number of operating parameters. Users write “code” or develop a “recipe” that specifies the settings for various operating parameters in order to make a particular component. If several such pieces of code or recipes exist, one different from another, and they are used to make a particular component, they will produce pieces of that component that vary from one to another.
When and how an adjustment is made to control parameters of a tool will affect the degree of variation between one piece and another. Consider the method where a worker makes adjustment(s) after each piece is made to account for its deviation from the target versus one where a worker makes an adjustment only when a process shift is detected. Dr. Deming and Dr. Wheeler have shown that tampering with a stable process, as the first worker does, will serve to increase the variation in the process.
All such variation in method will introduce variability into the manufactured pieces.
Man There are a great many ways in which humans vary physically from one another. Some workers are men, others are women. Some are short, others are tall. Some are young, others are older. Some have short fat fingers, others have long thin fingers. Some have great eyesight, others need vision correction. Some have great hearing, others need hearing aids. Some are right handed, others are left handed. Some are strong, others not so much. Some have great hand-eye coordination, others do not. We all come from diverse ethnic backgrounds.
Not all workers have identical knowledge. Some have multiple degrees, others are high school graduates. Some have long experience doing a job, others are fresh out of school. Some have strong knowledge in a particular subject, others do not. Some have deep experience in a single task, others have shallow experience. Some have broad experience, others have focused experience.
Last, but not least, we all bring varying mindsets to work. Some may be intrinsically motivated, others need to be motivated externally. Some may be optimists, others may be pessimists. Some want to get better everyday, others are happy where they are. Some like change, others resist it. Some are data driven, others use their instinct.
All this variation affects the way a job gets done. The variation is propagated into the work and ultimately manifests itself in the variation of the manufactured component.
Measurement We consider a measured value as fact, immutable. But that’s not true. Measuring the same attribute repeatedly does not produce identical results between measurements.
Just like production tools, measurement tools wear from use. This affects the measurement made with it over the course of its use.
And also just like production tools, the method (e.g. how a part is oriented, where on the part the measurement is made, etc.) used to make a measurement affects the measured value. There is no true value of any measured attribute. Different measurement methods produce different measurements of the same attribute.
So even if by chance two pieces were made identical we wouldn’t be able to tell because of the variability inherent in the measurement process.
Environment Certain environmental factors affect all operations regardless of industry. One of them is time. It is not identical from one period to the next. Months in a year are not identical in duration. Seasons in a year are different from one another. Daytime and nighttime are not identical to one another. Weekdays and weekends are not identical to one another.
Even in a climate controlled facility the temperature cycles periodically around a target. It varies between locations as well. Lighting changes over the course of the day. Certain parts of the workplace may be darker than others. Noise, too, changes over the course of the day: quiet early in the morning or into the night, and noisier later into the day. There is variation in the type of noise, as well. Vibration by definition is variation. It can come from a heavy truck rolling down the street or the motor spinning the cutting tool in a production machine. Air movement or circulation isn’t the same under a vent as compared to a spot away from a vent, or when the system is on versus when it is off.
The 5M+E (Material, Machine, Method, Man, Measurement, and Environment) is just one way to categorize sources of variation. The examples in each are just a few of the different sources of variation that can affect the quality of individual pieces of a component. While we cannot eliminate variation, it is possible to systematically reduce it and achieve greater and greater uniformity in the output of a process. The objective of a business is to match the Voice of the Customer (VOC) and the Voice of the Process (VOP). The modern day world-class definition of quality is run-to-target with minimal variation!
“Our approach has been to investigate one by one the causes of various “unnecessaries” in manufacturing operations…”
— Taiichi Ohno describing the development of the Toyota Production System
 Kume, Hitoshi. Statistical Methods for Quality Improvement. Tokyo, Japan: The Association for Overseas Technical Scholarship. 2000. Print. ISBN 4-906224-34-2
 Monden, Yasuhiro. Toyota Production System. Norcross, GA: Industrial Engineering and Management Press. 1983. Print. ISBN 0-89806-034-6
 Wheeler, Donald J. and David S. Chambers. Understanding Statistical Process Control. Knoxville, TN: SPC Press, Inc. 1986. Print. ISBN 0-945320-01-9