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dEvEloPIng oPERATIons CAPAbIlITIEs 255
● Stage 3: Measurement – There is an awareness of significant variables that seem to
affect the process with some measurement, but the variables cannot be controlled
as such. The best that managers could do would be to alter the process in response
to changes in the variables.
● Stage 4: Control of the mean – There is some idea of how to control the significant
variables that affect the process, even if the control is not precise. Managers can
control the average level of variables in the process even if they cannot control the
variation around the average. Once processes have reached this level of knowledge,
managers can start to carry out experiments and quantify the impact of the vari-
ables on the process.
● Stage 5: Process capability – The knowledge exists to control both the average and the
variation in significant process variables. This enables the way in which processes
can be managed and controlled to be written down in some detail. This, in turn,
means that managers do not have to ‘reinvent the wheel’ when repeating activities.
● Stage 6: Know how – By now the degree of control has enabled managers to know
how the variables affect the output of the process. They can begin to fine-tune and
optimise the process.
● Stage 7: Know why – The level of knowledge about the processes is now at the ‘scientific’
level, with a full model of the process predicting behaviour over a wide range of condi-
tions. At this stage of knowledge, control can be performed automatically, probably by
microprocessors. The model of the process allows the automatic control mechanisms
to optimise processing across all previously experienced products and conditions.
● Stage 8: Complete knowledge – In practice, this stage is never reached because it means
that the effects of every conceivable variable and condition are known and under-
stood, even when those variables and conditions have not even been considered
before. Stage 8 therefore might be best considered as moving towards this hypotheti-
cally complete knowledge.

example The Checklist manifesto 8

Improvement methodologies are often associated with repetitive operations. Performing the
same task repeatedly means that there are plenty of opportunities to ‘get it right’. The whole
idea behind continuous improvement (see Chapter 3) derives from this simple idea. By contrast,
operations that have to perform more difficult activities, especially those that call for expert
judgement and diagnostic ability, must call for equally complex improvement approaches – no?
Well no, according to Atul Gawande, an oncologist at the prestigious Johns Hopkins Hospital.
Gawande thinks that the very opposite is true. Although medicine is advancing at an astound-
ing rate and medical journals produce learned papers adding the results of advanced research to
an ever-expanding pool of knowledge, surgeons carry out over two hundred major operations a
year and unfortunately not all of them are successful. The medical profession overall does not
always have a reliable method for learning from its mistakes. Atul Gawande’s idea is that his,
and similar ‘knowledge-based’ professions, are in danger of sinking under the weight of facts.
Scientists are accumulating more and more information and professions are fragmenting into
ever-narrower specialisms.

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