Stories – Page 2 – HCSE Blog

01/08/2015

Early Adoption

The early phases of a transformation are where most fall by the wayside.

And the failure rate is horrifying – an estimated 80% of improvement initiatives fail to achieve their goals.

The recent history of the NHS is littered with the rusting wreckage of a series of improvement bandwagons. Many who survived the crashes are too scarred and too scared to try again.

Transformation and improvement imply change which implies innovation … new ways of thinking, new ways of behaving, new techniques, new tools, and new ways of working.

And it has been known for over 50 years that innovation spreads in a very characteristic way. This process was described by Everett Rogers in a book called ‘Diffusion of Innovations‘ and is described visually in the diagram above.

The horizontal axis is a measure of individual receptiveness to the specific innovation … and the labels are behaviours: ‘I exhibit early adopter behaviour‘ (i.e. not ‘I am an early adopter’).

What Roger’s discovered through empirical observation was that in all cases the innovation diffuses from left-to-right; from innovation through early adoption to the ‘silent’ majority.

Complete diffusion is not guaranteed though … there are barriers between the phases.

One barrier is between innovation and early adoption.

There are many innovations that we never hear about and very often the same innovation appears in many places and often around the same time.

This innovation-adoption barrier is caused by two things:
1) most are not even aware of the problem … they are blissfully ignorant;
2) news of the innovation is not shared widely enough.

Innovators are sensitive people. They sense there is a problem long before others do. They feel the fear and the excitement of need for innovation. They challenge their own assumptions and they actively seek solutions. They swim against the tide of ignorance, disinterest, skepticism and often toxic cynicism. So when they do discover a way forward they often feel nervous about sharing it. They have learned (the hard way) that the usual reaction is to be dismissed and discounted. Most people do not like to learn about unknown problems and hazards; and they like it even less to learn that there are solutions that they neither recognise nor understand.

But not everyone.

There is a group called the early adopters who, like the innovators, are aware of the problem. They just do not share the innovator’s passion to find a solution … irrespective of the risks … so they wait … their antennae tuned for news that a solution has been found.

Then they act.

And they act in one of two ways:

1) Talkers … re-transmit the news of the problem and the discovery of a generic solution … which is essential in building awareness.

2) Walkers … try the innovative approach themselves and in so doing learn a lot about their specific problem and the new ways to solving it.

And it is the early adopters that do both of these actions that are the most effective and the most valuable to everyone else. Those that talk-the-new-walk and walk-the-new-talk.

And we can identify who they are because they will be able to tell stories of how they have applied the innovation in their world; and the results that they have achieved; and how they achieved them; and what worked well; and what did not; and what they learned; and how they evolved and applied the innovation to meet their specific needs.

They are the leaders, the coaches and the teachers of improvement and transformation.

They See One, Do Some, and Teach Many.

The early adopters are the bridge across the Innovation and Transformation Chasm.

18/04/2015

Celebrate and Share

There comes a point in every improvement journey when it is time to celebrate and share. This is the most rewarding part of the Improvement Science Practitioner (ISP) coaching role so I am going to share a real celebration that happened this week.

The picture shows Chris Jones holding his well-earned ISP-1 Certificate of Competence. The “Maintaining the Momentum of Medicines” redesign project is shown on the poster on the left and it is the tangible Proof of Competence. The hard evidence that the science of improvement delivers.

Behind us are the A3s for one of the Welsh Health Boards; ABMU in fact.

An A3 is a way of summarising an improvement project very succinctly – the name comes from the size of paper used. A3 is the biggest size that will go through an A4 fax machine (i.e. folded over) and the A3 discipline is to be concise and clear at the same time.

The three core questions that the A3 answers are:
Q1: What is the issue?
Q2: What would improvement need to look like?
Q3: How would we know that a change is an improvement?

This display board is one of many in the room, each sharing a succinct story of a different improvement journey and collectively a veritable treasure trove of creativity and discovery.

The A3s were of variable quality … and that is OK and is expected … because like all skills it takes practice. Lots of practice. Perfection is not the goal because it is unachievable. Best is not the goal because only one can be best. Progress is the goal because everyone can progress … and so progress is what we share and what we celebrate.

The event was the Fifth Sharing Event in the Welsh Flow Programme that has been running for just over a year and Chris is the first to earn an ISP-1 Certificate … so we all celebrated with him and shared the story. It is a team achievement – everyone in the room played a part in some way – as did many more who were not in the room on the day.

Improvement is like mountain walking.

After a tough uphill section we reach a level spot where we can rest; catch our breath; take in the view; reflect on our progress and the slips, trips and breakthroughs along the way; perhaps celebrate with drink and nibble of our chocolate ration; and then get up, look up, and square up for the next uphill bit.

New territory for us. New challenges and new opportunities to learn and to progress and to celebrate and share our improvement stories.

11/04/2015

The Improvement Pyramid

Developing productive improvement capability in an organisation is like building a pyramid in the desert.

It is not easy and it takes time before there is any visible evidence of success.

The height of the pyramid is a measure of the level of improvement complexity that we can take on.

An improvement of a single step in a system would only require a small pyramid.

Improving the whole system will require a much taller one.

But if we rush and attempt to build a sky-scraper on top of the sand then we will not be surprised when it topples over before we have made very much progress. The Egyptians knew this!

First, we need to dig down and to lay some foundations. Stable enough and strong enough to support the whole structure. We will never see the foundations so it is easy to forget them in our rush but they need to be there and they need to be there first.

It is the same when developing improvement science capability … the foundations are laid first and when enough of that foundation knowledge is in place we can start to build the next layer of the pyramid: the practitioner layer.

It is the the Improvement Science Practitioners (ISPs) who start to generate tangible evidence of progress. The first success stories help to spur us all on to continue to invest effort, time and money in widening our foundations to be able to build even higher – more layers of capability -until we can realistically take on a system wide improvement challenge.

So sharing the first hard evidence of improvement is an important milestone … it is proof of fitness for purpose … and that news should be shared with those toiling in the hot desert sun and with those watching from the safety of the shade.

So here is a real story of a real improvement pyramid achieving this magical and motivating milestone.

14/03/2015

Co-Labor-Ation

Bob and Leslie were already into the dialogue of their regular ISP coaching session when Bob saw an incoming text from one of his other ISPees. It was simply marked: “Very Urgent”.

<Bob> Leslie, I have just received an urgent SMS that I think I need to investigate immediately. Could we put this conversation on ice for 10 minutes and I will call you back?

<Leslie> Of course. I have lots to do. Please do not rush back if it requires more time.

<Bob> Thank you.

Ten minutes later Leslie saw that Bob was phoning and picked up.

<Leslie> Hi Bob. I hope you were able to sort out the urgent problem. The fact that you are back suggests you did.

<Bob> Hi Leslie. Thank you for your understanding and patience. The issue was urgent and the root cause is not yet solved, but lessons are being learned. And this is one you are going to come up against too so it may be an opportune time to explore it.

<Leslie> H’mm. Now you have pricked my curiosity. But you can’t discuss someone else’s problem with me surely!

<Bob> No indeed. Strict confidentiality is essential. We can talk about the generic issue though, without disclosing any details. Do you remember that project you were doing last year where you achieved an initial success and then it all seemed to go wobbly?

<Leslie> Yes. At the time you said that I needed to put that one on the shelf and to press on with other projects. I think the phrase you used was “it needs to stew for a while“.

<Bob> And what happened?

<Leslie> The hard won improvement in performance slipped back and I felt like a failure and started to lose confidence. You said not to blame myself but to learn and move on. The lesson was I did not appreciate the difference between circles of control and circles of influence. I was trying to influence others before I had mastered self-control.

<Bob> Yes. There was another factor too but I did not feel it was the time to explore it. Now feels like a better time.

<Leslie> OK … now my curiosity is really fired up.

<Bob> Do you remember last week’s blog about the Improvement Gearbox?

<Leslie> Yes. I really liked the mechanical metaphor. It resonated with so many things. I have used it several times this week in conversations.

<Bob> Well, there is a close relationship between the level of challenge and the gearbox. As complexity increases we need to be able to use more of the gears, and to change up and down with ease and according to need.

<Leslie> Change down? I sort of assumed that once you got to fourth gear you stay there.

<Bob> That is true if the terrain is level and everyone is on board the bus with the same destination in mind. In reality the terrain goes up and down and as we learn we need to stop and let some people get off and take others on board.

<Leslie> So we need to change down gears on the uphill bits, change up gears on the downhill, and go through the whole gear sequence when we deliberately slow to a halt, and then get on our way again.

<Bob> Yes. Well put. The world is changing all the time and the team on board is in dynamic flux. Some arrive, some leave and others stay on the bus but change seats as we move along. Not all seats suit all people. What is comfortable for one may be painful for another.

<Leslie> So how come the urgent call?

<Bob> A fight had broken out on their bus, the tribes were arguing because the improvements they have made have blown away some of the fog and exposed some deeper cultural cracks. Cracks that had been there all the time but were concealed by the fog of the daily chaos and the smoke of the burning martyrs. They had taken their eye off the road and were heading for a blind bend unaware of what was around the corner.

<Leslie> So your intervention was to shout “Pay attention to the road and make a decision … steer or stop!“

<Bob> Yes, that about sums it up. A co-labor-ation call.

<Leslie> Eh? Dis you just say collaboration in a weird way?

<Bob> Yes. I chopped it up into concepts … “co” means together, “labor” means work and “ation” means action or process. If they do not learn to co-labor-ate then they will come off the road, crash, and burn. And join the graveyard of improvement train wrecks that litter the verges of the rocky road of change.

<Leslie> Fourth gear stuff?

<Bob> Whole gearbox stuff. All gears between first and fourth because they are all necessary at different times. Each gear builds on those which go before. There are no good or bad gears just fit-for-current-purpose or not. Bad driving is ineptitude. Not using the vehicle’s gearbox effectively and efficiently and risking the safety and comfort of the passengers and other road users. Poor leadership is analogous to poor driving. Dangerous.

<Leslie> So an effective leader of change needs to be able to use all the gears competently and to know when to use which and when to change. And in doing so demonstrate what a safe pair of leadership hands looks like and what it can achieve … through collaborative effort.

<Bob> Perfect! It is time for you to tear up your L plates.

07/03/2015

The Improvement Gearbox

One of the most rewarding experiences for an improvement science coach is to sense when an individual or team shift up a gear and start to accelerate up their learning curve.

It is like there is a mental gearbox hidden inside them somewhere. Before they were thrashing themselves by trying to go too fast in a low gear. Noisy, ineffective, inefficient and at high risk of blowing a gasket!

Then, they discover that there is a higher gear … and that to get to it they have to take a risk … depress the emotional clutch, ease back on the gas, slip into neutral, and trust themselves to find the new groove and … click … into the higher gear, and then ease up the power while letting out the clutch. And then accelerate up the learning curve. More effective, more efficient. More productive. More fun.

Organisations appear to behave in much the same way.

Some scream along in the slow-lane … thrashing their employee engine. The majority chug complacently in the middle-lane of mediocrity. A few accelerate past in the fast-lane to excellence.

And they are all driving exactly the same model of car.

So it is not the car that is making the difference … it is the driving.

Those who have studied organisations have observed five cultural “gears”; and which gear an organisation is in most of the time can be diagnosed by listening to the sound of the engine – the conversations of the employees.

If they are muttering “work sucks” then they are in first gear. The sense of hopelessness, futility, despair and anger consumes all their emotional fuel. Fortunately this is uncommon.

If we mainly hear “my work sucks” then they are in second gear. The feeling is of helplessness and apathy and the behaviour is Victim-like. They believe that they cannot solve their own problems … someone else must do it for them or tell them what to do. They grumble a lot.

If the dominant voice is “I’m great but you lot suck” then we are hearing third gear attitudes. The selfishly competitive behaviour of the individualist achiever. The “keep your cards close to your chest” style of dyadic leadership. The advocate of “it is OK to screw others to get ahead”. They grumble a lot too – about the apathetic bunch.

And those who have studied organisations suggest that about 80% of healthcare organisations are stuck in first, second or third cultural gear. And we can tell who they are … the lower 80% of the league tables. The ones clamouring for more … of everything.

So how come so many organisations are so stuck? Unable to find fourth gear?

One cause is the design of their feedback loops. Their learning loops.

If an organisation only uses failure as a feedback loop then it is destined to get no more than mediocrity. Third gear at best, and usually only second.

Example.
We all feel disappointment when our experience does not live up to our expectation. But only the most angry of us will actually do something and complain. Especially when we have no other choice of provider!

Suppose we are commissioners of healthcare services and we are seeing a rising tide of patient and staff complaints. We want to improve the safety and quality of the services that we are paying for; so we draw up a league table using complaints as feedback fodder and we focus on the worst performing providers … threatening them with dire consequences for being in the bottom 20%. What happens? Fear of failure motivates them to ‘pull up their socks’ and the number of complaints falls.

Job done?

Unfortunately not.

All we have done is to bully those stuck in first or second gear into thrashing their over-burdened employee engine even harder. We have not helped anyone find their higher gear. We have hit the target, missed the point, and increased the risk of system failure!

So what about those organisations stuck in third gear?

Well they are ticking their performance boxes, meeting our targets, keeping their noses clean. Some are just below, and some just above the collective mean of barely acceptable mediocrity.

But expectation is changing.

The 20% who have discovered fourth gear are accelerating ahead and are demonstrating what is possible. And they are raising expectation, increasing the variation of service quality … for the better.

And the other 80% are falling further and further behind; thrashing their tired and demoralised staff harder and harder to keep up. Complaining increasingly that life is unfair and that they need more, time, money and staff engagement. Eventually their executive head gaskets go “pop” and they fall by the wayside.

Finding cultural fourth gear is possible but it is not easy. There are no short cuts. We have to work our way up the gears and we have to learn when and how to make smooth transitions from first to second, second to third and then third to fourth.

And when we do that the loudest voice we hear is “We are OK“.

We need to learn how to do a smooth cultural hill start on the steep slope from apathy to excellence.

And we need to constantly listen to the sound of our improvement engine; to learn to understand what it is saying; and learn how and when to change to the next cultural gear.

21/02/2015

Cumulative Sum

[Bing] Bob logged in for the weekly Webex coaching session. Leslie was not yet on line, but joined a few minutes later.

<Leslie> Hi Bob, sorry I am a bit late, I have been grappling with a data analysis problem and did not notice the time.

<Bob> Hi Leslie. Sounds interesting. Would you like to talk about that?

<Leslie> Yes please! It has been driving me nuts!

<Bob> OK. Some context first please.

<Leslie> Right, yes. The context is an improvement-by-design assignment with a primary care team who are looking at ways to reduce the unplanned admissions for elderly patients by 10%.

<Bob> OK. Why 10%?

<Leslie> Because they said that would be an operationally very significant reduction. Most of their unplanned admissions, and therefore costs for admissions, are in that age group. They feel that some admissions are avoidable with better primary care support and a 10% reduction would make their investment of time and effort worthwhile.

<Bob> OK. That makes complete sense. Setting a new design specification is OK. I assume they have some baseline flow data.

<Leslie> Yes. We have historical weekly unplanned admissions data for two years. It looks stable, though rather variable on a week-by-week basis.

<Bob> So has the design change been made?

<Leslie> Yes, over three months ago – so I expected to be able to see something by now but there are no red flags on the XmR chart of weekly admissions. No change. They are adamant that they are making a difference, particularly in reducing re-admissions. I do not want to disappoint them by saying that all their hard work has made no difference!

<Bob> OK Leslie. Let us approach this rationally. What are the possible causes that the weekly admissions chart is not signalling a change?

<Leslie> If there has not been a change in admissions. This could be because they have indeed reduced readmissions but new admissions have gone up and is masking the effect.

<Bob> Yes. That is possible. Any other ideas?

<Leslie> That their intervention has made no difference to re-admissions and their data is erroneous … or worse still … fabricated!

<Bob> Yes. That is possible too. Any other ideas?

<Leslie> Um. No. I cannot think of any.

<Bob> What about the idea that the XmR chart is not showing a change that is actually there?

<Leslie> You mean a false negative? That the sensitivity of the XmR chart is limited? How can that be? I thought these charts will always signal a significant shift.

<Bob> It depends on the degree of shift and the amount of variation. The more variation there is the harder it is to detect a small shift. In a conventional statistical test we would just use bigger samples, but that does not work with an XmR chart because the run tests are all fixed length. Pre-defined sample sizes.

<Leslie> So that means we can miss small but significant changes and come to the wrong conclusion that our change has had no effect! Isn’t that called a Type 2 error?

<Bob> Yes, it is. And we need to be aware of the limitations of the analysis tool we are using. So, now you know that how might you get around the problem?

<Leslie> One way would be to aggregate the data over a longer time period before plotting on the chart … we know that will reduce the sample variation.

<Bob> Yes. That would work … but what is the downside?

<Leslie> That we have to wait a lot longer to show a change, or not. We do not want that.

<Bob> I agree. So what we do is we use a chart that is much more sensitive to small shifts of the mean. And that is called a cusum chart. These were not invented until 30 years after Shewhart first described his time-series chart. To give you an example, do you recall that the work-in-progress chart is much more sensitive to changes in flow than either demand or activity charts?

<Leslie> Yes, and the WIP chart also reacts immediately if either demand or activity change. It is the one I always look at first.

<Bob> That is because a WIP chart is actually a cusum chart. It is the cumulative sum of the difference between demand and activity.

<Leslie> OK! That makes sense. So how do I create and use a cusum chart?

<Bob> I have just emailed you some instructions and a few examples. You can try with your unplanned admissions data. It should only take a few minutes. I will get a cup of tea and a chocolate Hobnob while I wait.

[Five minutes later]

<Leslie> Wow! That is just brilliant! I can see clearly on the cusum chart when the shifts happened and when I split the XmR chart at those points the underlying changes become clear and measurable. The team did indeed achieve a 10% reduction in admissions just as they claimed they had. And I checked with a statistical test which confirmed that it is statistically significant.

<Bob> Good work. Cusum charts take a bit of getting used to and we have be careful about the metric we are plotting and a few other things but it is a useful trick to have up our sleeves for situations like this.

<Leslie> Thanks Bob. I will bear that in mind. Now I just need to work out how to explain cusum charts to others! I do not want to be accused of using statistical smoke-and-mirrors! I think a golf metaphor may work with the GPs.

17/01/2015

Learning Loops

[Beep Beep] Bob’s phone reminded him that it was time for the remote coaching session with Leslie, one of the CHIPs (community of healthcare improvement science practitioners). He flipped open his laptop and logged in. Leslie was already there.

<Leslie> Hi Bob. I hope you had a good Xmas.

<Bob> Thank you Leslie. Yes, I did. I was about to ask the same question.

<Leslie> Not so good here I am afraid to say. The whole urgent care system is in meltdown. The hospital is gridlocked, the 4-hour target performance has crashed like the Stock Market on Black Wednesday, emergency admissions have spilled over into the Day Surgery Unit, hundreds of operations have been cancelled, waiting lists are spiralling upwards and the fragile 18-week performance ceiling has been smashed. It is chaos. Dangerous chaos.

<Bob> Oh dear. It sounds as if the butterfly has flapped its wings. Do you remember seeing this pattern of behaviour before?

<Leslie> Sadly yes. When I saw you demonstrate the Save the NHS Game. This is exactly the chaos I created when I attempted to solve the 4-hour target problem, and the chaos I have seen every doctor, manager and executive create when they do too. We seem to be the root cause!

<Bob> Please do not be too hard on yourself Leslie. I am no different. I had to realise that I was contributing to the chaos I was complaining about, by complaining about it. Paradoxically not complaining about it made no difference. My error was one of omission. I was not learning. I was stuck in a self-justifying delusional blame-bubble of my own making. My humility and curiosity disabled by my disappointment, frustration and anxiety. My inner chimp was running the show!

<Leslie> Wow! That is just how everyone is feeling and behaving. Including me. So how did you escape from the blame-bubble?

<Bob> Well first of all I haven’t completely escaped. I just spend less time there. It is always possible to get sucked back in. The way out started to appear when I installed a “learning loop”.

<Leslie> A what? Is that like a hearing loop for the partially deaf?

<Bob> Ha! Yes! A very apt metaphor. Yes, just like that. Very good. I will borrow that if I may.

<Leslie> So what did your learning loop consist of?

<Bob> A journal. I started a journal. I invested a few minutes each day reflecting and writing it down. The first entries were short and rather “ranty”. I cannot possibly share them in public. It is too embarrassing. But it was therapeutic and over time the anger subsided and a quieter, calmer inner voice could be heard. The voice of curiosity. It was asking one question over and over again. “How?” … not “Why?”.

<Leslie> Like “How did I get myself into this state?“

<Bob> Exactly so. And also “How come I cannot get myself out of this mess?“

<Leslie> And what happened next?

<Bob> I started to take more notice of things that I had discounted before. Apparently insignificant things that I discovered had profound implications. Like the “butterflies wing” effect … I discovered that small changes can have big effects. I also learned to tune in to specific feelings because they were my warning signals.

<Leslie> Niggles you mean?

<Bob> Yes. Niggles are flashes of negative emotion that signal a design flaw. They are usually followed by an untested assumption, an invalid conclusion, an unwise decision and a counter-productive action. It all happens unconsciously and very fast so we are only aware of the final action – the MR ANGRY reply to the email that we stupidly broadcast via the Reply All button!

<Leslie> So you learned to tune into the niggle to avoid the chain reaction that led to hitting the Red Button.

<Bob> Sort of. What actually happened is that the passion unleashed by the niggle got redirected into a more constructive channel – via my Curiosity Centre to power up the Improvement Engine. It was a bit rusty! It had not been used for a long while.

<Leslie> And once the “engine” was running it sucked in niggles that were now a source of fuel! You started harvesting them using the 4N Chart! So what was the output?

<Bob> Purposeful, focused, constructive, rational actions. Not random, destructive, emotional explosions.

<Leslie> Constructive actions such as?

<Bob> Well designing and building the FISH course is one, and this ISP programme is another.

<Leslie> More learning loops!

<Bob> Yup.

<Leslie> OK. So I can see that a private journal can help an individual to build their own learning loop. How does that work with groups? We do not all need to design and build a FISH-equivalent surely!

<Bob> No indeed. What we do is we share stories. We gather together in small groups around camp fires and we share what we are learning … as we are learning it. We contribute our perspective to the collective awareness … and we all gain from everyone’s learning. We learn and teach together.

<Leslie> So the stories are about what we are learning, not what we achieved with that learning.

<Bob> Well put! The “how” we achieved it is more valuable knowledge than “what” we achieved. The “how” is the process, the “what” is just the product. And the “how” we failed to achieve is even more valuable.

<Leslie> Wow! So are you saying that the chaos we are experiencing is the expected effect of not installing enough learning loops! A system-wide error of omission.

<Bob> I would say that is a reasonable diagnosis.

<Leslie> So a rational and reasonable course of treatment becomes clear. I am on the case!

29/11/2014

Counter-Productivity

The Webex icon bounced up and down on Bob’s task bar signalling that Leslie had just joined the weekly ISP coaching session.

<Leslie> Hi Bob. I have been so busy this week that I have not had time to consider a topic to explore.

<Bob> No problem Leslie, I have shelf full of topics we have not touched yet. So shall we talk about counter-productivity?

<Leslie> Don’t you mean productivity … the fourth dimension of system improvement.

<Bob>They are related of course but we will approach the issue of productivity from a different angle. Rather like we did with safety. To improve safety we considered at the causes of un-safety and focussed our efforts there.

<Leslie> Ah yes, I see. So to improve productivity we look at the causes of un-productivity … in other words counter-productive beliefs and behaviours that are manifest as system design flaws.

<Bob> Exactly. So remind me what the definition of a productivity metric is from your FISH course.

<Leslie> Productivity is the ratio of a stream metric and a stage metric. Value-for-Money for example.

<Bob> Good. So counter-productivity is also a ratio of a stream and a stage metric.

<Leslie> Um, I’m not sure I quite get that. Can you explain a bit more.

<Bob> OK. To explore deeper we need to be clear about how each metric relates to our intended outcome. Remember in safety-by-design we count the number and severity of risks and harm because as harm is going up then safety is going down. So harm is an un-safety stream metric.

<Leslie> Ah! Yes I see. So if we look at cycle-time, which is a stage metric; as cycle-time increases, the activity falls and productivity falls. So cycle-time is actually a counter-productivity metric.

<Bob>Excellent. You are getting the hang of the concept of counter-productivity.

<Leslie> And we need to be careful because productivity is a ratio so the numerator and denominator metrics work in opposite ways: increasing the magnitude of the numerator is equivalent to decreasing the magnitude of the denominator – the ratio increases.

<Bob> Indeed, there are many hazards with ratios as we have explored before. So let is consider a real and rather useful example. Let us look at Little’s Law from the perspective of counter-productivity. Remind me of the definition of Little’s Law for a single step system.

<Leslie> Little’s Law is a mathematically proven law of flow physics which states that the average lead-time is the product of the average work-in-progress and the average cycle-time.

LT = WIP * CT

<Bob> Good and I am pleased to see that you have used cycle-time. We are considering a single stream, single stage, single step system.

<Leslie> Yes, I avoided using the unqualified term ‘activity’. I have learned that lesson the hard way too!

<Bob> So how do the terms in Little’s Law relate to streams, stages and systems?

<Leslie> Lead-time is a stream metric, cycle-time is a stage metric and work-in-progress is a …. h’mm. What it is? A stream metric or a stage metric?

<Bob>Or?

<Leslie>A system metric? WIP is a system metric!

<Bob> Good. So now re-arrange Little’s Law as a productivity formula.

<Leslie> Work-in-Progress equals lead-time divided by cycle-time

WIP = LT / CT

<Bob> So is WIP a productivity or a counter-productivity metric?

<Leslie> H’mmm …. I will need to work this through logically and step-by-step. I do not trust my intuition on this flow stuff.

Increasing cycle-time is counter-productive because it implies activity is falling while costs are not.

But cycle-time is on the bottom of the ratio so it’s effect reverses.

So if lead-time stays the same and cycle-time increases then because it is on the bottom of the ratio that implies a more productive design. And at the same time work in progress must be falling. Urrgh! This is hurting my head.

<Bob> Good, keep going … you are nearly there.

<Leslie> So a falling WIP is a sign of increasing productivity.

<Bob> Good … and that implies?

<Leslie> WIP is a counter-productivity system metric!

<Bob> Well done. Your logic is flawless.

<Leslie> So that is why we focus on WIP so much! Whatever causes WIP to increase is counter-productive!

Ahhhh …. that makes complete sense.

Lo-WIP designs are more productive than Hi-WIP designs.

<Bob> Bravo! And translating this into financial metrics … it is because a big queue of waiting work incurs costs. Storage cost, maintenance cost, processing cost and so on. So WIP is a liability. It is not an asset!

<Leslie> But doesn’t that imply treating work-in-progress as an asset on the financial balance sheet is counter-productive?

<Bob> It does indeed.

<Leslie> Oh dear! That revelation is going to upset a lot of people in the accounting department!

<Bob> The painful reality is that the Laws of Flow Physics are completely indifferent to what any of us believe or do not believe.

<Leslie> Wow! I like this concept of counter-productivity … it really helps to expose some of our invalid assumptions that invisibly block improvement!

<Bob> So here is a question to ponder. Is zero WIP desirable or even possible?

<Leslie> H’mmm. I will have to think about that. I know you would not have asked the question for no reason.

22/11/2014

Metamorphosis

Some animals undergo a remarkable transformation on their journey to becoming an adult.

This metamorphosis is most obvious with a butterfly: the caterpillar enters the stage and a butterfly emerges.

The capabilities and behaviours of these development stages are very different. A baby caterpillar crawls and feeds on leaves; an adult butterfly flies and feeds on nectar.

There are many similarities to the transformation of an organisation from chaotic to calm; from depressed to enthused; and from struggling to flying.

It is the metamorphosis of individuals within organisations that drives the system change – the transformation from inept sceptics to capable advocates.

The journey starts with the tiny, hungry, baby caterpillar emerging from the egg.

This like a curious new sceptic emerging from denial and tentatively engaging the the process of learning. Usually triggered by seeing or hearing of a significant and sustained success that disproves their ‘impossibility hypothesis’.

A caterpillar is an eating machine. As it grows it sheds its skin and becomes larger. It also changes its appearance and eventually its behaviour.

Our curious improvement sceptic is devouring new information and is visibly growing in knowledge, understanding and confidence.

When the caterpillar sheds the last skin a new form emerges. A pupa. It has a different appearance and behaviour. It is now stationary and it does not move or eat.

This is the contemplative sceptic who appears to have become dormant but is not … they are planning to change. This stage is very variable: it may be minutes or years.

Inside the pupa the solid body of the caterpillar is converted to ‘cellular soup’ and the cells are reassembled into a completely new structure called an adult butterfly.

Our healthy sceptic is dissolving their self-limiting beliefs and restructuring their mental model. It is stage of apparent confusion and success is not guaranteed.

And suddenly the adult butterfly emerges: fully formed but not yet able to fly. Its wings are not yet ready – they need to be inflated, to dry and be flexed.

So it is with our newly hatched improvement practitioner. They need to pause, prepare, and practice before they feel safe to fly solo. They start small but are thinking big.

After a short rest the new wings are fully expanded and able to lift the butterfly aloft to explore the new opportunities that await. A whole new and exciting world full of flowers and nectar.

Our improvement practitioner can also feel when they are ready to explore. And then they fly – right first time.

An active improvement practitioner will inspire others to emerge, and many of those will hatch into improvement caterpillars who will busily munch on the new knowledge and grow in understanding and confidence. Then it goes quiet and, as if by magic, a new generation of improvement butterflies appear. And they continue to spread the word and the knowledge.

That is how Improvement Science grows and spreads – by metamorphosis.

15/11/2014

Seeing and Believing

[Beep] It was time again for the weekly Webex coaching session. Bob dialled into the teleconference to find Leslie already there … and very excited.

<Leslie> Hi Bob, I am so excited. I cannot wait to tell you about what has happened this week.

<Bob> Hi Leslie. You really do sound excited. I cannot wait to hear.

<Leslie> Well, let us go back a bit in the story. You remember that I was really struggling to convince the teams I am working with to actually make changes. I kept getting the ‘Yes … but‘ reaction from the sceptics. It was as if they were more comfortable with complaining.

<Bob> That is the normal situation. We are all very able to delude ourselves that what we have is all we can expect.

<Leslie> Well, I listened to what you said and I asked them to work through what they predicted could happen if they did nothing. Their healthy scepticism then worked to build their conviction that doing nothing was a very dangerous choice.

<Bob> OK. And I am guessing that insight was not enough.

<Leslie> Correct. So then I shared some examples of what others had achieved and how they had done it, and I started to see some curiosity building, but no engagement still. So I kept going, sharing stories of ‘what’, and ‘how’. And eventually I got an email saying “We have thought about what you said about a one day experiment and we are prepared to give that a try“.

<Bob> Excellent. How long ago was that?

<Leslie> Three months. And I confess that I was part of the delay. I was so surprised that they said ‘OK‘ that I was not ready to follow on.

<Bob> OK. It sounds like you did not really believe it was possible either. So what did you do next?

<Leslie> Well I knew for sure that we would only get one chance. If the experiment failed then it would be Game Over. So I needed to know before the change what the effect would be. I needed to be able to predict it accurately. I also needed to feel reassured enough to take the leap of faith.

<Bob> Very good, so did you use some of your ISP-2 skills?

<Leslie> Yes! And it was a bit of a struggle because doing it in theory is one thing; doing it in reality is a lot messier.

<Bob> So what did you focus on?

<Leslie> The top niggle of course! At St Elsewhere® we have a call-centre that provides out-of-office-hours telephone advice and guidance – and it is especially busy at weekends. We are required to answer all calls quickly, which we do, and then we categorise them into ‘urgent’ and ‘non-urgent’ and pass them on to the specialists. They call the clients back and provide expert advice and guidance for their specific problem.

<Bob>So you do not use standard scripts?

<Leslie> No, that does not work. The variety of the problems we have to solve is too wide. And the specialist has to come to a decision quite quickly … solve the problem over the phone, arrange a visit to an out of hours clinic, or to dispatch a mobile specialist to the client immediately.

<Bob> OK. So what was the top niggle?

<Leslie> We have contractual performance specifications we have to meet for the maximum waiting time for our specialists to call clients back; and we were not meeting them. That implied that we were at risk of losing the contract and that meant loss of revenue and jobs.

<Bob> So doing nothing was not an option.

<Leslie> Correct. And asking for more resources was not either … the contract was a fixed price one. We got it because we offered the lowest price. If we employed more staff we would go out of business. It was a rock-and-a-hard-place problem.

<Bob> OK. So if this was ranked as your top niggle then you must have had a solution in mind.

<Leslie> I had a diagnosis. The Vitals Chart© showed that we already had enough resources to do the work. The performance failure was caused by a scheduling policy – one that we created – our intuitively-obvious policy.

<Bob> Ah ha! So you suggested doing something that felt counter-intuitive.

<Leslie> Yes. And that generated all the ‘Yes .. but‘ discussion.

<Bob> OK. Do you have the Vitals Chart© to hand? Can you send me the Wait-Time run chart?

<Leslie> Yes, I expected you would ask for that … here it is.

<Bob> OK. So I am looking at the run chart of waiting time for the call backs for one Saturday, and it is in call arrival order, and the blue line is the maximum allowed waiting time is that correct?

<Leslie>Yup. Can you see the diagnosis?

<Bob> Yes. This chart shows the classic pattern of ‘prioritycarveoutosis’. The upper border is the ‘non-urgents’ and the lower group are the ‘urgents’ … the queue jumpers.

<Leslie> Spot on. It is the rising tide of non-urgent calls that spill over the specification limit. And when I shared this chart the immediate reaction was ‘Well that proves we need more capacity!‘

<Bob> And the WIP chart did not support that assertion.

<Leslie> Correct. It showed we had enough total flow-capacity already.

<Bob> So you suggested a change in the scheduling policy would solve the problem without costing any money.

<Leslie> Yes. And the reaction to that was ‘That is impossible. We are already working flat out. We need more capacity because to work quicker will mean cutting corners and it is unsafe to cut-corners‘.

<Bob> So how did you get around that invalid but widely held belief?

<Leslie> I used one of the FISH techniques. I got a few of them to play a table top game where we simulated a much simpler process and demonstrated the same waiting time pattern on a hand-drawn run chart.

<Bob> Excellent. Did that get you to the ‘OK, we will give it a go for one day‘ decision.

<Leslie>Yes. But then I had to come up with a new design and I had test it so I know it would work.

<Bob> Because that was a step too far for them. And It sounds like you achieved that.

<Leslie> Yes. It was tough though because I knew I had to prove to myself I could do it. If I had asked you I know what you would have said – ‘I know you can do this‘. And last Saturday we ran the ‘experiment’. I was pacing up and down like an expectant parent!

<Bob> I expect rather like the ESA team who have just landed Rosetta’s little probe-child on an asteroid travelling at 38,000 miles per hour, billions of miles from Earth after a 10 year journey through deep space! Totally inspiring stuff!

<Leslie> Yes. And that is why I am so excited because OUR DESIGN WORKED! Exactly as predicted.

<Bob> Three cheers for you! You have experienced that wonderful feeling when you see the effect of improvement-by-design with your own eyes. When that happens then you really believe what opportunities become possible.

<Leslie> So I want to show you the ‘after’ chart …

<Bob> Wow! That is a spectacular result! The activity looks very similar, and other than a ‘blip’ between 15:00 and 19:00 the prioritycarveoutosis has gone. The spikes have assignable causes I assume?

<Leslie> Spot on again! The activity was actually well above average for a Saturday. The subjective feedback was that the new design felt calm and under-control. The chaos had evaporated. The performance was easily achieved and everyone was very positive about the whole experience. The sceptics were generous enough to say it had gone better than they expected. And yes, I am now working through the ‘spikes’ and excluding them … but only once I have a root cause that explains them.

<Bob> Well done Leslie! I sense that you now believe what is possible whereas before you just hoped it would be.

<Leslie> Yes! And the most important thing to me is that we did it ourselves. Which means improvement-by-design can be learned. It is not obvious, it feels counter-intuitive, so it is not easy … but it works.

<Bob> Yes. That is the most important message. And you have now earned your ISP Certificate of Competency.

18/10/2014

A Little Law and Order

[Bing bong]. The sound heralded Lesley logging on to the weekly Webex coaching session with Bob, an experienced Improvement Science Practitioner.

<Bob> Good afternoon Lesley. How has your week been and what topic shall we explore today?

<Lesley> Hi Bob. Well in a nutshell, the bit of the system that I have control over feels like a fragile oasis of calm in a perpetual desert of chaos. It is hard work keeping the oasis clear of the toxic sand that blows in!

<Bob> A compelling metaphor. I can just picture it. Maintaining order amidst chaos requires energy. So what would you like to talk about?

<Lesley> Well, I have a small shoal of FISHees who I am guiding through the foundation shallows and they are getting stuck on Little’s Law. I confess I am not very good at explaining it and that suggests to me that I do not really understand it well enough either.

<Bob> OK. So shall we link those two theme – chaos and Little’s Law?

<Lesley> That sounds like an excellent plan!

<Bob> OK. So let us refresh the foundation knowledge. What is Little’s Law?

<Lesley>It is a fundamental Law of process physics that relates flow, with lead time and work in progress.

<Bob> Good. And specifically?

<Lesley> Average lead time is equal to the average flow multiplied by the average work in progress.

<Bob>Yes. And what are the units of flow in your equation?

<Lesley> Ah yes! That is a trap for the unwary. We need to be clear how we express flow. The usual way is to state it as number of tasks in a defined period of time, such as patients admitted per day. In Little’s Law the convention is to use the inverse of that which is the average interval between consecutive flow events. This is an unfamiliar way to present flow to most people.

<Bob> Good. And what is the reason that we use the ‘interval between events’ form?

<Leslie> Because it is easier to compare it with two critically important flow metrics … the takt time and the cycle time.

<Bob> And what is the takt time?

<Leslie> It is the average interval between new tasks arriving … the average demand interval.

<Bob> And the cycle time?

<Leslie> It is the shortest average interval between tasks departing …. and is determined by the design of the flow constraint step.

<Bob> Excellent. And what is the essence of a stable flow design?

<Lesley> That the cycle time is less than the takt time.

<Bob>Why less than? Why not equal to?

<Leslie> Because all realistic systems need some flow resilience to exhibit stable and predictable-within-limits behaviour.

<Bob> Excellent. Now describe the design requirements for creating chronically chaotic system behaviour?

<Leslie> This is a bit trickier to explain. The essence is that for chronically chaotic behaviour to happen then there must be two feedback loops – a destabilising loop and a stabilising loop. The destabilising loop creates the chaos, the stabilising loop ensures it is chronic.

<Bob> Good … so can you give me an example of a destabilising feedback loop?

<Leslie> A common one that I see is when there is a long delay between detecting a safety risk and the diagnosis, decision and corrective action. The risks are often transitory so if the corrective action arrives long after the root cause has gone away then it can actually destabilise the process and paradoxically increase the risk of harm.

<Bob> Can you give me an example?

<Leslie>Yes. Suppose a safety risk is exposed by a near miss. A delay in communicating the niggle and a root cause analysis means that the specific combination of factors that led to the near miss has gone. The holes in the Swiss cheese are not static … they move about in the chaos. So the action that follows the accumulation of many undiagnosed near misses is usually the non-specific mantra of adding yet another safety-check to the already burgeoning check-list. The longer check-list takes more time to do, and is often repeated many times, so the whole flow slows down, queues grow bigger, waiting times get longer and as pressure comes from the delivery targets corners start being cut, and new near misses start to occur; on top of the other ones. So more checks are added and so on.

<Bob> An excellent example! And what is the outcome?

<Leslie> Chronic chaos which is more dangerous, more disordered and more expensive. Lose lose lose.

<Bob> And how do the people feel who work in the system?

<Leslie> Chronically naffed off! Angry. Demotivated. Cynical.

<Bob>And those feelings are the key symptoms. Niggles are not only symptoms of poor process design, they are also symptoms of a much deeper problem: a violation of values.

<Leslie> I get the first bit about poor design; but what is that second bit about values?

<Bob> We all have a set of values that we learned when we were very young and that have bee shaped by life experience. They are our source of emotional energy, and our guiding lights in an uncertain world. Our internal unconscious check-list. So when one of our values is violated we know because we feel angry. How that anger is directed varies from person to person … some internalise it and some externalise it.

<Leslie> OK. That explains the commonest emotion that people report when they feel a niggle … frustration which is the same as anger.

<Bob>Yes. And we reveal our values by uncovering the specific root causes of our niggles. For example if I value ‘Hard Work’ then I will be niggled by laziness. If you value ‘Experimentation’ then you may be niggled by ‘Rigid Rules’. If someone else values ‘Safety’ then they may value ‘Rigid Rules’ and be niggled by ‘Innovation’ which they interpret as risky.

<Leslie> Ahhhh! Yes, I see. This explains why there is so much impassioned discussion when we do a 4N Chart! But if this behaviour is so innate then it must be impossible to resolve!

<Bob> Understanding how our values motivate us actually helps a lot because we are naturally attracted to others who share the same values – because we have learned that it reduces conflict and stress and improves our chance of survival. We are tribal and tribes share the same values.

<Leslie> Is that why different departments appear to have different cultures and behaviours and why they fight each other?

<Bob> It is one factor in the Silo Wars that are a characteristic of some large organisations. But Silo Wars are not inevitable.

<Leslie> So how are they avoided?

<Bob> By everyone knowing what common purpose of the organisation is and by being clear about what values are aligned with that purpose.

<Leslie> So in the healthcare context one purpose is avoidance of harm … primum non nocere … so ‘safety’ is a core value. Which implies anything that is felt to be unsafe generates niggles and well-intended but potentially self-destructive negative behaviour.

<Bob> Indeed so, as you described very well.

<Leslie> So how does all this link to Little’s Law?

<Bob>Let us go back to the foundation knowledge. What are the four interdependent dimensions of system improvement?

<Leslie> Safety, Flow, Quality and Productivity.

<Bob> And one measure of productivity is profit. So organisations that have only short term profit as their primary goal are at risk of making poor long term safety, flow and quality decisions.

<Leslie> And flow is the key dimension – because profit is just the difference between two cash flows: income and expenses.

<Bob> Exactly. One way or another it all comes down to flow … and Little’s Law is a fundamental Law of flow physics. So if you want all the other outcomes … without the emotionally painful disorder and chaos … then you cannot avoid learning to use Little’s Law.

<Leslie> Wow! That is a profound insight. I will need to lie down in a darkened room and meditate on that!

<Bob> An oasis of calm is the perfect place to pause, rest and reflect.

27/09/2014

Strength and Resilience

The dictionary definition of resilience is “something that is capable of returning to its original shape after being stretched, bent or otherwise deformed“.

The term is applied to inanimate objects, to people and to systems.

A rubber ball is resilient … it is that physical property that gives it bounce.

A person is described as resilient if they are able to cope with stress without being psychologically deformed in the process. Emotional resilience is regarded as an asset.

Systems are described as resilient when they are able to cope with variation without failing. And this use of the term is associated with another concept: strength.

Strong things can withstand a lot of force before they break. Strength is not the same as resilience.

Engineers use another term – strain – which means the amount of deformation that happens when a force is applied.

Stress is the force applied, strain is the deformation that results.

So someone who is strong and resilient will not buckle under high pressure and will absorb variation – like the suspension of you car.

But is strength-and-resilience always an asset?

Suppose some strong and resilient people finds themselves in a relentlessly changing context … one in which they actually need to adapt and evolve to survive in the long term.

How well does their highly valued strength-and-resilience asset serve them?

Not very well.

They will resist the change – they are resilient – and they will resist it for a long time – they are strong.

But the change is relentless and eventually the limit of their strength will be reached … and they snap!

And when that happens all the stored energy is suddenly released. So they do not just snap – they explode!

Just like the wall in the animation above.

The final straw that triggers the sudden failure may appear insignificant … and at any other time it would be.

But when the pressure is really on and the system is at the limit then it can be just enough to trigger the catastrophic failure from which there is no return.

Social systems behave in exactly the same way.

Those that have demonstrated durability are both strong and resilient – but in a relentlessly changing context even they will fail eventually, and when they do the collapse is sudden and catastrophic.

Structural engineers know that catastrophic failure usually starts as a localised failure and spreads rapidly through the hyper-stressed structure; each part failing in sequence as it becomes exposed and exceeds the limit of its strength. That is how the strong and resilient Twin Towers failed and fell on Sept 11th 2001. They were not knocked over. They were weakened to the point of catastrophic failure.

When systems are exposed to varying strains then these localised micro-fractures only occur at the peaks of stress and may not have time to spread very far. The damage is done though. The system is a bit weaker than it was before. And catastrophic failure is more likely in the future.

That is what caused the sudden loss of some of the first jet airliners which inexplicably just fell out of the sky on otherwise uneventful flights. It took a long time for the root cause to be uncovered … the square windows.

Jet airliners fly at high altitude because it allows higher speeds and requires less fuel and so allows long distance flight over wide oceans, steppes, deserts and icecaps. But the air pressure is low at high altitude and passengers could not tolerate that; so the air pressure inside an airliner at high altitude is much higher than outside. It is a huge pressurised metal flying cannister. And as it goes up and down the thin metal skin is exposed to high variations in stress which a metal tube can actually handle rather well … until we punch holes in it to fit windows to allow our passengers a nice view of the clouds outside. We are used to square windows in our houses (because they are easier to make) so the original aircraft engineers naturally put square windows in the early airliners. And that is where the problem arose … the corners of the windows concentrate the stress and over time, with enough take-offs and landings, the metal skin at the corners of the windows will accumulate invisible micro-fractures. The metal actually fatigues. Then one day – pop – a single rivet at the corner of a square window fails and triggers the catastrophic failure of the whole structure. But the aircraft designers did not understand that process and it took quite a long time to diagnose the root cause.

The solution?

A more resilient design – use round-cornered windows that dissipate the strain rather than concentrate it. It was that simple!

So what is the equivalent resilient design for social system? Adaptability.

But how it is possible for a system to be strong, resilient and adaptable?

The design trick is to install “emotional strain gauges” that indicate when and where the internal cultural stress is being concentrated and where the emotional strain shows first.

These emotometers will alert us to where the stresses and strains are being felt strongest and most often – rather like pain detectors. We use the patterns of information from our network of emotometers to help us focus our re-design attention to continuously adapt parts of our system to relieve the strain and to reduce the system wide risk of catastrophic failure.

And by installing emotometers across our system we will move towards a design that is strong, resilient and that continuously adapts to a changing environment.

It really is that simple.

Welcome to complex adaptive systems engineering (CASE).

30/08/2014

See-and-Share

Common-sense tells us that to achieve system-wide improvement we need to grasp the “culture nettle”.

Most of us believe that culture drives attitudes; and attitudes drive behaviour; and behaviour drives improvement.

Therefore to get improvement we must start with culture.

And that requires effective leadership.

So our unspoken assumptions about how leaders motivate our behaviour seem rather important to understand.

In 1960 a book was published with the title “The Human Side of Enterprise” which went right to the heart of this issue. The author was Doug McGregor who was a social scientist and his explanation of why improvement appears to be so difficult in large organisations was a paradigm shift in thinking. His book inspired many leaders to try a different approach – and they discovered that it worked and that enterprise-wide transformation followed. The organisations that these early-adopters led evolved into commercial successes and more enjoyable places to work.

The new leaders learned to create the context for change – not to dictate the content.

Since then social scientists have disproved many other ‘common sense’ beliefs by applying a rigorous scientific approach and using robust evidence.

They have busted the culture-drives-change myth …. the evidence shows that it is the other way around … change drives culture.

And what changes first is behaviour.

We are social animals …. most of us are much more likely to change our behaviour if we see other people doing the same. We do not like being too different.

As we speak there is a new behaviour spreading – having a bucket of cold water tipped over your head as part of a challenge to raise money for charity.

This craze has a positive purpose … feeling good about helping others through donating money to a worthwhile cause … but most of us need a nudge to get us to do it.

Seeing well-known public figures having iced-water dumped on them on a picture or video shared through multiple, parallel, social media channels is a powerful cultural signal that says “This new behaviour is OK”.

Exhortation and threats are largely ineffective – fear will move people – it will scatter them, not align them. Shaming-and-blaming into behaving differently is largely ineffective too – it generates short-term anger and long-term resentment.

This is what Doug McGregor highlighted over half a century ago … and his message is timeless.

“.. the research evidence indicates quite clearly that skillful and sensitive membership behaviour is the real clue to effective group operation“.

Appreciating this critical piece of evidence opens a new door to system-wide improvement … one that we can all walk through: Sharing improvement stories.

Sharing stories of actions that others have done and the benefits they achieved as a result; and also sharing stories of things that we ourselves have done and achieved.

Stories of small changes that delivered big benefits for others and for ourselves. Win-win-wins. Stories of things that took little time and little effort to do because they fell inside our circles of control.

See-and-Share is an example of skillful and sensitive membership behaviour.

Effective leaders are necessary … yes … they are needed to create the context for change. It is we members who create and share the content.

26/04/2014

Synchronicity

[Beep, Beep, Beep, Beep, Beeeeep] The reminder roused Bob from deep reflection and he clicked the Webex link on his desktop to start the meeting. Leslie was already online.

<Bob> Hi Leslie. How are you? And what would you like to share and explore today?

<Leslie> Hi Bob, I am well thank you and I would like to talk about chaos again.

<Bob> OK. That is always a rich mine of new insights! Is there a specific reason?

<Leslie>Yes. The story I want to share is of the chaos that I have been experiencing just trying to get a new piece of software available for my team to use. You would not believe the amount of time, emails, frustration and angst it has taken to negotiate this through the ‘proper channels’.

<Bob> Let me guess … about six months?

<Leslie> Spot on! How did you know?

<Bob> Just prior experience of similar stories. So what is your diagnosis of the cause of the chaos?

<Leslie> My intuition shouts at me that people are just being deliberately difficult and that makes me feel angry and want to shout at them … but I have learned that behaviour is counter-productive.

<Bob> So what did you do?

<Leslie> I escalated the ‘problem’ to my line manager.

<Bob> And what did they do?

<Leslie> I am not sure, I was not copied in, but it seemed to clear the ‘obstruction’.

<Bob> And were the ‘people’ you mentioned suddenly happy and willing to help?

<Leslie> Not really … they did what we needed but they did not seem very happy about it.

<Bob> OK. You are describing a Drama Triangle, a game, and your behaviour was from the Persecutor role.

<Leslie>What! But I deliberately did not send any ANGRY emails or get into a childish argument. I escalated the issue I could not solve because that is what we are expected to do.

<Bob> Yes I know. If you had engaged in a direct angry conversation, by whatever means, that would have been an actively aggressive act. By escalating the issue and someone Bigger having the angry conversation you have engaged in a passive aggressive act. It is still playing the game from the Persecutor role and in fact is the more common mode of Persecution.

<Leslie> But it got the barrier cleared and the problem sorted?

<Bob> And did it leave everyone feeling happier than before?

<Leslie> I guess not. I certainly felt like a bit of a ‘tale teller’ and the IT technician probably hates me and fears for his job, and the departmental heads probably distrust each other even more than before.

<Bob> So this approach may appear to work in the short term but it creates a much bigger long term problem – and it is that long term problem of ‘distrust’ that creates the chaos. So it is a self-sustaining design.

<Leslie> Oh dear! Is there a way to avoid this and to defuse the chronic distrust?

<Bob> Yes. You have demonstrated a process that you would like to improve – you want the same short term outcome, your software installed and working, and you want it quicker and with less angst and leaving everyone feeling good about how they have played a part in achieving that objective.

<Leslie>Yes. That would be my ideal.

<Bob>So what is different between what you did and your ‘ideal’ scenario? What did you do that you should not have and what did you not do that you could have?

<Leslie> Well I triggered off a drama triangle which I should not have. I also assumed that the IT people would know what to do because I do not understand the technical nuances of getting new software procured and installed. What I could have done is make it much clearer for them what I needed, why I needed it and how and when I needed it. I could have done a lot more homework before asking them for assistance. I could also have given my inner Chimp a banana and gone to talk to them face-to-face and ask their opinion early on so I could see the problem from their perspective as well as mine.

<Bob> Yes – that all sounds reasonable and respectful. What you are doing is ‘synchronising‘. You are engaging in understanding the process well enough so that you can align all the actions that need to be done, in the correct order and then sharing that. It is rather like being the composer of a piece of music – you share the score so that the individual players know what to do and when. There is one other task you need to do.

<Leslie>I need to be the conductor!

<Bob> Yes. You are the metronome. You set the pace and guide the orchestra. They are the specialists with their instruments – that is not your role.

<Leslie> And when I do that then the music is harmonious and pleasing-to-the-ear; not a chaotic cacophony!

<Bob> Indeed … and the music is the voice of the system – and is the feedback that everyone hears – and not only do the musicians derive pleasure from contributing then the wider audience will hear what can be achieved and see how it is achieved.

<Leslie> Wow! That musical metaphor works really well for me. Thanks Bob, I need to go and work on my communicating, composing and conducting capabilities.

19/04/2014

SuDoKu

An Improvement-by-Design challenge is very like a Sudoku puzzle. The rules are deceptively simple but the solving the puzzle is not so simple.

For those who have never tried a Sudoku puzzle the objective is to fill in all the empty boxes with a number between 1 and 9. The constraint is that each row, column and 3×3 box (outlined in bold) must include all the numbers between 1 and 9 i.e. no duplicates.

What you will find when you try is that, at each point in the puzzle solving process there are more than one choice for most empty cells.

The trick is to find the empty cells that have only one option and fill those in. That changes the puzzle and makes it ‘easier’.

And when you keep following this strategy, and so long as you do not make any mistakes, then you will solve the puzzle. It just takes concentration, attention to detail, and discipline.

In the example above, the top-right cell in the left-box on the middle-row can only hold a 6; and the top-middle cell in the middle-box on the bottom-row must be a 3.

So we can see already there are three ways ‘into’ the solution – put the 6 in and see where that takes us; put the 3 in and see where that takes us; or put both in and see where that takes us.

The final solution will be the same – so there are multiple paths from where we are to our objective. Some may involve more mental work than others but all will involve completing the same number of empty cells.

What is also clear is that the sequence order that we complete the empty cells is not arbitrary. Usually the boxes and rows with the fewest empty cells get competed earlier and those with the most empty cells at the start get completed later.

And even if the final configuration is the same, if we start with a different set of missing cells the solution path will be different. It may be very easy, very hard or even impossible without some ‘guessing’ and hoping for the best.

Exactly the same is true of improvement-by-design challenges.

The rules of flow science are rather simple; but when we have a system of parallel streams (the rows) interacting with parallel stages (the columns); and when we have safety, delivery, and economy constraints to comply with at every part of the system … then finding and ‘improvement plan’ that will deliver our objective is a tough challenge.

But it is possible with concentration, attention-to-detail and discipline; and that requires some flow science training and some improvement science practice.

OK – I am off for lunch and then maybe indulge in a Sudoku puzzle or two – just for fun – and then maybe design an improvement plan to two – just for fun!

05/04/2014

Firewall

Fires are destructive, indifferent, and they can grow and spread very fast.

The picture is of the Buncefield explosion and conflagration that occurred on 11th December 2005 near Hemel Hempstead in the UK. The root cause was a faulty switch that failed to prevent tank number 912 from being overfilled. This resulted in an initial 300 gallon petrol spill which created the perfect conditions for an air-fuel explosion. The explosion was triggered by a spark and devastated the facility. Over 2000 local residents needed to be evacuated and the massive fuel fire took days to bring under control. The financial cost of the accident has been estimated to run into tens of millions of pounds.

The Great Fire of London in September 1666 led directly to the adoption of new building standards – notably brick and stone instead of wood because they are more effective barriers to fire.

A common design to limit the spread of a fire is called a firewall.

And we use the same principle in computer systems to limit the spread of damage when a computer system goes out of control.

Money is the fuel that keeps the wheels of healthcare systems turning. And healthcare is an expensive business so every drop of cash-fuel is precious. Healthcare is also a risky business – from both a professional and a financial perspective. Mistakes can quickly lead to loss of livelihood, expensive recovery plans and huge compensation claims. The social and financial equivalent of a conflagration.

Financial fires spread just like real ones – quickly. So it makes good sense not to have all the cash-fuel in one big pot. It makes sense to distribute it to smaller pots – in each department – and to distribute the cash-fuel intermittently. These cash-fuel silos are separated by robust financial firewalls and they are called Budgets.

The social sparks that ignite financial fires are called ‘Niggles‘. They are very numerous but we have effective mechanisms for containing them. The problem happens when a multiple sparks happen at the same time and place and together create a small chain reaction. Then we get a complaint. A ‘Not Again‘. And we are required to spend some of our precious cash-fuel investigating and apologizing. We do not deal with the root cause, we just scrape the burned toast.

And then one day the chain reaction goes a bit further and we get a ‘Near Miss‘. That has a different reporting mechanism so it stimulates a bigger investigation and it usually culminates in some recommendations that involve more expensive checking, documenting and auditing of the checking and documentation. The root cause, the Niggles, go untreated – because there are too many of them.

But this check-and-correct reaction is also expensive and we need even more cash-fuel to keep the organizational engine running – but we do not have any more. Our budgets are capped. So we start cutting corners. A bit here and a bit there. And that increases the risk of more Niggles, Not Agains, and Near Misses.

Then the ‘Never Event‘ happens … a Safety and Quality catastrophe that triggers the financial conflagration and toasts the whole organization.

So although our financial firewalls, the Budgets, are partially effective they also have downsides:

1. Paradoxically they can create the perfect condition for a financial conflagration when too small a budget leads to corner-cutting on safety.

2. They lead to ‘off-loading’ which means that too-expensive-to-solve problems are chucked over the financial firewalls into the next department. The cost is felt downstream of the source – in a different department – and is often much larger. The sparks are blown downwind.

For example: a waiting list management department is under financial pressure and is running short staffed as a recruitment freeze has been imposed. The overburdening of the remaining staff leads to errors in booking patients for operations. The knock on effect that is patients being cancelled on the day and the allocated operating theatre time is wasted. The additional cost of wasted theatre time is orders of magnitude greater than the cost-saving achieved in the upstream stage. The result is a lower quality service, a greater cost to the whole system, and the risk that safety corners will be cut leading to a Near Miss or a Never Event.

The nature of real systems is that small perturbations can be rapidly amplified by a ‘tight’ financial design to create a very large and expensive perturbation called a ‘catastrophe’. A silo-based financial budget design with a cost-improvement thumbscrew feature increases the likelihood of this universally unwanted outcome.

So if we cannot use one big fuel tank or multiple, smaller, independent fuel tanks then what is the solution?

We want to ensure smooth responsiveness of our healthcare engine, we want healthcare cash-fuel-efficiency and we want low levels of toxic emissions (i.e. complaints) at the same time. How can we do that?

Fuel-injection.

Electronic Fuel Injection (EFI) designs have now replaced the old-fashioned, inefficient, high-emission carburettor-based engines of the 1970’s and 1980’s.

The safer, more effective and more efficient cash-flow design is to inject the cash-fuel where and when it is needed and in just the right amount.

And to do that we need to have a robust, reliable and rapid feedback system that controls the cash-injectors.

But we do not have such a feedback system in healthcare so that is where we need to start our design work.

Designing an automated cash-injection system requires understanding how the Seven Flows of any system work together and the two critical flows are Data Flow and Cash Flow.

And that is possible.

29/03/2014

The Improvement Pyramid

The image of a tornado is what many associate with improvement. An unpredictable, powerful, force that sweeps away the wood in its path. It certainly transforms – but it leaves a trail of destruction and disappointment in its wake. It does not discriminate between the green wood and the dead wood.

A whirlwind is created by a combination of powerful forces – but the trigger that unleashes the beast is innocuous. The classic ‘butterfly wing effect’. A spark that creates an inferno.

This is not the safest way to achieve significant and sustained improvement. A transformation tornado is a blunt and destructive tool. All it can hope to achieve is to clear the way for something more elegant. Improvement Science.

We need to build the capability for improvement progressively and to build it effective, efficient, strong, reliable, and resilient. In a word – trustworthy. We need a durable structure.

But what sort of structure? A tower from whose lofty penthouse we can peer far into the distance? A bridge between the past and the future? A house with foundations, walls and a roof? Do these man-made edifices meet our criteria? Well partly.

Let us see what nature suggests. What are the naturally durable designs?

Suppose we have a bag of dry sand – an unstructured mix of individual grains – and that each grain represents an improvement idea.

Suppose we have a specific issue that we would like to improve – a Niggle.

Let us try dropping the Improvement Sand on the Niggle – not in a great big reactive dollop – but in a proactive, exploratory bit-at-a-time way. What shape emerges?

What we see is illustrated by the hourglass. We get a pyramid.

The shape of the pyramid is determined by two factors: how sticky the sand is and how fast we pour it.

What we want is a tall pyramid – one whose sturdy pinnacle gives us the capability to see far and to do much.

The stickier the sand the steeper the sides of our pyramid. The faster we pour the quicker we get the height we need. But there is a limit. If we pour too quickly we create instability – we create avalanches.

So we need to give the sand time to settle into its stable configuration; time for it to trickle to where it feels most comfortable.

And, in translating this metaphor to building improvement capability in system we could suggest that the ‘stickiness’ factor is how well ideas hang together and how well individuals get on with each other and how well they share ideas and learning. How cohesive our people are. Distrust and conflict represent repulsive forces. Repulsion creates a large, wide, flat structure – stable maybe but incapable of vision and improvement. That is not what we need

So when developing a strategy for building improvement capability we build small pyramids where the niggles point to. Over time they will merge and bigger pyramids will appear and merge – until we achieve the height. Then was have a stable and capable improvement structure. One that we can use and we can trust.

Just from sprinkling Improvement Science Sand on our Niggles.

15/03/2014

Reducing Avoidable Harm

“Primum non nocere” is Latin for “First do no harm”.

It is a warning mantra that had been repeated by doctors for thousands of years and for good reason.

Doctors can be bad for your health.

I am not referring to the rare case where the doctor deliberately causes harm. Such people are criminals and deserve to be in prison.

I am referring to the much more frequent situation where the doctor has no intention to cause harm – but harm is the outcome anyway.

Very often the risk of harm is unavoidable. Healthcare is a high risk business. Seriously unwell patients can be very unstable and very unpredictable. Heroic efforts to do whatever can be done can result in unintended harm and we have to accept those risks. It is the nature of the work. Much of the judgement in healthcare is balancing benefit with risk on a patient by patient basis. It is not an exact science. It requires wisdom, judgement, training and experience. It feels more like an art than a science.

The focus of this essay is not the above. It is on unintentionally causing avoidable harm.

Or rather unintentionally not preventing avoidable harm which is not quite the same thing.

Safety means prevention of avoidable harm. A safe system is one that does that. There is no evidence of harm to collect. A safe system does not cause harm. Never events never happen.

Safe systems are designed to be safe. The root causes of harm are deliberately designed out one way or another. But it is not always easy because to do that we need to understand the cause-and-effect relationships that lead to unintended harm. Very often we do not.

In 1847 a doctor called Ignaz Semmelweis made a very important discovery. He discovered that if the doctors and medical students washed their hands in disinfectant when they entered the labour ward, then the number of mothers and babies who died from infection was reduced.

And the number dropped a lot.

It fell from an annual average of 10% to less than 2%! In really bad months the rate was 30%.

The chart below shows the actual data plotted as a time-series chart. The yellow flag in 1848 is just after Semmelweis enforced a standard practice of hand-washing.

Semmelweis did not know the mechanism though. This was not a carefully designed randomised controlled trial (RCT). He was desperate. And he was desperate because this horrendous waste of young lives was only happening on the doctors ward. On the nurses ward, which was just across the corridor, the maternal mortality was less than 2%.

The hospital authorities explained it away as ‘bad air’ from outside. That was the prevailing belief at the time. Unavoidable. A risk that had to be just accepted.

Semmeleis could not do a randomized controlled trial because they were not invented until a century later.

And Semmelweis suspected that the difference between the mortality on the nurses and the doctors wards was something to do with the Mortuary. Only the doctors performed the post-mortems and the practice of teaching anatomy to medical students using post-mortem dissection was an innovation pioneered in Vienna in 1823 (the first yellow flag on the chart above). But Semmelweis did not have this data in 1847. He collated it later and did not publish it until 1861.

What Semmelweis demonstrated was the unintended and avoidable deaths were caused by ignorance of the mechanism of how microorganisms cause disease. We know that now. He did not.

It would be another 20 years before Louis Pasteur demonstrated the mechanism using the famous experiment with the swan neck flask. Pasteur did not discover microorganisms; he proved that they did not appear spontaneously in decaying matter as was believed. He proved that by killing the bugs by boiling, the broth in the flask stayed fresh even though it was exposed to the air. That was a big shock but it was a simple and repeatable experiment. He had a mechanism. He was believed. Germ theory was born. A Scottish surgeon called Joseph Lister read of this discovery and surgical antisepsis was born.

Semmelweis suspected that some ‘agent’ may have been unwittingly transported from the dead bodies to the live mothers and babies on the hands of the doctors. It was a deeply shocking suggestion that the doctors were unwittingly killing their patients.

The other doctors did not take this suggestion well. Not well at all. They went into denial. They discounted the message and they discharged the messenger. Semmelweis never worked in Vienna again. He went back to Hungary and repeated the experiment. It worked.

Even today the message that healthcare practitioners can unwittingly bring avoidable harm to their patients is disturbing. We still seek solace in denial.

Hospital acquired infections (HAI) are a common cause of harm and many are avoidable using simple, cheap and effective measures such as hand-washing.

The harm does not come from what we do. It comes from what we do not do. It happens when we omit to follow the simple safety measures that have be proven to work. Scientifically. Statistically Significantly. Understood and avoidable errors of omission.

So how is this “statistically significant scientific proof” acquired?

By doing experiments. Just like the one Ignaz Semmelweis conducted. But the improvement he showed was so large that it did not need statistical analysis to validate it. And anyway such analysis tools were not available in 1847. If they had been he might have had more success influencing his peers. And if he had achieved that goal then thousands, if not millions, of deaths from hospital acquired infections may have been prevented. With the clarity of hindsight we now know this harm was avoidable.

No. The problem we have now is because the improvement that follows a single intervention is not very large. And when the causal mechanisms are multi-factorial we need more than one intervention to achieve the improvement we want. The big reduction in avoidable harm. How do we do that scientifically and safely?

About 20% of hospital acquired infections occur after surgical operations.

We have learned much since 1847 and we have designed much safer surgical systems and processes. Joseph Lister ushered in the era of safe surgery, much has happened since.

We routinely use carefully designed, ultra-clean operating theatres, sterilized surgical instruments, gloves and gowns, and aseptic techniques – all to reduce bacterial contamination from outside.

But surgical site infections (SSIs) are still common place. Studies show that 5% of patients on average will suffer this complication. Some procedures are much higher risk than others, despite the precautions we take. And many surgeons assume that this risk must just be accepted.

Others have tried to understand the mechanism of SSI and their research shows that the source of the infections is the patients themselves. We all carry a ‘bacterial flora’ and normally that is no problem. Our natural defense – our skin – is enough. But when that biological barrier is deliberately breached during a surgical operation then we have a problem. The bugs get in and cause mischief. They cause surgical site infections.

So we have done more research to test interventions to prevent this harm. Each intervention has been subject to well-designed, carefully-conducted, statistically-valid and very expensive randomized controlled trials. And the results are often equivocal. So we repeat the trials – bigger, better controlled trials. But the effects of the individual interventions are small and they easily get lost in the noise. So we pool the results of many RCTs in what is called a ‘meta-analysis’ and the answer from that is very often ‘not proven’ – either way. So individual surgeons are left to make the judgement call and not surprisingly there is wide variation in practice. So is this the best that medical science can do?

No. There is another way. What we can do is pool all the learning from all the trials and design a multi-facetted intervention. A bundle of care. And the idea of a bundle is that the separate small effects will add or even synergise to create one big effect. We are not so much interested in the mechanism as the outcome. Just like Ignaz Semmelweiss.

And we can now do something else. We can test our bundle of care using statistically robust tools that do not require a RCT. They are just as statistically valid as a RCT but a different design.

And the appropriate tool for this to measure the time interval between adverse the events – and then to plot this continuous metric as a time-series chart.

But we must be disciplined. First we must establish the baseline average interval and then we introduce our bundle and then we just keep measuring the intervals.

If our bundle works then the interval between the adverse events gets longer – and we can easily prove that using our time-series chart. The longer the interval the more ‘proof’ we have. In fact we can even predict how long we need to observe to prove that ‘no events’ is a statistically significant improvement. That is an elegant an efficient design.

Here is a real and recent example.

The time-series chart below shows the interval in days between surgical site infections following routine hernia surgery. These are not life threatening complications. They rarely require re-admission or re-operation. But they are disruptive for patients. They cause pain, require treatment with antibiotics, and the delay recovery and return to normal activities. So we would like to avoid them if possible.

The green and red lines show the baseline period. The green line says that the average interval between SSIs is 14 days. The red line says that an interval more than about 60 days would be surprisingly long: valid statistical evidence of an improvement. The end of the green and red lines indicates when the intervention was made: when the evidence-based designer care bundle was adopted together with the discipline of applying it to every patient. No judgement. No variation.

The chart tells the story. No complicated statistical analysis is required. It shows a statistically significant improvement. And the SSI rate fell by over 80%. That is a big improvement.

We still do not know how the care bundle works. We do not know which of the seven simultaneous simple and low-cost interventions we chose are the most important or even if they work independently or in synergy. Knowledge of the mechanism was not our goal.

Our goal was to improve outcomes for our patients – to reduce avoidable harm – and that has been achieved. The evidence is clear.

That is Improvement Science in action.

And to read the full account of this example of the Science of Improvement please go to:

http://www.journalofimprovementscience.org

It is essay number 18.

And avoid another error of omission. If you have read this far please share this message – it is important.

01/03/2014

Miserable or Motivated?

[Beep Beep] The alarm on Bob’s smartphone was the reminder that in a few minutes his e-mentoring session with Lesley was due. Bob had just finished the e-mail he was composing so he sent it and then fired-up the Webex session. Lesley was already logged in and on line.

<Bob> Hi Lesley. What aspect of Improvement Science shall we talk about today? What is next on your map?

<Lesley> Hi Bob. Let me see. It looks like ‘Employee Engagement‘ is the one that we have explored least yet – and it links to lots of other things.

<Bob> OK. What would you say the average level of Employee Engagement is in your organisation at the moment? On a scale of zero to ten where zero is defined as ‘complete apathy’.

<Lesley> Good question. I see a wide range of engagement and I would say the average is about four out of ten. There are some very visible, fully-engaged, energetic, action-focused movers-and-shakers. There are many more nearer the apathy end of the spectrum. Most employees seem to turn up, do their jobs well enough to avoid being disciplined, and then go home.

<Bob> OK. And do you feel that is a problem?

<Lesley> You betcha! Improvement means change and change means action. Disengaged employees are a deadweight. They do not actively block change – they will go along with it if pushed – but they do not contribute to making it happen. And that creates a different problem. The movers-and-shakers get frustrated and eventually get tired trying to move the deadweight up hill and give up and then can become increasingly critical and then cynical. After they give up in despair they then actively block any new ideas saying – “Do not try you will fail.”

<Bob> So how would you describe the emotional state of those you describe as “disengaged”?

<Lesley> Miserable.

<Bob> And who is making them feel miserable?

<Lesley> That is another good question. They appear to be making themselves feel miserable. And it is not what is happening that triggers this emotion. It is what is not happening. Apathy seems to be self-sustaining.

<Bob> Can you explain in a bit more about what you mean by that and maybe share an example?

<Lesley> An example is easier. I have reflected on this a bit and I have used one of the 6M Design® techniques to help me understand it better. I used a Right-2-Left® map to compare a personal example of when I felt really motivated and delivered a significant and measurable improvement; with one where I felt miserable and no change happened.

<Bob> Excellent. What did you discover?

<Lesley> I discovered that there were four classes of difference between the two examples. And I then understood what you mean by ‘Acts and Errors of Omission and Commission’.

<Bob> OK. And which was the commonest of the four combinations in your example?

<Lesley> The Errors of Omission. And within just that group there were three different types that were most obvious.

<Bob> Can you list them for me?

<Lesley> For sure. The first is the miserableness I felt when what I was doing felt to me that it was irrelevant. When what I was being asked to do had no worthwhile purpose that I was aware of.

<Bob> So which was it? No worth or not being aware of the worth?

<Lesley>Me not being aware of the worth. I hoped it was of value to someone higher up the corporate food chain otherwise I would not have been asked to do it! But I was never sure. And that uncertainty generated some questions. What if what I am doing is of no worth to anyone? What if I am just wasting my lifetime doing it? That fearful thought left me feeling more miserable than motivated.

<Bob> OK. What was the second Error of Omission?

<Lesley> It is linked to the first one. I had no objective way of knowing if I was doing a worthwhile job. And the word objective is important. I am not asking for subjective feedback – there is too much expectation, variation, assumption, prejudgement and politics mixed up in opinions of what I achieve. I needed specific, objective and timely feedback. I associated my feeling of miserableness with not getting objective feedback that told me what I was doing was making a worthwhile difference to someone else. Anyone else!

<Bob> I thought that you get a lot of objective feedback on a whole raft of organisational performance metrics?

<Lesley> Oh yes! We do!! The problem is that it is high level, aggregated, anonymous, and delayed. To get a copy of a report that says as an organisation we did or did not meet last quarters arbitrary performance target for x, y or z usually generates a ‘So what? How does that relate to what I do?’ reaction. I need objective, specific and timely feedback about the effects of my work. Good or bad.

<Bob> OK. And Error of Omission Three?

<Lesley> This was the trickiest one to nail down. What it came down to was being treated as a process and not as a person. I felt anonymous. I was just a headcount, a number on a payroll ledger, an overhead cost. That feeling was actually the most demotivating of all.

<Bob> And did it require all Three Errors of Omission to be present for the ‘miserableness’ to become manifest?

<Lesley> Alas no! Any one of them was enough. The more of them at the same time the deeper the feeling of misery the less motivated I felt.

<Bob> Thank you for being so frank and open. So what have you ‘abstracted’ from your ‘reflection’?

<Lesley> That employee engagement requires that these Three Errors of Omission must be deliberately checked for and proactively addressed if discovered.

<Bob> And who would, could or should do this check-and-correct work?

<Lesley> H’mm. Another very god question. The employee could do it but it is difficult for them because a lot of the purpose-setting and feedback comes from outside their circle of control and from higher up. Approaching a line-manager with a list of their Errors of Omission will be too much of a challenge!

<Bob> So?

<Lesley> The manager should do it. They should ask themselves these questions. Only they can correct their own Errors of Omission. I doubt if that would happen spontaneously though! Humility seems a bit of a rare commodity.

<Bob> I agree. So what can the employee do to help their boss?

<Lesley> They could ask how they can be of most value to their boss and they could ask for objective and timely feedback on how well they are performing as an individual on those measures of worth. It sounds so simple and obvious when said out loud. So why does no one do it?

<Bob> A very good question. Some do and they are the often described as ‘motivating leaders’. So does this insight suggest to you any strategies for grasping the ‘Employee Engagement’ nettle without getting stung?

<Lesley> Yes indeed! I am already planning my next action. A chat with my line-manager about what I could do. Thanks Bob.

<Bob> My pleasure. And remember that the same principle works for everyone that we work directly with – especially those immediately ‘upstream’ and ‘downstream’ of us in our daily work.

22/02/2014

Rocket Science

This is a picture of Chris Hadfield. He is an astronaut and to prove it here he is in the ‘cupola’ of the International Space Station (ISS). Through the windows is a spectacular view of the Earth from space.

Our home seen from space.

What is remarkable about this image is that it even exists.

This image is tangible evidence of a successful outcome of a very long path of collaborative effort by 100’s of 1000’s of people who share a common dream.

That if we can learn to overcome the challenge of establishing a permanent manned presence in space then just imagine what else we might achieve?

Chis is unusual for many reasons. One is that he is Canadian and there are not many Canadian astronauts. He is also the first Canadian astronaut to command the ISS. Another claim to fame is that when he recently lived in space for 5 months on the ISS, he recorded a version of David Bowie’s classic song – for real – in space. To date this has clocked up 21 million YouTube hits and had helped to bring the inspiring story of space exploration back to the public consciousness.

Especially the next generation of explorers – our children.

Chris has also written a book ‘An Astronaut’s View of Life on Earth‘ that tells his story. It describes how he was inspired at a young age by seeing the first man to step onto the Moon in 1969. He overcame seemingly impossible obstacles to become an astronaut, to go into space, and to command the ISS. The image is tangible evidence.

We all know that space is a VERY dangerous place. I clearly remember the two space shuttle disasters. There have been many other much less public accidents. Those tragic events have shocked us all out of complacency and have created a deep sense of humility in those who face up to the task of learning to overcome the enormous technical and cultural barriers.

Getting six people into space safely, staying there long enough to conduct experiments on the long-term effects of weightlessness, and getting them back again safely is a VERY difficult challenge. And it has been overcome. We have the proof.

Many of the seemingly impossible day-to-day problems that we face seem puny in comparison.

For example: getting every patient into hospital, staying there just long enough to benefit from cutting edge high-technology healthcare, and getting them back home again safely.

And doing it repeatedly and consistently so that the system can be trusted and we are not greeted with tragic stories every time we open a newspaper. Stories that erode our trust in the ability of groups of well-intended people to do anything more constructive than bully, bicker and complain.

So when the exasperated healthcare executive exclaims ‘Getting 95% of emergency admissions into hospital in less than 4 hours is not rocket science!‘ – then perhaps a bit more humility is in order. It is rocket science.

Rocket science is Improvement science.

And reading the story of a real-life rocket-scientist might be just the medicine our exasperated executives need.

Because Chris explains exactly how it is done.

And he is credible because he has walked-the-talk so he has earned the right to talk-the-walk.

The least we can do is listen and learn.

Here is is Chris answering the question ‘How to achieve an impossible dream?‘

15/02/201423/10/2021

Navigating the Nerve Curve

The emotional roller-coaster ride that is associated with change, learning and improvement is called the Nerve Curve.

We are all very familiar with the first stages – of Shock, Denial, Anger, Bargaining, Depression and Despair. We are less familiar with the stages associated with the long climb out to Resolution: because most improvement initiatives fail for one reason of another.

The critical first step is to “Disprove Impossibility” and this is the first injection of innovation. Someone (the ‘innovator’) discovers that what was believed to be impossible is not. They only have to have one example too. One Black Swan.

The tougher task is to influence those languishing in the ‘Depths of Despair’ that there is hope and that there is a ‘how’. This is not easy because cynicism is toxic to innovation. So an experienced Improvement Science Practitioner (ISP) bypasses the cynics and engages with the depressed-but-still-healthy-sceptics.

The challenge now is how to get a shed load of them up the hill.

When we first learn to drive we start on the flat, not on hills, for a very good reason. Safety.

We need to learn to become confident with the controls first. The brake, the accelerator, the clutch and the steering wheel. This takes practice until it is comfortable, unconscious and almost second nature. We want to achieve a smooth transition from depression to delight, not chaotic kangaroo jumps!

Only when we can do that on the flat do we attempt a hill-start. And the key to a successful hill start is the sequence. Hand brake on for safety, out of gear, engine running, pointing at the goal. Then we depress the clutch and select a low gear – we do not want to stall. Speed is not the goal. Safety comes first. Then we rev the engine to give us the power we need to draw on. Then we ease the clutch until the force of the engine has overcome the force of gravity and we feel the car wanting to move forward. And only then do we ease the handbrake off, let the clutch out more and hit the gas to keep the engine revs in the green.

So when we are planning to navigate a group of healthy sceptics up the final climb of the Nerve Curve we need to plan and prepare carefully.

What is least likely to be successful?

Well, if all we have is our own set of wheels, a cheap and cheerful mini-motor, then it is not going to be a good idea to shackle a trailer to it; fill the trailer with sceptics and attempt a hill start. We will either stall completely or burn out our clutch. We may even be dragged backwards into the Cynic Infested Toxic Swamp.

So what if we hire a bus, load up our sceptical passengers, and have a go. We may be lucky – but if we have no practice doing hill starts with a full bus then we could be heading for disappointment; or disaster.

So what is a safer plan:
1) First we need to go up the mountain ourselves to demonstrate it is possible.
2) Then we take one or two of the least sceptical up in our car to show it is safe.
3) We then invite those sceptics with cars to learn how to do safe hill starts.
4) Finally we ask the ex-sceptics to teach the fresh-sceptics how to do it.

Brmmmm Brmmmm. Off we go.

18/01/2014

Sticks or Carrots?

[Beep Beep] Bob’s laptop signaled the arrival of Leslie to their regular Webex mentoring session. Bob picked up the phone and connected to the conference call.

<Bob> Hi Leslie, how are you today?

<Leslie> Great thanks Bob. I am sorry but that I do not have a red-hot burning issue to talk about today.

<Bob> OK – so your world is completely calm and orderly now. Excellent.

<Leslie> I wish! The reason is that I have been busy preparing for the monthly 1-2-1 with my boss.

<Bob> OK. So do you have a few minutes to talk about that?

<Leslie> What can I tell you about it?

<Bob> Can you just describe the purpose and the process for me?

<Leslie> OK. The purpose is improvement – for both the department and the individual. The process is that all departmental managers have an annual appraisal based on their monthly 1-2-1 chats and the performance scores for their departments are used to reward the top 15% and to ‘performance manage’ the bottom 15%.

<Bob> H’mmm. What is the commonest emotion that is associated with this process?

<Leslie> I would say somewhere between severe anxiety and abject terror. No one looks forward to it. The annual appraisal feels like a lottery where the odds are stacked against you.

<Bob> Can you explain that a bit more for me?

<Leslie> Well, the most fear comes from being in the bottom 15% – the fear of being ‘handed your hat’ so to speak. Fortunately that fear motivates us to try harder and that usually saves us from the chopper because our performance improves. The cost is the extra stress, working late and taking ‘stuff’ home.

<Bob> OK. And the anxiety?

<Leslie> Paradoxically that mostly comes from the top 15%. They are anxious to sustain their performance. Most do not and the Boss’s Golden Manager can crash spectacularly! We have seen it so often. It is almost as if being the Best carries a curse! So most of us try to stay in the middle of the pack where we do not stick out – a sort of safety in the herd strategy. It is illogical I know because there is always a ‘top’ 15% and a ‘bottom’ 15%.

<Bob> You mentioned before that it feels like a lottery. How come?

<Leslie> Yes – it feels like a lottery but I know it has a rational scientific basis. Someone once showed me the ‘statistically significant evidence’ that proves it works.

<Bob> That what works exactly?

<Leslie> That sticks are more effective than carrots!

<Bob> Really! And what does the performance run charts look like – over the long term – say monthly over 2-3 years?

<Leslie> That is a really good question. They are surprisingly stable – well completely stable in fact. The wobble up and down of course but there is no sign of improvement over the long term – no trend. If anything it is the other way.

<Bob> So what is the rationale for maintaining the stick-is-better-than-the-carrot policy?

<Leslie> Ah! The message we are getting is ‘as performance is not improving and sticks have been scientifically proven to be more effective than carrots then we will be using a bigger stick in future‘.

<Bob> Hence the atmosphere of fear and anxiety?

<Leslie> Exactly. But that is the way it must be I suppose.

<Bob> Actually it is not. This is an invalid design based on rubbish intuitive assumptions and statistical smoke-and-mirrors that creates unmeasurable emotional pain and destroys both people and organisations!

<Leslie> Wow! Bob! I have never heard you use language like that. You are usually so calm and reasonable. This must be really important!

<Bob> It is – and for that reason I need to shock you out of your apathy – and I can do that best by you proving it to yourself – scientifically – with a simple experiment. Are you up for that?

<Leslie> You betcha! This sounds like it is going to be interesting. I had better fasten my safety belt! The Nerve Curve awaits.

The Stick-or-Carrot Experiment

<Bob> Here we go. You will need five coins, some squared-paper and a pencil. Coloured ones are even better.

<Leslie> OK. Does it matter what sort of coins?

<Bob> No. Any will do. Imagine you have four managers called A,B,C and D respectively. Each month the performance of their department is measured as the number of organisational targets that they are above average on. Above average is like throwing a ‘head’, below average is like throwing a ‘tail’. There are five targets – hence the coins

<Leslie>OK. That makes sense – and it feels better to use the measured average – we have demonstrated that arbitrary performance targets are dangers – especially when imposed blindly across all departments.

<Bob> Indeed. So can you design a score sheet to track the data for the experiment.

<Leslie>Give me a minute. Will this suffice?

<Bob> Perfect! Now simulate a month by tossing all five coins – once for each manager – and record the outcome of each as H to T , then tot up the number of heads for each manager.

<Leslie> OK … here is what I got.

<Bob>Good. Now repeat this 11 more times to give you the results for a whole year. In the n(Heads) column colour the boxes that have scores of zero or one as red – these are the Losers. Then colour the boxes that have 4 or 5 as green – these are the Winners.

<Leslie>OK, that will take me a few minutes – do you want to get a coffee or something.

[Five minutes later]

Here you go. That gives 96 opportunities to win or lose and I counted 9 Losers and 9 Winners so just under 20% for each. The majority were in the unexceptional middle. The herd.

<Bob> Excellent. A useful way to visualise this is using a Tally chart. Just run down the column of n(Heads) and create the Tally chart as you go. This is one of the oldest forms of counting in existence. There are fossil records that show Tally charts being used thousands of years ago.

<Leslie> I think I understand what you mean. We do not wait until all the data is in then draw the chart, we update it as we go along – as the data comes in.

<Bob> Spot on!

<Leslie> Let me see. Wow! That is so cool! I can see the pattern appearing almost magically – and the more data I have the clearer the pattern is.

<Bob>Can you show me?

<Leslie> Here we go.

<Bob> Good. This is the expected picture. If you repeated this many times you would get the same general pattern with more 2 and 3 scores.

Now I want you to do an experiment.

Assume each manager that is classed as a Winner in one month is given a reward – a ‘pat on the back’ from their Boss. And each manager that is classed as a Loser is given a ‘written warning’. Now look for the effect that this has.

<Leslie> But we are using coins – which means the outcome is just a matter of chance! It is a lottery.

<Bob> I know that and you know that but let us assume that the Boss believes that the monthly feedback has an effect. The experiment we are doing is to compare the effect of the carrot with the stick. The Boss wants to know which results in more improvement and to know that with scientific and statistical confidence!

<Leslie> OK. So what I will do is look at the score the following month for each manager that was either a Winner or a Loser; work out the difference, and then calculate the average of those differences and compare them with each other. That feels suitably scientific!

<Bob> OK. What do you get.

<Leslie> Just a minute, I need to do this carefully. OK – here it is.

<Bob> Excellent. Just eye-balling the ‘Measured improvement after feedback’ columns I would say the Losers have improved and the Winners have deteriorated!

<Leslie> Yes! And the Losers have improved by 1.29 on average and the Winners have deteriorated by 1.78 – and that is a big difference for such small sample. I am sure that with enough data this would be a statistically significant difference! So it is true, sticks work better than carrots!

<Bob>Not so fast. What you are seeing is a completely expected behaviour called “Regression to the Mean“. Remember we know that the score for each manager each month is the result of a game of chance, a coin toss, a lottery. So no amount of stick or carrot feedback is going to influence that.

<Leslie>But the data is saying there is a difference! And that feels like the experience we have – and why fear stalks the management corridors. This is really confusing!

<Bob>Remember that confusion arises from invalid or conflicting unconscious assumptions. There is a flaw in the statistical design of this experiment. The ‘obvious’ conclusion is invalid because of this flaw. And do not be too hard on yourself. The flaw eluded mathematicians for centuries. But now you know there is one can you find it?

<Leslie>OMG! The use of the average to classify the managers into Winners or Losers is the flaw! That is just a lottery. Who the managers are is irrelevant. This is just a demonstration of how chance works.

But that means … OMG! If the conclusion is invalid then sticks are not better than carrots and we have been brain-washed for decades into accepting a performance management system that is invalid – and worse still is used to ‘scientifically’ justify systematic persecution! I can see now why you get so angry!

<Bob>Bravo Leslie. We need to check your understanding. Does that mean carrots are better than sticks?

<Leslie>No! The conclusion is invalid because the assumptions are invalid and the design is fatally flawed. It does not matter what the conclusion actually is.

<Bob>Excellent. So what conclusion can you draw?

<Leslie>That this short-term carrot-or-stick feedback design for achieving improvement in a stable system is both ineffective and emotionally damaging. In fact it could well be achieving precisely the opposite effect that it is intended to. It may be preventing improvement! But the story feels so plausible and the data appears to back it up. What is happening here is we are using statistical smoke-and-mirrors to justify what we have already decided – and only an true expert would spot the flaw! Once again our intuition has tricked us!

<Bob>Well done! And with this new insight – how would you do it differently? What would be a better design?

<Leslie>That is a very good question. I am going to have to think about that – before my 1-2-1 tomorrow. I wonder what might happen if I show this demonstration to my Boss? Thanks Bob, as always … lots of food for thought.

28/12/201313/08/2024

The Time Trap

[Hmmmmmm]

The desk amplified the vibration of Bob’s smartphone as it signaled the time for his planned e-mentoring session with Leslie.

<Bob> Hi Leslie, right-on-time, how are you today?

<Leslie> Good thanks Bob. I have a specific topic to explore if that is OK. Can we talk about time traps.

<Bob> OK – do you have a specific reason for choosing that topic?

<Leslie> Yes. The blog last week about ‘Recipe for Chaos‘ set me thinking and I remembered that time-traps were mentioned in the FISH course but I confess, at the time, I did not understand them. I still do not.

<Bob> Can you describe how the ‘Recipe for Chaos‘ blog triggered this renewed interest in time-traps?

<Leslie> Yes – the question that occurred to me was: ‘Is a time-trap a recipe for chaos?’

<Bob> A very good question! What do you feel the answer is?

<Leslie> I feel that time-traps can and do trigger chaos but I cannot explain how. I feel confused.

<Bob> Your intuition is spot on – so can you localize the source of your confusion?

<Leslie> OK. I will try. I confess I got the answer to the MCQ correct by guessing – and I wrote down the answer when I eventually guessed correctly – but I did not understand it.

<Bob> What did you write down?

<Leslie> “The lead time is independent of the flow”.

<Bob> OK. That is accurate – though I agree it is perhaps a bit abstract. One source of confusion may be that there are different causes of time-traps and there is a lot of overlap with other chaos-creating policies. Do you have a specific example we can use to connect theory with reality?

<Leslie> OK – that might explain my confusion. The example that jumped to mind is the RTT target.

<Bob> RTT?

<Leslie> Oops – sorry – I know I should not use undefined abbreviations. Referral to Treatment Time.

<Bob> OK – can you describe what you have mapped and measured already?

<Leslie> Yes. When I plot the lead-time for patients in date-of-treatment order the process looks stable but the histogram is multi-modal with a big spike just underneath the RTT target of 18 weeks. What you describe as the ‘Horned Gaussian’ – the sign that the performance target is distorting the behaviour of the system and the design of the system is not capable on its own.

<Bob> OK, and have you investigated why there is not just one spike?

<Leslie> Yes – the factor that best explains that is the ‘priority’ of the referral. The ‘urgents’ jump in front of the ‘soons’ and both jump in front of the ‘routines’. The chart has three overlapping spikes.

<Bob> That sounds like a reasonable policy for mixed-priority demand. So what is the problem?

<Leslie> The ‘Routine’ group is the one that clusters just underneath the target. The lead time for routines is almost constant but most of the time those patients sit in one queue or another being leap-frogged by other higher-priority patients. Until they become high-priority – then they do the leap frogging.

<Bob> OK – and what is the condition for a time trap again?

<Leslie> That the lead time is independent of flow.

<Bob> Which implies?

<Leslie> Um. Let me think. That the flow can be varying but the lead time stays the same?

<Bob> Yup. So is the flow of routine referrals varying?

<Leslie> Not over the long term. The chart is stable.

<Bob> What about over the short term? Is demand constant?

<Leslie> No of course not – it varies – but that is expected for all systems. Constant means ‘over-smoothed data’ – the Flaw of Averages trap!

<Bob> OK. And how close is the average lead time for routines to the RTT maximum allowable target?

<Leslie> Ah! I see what you mean. The average is about 17 weeks and the target is 18 weeks.

<Bob> So, what is the flow variation on a week-to-week time scale?

<Leslie> Demand or Activity?

<Bob> Both.

<Leslie> H’mm – give me a minute to re-plot flow as a weekly-aggregated chart. Oh! I see what you mean – both the weekly activity and demand are both varying widely and they are not in sync with each other. Work in progress must be wobbling up and down a lot! So how can the lead time variation be so low?

<Bob> What do the flow histograms look like?

<Leslie> Um. Just a second. That is weird! They are both bi-modal with peaks at the extremes and not much in the middle – the exact opposite of what I expected to see! I expected a centered peak.

<Bob> What you are looking at is the characteristic flow fingerprint of a chaotic system – it is called ‘thrashing’.

<Leslie> So, I was right!

<Bob> Yes. And now you know the characteristic pattern to look for. So, what is the policy design flaw here?

<Leslie> The DRAT – the delusional ratio and arbitrary target?

<Bob> That is part of it – that is the external driver policy. The one you cannot change easily. What is the internally driven policy? The reaction to the DRAT?

<Leslie> The policy of leaving routine patients until they are about to breach then re-classifying them as ‘urgent’.

<Bob> Yes! It is called a ‘Prevarication Policy’ and it is surprisingly and uncomfortably common. Ask yourself – do you ever prevaricate? Do you ever put off ‘lower priority’ tasks until later and then not fill the time freed up with ‘higher priority tasks’?

<Leslie> OMG! I do that all the time! I put low priority and unexciting jobs on a ‘to do later’ heap but I do not sit idle – I do then focus on the high priority ones.

<Bob> High priority for whom?

<Leslie> Ah! I see what you mean. High priority for me. The ones that give me the biggest reward! The fun stuff or the stuff that I get a pat on the back for doing or that I feel good about.

<Bob> And what happens?

<Leslie> The heap of ‘no-fun-for-me-to-do’ jobs gets bigger and I await the ‘reminders’ and then have to rush round in a mad panic to avoid disappointment, criticism and blame. It feels chaotic. I get grumpy. I make more mistakes and I deliver lower-quality work. If I do not get a reminder I assume that the job was not that urgent after all and if I am challenged I claim I am too busy doing the other stuff.

<Bob> And have you avoided disappointment?

<Leslie> Ah! No – that I needed to be reminded meant that I had already disappointed. And when I do not get a reminded does not prove I have not disappointed either. Most people blame rather than complain. I have just managed to erode other people’s trust in my reliability. I have disappointed myself. I have achieved exactly the opposite of what I intended. Drat!

<Bob> So, what is the reason that you work this way? There will be a reason. A good reason.

<Leslie> That is a very good question! I will reflect on that because I believe it will help me understand why others behave this way too.

<Bob> OK – I will be interested to hear your conclusion. Let us return to the question. What is the downside of a ‘Prevarication Policy’?

<Leslie> It creates stress, chaos, fire-fighting, last minute changes, increased risk of errors, more work and it erodes both quality, confidence and trust.

<Bob> Indeed so – and the impact on productivity?

<Leslie> The activity falls, the system productivity falls, revenue falls, queues increase, waiting times increase and the chaos increases!

<Bob> And?

<Leslie> We treat the symptoms by throwing resources at the problem – waiting list initiatives – and that pushes our costs up. Either way we are heading into a spiral of decline and disappointment. We do not address the root cause.

<Bob> So what is the way out of chaos?

<Leslie> Reduce the volume on the destabilizing feedback loop? Stop the managers meddling!

<Bob> Or?

<Leslie> Eh? I do not understand what you mean. The blog last week said management meddling was the problem.

<Bob> It is a problem. How many feedback loops are there?

<Leslie> Two – that need to be balanced.

<Bob> So, what is another option?

<Leslie> OMG! I see. Turn UP the volume of the stabilizing feedback loop!

<Bob> Yup. And that is a lot easier to do in reality. So, that is your other challenge to reflect on this week. And I am delighted to hear you using the terms ‘stabilizing feedback loop’ and ‘destabilizing feedback loop’.

<Leslie> Thank you. That was a lesson for me after last week – when I used the terms ‘positive and negative feedback’ it was interpreted in the emotional context – positive feedback as encouragement and negative feedback as criticism. So ‘reducing positive feedback’ in that sense is the exact opposite of what I was intending. So I switched my language to using ‘stabilizing and destabilizing’ feedback loops that are much less ambiguous and the confusion and conflict disappeared.

<Bob> That is very useful learning Leslie … I think I need to emphasize that distinction more in the blog. That is one advantage of online media – it can be updated!

<Leslie> Thanks again Bob! And I have the perfect opportunity to test a new no-prevarication-policy design – in part of the system that I have complete control over – me!

09/11/2013

The Mirror

[Dring Dring]

The phone announced the arrival of Leslie for the weekly ISP mentoring conversation with Bob.

<Leslie> Hi Bob.

<Bob> Hi Leslie. What would you like to talk about today?

<Leslie> A new challenge – one that I have not encountered before.

<Bob>Excellent. As ever you have pricked my curiosity. Tell me more.

<Leslie> OK. Up until very recently whenever I have demonstrated the results of our improvement work to individuals or groups the usual response has been “Yes, but“. The habitual discount as you call it. “Yes, but your service is simpler; Yes, but your budget is bigger; Yes, but your staff are less militant.” I have learned to expect it so I do not get angry any more.

<Bob> OK. The mantra of the skeptics is to be expected and you have learned to stay calm and maintain respect. So what is the new challenge?

<Leslie>There are two parts to it. Firstly, because the habitual discounting is such an effective barrier to diffusion of learning; our system has not changed; the performance is steadily deteriorating; the chaos is worsening and everything that is ‘obvious’ has been tried and has not worked. More red lights are flashing on the patient-harm dashboard and the Inspectors are on their way. There is an increasing turnover of staff at all levels – including Executive. There is an anguished call for “A return to compassion first” and “A search for new leaders” and “A cultural transformation“.

<Bob> OK. It sounds like the tipping point of awareness has been reached, enough people now appreciate that their platform is burning and radical change of strategy is required to avoid the ship sinking and them all drowning. What is the second part?

<Leslie> I am getting more emails along the line of “What would you do?”

<Bob> And your reply?

<Leslie> I say that I do not know because I do not have a diagnosis of the cause of the problem. I do know a lot of possible causes but I do not know which plausible ones are the actual ones.

<Bob> That is a good answer. What was the response?

<Leslie>The commonest one is “Yes, but you have shown us that Plan-Do-Study-Act is the way to improve – and we have tried that and it does not work for us. So we think that improvement science is just more snake oil!”

<Bob>Ah ha. And how do you feel about that?

<Leslie>I have learned the hard way to respect the opinion of skeptics. PDSA does work for me but not for them. And I do not understand why that is. I would like to conclude that they are not doing it right but that is just discounting them and I am wary of doing that.

<Bob>OK. You are wise to be wary. We have reached what I call the Mirror-on-the-Wall moment. Let me ask what your understanding of the history of PDSA is?

<Leslie>It was called Plan-Do-Check-Act by Walter Shewhart in the 1930’s and was presented as a form of the scientific method that could be applied on the factory floor to improving the quality of manufactured products. W Edwards Deming modified it to PDSA where the “Check” was changed to “Study”. Since then it has been the key tool in the improvement toolbox.

<Bob>Good. That is an excellent summary. What the Zealots do not talk about are the limitations of their wonder-tool. Perhaps that is because they believe it has no limitations. Your experience would seem to suggest otherwise though.

<Leslie>Spot on Bob. I have a nagging doubt that I am missing something here. And not just me.

<Bob>The reason PDSA works for you is because you are using it for the purpose it was designed for: incremental improvement of small bits of the big system; the steps; the points where the streams cross the stages. You are using your FISH training to come up with change plans that will work because you understand the Physics of Flow better. You make wise improvement decisions. In fact you are using PDSA in two separate modes: discovery mode and delivery mode. In discovery mode we use the Study phase to build your competence – and we learn most when what happens is not what we expected. In delivery mode we use the Study phase to build our confidence – and that grows most when what happens is what we predicted.

<Leslie>Yes, that makes sense. I see the two modes clearly now you have framed it that way – and I see that I am doing both at the same time, almost by second nature.

<Bob>Yes – so when you demonstrate it you describe PDSA generically – not as two complimentary but contrasting modes. And by demonstrating success you omit to show that there are some design challenges that cannot be solved with either mode. That hidden gap attracts some of the “Yes, but” reactions.

<Leslie>Do you mean the challenges that others are trying to solve and failing?

<Bob>Yes. The commonest error is to discount the value of improvement science in general; so nothing is done and the inevitable crisis happens because the system design is increasingly unfit for the evolving needs. The toast is not just burned it is on fire and is now too late to use the discovery mode of PDSA because prompt and effective action is needed. So the delivery mode of PDSA is applied to a emergent, ill-understood crisis. The Plan is created using invalid assumptions and guesswork so it is fundamentally flawed and the Do then just makes the chaos worse. In the ensuing panic the Study and Act steps are skipped so all hope of learning is lost and and a vicious and damaging spiral of knee-jerk Plan-Do-Plan-Do follows. The chaos worsens, quality falls, safety falls, confidence falls, trust falls, expectation falls and depression and despair increase.

<Leslie>That is exactly what is happening and why I feel powerless to help. What do I do?

<Bob>The toughest bit is past. You have looked squarely in the mirror and can now see harsh reality rather than hasty rhetoric. Now you can look out of the window with different eyes. And you are now looking for a real-world example of where complex problems are solved effectively and efficiently. Can you think of one?

<Leslie>Well medicine is one that jumps to mind. Solving a complex, emergent clinical problems requires a clear diagnosis and prompt and effective action to stabilise the patient and then to cure the underlying cause: the disease.

<Bob>An excellent example. Can you describe what happens as a PDSA sequence?

<Leslie>That is a really interesting question. I can say for starters that it does not start with P – we have learned are not to have a preconceived idea of what to do at the start because it badly distorts our clinical judgement. The first thing we do is assess the patient to see how sick and unstable they are – we use the Vital Signs. So that means that we decide to Act first and our first action is to Study the patient.

<Bob>OK – what happens next?

<Leslie>Then we will do whatever is needed to stabilise the patient based on what we have observed – it is called resuscitation – and only then we can plan how we will establish the diagnosis; the root cause of the crisis.

<Bob> So what does that spell?

<Leslie> A-S-D-P. It is the exact opposite of P-D-S-A … the mirror image!

<Bob>Yes. Now consider the treatment that addresses the root cause and that cures the patient. What happens then?

<Leslie>We use the diagnosis is used to create a treatment Plan for the specific patient; we then Do that, and we Study the effect of the treatment in that specific patient, using our various charts to compare what actually happens with what we predicted would happen. Then we decide what to do next: the final action. We may stop because we have achieved our goal, or repeat the whole cycle to achieve further improvement. So that is our old friend P-D-S-A.

<Bob>Yes. And what links the two bits together … what is the bit in the middle?

<Leslie>Once we have a diagnosis we look up the appropriate treatment options that have been proven to work through research trials and experience; and we tailor the treatment to the specific patient. Oh I see! The missing link is design. We design a specific treatment plan using generic principles.

<Bob>Yup. The design step is the jam in the improvement sandwich and it acts like a mirror: A-S-D-P is reflected back as P-D-S-A

<Leslie>So I need to teach this backwards: P-D-S-A and then Design and then A-S-P-D!

<Bob>Yup – and you know that by another name.

<Leslie> 6M Design®! That is what my Improvement Science Practitioner course is all about.

<Bob> Yup.

<Leslie> If you had told me that at the start it would not have made much sense – it would just have confused me.

<Bob>I know. That is the reason I did not. The Mirror needs to be discovered in order for the true value to appreciated. At the start we look in the mirror and perceive what we want to see. We have to learn to see what is actually there. Us. Now you can see clearly where P-D-S-A and Design fit together and the missing A-S-D-P component that is needed to assemble a 6M Design® engine. That is Improvement-by-Design in a nine-letter nutshell.

<Leslie> Wow! I can’t wait to share this.

<Bob> And what do you expect the response to be?

<Leslie>”Yes, but”?

<Bob> From the die hard skeptics – yes. It is the ones who do not say “Yes, but” that you want to engage with. The ones who are quiet. It is always the quiet ones that hold the key.

19/10/2013

Improvement-by-Twitter

Sat 5th October

It started with a tweet.

08:17 [JG] The NHS is its people. If you lose them, you lose the NHS.

09:15 [DO] We are in a PEOPLE business – educating people and creating value.

Sun 6th October

08:32 [SD] Who isn’t in people business? It is only people who buy stuff. Plants, animals, rocks and machines don’t.

09:42 [DO] Very true – it is people who use a service and people who deliver a service and we ALL know what good service is.

09:47 [SD] So onus is on us to walk our own talk. If we don’t all improve our small bits of the NHS then who can do it for us?

Then we were off … the debate was on …

10:04 [DO] True – I can prove I am saving over £160 000.00 a year – roll on PBR !?

10:15 [SD] Bravo David. I recently changed my surgery process: productivity up by 35%. Cost? Zero. How? Process design methods.

11:54 [DO] Exactly – cost neutral because we were thinking differently – so how to persuade the rest?

12:10 [SD] First demonstrate it is possible then show those who want to learn how to do it themselves. http://www.saasoft.com/fish/course

We had hard evidence it was possible … and now MC joined the debate …

12:48 [MC] Simon why are there different FISH courses for safety, quality and efficiency? Shouldn’t good design do all of that?

12:52 [SD] Yes – goal of good design is all three. It just depends where you are starting from: Governance, Operations or Finance.

A number of parallel threads then took off and we all had lots of fun exploring each others knowledge and understanding.

17:28 MC registers on the FISH course.

And that gave me an idea. I emailed an offer – that he could have a complimentary pass for the whole FISH course in return for sharing what he learns as he learns it. He thought it over for a couple of days then said “OK”.

Weds 9th October

06:38 [MC] Over the last 4 years of so, I’ve been involved in incrementally improving systems in hospitals. Today I’m going to start an experiment.

06:40 [MC] I’m going to see if we can do less of the incremental change and more system redesign. To do this I’ve enrolled in FISH

Fri 11th October

06:47 [MC] So as part of my exploration into system design, I’ve done some studies in my clinic this week. Will share data shortly.

21:21 [MC] Here’s a chart showing cycle time of patients in my clinic. Median cycle time 14 mins, but much longer in 2 pic.twitter.com/wu5MsAKk80

21:22 [MC] Here’s the same clinic from patients’ point if view, wait time. Much longer than I thought or would like pic.twitter.com/iVLTDsbG8m

21:24 [MC] Two patients needed to discuss surgery or significant news, that takes time and can’t be rushed.

21:25 [MC] So, although I started on time, worked hard and finished on time. People were waited ages to see me. Template is wrong!

21:27 [MC] By the time I had seen the the 3rd patient, people were waiting 45 mins to see me. That’s poor.

21:28 [MC] The wait got progressively worse until the end of the clinic.

Sunday 13th October

16:02 [MC] As part of my homework on systems, I’ve put my clinic study data into a Gantt chart. Red = waiting, green = seeing me pic.twitter.com/iep2PDoruN

16:34 [SD] Hurrah! The visual power of the Gantt Chart. Worth adding the booked time too – there are Seven Sins of Scheduling to find.

16:36 [SD] Excellent – good idea to sort into booked time order – it makes the planned rate of demand easier to see.

16:42 [SD] Best chart is Work In Progress – count the number of patients at each time step and plot as a run chart.

17:23 [SD] Yes – just count how many lines you cross vertically at each time interval. It can be automated in Excel

17:38 [MC] Like this? pic.twitter.com/fTnTK7MdOp

This is the work-in-progress chart. The most useful process monitoring chart of all. It shows the changing size of the queue over time. Good flow design is associated with small, steady queues.

18:22 [SD] Perfect! You’re right not to plot as XmR – this is a cusum metric. Not a healthy WIP chart this!

There was more to follow but the “ah ha” moment had been seen and shared.

Weds 16th October

MC completes the Online FISH course and receives his well-earned Certificate of Achievement.

This was his with-the-benefit-of-hindsight conclusion:

I wish I had known some of this before. I will have totally different approach to improvement projects now. Key is to measure and model well before doing anything radical.

Improvement Science works.
Improvement-by-Design is a skill that can be learned quickly.
FISH is just a first step.

12/10/2013

A Treaty with the Lions

This week I heard an inspiring story of applied Improvement Science that has delivered a win-win-win result. Not in a hospital. Not in a factory. In the red-in-tooth-and-claw reality of rural Kenya.

Africa has vast herds of four-hoofed herbivors called zebra and wildebeast who are accompanied by clever and powerful carnivors – called lions. The sun and rain make the grass grow; the herbivors eat the grass and the carnivors eat the herbivors. It is the way of Nature – and has been so for millions of years.

Enter Man a few thousand years ago with his domesticated cattle and the scene is set for conflict. Domestic cattle are easy pickings for a hungry lion. Why spend a lot of energy chasing a lively zebra or wildebeast and run the risk of injury that would spell death-by-starvation? Lions are strong and smart but they do not have a social security system to look after the injured and sick. So why not go for the easier option?

So Man protects his valuable cattle from hungry lions. And Man is inventive. The cattle need to eat and sleep like the rest of us – so during the day the cattle are guarded by brave Maasai warriors armed with spears; and at night the cattle are herded into acacia thorn-ringed kraals and watched over by the boys of the tribe.

The lions come at night. Their sense of smell and sight is much better developed than Man’s.

The boys job is to deter the lions from killing the cattle.

And this conflict has been going on for thousands of years.

So when a hungry lion kills a poorly guarded cow or bull – then Man will get revenge and kill the lion. Everyone loses.

But the application of Improvement Science is changing that ancient conflict. And it was not done by a scientist or an animal welfare evangelist or a trained Improvementologist. It was done by young Maasai boy called Richard Turere.

He describes the why, the what and the how … HERE.

So what was his breakthrough?

It was noticing that walking about with a torch was a more effective lion deterrent than a fire or a scarecrow.

That was the chance discovery. Chance favours the prepared mind.

So how do we create a prepared mind that is receptive to the hints that chance throws at us?

That is one purpose of learning Improvement Science.

What came after the discovery was not luck … it was design.

Richard used what was to hand to design a solution that achieved the required purpose – an effective lion deterrent – in a way that was also an efficient use of his lifetime.

He had bigger dreams than just protecting his tribe’s cattle. His dream was to fly in one of those silver things that he saw passing high over the savannah every day.

And sitting up every night waving a torch to deter hungry lions from eating his father’s cattle was not going to deliver that dream.

So he had to nail that Niggle before he could achieve his Nice If.

Like many budding inventors and engineers Richard is curious about how things work – and he learned a lot about electronics by dismantling his mother’s radio! It got him into a lot of trouble – but the knowledge and understanding that he gained was put to good use when he designed his “lion lights”.

This true story captures the essence of Improvement Science better than any blog, talk, lecture, course or book could.

That is why it was shared by those who learned of his improvement; then to TED; then to the World; then passed to me and I am passing it on too. It is an inspiring story. It says that anyone can do this sort of thing if they choose to.

And it shows how Improvement Science spreads. Through the grapevine. And understanding how that works is part of the Science.

05/10/2013

The Power of the Converted Skeptic

One of the biggest challenges in Improvement Science is diffusion of an improvement outside the circle of control of the innovator.

It is difficult enough to make a significant improvement in one small area – it is an order of magnitude more difficult to spread the word and to influence others to adopt the new idea!

One strategy is to shame others into change by demonstrating that their attitude and behaviour are blocking the diffusion of innovation.

This strategy does not work. It generates more resistance and amplifies the differences of opinion.

Another approach is to bully others into change by discounting their opinion and just rolling out the “obvious solution” by top-down diktat.

This strategy does not work either. It generates resentment – even if the solution is fit-for-purpose – which it usually is not!

So what does work?

The key to it is to convert some skeptics because a converted skeptic is a powerful force for change.

But doesn’t that fly in the face of established change management theory?

Innovation diffuses from innovators to early-adopters, then to the silent majority, then to the laggards and maybe even dinosaurs … doesn’t it?

Yes – but that style of diffusion is incremental, slow and has a very high failure rate. What is very often required is something more radical, much faster and more reliable. For that it needs both push from the Confident Optimists and pull from some Converted Pessimists. The tipping point does not happen until the silent majority start to come off the fence in droves: and they do that when the noisy optimists and equally noisy pessimists start to agree.

The fence-sitters jump when the tug-o-war stalemate stops and the force for change becomes aligned in the direction of progress.

So how is a skeptic converted?

Simple. By another Converted Skeptic.

Here is a real example.

We are all skeptical about many things that we would actually like to improve.

Personal health for instance. Something like weight. Yawn! Not that Old Chestnut!

We are bombarded with shroud-waver stories that we are facing an epidemic of obesity, rapidly rising rates of diabetes, and all the nasty and life-shortening consequences of that. We are exhorted to eat “five portions of fruit and veg a day” … or else! We are told that we must all exercise our flab away. We are warned of the Evils of Cholesterol and told that overweight children are caused by bad parenting.

The more gullible and fearful are herded en-masse in the direction of the Get-Thin-Quick sharks who then have a veritable feeding frenzy. Their goal is their short-term financial health not the long-term health of their customers.

The more insightful, skeptical and frustrated seek solace in the chocolate Hob Nob jar.

For their part, the healthcare professionals are rewarded for providing ineffective healthcare by being paid-for-activity not for outcome. They dutifully measure the decline and hand out ineffective advice. Their goal is survival too.

The outcome is predictable and seemingly unavoidable.

So when a disruptive innovation comes along that challenges the current dogma and status quo, the healthy skeptics inevitably line up and proclaim that it will not work.

Not that it does not work. They do not know that because they never try it. They are skeptics. Someone else has to prove it to them.

And I am a healthy skeptic about many things.

I am skeptical about diets – the evidence suggests that their proclaimed benefit is difficult to achieve and even more difficult to sustain: and that is the hall-mark of either a poor design or a deliberate, profit-driven, yet legal scam.

So I decided to put an innovative approach to weight loss to the test. It is not a diet – it is a design to achieve and sustain a healthier weight to height ratio. And for it to work it must work for me because I am a diet skeptic.

The start of the story is HERE

I am now a Converted Healthier Skeptic.

I call the innovative design a “2 out of 7 Lo-CHO” policy and what that means is for two days a week I just cut out as much carbohydrate (CHO) as feasible. Stuff like bread, potatoes, rice, pasta and sugar. The rest of the time I do what I normally do. There is no need for me to exercise and no need for me to fill up on Five Fruit and Veg.

The chart above is the evidence of what happened. It shows a 7 kg reduction in weight over 140 days – and that is impressive given that it has required no extra exercise and no need to give up tasty treats completely and definitely no need to boost the bottom-line of a Get-Thin-Quick shark!

It also shows what to expect. The weight loss starts steeper then tails off as it approaches a new equilibrium weight. This is the classic picture of what happens to a “system” when one of its “operational policies” is wisely re-designed.

Patience, persistence and a time-series chart are all that is needed. It takes less than a minute per day to monitor the improvement.

Even I can afford to invest a minute per day.

The BaseLine© chart clearly shows that the day-to-day variation is quite high: and that is expected – it is inherent in the 2-out-of-7 Lo-CHO design. It is the not the short-term change that is the measure of success – it is the long-term improvement that is important.

It is important to measure daily – because it is the daily habit that keeps me mindful, aligned, and on-goal. It is not the measurement itself that is the most important thing – it is the conscious act of measuring and then plotting the dot in the context of the previous dots. The picture tells the story. No further “statistical” analysis is required.

The power of this chart is that it provides hard evidence that is very effective for nudging other skeptics like me into giving the innovative idea a try. I know because I have done that many times now. I have converted other skeptics. It is an innovation infection.

And the same principle appears to apply to other areas. What is critical to success is tangible and visible proof of progress. That is what skeptics need. Then a rational and logical method and explanation that respects their individual opinion and requirements. The design has to work for them. And it must make sense.

They will come out with a string of “Yes … buts” and that is OK because that is how skeptics work. Just answer their questions with evidence and explanations. It can get a bit wearing I admit but it is worth the effort.

An effective Improvement Scientist needs to be a healthy skeptic too – i.e. an open minded one.

28/09/2013

The Victim Vortex

[Beep Beep] Bob tapped the “Answer” button on his smartphone – it was Lesley calling in for their regular ISP coaching session.

<Bob>Hi Lesley. How are you today? And which tunnel in the ISP Learning Labyrinth shall we explore today?

<Lesley>Hi Bob. I am OK thank you. Can we invest some time in the Engagement Maze?

<Bob>OK. Do you have a specific example?

<Lesley>Sort of. This week I had a conversation with our Chief Executive about the potential of Improvement Science and the reply I got was “I am convinced by what you say but it is your colleagues who need to engage. If you have not succeeded in convincing them then how can I?” I was surprised by that response and slightly niggled because it had an uncomfortable nugget of truth in it.

<Bob>That sounds like the wisdom of a leader who understands that the “power” to make things happen does not sit wholly in the lap of those charged with accountability.

<Lesley> I agree. And at the same time everything that the “Top Team” suggest gets shot down in flames by a small and very vocal group of my more skeptical colleagues.

<Bob>Ah ha! It sounds like the Victim Vortex is causing trouble here.

<Lesley>The Victim Vortex?

<Bob>Yes. Let me give you an example. One of the common initiators of the Victim Vortex is the data flow part of a complex system design. The Sixth Flow. So can I ask you: “How are new information systems developed in your organization?“

<Lesley>Wow! You hit the nail on the head first time! Just this week there has been another firestorm of angry emails triggered by yet another silver-bullet IT system being foisted on us!

<Bob>Interesting use of language Lesley. You sound quite “niggled”.

<Lesley>I am. Not by the constant “drizzle of IT magic” – that is irritating enough – but more by the vehemently cynical reaction of my peers.

<Bob>OK. This sounds like good enough example of the Victim Vortex. What do you expect the outcome will be?

<Lesley>Well, if past experience is a predictor for future performance – an expensive failure, more frustration and a deeper well of cynicism.

<Bob>Frustrating for whom?

<Lesley>Everyone. The IT department as well. It feels like we are all being sucked into a lose-lose-lose black hole of depression and despair!

<Bob>A very good description of the Victim Vortex.

<Lesley>So the Victim Vortex is an example of the Drama Triangle acting on an organizational level?

<Bob>Yes. Visualize a cultural tornado. The energy that drives it is the emotional currency spent in playing the OK – Not OK Games. It is a self-fueling system, a stable design, very destructive and very resistant to change.

<Lesley>That metaphor works really well for me!

<Bob>A similar one is a whirlpool – a water vortex. If you were out swimming and were caught up in a whirlpool what are your exit strategy options?

<Lesley>An interesting question. I have never had that experience and would not want it – it sounds rather hazardous. Let me think. If I do nothing I will just get swept around in the chaos and I am at risk of getting bashed, bruised and then sucked under.

<Bob>Yes – you would probably spend all your time and energy just treading water and dodging the flotsam and jetsam that has been sucked into the Vortex. That is what most people do. It is called the Hamster Wheel effect.

<Lesley>So another option is to actively swim towards the middle of the Vortex – the end would at least be quick! But that is giving up and adopting the Hopelessness attitude of burned out Victim. That would be the equivalent of taking voluntary redundancy or early retirement. It is not my style!

<Bob>Yes. It does not solve the problem either. The Vortex is always hoovering up new Victims. It is insatiable.

<Lesley> And another option would be to swim with the flow to avoid being “got” from behind. That would be seem sensible and is possible; and at least I would feel better for doing something. I might even escape if I swim fast enough!

<Bob>That is indeed what some try. The movers and shakers. The pace setters. The optimists. The extrovert leaders. The problem is that it makes the Vortex spin even faster. It actually makes the Vortex bigger, more chaotic and more dangerous than before.

<Lesley>Yes – I can see that. So my other option is to swim against the flow in an attempt to slow the Vortex down. Would that work?

<Bob>If everyone did that at the same time it might but that is unlikely to happen spontaneously. If you could achieve that degree of action alignment you would not have a Victim Vortex in the first place. Trying to do it alone is ineffective, you tire very quickly, the other Victims bash into you, you slow them down, and then you all get sucked down the Plughole of Despair.

<Lesley>And I suppose a small group of like-minded champions who try to swim-against the flow might last longer if they stick together but even then eventually they would get bashed up and broken up too. I have seen that happen. And that is probably where our team are heading at the moment. I am out of options. Is it impossible to escape the Victim Vortex?

<Bob>There is one more direction you can swim.

<Lesley>Um? You mean across the flow heading directly away from the center?

<Bob>Exactly. Consider that option.

<Lesley>Well, it would still be hard work and I would still be going around with the Vortex and I would still need to watch out for flotsam but every stroke I make would take me further from the center. The chaos would get gradually less and eventually I would be in clear water and out of danger. I could escape the Victim Vortex!

<Bob>Yes. And what would happen if others saw you do that and did the same?

<Lesley>The Victim Vortex would dissipate!

<Bob>Yes. So that is your best strategy. It is a win-win-win strategy too. You can lead others out of the Victim Vortex.

<Lesley>Wow! That is so cool! So how would I apply that metaphor to the Information System niggle?

<Bob>I will leave you to ponder on that. Think about it as a design assignment. The design of the system that generates IT solutions that are fit-for-purpose.

<Lesley> Somehow I knew you were going to say that! I have my squared-paper and sharpened pencil at the ready. Yes – an improvement-by-design assignment. Thank you once again Bob. This ISP course is the business!

08/09/2013

DRAT!

[Bing Bong] The sound bite heralded Leslie joining the regular Improvement Science mentoring session with Bob. They were now using web-technology to run virtual meetings because it allows a richer conversation and saves a lot of time. It is a big improvement.

<Bob> Hi Lesley, how are you today?

<Leslie> OK thank you Bob. I have a thorny issue to ask you about today. It has been niggling me even since we started to share the experience we are gaining from our current improvement-by-design project.

<Bob> OK. That sounds interesting. Can you paint the picture for me?

<Leslie> Better than that – I can show you the picture, I will share my screen with you.

<Bob> OK. I can see that RAG table. Can you give me a bit more context?

<Leslie> Yes. This is how our performance management team have been asked to produce their 4-weekly reports for the monthly performance committee meetings.

<Bob> OK. I assume the “Period” means sequential four week periods … so what is Count, Fail and Fail%?

<Leslie> Count is the number of discharges in that 4 week period, Fail is the number whose length of stay is longer than the target, and Fail% is the ratio of Fail/Count for each 4 week period.

<Bob> It looks odd that the counts are all 28. Is there some form of admission slot carve-out policy?

<Leslie> Yes. There is one admission slot per day for this particular stream – that has been worked out from the average historical activity.

<Bob> Ah! And the Red, Amber, Green indicates what?

<Leslie> That is depends where the Fail% falls in a set of predefined target ranges; less than 5% is green, 5-10% is Amber and more than 10% is red.

<Bob> OK. So what is the niggle?

<Leslie>Each month when we are in the green we get no feedback – a deafening silence. Each month we are in amber we get a warning email. Each month we are in the red we have to “go and explain ourselves” and provide a “back-on-track” plan.

<Bob> Let me guess – this feedback design is not helping much.

<Leslie> It is worse than that – it creates a perpetual sense of fear. The risk of breaching the target is distorting people’s priorities and their behaviour.

<Bob> Do you have any evidence of that?

<Leslie> Yes – but it is anecdotal. There is a daily operational meeting and the highest priority topic is “Which patients are closest to the target length of stay and therefore need to have their discharge expedited?“.

<Bob> Ah yes. The “target tail wagging the quality dog” problem. So what is your question?

<Leslie> How do we focus on the cause of the problem rather than the symptoms? We want to be rid of the “fear of the stick”.

<Bob> OK. What you have hear is a very common system design flaw. It is called a DRAT.

<Leslie> DRAT?

<Bob> “Delusional Ratio and Arbitrary Target”.

<Leslie> Ha! That sounds spot on! “DRAT” is what we say every time we miss the target!

<Bob> Indeed. So first plot this yield data as a time series chart.

<Leslie> Here we go.

<Bob>Good. I see you have added the cut-off thresholds for the RAG chart. These 5% and 10% thresholds are arbitrary and the data shows your current system is unable to meet them. Your design looks incapable.

<Leslie>Yes – and it also shows that the % expressed to one decimal place is meaningless because there are limited possibilities for the value.

<Bob> Yes. These are two reasons that this is a Delusional Ratio; there are quite a few more.

<Leslie> OK and if I plot this as an Individuals charts I can see that this variation is not exceptional.

<Bob> Careful Leslie. It can be dangerous to do this: an Individuals chart of aggregate yield becomes quite insensitive with aggregated counts of relatively rare events, a small number of levels that go down to zero, and a limited number of points. The SPC zealots are compounding the problem and plotting this data as a C-chart or a P-chart makes no difference.

This is all the effect of the common practice of applying an arbitrary performance target then counting the failures and using that as means of control.

It is poor feedback loop design – but a depressingly common one.

<Leslie> So what do we do? What is a better design?

<Bob> First ask what the purpose of the feedback is?

<Leslie> To reduce the number of beds and save money by forcing down the length of stay so that the bed-day load is reduced and so we can do the same activity with fewer beds and at the same time avoid cancellations.

<Bob> OK. That sounds reasonable from the perspective of a tax-payer and a patient. It would also be a more productive design.

<Leslie> I agree but it seems to be having the opposite effect. We are focusing on avoiding breaches so much that other patients get delayed who could have gone home sooner and we end up with more patients to expedite. It is like a vicious circle. And every time we fail we get whacked with the RAG stick again. It is very demoralizing and it generates a lot of resentment and conflict. That is not good for anyone – least of all the patients.

<Bob>Yes. That is the usual effect of a DRAT design. Remember that senior managers have not been trained in process improvement-by-design either so blaming them is also counter-productive. We need to go back to the raw data. Can you plot actual LOS by patient in order of discharge as a run chart.

<Bob> OK – is the maximum LOS target 8 days?

<Leslie> Yes – and this shows we are meeting it most of the time. But it is only with a huge amount of effort.

<Bob> Do you know where 8 days came from?

<Leslie> I think it was the historical average divided by 85% – someone read in a book somewhere that 85% average occupancy was optimum and put 2 and 2 together.

<Bob> Oh dear! The “85% Occupancy is Best” myth combined with the “Flaw of Averages” trap. Never mind – let me explain the reasons why it is invalid to do this.

<Leslie> Yes please!

<Bob> First plot the data as a run chart and as a histogram – do not plot the natural process limits yet as you have done. We need to do some validity checks first.

<Leslie> Here you go.

<Bob> What do you see?

<Leslie> The histogram has more than one peak – and there is a big one sitting just under the target.

<Bob>Yes. This is called the “Horned Gaussian” and is the characteristic pattern of an arbitrary lead-time target that is distorting the behaviour of the system. Just as you have described subjectively. There is a smaller peak with a mode of 4 days and are a few very long length of stay outliers. This multi-modal pattern means that the mean and standard deviation of this data are meaningless numbers as are any numbers derived from them. It is like having a bag of mixed fruit and then setting a maximum allowable size for an unspecified piece of fruit. Meaningless.

<Leslie> And the cases causing the breaches are completely different and could never realistically achieve that target! So we are effectively being randomly beaten with a stick. That is certainly how it feels.

<Bob> They are certainly different but you cannot yet assume that their longer LOS is inevitable. This chart just says – “go and have a look at these specific cases for a possible cause for the difference“.

<Leslie> OK … so if they are from a different system and I exclude them from the analysis what happens?

<Bob> It will not change reality. The current design of this process may not be capable of delivering an 8 day upper limit for the LOS. Imposing a DRAT does not help – it actually makes the design worse! As you can see. Only removing the DRAT will remove the distortion and reveal the underlying process behaviour.

<Leslie> So what do we do? There is no way that will happen in the current chaos!

<Bob> Apply the 6M Design® method. Map, Measure and Model it. Understand how it is behaving as it is then design out all the causes of longer LOS and that way deliver with a shorter and less variable LOS. Your chart shows that your process is stable. That means you have enough flow capacity – so look at the policies. Draw on all your FISH training. That way you achieve your common purpose, and the big nasty stick goes away, and everyone feels better. And in the process you will demonstrate that there is a better feedback design than DRATs and RAGs. A win-win-win design.

<Leslie> OK. That makes complete sense. Thanks Bob! But what you have described is not part of the FISH course.

<Bob> You are right. It is part of the ISP training that comes after FISH. Improvement Science Practitioner.

<Leslie> I think we will need to get a few more people trained in the theory, techniques and tools of Improvement Science.

<Bob> That would appear to be the case. They will need a real example to see what is possible.

<Leslie> OK. I am on the case!

25/08/2013

Find and Fill

Many barriers to improvement are invisible.

This is because they are caused by what is not present rather than what is. They are gaps or omissions.

Some gaps are blindingly obvious. This is because we expect to see something there so we notice when it is missing. We would notice the gap if a rope bridge across chasm is obviously missing because only end posts are visible.

Many gaps are not obvious. This is because we have no experience or expectation. The gap is invisible. We are blind to the omission.

These are the gaps that we accidentally stumble into. Such as a gap in our knowledge and understanding that we cannot see. These are the gaps that create the fear of failure. And the fear is especially real because the gap is invisible and we only know when it is too late.

It is like walking across an emotional minefield. At any moment we could step on an ignorance mine and our confidence would be blasted into fragments.

So our natural and reasonable reaction is to stay outside the emotional minefield and inside our comfort zones – where we feel safe. We give up trying to learn and trying to improve. Every-one hopes that Some-one or Any-one will do it for us. No-one does.

The path to Improvement is always across an emotional minefield because improvement implies unlearning. So we need a better design than blundering about hoping not to fall into an invisible gap. We need a safer design.

There are a number of options:

Option 1. Ask someone who knows the way across the minefield and can demonstrate it. Someone who knows where the mines are and knows how to avoid them. Someone to tell us where to step and where not to.

Option 2. Clear a new path and mark it clearly so others can trust that it is safe. Remove the ignorance mines. Find and Fill the knowledge map.

Option 1 is quicker but it leaves the ignorance mines in place. So sooner or later someone will step on one. Boom!

We need to be able to do Option 2.

The obvious strategy for Option 2 is to clear the ignorance mines. We could do this by deliberately blundering about setting off the mines. We could adopt the burn-and-scrape or learn-from-mistakes approach.

Or we could detect, defuse and remove them.

The former requires people willing to take emotional risks; the latter does not require such a sacrifice.

And “learn-by-mistakes” only works if people are able to make mistakes visibly so everyone can learn. In an adversarial, competitive, distrustful context this can not happen: and the result is usually for the unwilling troops to be forced into the minefield with the threat of a firing-squad if they do not!

And where a mistake implies irreversible harm it is not acceptable to learn that way. Mistakes are covered up. The ignorance mines are re-set for the next hapless victim to step on. The emotional carnage continues. Any change 0f sustained, system-wide improvement is blocked.

So in a low-trust cultural context the detect-defuse-and-remove strategy is the safer option.

And this requires a proactive approach to finding the gaps in understanding; a proactive approach to filling the knowledge holes; and a proactive approach to sharing what was learned.

Or we could ask someone who knows where the ignorance mines are and work our way through finding and filling our knowledge gaps. By that means any of us can build a safe, effective and efficient path to sustainable improvement.

And the person to ask is someone who can demonstrate a portfolio of improvement in practice – an experienced Improvement Science Practitioner.

And we can all learn to become an ISP and then guide others across their own emotional minefields.

All we need to do is take the first step on a well-trodden path to sustained improvement.

17/08/2013

Fudge? We Love Fudge!

It is almost autumn again. The new school year brings anticipation and excitement. The evenings are drawing in and there is a refreshing chill in the early morning air.

This is the time of year for fudge.

Alas not the yummy sweet sort that Grandma cooked up and gave out as treats.

In healthcare we are already preparing the Winter Fudge – the annual guessing game of attempting to survive the Winter Pressures. By fudging the issues.

This year with three landmark Safety and Quality reports under our belts we have more at stake than ever … yet we seem as ill prepared as usual. Mr Francis, Prof Keogh and Dr Berwick have collectively exhorted us to pull up our socks.

So let us explore how and why we resort to fudging the issues.

Watch the animation of a highly simplified emergency department and follow the thoughts of the manager. You can pause, rewind, and replay as much as you like. Follow the apparently flawless logic – it is very compelling. The exercise is deliberately simplified to eliminate wriggle room. But it is valid because the behaviour is defined by the Laws of Physics – and they are not negotiable.

http://www.youtube.com/watch?v=geRBGP-u5zg&rel=0&loop=1&modestbranding=1

The problem was combination of several planning flaws – two in particular.

First is the “Flaw of Averages” which is where the past performance-over-time is boiled down to one number. An average. And that is then used to predict precise future behaviour. This is a very big mistake.

The second is the “Flaw of Fudge Factors” which is a attempt to mitigate the effects of first error by fudging the answer – by adding an arbitrary “safety margin”.

This pseudo-scientific sleight-of-hand may polish the planning rhetoric and render it more plausible to an unsuspecting Board – but it does not fool Reality.

In reality the flawed design failed – as the animation dramatically demonstrated. The simulated patients came to harm. Unintended harm to be sure – but harm nevertheless.

So what is the alternative?

The alternative is to learn how to avoid Sir Flaw of Averages and his slippery friend Mr Fudge Factor.

And learning how to do that is possible … it is called Improvement Science.

And you can start right now … click HERE.

20/07/2013

The Grape Vine

Improvement Science is a collaborative community activity.

And word about what is possible spreads through The Grape Vine.

And it spreads in a particular way – through stories – personal accounts of “ah ha” moments.

Those “ah ha” moments are generated by a process – a process designed to generate them.

And that process is called the Nerve Curve. It is rather like an emotional roller-coaster ride.

The Nerve Curve starts comfortably enough with a few gentle ups, downs, twists and turns – just to settle everyone in their seats.

Then it picks up pace and you have to hold on a bit tighter.

Then comes the Challenge – an interactive group-led improvement activity. Something like the “Save the NHS Game“.

Then comes the Shock! When the “intuitively obvious” and “collectively agreed” decisions and actions make the problem worse rather than better. The shock is magnified by learning that there is a solution – and that it was hidden from us. We did not know what we did not know. We were blissfully ignorant.

Now we are not. We are painfully aware of what we did not know.

Then we head for Denial like a scared rabbit – but the cars are moving fast now and the is no stopping or going back. We cannot get off – we cannot go back – so we cover our eyes and ears to block out the New Reality.

It does not work very well. We quickly realize that it is safer to be able to see where we are heading so we can prepare for what is coming. An emotional brick wall looms up in front of us – and written on it are the words “Impossibility Hypothesis”. And we are heading right at it. A new emotion bubbles to the surface.

Anger.

“Who’s ****** idea was it to get on this infernal contraption? Why weren’t we warned? Who is in charge? Who is to blame?“

That does not work very well either. So we try a different strategy.

Bargaining.

We desperately want to limit the damage to comfort zone and confidence so we try negotiating a compromise, finding an exit option, and looking for the emergency stop cord. There isn’t one. Reality is relentless and ruthless. Uncompromising.

Now we are really scared and with no viable options for staying where we were and no credible options for avoiding a catastrophe we are emotionally stuck – and we start to sink into Depression which is the path to Hopelessness, Apathy and Despair (HAD). We have run out of options. And we cannot stay in the past.

But the seed of innovation has been sown. A hidden problem has been uncovered and an unknown option has been demonstrated. The “Way Over The Impossible-for-Me barrier” is clearly signposted. The light at the end of the tunnel has been switched on. We have a choice.

And at the last second we sweep over the Can’t Do Barrier and when we look back it has disappeared – it was a mirage – a perceptual trick our Intuition was playing on us. It only existed in our minds.

That is the “Ah ha”.

And now we can see a way forward – and how with support, guidance, encouragement and effort we can climb up Acceptance Mountain to Resolution Peak. It is will not be quick. It will not be comfortable. We have some unlearning to do. A few old assumptions and habits that need to be challenged, dismantled and re-designed.

It is hard work but it is surprisingly invigorating as a previously unrecognized inner well of hope, enthusiasm and confidence is tapped. We surprise ourselves with what we can do already. We realize that the only thing that was actually blocking us before was our belief it was too difficult. And the lack of a guide.

And then we share our “ah ha” with others through The Grape Vine.

Here is a shared “ah ha” from this week:

The Post It® Note exercise was my biggest “Aha” moment on a combination of levels. The aspect that particularly resonated was the range of behaviours and responses from the different pairings, an aspect that would have been hidden had I done the exercise on my own. I’m still smiling at the simple elegance of this particular exercise and the depth of learning I am getting from it. [PD, Consultant Paediatrician. 15th July 2013].

The Post It® Note exercise is part of the FISH course … you can try it yourself here

This blog is part of The Grape Vine.

The Nerve Curve is ready and waiting to take you on an exciting ride through Improvement Science!

29/06/201322/02/2022

Step 6 – Maintain

Anyone with much experience of change will testify that one of the hardest parts is sustaining the hard won improvement.

The typical story is all too familiar – a big push for improvement, a dramatic improvement, congratulations and presentations then six months later it is back where it was before but worse. The cynics are feeding on the corpse of the dead change effort.

The cause of this recurrent nightmare is a simple error of omission.

Failure to complete the change sequence. Missing out the last and most important step. Step 6 – Maintain.

Regular readers may remember the story of the pharmacy project – where a sceptical department were surprised and delighted to discover that zero-cost improvement was achievable and that a win-win-win outcome was not an impossible dream.

Enough time has now passed to ask the question: “Was the improvement sustained?”

The BaseLine© chart above shows their daily performance data on their 2-hour turnaround target for to-take-out prescriptions (TTOs) . The weekends are excluded because the weekend system is different from the weekday system. The first split in the data in Jan 2013 is when the improvement-by-design change was made. Step 4 on the 6M Design® sequence – Modify.

There was an immediate and dramatic improvement in performance that was sustained for about six weeks – then it started to drift back. Bit by Bit. The time-series chart flags it clearly.

So what happened next?

The 12-week review happened next – and it was done by the change leader – in this case the Inspector/Designer/Educator. The review data plotted as a time-series chart revealed instability and that justified an investigation of the root cause – which was that the final and critical step had not been completed as recommended. The inner feedback loop was missing. Step 6 – Maintain was not in place.

The outer feedback loop had not been omitted. That was the responsibility of the experienced change leader.

And the effect of closing the outer-loop is clearly shown by the third segment – a restoration of stability and improved capability. The system is again delivering the improvement it was designed to deliver.

What does this lesson teach us?

The message here is that the sponsors of improvement have essential parts to play in the initiation and the maintenance of change and improvement. If they fail in their responsibility then the outcome is inevitable and predictable. Mediocrity and cynicism.

Part 1: Setting the clarity and constancy of common purpose.

Without a clear purpose then alignment, focus and effectiveness are thwarted. Purpose that changes frequently is not a purpose – it is reactive knee-jerk politics. Constancy of purpose is required because improvement takes time to achieve and to embed. There is always a lag so moving the target while the arrow is in flight is both dangerous and leads to disengagement. Establishing common ground is essential to avoiding the time-wasting discussion and negotiation that is inevitable when opinions differ – which they always do.

Part 2: Respectful challenge.

Effective change leadership requires an ability to challenge from a position of mutual respect. Telling people what to do is not leadership – it is dictatorship. Dodging the difficult conversations and passing the buck to others is not leadership – it is ineffective delegation. Asking people what they want to do is not leadership – it is abdication of responsibility. People need their leaders to challenge them and to respect them at the same time. It is not a contradiction. It is possible to do both.

And one way that a leader of change can challenge with respect is to expose the need for change; to create the context for change; and then to commit to holding those charged with change to account – including themselves. And to make it clear at the start what their expectation is as a leader – and what the consequences of disappointment are.

It is a delight to see individuals, teams, departments and organisations blossom and grow when the context of change is conducive. And it is disappointing to see them wither and shrink when the context of change is laced with cynicide – the toxic product of cynicism.

So what is the next step?

What could an aspirant change leader do to get this for themselves and their organisations?

One option is to become a Student of Improvementology® – and they can do that here.

16/06/2013

Spreading the Word

Patience is a virtue for an advocate of Improvementology®.

This week Mike Davidge (Head of Measurement for the former NHS Institute for Innovation and Improvement) posted some feedback on the Journal of Improvement Science site.

His feedback is reproduced here in full with Mike’s permission. The rationale for reproduction that the activity data shows that more people the Blog than the Journal.

Feedback posted on 15/06/2013 at 07:35:05 for paper entitled:

Dodds S. A Case Study of a Successful One-Stop Clinic Schedule Design using Formal Methods . Journal of Improvement Science 2012:6; 1-13.

“It’s only taken me a year to get round to reading this, an improvement on your 9 years to write it! It was well worth the read. You should make a serious attempt to publish this where it gets a wider audience. Rank = 5/5”

Mike is a world expert in healthcare system measurement and improvement so this is a huge compliment. Thank you Mike. He is right too – 1 year is a big improvement on 9 years. So why did it take 9 years to write up?

One reason is that publication was not the purpose. Improvement was the purpose. Another reason was that this was a step in a bigger improvement project – one that is described in Three Wins. There is a third reason: the design flaws of the traditional academic peer review process. This is radical stuff and upsets a lot of people so we need to be careful.

The two primary design flaws of conventional peer-reviewed academic journals are:

1) that it has a long lead time and
2) that it has a low yield.

So it is very expensive in author-lifetime. Improvement is not the same as research. Perfection is not the goal. Author lifetime is a very valuable resource. If it is wasted with an inefficient publication process design then the result is less output and less dissemination of valuable Improvement Science.

So if any visitors would like to benefit from Mike’s recommendation then you can download the full text of the essay here. It has not been peer-reviewed so you will have to make you own minds up about the value. And if you have any questions then you are free to ask the author.

PS. The visitor who points out the most spelling and grammar errors will earn themselves a copy of BaseLine© the time-series analysis software used to create the charts.

01/06/2013

Closing the Two Loops

Over the past few weeks I have been conducting an Improvement Science Experiment (ISE). I do that a lot. This one is a health improvement experiment. I do that a lot too. Specifically – improving my own health. Ah! Not so diligent with that one.

The domain of health that I am focusing on is weight – for several reasons:
(1) because a stable weight that is within “healthy” limits is a good idea for many reasons and
(2) because weight is very easy to measure objectively and accurately.

But like most people I have constraints: motivation constraints, time constraints and money constraints. What I need is a weight reduction design that requires no motivation, no time, and no money. That sounds like a tough design challenge – so some consideration is needed.

Design starts with a specific purpose and a way of monitoring progress. And I have a purpose – weight within acceptable limits; a method for monitoring progress – a dusty set of digital scales. What I need is a design for delivering the improvement and a method for maintaining it. That is the challenge.

So I need a tested design that will deliver the purpose. I could invent something here but it is usually quicker to learn from others who have done it, or something very similar. And there is lots of knowledge and experience out there. And they fall into two broad schools – Eat Healthier or Exercise More and usually Both.

Eat Healthier is sold as Eat Less of the Yummy Bad Stuff and more of the Yukky Good Stuff. It sounds like a Puritanical Policy and is not very motivating. So with zero motivation as a constraint this is a problem. And Yukky Good Stuff seems to come with a high price tag. So with zero budget as a constraint this is a problem too.

Exercise More is sold as Get off Your Bottom and Go for a Walk. It sounds like a Macho Man Mantra. Not very motivating either. It takes time to build up a “healthy” sweat and I have no desire to expose myself as a health-desperado by jogging around my locality in my moth-eaten track suit. So with zero time as a constraint this is a problem. Gym subscriptions and the necessary hi-tech designer garb do not come cheap. So with a zero budget constraint this is another problem.

So far all the conventional wisdom is failing to meet any of my design constraints. On all dimensions.

Oh dear!

The rhetoric is not working. That packet of Chocolate Hob Nobs is calling to me from the cupboard. And I know I will feel better if I put them out of their misery. Just one will not do any harm. Yum Yum. Arrrgh!!! The Guilt. The Guilt.

OK – get a grip – time for Improvement Scientist to step in – we need some Science.

[Improvement Science hat on]

The physics and physiology are easy on this one:

(a) What we eat provides us with energy to do necessary stuff (keep warm, move about, think, etc). Food energy is measured in “Cals”; work energy is measured in “Ergs”.
(b) If we eat more Cals than we burn as Ergs then the difference is stored for later – ultimately as blubber (=fat).
(c) There are four contributors to or weight: dry (bones and stuff), lean (muscles and glands of various sorts), fluid (blood, wee etc), and blubber (fat).
(d) The sum of the dry, lean, and fluids should be constant – we need them – we do not store energy there.
(e) The fat component varies. It is stored energy. Work-in-progress so to speak.
(f) One kilogram of blubber is equivalent to about 9000 Cals.
(g) An adult of average weight, composition, and activity uses between 2000 and 2500 Cals per day – just to stay at a stable weight.

These facts are all we need to build an energy flow model.

Food Cals = Energy In.
Work Ergs = Energy Out.
Difference between Energy In and Energy Out is converted to-and-from blubber at a rate of 1 gram per 9 Cal.
Some of our weight is the accumulated blubber – the accumulated difference between Cals-In and Ergs-Out

The Laws Of Physics are 100% Absolute and 0% Negotiable. The Behaviours of People are 100% Relative and 100% Negotiable. Weight loss is more about behaviour. Habits. Lifestyle.

Bit more Science needed now:

Which foods have the Cals?

(1) Fat (9 Cal per gram)
(2) Carbs (4 Cal per gram)
(3) Protein (4 Cal per gram)
(4) Water, Vitamins, Minerals, Fibre, Air, Sunshine, Fags, Motivation (0 Cal per gram).

So how much of each do we get from the stuff we nosh?

It is easy enough to work out – but it is very tedious to do so. This is how calorie counting weight loss diets work. You weigh everything that goes in, look up the Cal conversions per gram in a big book, do some maths and come up with a number. That takes lots of time. Then you convert to points and engage in a pseudo-accounting game where you save points up and cash them in as an occasional cream cake. Time is a constraint and Saving-the-Yummies-for-Later is not changing a habit – it is feeding it!

So it is just easier for me to know what a big bowel of tortilla chips translates to as Cals. Then I can make an informed choice. But I do not know that.

Why not?

Because I never invested time in learning. Like everyone else I gossip, I guess, and I generalise. I say “Yummy stuff is bad because it is Hi-Cal; Yukky stuff is good because it is Lo-Cal“. And from this generalisation I conclude “Cutting Cals feels bad“. Which is a problem because my motivation is already rock bottom. So I do nothing, and my weight stays the same, and I still feel bad.

The Get-Thin-Quick industry knows this … so they use Shock Tactics to motivate us. They scare us with stories of fat young people having heart attacks and dying wracked with regret. Those they leave behind are the real victims. The industry bludgeons us into fearful submission and into coughing up cash for their Get Thin Quick Panaceas. Their real goal is the repeat work – the loyal customers. And using scare mongering and a few whale-to-waif conversions as rabble-rousing zealots they cook up the ideal design to achieve that. They know that, for most of us, as soon as the fear subsides, the will weakens, the chips are down (the neck), the blubber builds, and we are back with our heads hung low and our wallets open.

I have no motivation – that is a constraint. So flogging an over-weight and under-motivated middle-aged curmudgeon will only get a more over-weight, ego-bruised-and-depressed, middle-aged cynic. I may even seek solace in the Chocolate Hob Nob jar.

Nah! I need a better design.

[Improvement Scientist hat back on]

First Rule of Improvement – Check the Assumptions.

Assumption 1:
Yummy => Hi-Cal => Bad for Health
Yukky => Lo-Cal => Good for Health

It turns out this is a gross over-simplification. Lots of Yummy things are Lo-Cal; lots of Yukky things are Hi-Cal. Yummy and Yukky are subjective. Cals are not.

OK – that knowledge is really useful because if I know which-is-which then I can made wiser decisions. I can do swaps so that the Yummy Score goes higher and the Cals Score goes lower. That sounds more like it! My Motiv-o-Meter twitches.

Assumption 2:
Hi-Cal => Cheap => Good for Wealth
Lo-Cal => Expensive => Bad for Wealth

This is a gross over-simplification too. Lots of Expensive things are Hi-Cal; lots of Cheap things are Lo-Cal.

OK so what about the combination?

Bingo! There are lots of Yummy+Cheap+Lo-Cal things out there ! So my process is to swap the Lose-Lose-Lose for the Win-Win-Win. I feel a motivation surge. The needle on my Motiv-o-Meter definitely moved this time.

But how much? And for how long? And how will I know if it is working?

[Improvement Science hat back on]

Second Rule of Improvement Science – Work from the Purpose

We need an output specification. What weight reduction in what time-scale?

OK – I work out my target weight – using something called the BMI (body mass index) which uses my height and a recommended healthy BMI range to give a target weight range. I plumb for 75 kg – not just “10% reduction” – I need an absolute goal. (PS. The BMI chart I used is at the end of the blog).

OK – I now I need a time-scale – and I know that motivation theory shows that if significant improvement is not seen within 15 repetitions of a behaviour change then it does not stick. It will not become a new habit. I need immediate feedback. I need to see a significant weight reduction within two weeks. I need a quick win to avoid eroding my fragile motivation. And so long as a get that I will keep going. And how long to get to target weight? One or two lunar cycles feels about right. Let us compromise on six weeks.

And what is a “significant improvement”?

Ah ha! Now I am on familiar ground – I have a tool for answering that question – a system behaviour chart (SBC). I need to measure my weight and plot it on a time-series chart using BaseLine. And I know that I need 9 points to show a significant shift, and I know I must not introduce variation into my measurements. So I do four things – I ensure my scales have high enough precision (+/- 0.1 kg); I do the weighing under standard conditions (same time of day and same state of dress); I weigh myself every day or every other day; and I plot-the-dots.

OK – how am I doing on my design checklist?
1. Purpose – check
2. Process – check
3. Progress – check

Anything missing?

Yes – I need to measure the energy input – the Cals per day going in – but I need a easy, quick and low-cost way of doing it.

Time for some brainstorming. What about an App? That fancy new smartphone can earn its living for a change. Yup – lots of free ones for tracking Cals. Choose one. Works OK. Another flick on the Motiv-o-Meter needle.

OK – next bit of the jigsaw. What is my internal process metric (IPM)? How many fewer Cals per day on average do I need to achieve … quick bit of beer-mat maths … that many kg reduction times Cal per kg of blubber divided by 6 weeks gives … 1300 Cals per day less than now (on average). So what is my daily Cals input now? I dunno. I do not have a baseline. And I do not fancy measuring it for a couple of weeks to get one. My feeble motivation will not last that long. I need action. I need a quick win.

OK – I need to approach this a different way. What if I just change the input to more Yummy+Cheap+Lo-Cal stuff and less Yummy+Cheap+Hi-Cal stuff and just measure what happens. What if I just do what I feel able to? I can measure the input Cals accurately enough and also the output weight. My curiosity is now pricked too and my Inner Nerd starts to take notice and chips in “You can work out the rest from that. It is a simple S&F model” . Thanks Inner Nerd – you do come in handy occasionally. My Motiv-o-Meter is now in the green – enough emotional fuel for a decision and some action.

I have all the bits of the design jigsaw – Purpose, Process, Progress and Pieces. Studying, and Planning over – time for Doing.

So what happened?

It is an ongoing experiment – but so far it has gone exactly as the design dictated (and the nerdy S&F model predicted).

And the experience has helped me move some Get-Thin-Quick mantras to the rubbish bin.

I have counted nine so far:

Mantra 1. Do not weight yourself every day – rubbish – weigh yourself every day using a consistent method and plot the dots.
Mantra 2. Focus on the fat – rubbish – it is Cals that count whatever the source – fat, carbs, protein (and alcohol).
Mantra 3. Five fresh fruit and veg a day – rubbish – they are just Hi-Cost+Low-Cal stocking fillers.
Mantra 4. Only eat balanced meals – rubbish – it is OK to increase protein and reduce both carbs and fat.
Mantra 5. It costs money to get healthy – rubbish – it is possible to reduce cost by switching to Yummy+Cheap+Lo-Cal stuff.
Mantra 6. Cholesterol is bad – rubbish – we make more cholesterol than we eat – just stay inside a recommended range.
Mantra 7. Give up all alcohol – rubbish – just be sensible – just stay inside a recommended range.
Mantra 8. Burn the fat with exercise – rubbish – this is scraping-the-burnt-toast thinking – less Cals in first.
Mantra 9. Eat less every day – rubbish – it is OK to have Lo-Cal days and OK-Cal days – it is the average Cals that count.

And the thing that has made the biggest difference is the App. Just being able to quickly look up the Cals in a “Waitrose Potato Croquette” when-ever and where-ever I want to is what I really needed. I have quickly learned what-is-in-what and that helps me make “Do I need that Chocolate Hob-Nob or not?” decisions on the fly. One tiny, insignificant Chocolate Hob-Nob = 95 Cals. Ouch! Maybe not.

I have been surprised by what I have learned. I now know that before I was making lots of unwise decisions based on completely wrong assumptions. Doh!

The other thing that has helped me build motivation is seeing the effect of those wiser design decisions translated into a tangible improvement – and quickly! With a low-variation and high-precision weight measurement protocol I can actually see the effect of the Cals ingested yesterday on the Weight recorded today. Our bodies obey the Laws of Physics. We are what we eat.

So what is the lesson to take away?

That there are two feedback loops that need to be included in all Improvement Science challenges – and both loops need to be closed so information flows if the Improvement exercise is to succeed and to sustain.

First the Rhetoric Feedback loop – where new, specific, knowledge replaces old, generic gossip. We want to expose the myths and mantras and reveal novel options. Challenge assumptions with scientifically valid evidence. If you do not know then look it up.

Second the Reality Feedback loop – where measured outcomes verifies the wisdom of the decision – the intended purpose was achieved. Measure the input, internal and output metrics and plot all as time-series charts. Seeing is believing.

So the design challenge has been achieved and with no motivation, no time and no budget.

Now where is that packet of Chocolate Hob Nobs. I think I have earned one. Yum yum.

[PS. This is not a new idea – it is called “double loop learning“. Do not know of it? Worth looking it up?]

25/05/2013

Burn-and-Scrape

[Ring Ring]

<Bob> Hi Leslie how are you to today?

<Leslie> I am good thanks Bob and looking forward to today’s session. What is the topic?

<Bob> We will use your Niggle-o-Gram® to choose something. What is top of the list?

<Leslie> Let me see. We have done “Engagement” and “Productivity” so it looks like “Near-Misses” is next.

<Bob> OK. That is an excellent topic. What is the specific Niggle?

<Leslie> “We feel scared when we have a safety near-miss because we know that there is a catastrophe waiting to happen.”

<Bob> OK so the Purpose is to have a system that we can trust not to generate avoidable harm. Is that OK?

<Leslie> Yes – well put. When I ask myself the purpose question I got a “do” answer rather than a “have” one. The word trust is key too.

<Bob> OK – what is the current safety design used in your organisation?

<Leslie> We have a computer system for reporting near misses – but it does not deliver the purpose above. If the issue is ranked as low harm it is just counted, if medium harm then it may be mentioned in a report, and if serious harm then all hell breaks loose and there is a root cause investigation conducted by a committee that usually results in a new “you must do this extra check” policy.

<Bob> Ah! The Burn-and-Scrape model.

<Leslie>Pardon? What was that? Our Governance Department call it the Swiss Cheese model.

<Bob> Burn-and-Scrape is where we wait for something to go wrong – we burn the toast – and then we attempt to fix it – we scrape the burnt toast to make it look better. It still tastes burnt though and badly burnt toast is not salvageable.

<Leslie>Yes! That is exactly what happens all the time – most issues never get reported – we just “scrape the burnt toast” at all levels.

<Bob> One flaw with the Burn-and-Scrape design is that harm has to happen for the design to work.

It is all reactive.

Another design flaw is that it focuses attention on the serious harm first – avoidable mortality for example. Counting the extra body bags completely misses the purpose. Avoidable death means avoidably shortened lifetime. Avoidable non-fatal will also shorten lifetime – and it is even harder to measure. Just consider the cumulative effect of all that non-fatal life-shortening avoidable-but-ignored harm?

Most of the reasons that we live longer today is because we have removed a lot of lifetime shortening hazards – like infectious disease and severe malnutrition.

Take health care as an example – accurately measuring avoidable mortality in an inherently high-risk system is rather difficult. And to conclude “no action needed” from “no statistically significant difference in mortality between us and the global average” is invalid and it leads to a complacent delusion that what we have is good enough. When it comes to harm it is never “good enough”.

<Leslie> But we do not have the resources to investigate the thousands of cases of minor harm – we have to concentrate on the biggies.

<Bob> And do the near misses keep happening?

<Leslie> Yes – that is why they are top rank on the Niggle-o-Gram®.

<Bob> So the Burn-and-Scrape design is not fit-for-purpose.

<Leslie> So it seems. But what is the alternative? If there was one we would be using it – surely?

<Bob> Look back Leslie. How many of the Improvement Science methods that you have already learned are business-as-usual?

<Leslie> Good point. Almost none.

<Bob> And do they work?

<Leslie> You betcha!

<Bob> This is another example. It is possible to design systems to be safe – so the frequent near misses become rare events.

<Leslie> Is it? Wow! That know-how would be really useful to have. Can you teach me?

<Bob> Yes. First we need to explore what the benefits would be.

<Leslie> OK – well first there would be no avoidable serious harm and we could trust in the safety of our system – which is the purpose.

<Bob> Yes …. and?

<Leslie> And … all the effort, time and cost spent “scraping the burnt toast” would be released.

<Bob> Yes …. and?

<Leslie> The safer-by-design processes would be quicker and smoother, a more enjoyable experience for both customers and suppliers, and probably less expensive as well!

<Bob> Yes. So what does that all add up to?

<Leslie> A win-win-win-win outcome!

<Bob> Indeed. So a one-off investment of effort, time and money in learning Safety-by-Design methods would appear to be a wise business decision.

<Leslie> Yes indeed! When do we start?

<Bob> We have already started.

For a real-world example of this approach delivering a significant and sustained improvement in safety click here.

11/05/2013

“When the Student is ready …”

Improvement Science is not a new idea. The principles are enduring and can be traced back as far as recorded memory – for Millennia. This means that there is a deep well of ancient wisdom that we can draw from. Much of this wisdom is condensed into short sayings which capture a fundamental principle or essence.

One such saying is attributed to Zen Buddhism and goes “When the Student is ready the Teacher will appear.“

This captures the essence of a paradigm shift – a term made popular by Thomas S Kuhn in his seminal 1962 book – The Structure of Scientific Revolutions. It was written just over 50 years ago.

System-wide change takes time and the first stage is the gradual build up of dissatisfaction with the current paradigm. The usual reaction from the Guardians of the Status Quo is to silence the first voices of dissent, often brutally. As the pressure grows there are too many voices to silence individually so more repressive Policies and Policing are introduced. This works for a while but does not dissolve the drivers of dissatisfaction. The pressure builds and the cracks start to appear. This is a dangerous phase.

There are three ways out: repression, revolution, and evolution. The last one is the preferred option – and it requires effective leadership to achieve. Effective leaders are both Teachers and Students. Knowledge and understanding flow through them as they acquire Wisdom.

The first essence of the message is that the solutions to the problems are already known – but the reason they are not widely known and used is our natural affection for the familiar and our distrust of the unfamiliar. If we are comfortable then why change?

It is only when we are uncomfortable enough that we will start to look for ways to regain comfort – physical and psychological.

The second essence of the message is that to change we need to learn something and that means we have to become Students, and to seek the guidance of a Teacher. Someone who understands the problems, their root causes, the solutions, the benefits and most importantly – how to disseminate that knowledge and understanding. A Teacher that can show us how not just tell us what.

The third essence of the message is that the Students become Teachers themselves as they put into practice what they have learned and prove to themselves that it works, and it is workable. The new understanding flows along the Optimism-Skepticism gradient until the Tipping Point is reached. It is then unstoppable and the Paradigm flips. Often remarkably quickly.

The risk is that change means opportunity and there are many who can sniff out an opportunity to cash in on the change chaos. They are the purveyors of Snakeoil – and they prey on the dissatisfied and desperate.

So how does a Student know a True-Teacher from a Snakeoil Salesperson?

Simple – the genuine Teacher will be able to show a portfolio of successes and delighted ex-students; will be able to explain and demonstrate how they were both achieved; will be willing to share their knowledge; and will respectfully decline to teach someone who they feel is not yet ready to learn.

27/04/2013

The Tyranny of Choice

[Ding-a-Ling]
Bob’s new all-singing-and-dancing touchscreen phone pronounced the arrival of an email from an Improvement Science apprentice. This was always an opportunity for learning so he swiped the flashing icon and read the email. It was from Leslie.

<Leslie>Hi Bob, I have come across a new challenge that I never thought I would see – the team that I am working with are generating so many improvement-by-design ideas that we cannot decide what to try. Can you help?

Bob thumbed a reply immediately:
<Bob>Ah ha! The Tyranny of Choice challenge. Yes, I believe I can help. I am free to talk now if you are.

[“You have a call from Leslie”]
Bob’s new all-singing-and-dancing touchscreen phone said that it was Leslie on the line – (it actually said it in the synthetic robot voice that Bob had set as the default).

<Bob>Hello Leslie.

<Leslie>Hi Bob, thank you for replying so quickly. I gather that you have encountered this challenge before?

<Bob>Yes. It usually appears when a team are nearing the end of a bumpy ride on the Nerve Curve and are starting to see new possibilities that previously were there but hidden.

<Leslie>That is just where we are. The problem is we have flipped from no options to so many we cannot decide what to do.

<Bob>It is often assumed that choice is a good thing, but you can have too much of a good thing. Many studies have shown that when the number of innovative choices are limited then people are more likely to make a decision and actually do something. As the number of choices increase it gets much harder to choose so we default to the more comfortable and familiar status quo. We avoid making a decision and we do nothing. That is the Tyranny of Choice.

<Leslie>Yes, that is just how it feels. Paralyzed by indecision. So how do we get past this barrier?

<Bob>The same way we get past all barriers. We step back, broaden our situational awareness and list all the obvious things and then consider doing exactly the opposite of what out intuition tells us. We just follow the tried-and-tested 6M Design script.

<Leslie>Arrgh! Yes, of course. We start with a 4N Chart.

<Bob>Yes, and specifically we start with the Nuggets. We look for what is working despite the odds. The positive deviants. Who do you know is decisive when faced with a host of confusing and conflicting options? Not tyrannized by choice.

<Leslie>Other than you?

<Bob>It does not matter who. How do they do it?

<Leslie>Well – “they” use a special sort of map that I confess I have not mastered yet – the Right-2-Left Map.

<Bob>Yes, an effective way to avoid getting lost in the Labyrinth of Options. What else?

<Leslie>“They” know what the critical steps are and “they” give clear step-by-step guidance of what to do to complete them.

<Bob>This is called “story-boarding”. It is rather like sketching each scene of a play – then practicing each scene script individually until they are second nature and ready when needed.

<Leslie>That is just like what the emergency medical teams do. They have scripts that they use for emergent situations where it is dangerous to try to plan what to do in the moment. They call them “care bundles”. It avoids a lot of time-wasting, debate, prevarication and the evidence shows that it delivers better outcomes and saves lives.

<Bob>In an emergency situation the natural feeling of fear creates the emotional drive to act; but without a well-designed and fully-tested script the same fear can paralyze the decision process. It is the rabbit-in-the-headlights effect. When the feeling of urgency is less a different approach is needed to engage the emotional-power-train.

<Leslie>Do you mean build engagement?

<Bob>Yes, and how do we do that?

<Leslie>We use a combination of subjective stories and objective evidence – heart stuff and head stuff. It is a very effective combination to break through the Carapace of Complacency as you call it. I have seen that work really well in practice.

<Bob>And the 4N Chart comes in handy here again because it helps us see the emotional-terrain in perspective and to align us in moving away from the Niggles towards the NiceIfs while avoiding the NoNos and leveraging the Nuggets.

<Leslie>Yes! I have seen that too. But what do we do when we are in new territory; when we are faced with a swarm of novel options; when we have no pre-designed scripts to help us?

<Bob>We use a meta-script?

<Leslie>A what?

<Bob>A meta-script is one that we use to design a novel action script when we need it.

<Leslie>You mean a single method for creating a plan that we are confident will work?

<Bob>Yes.

<Leslie>That is what the Right-2-Left Map is!

<Bob>Yes.

<Leslie>So the Tyranny of Choice is the result of our habitual Left-2-Right thinking.

<Bob>Yes.

<Leslie>And when the future choices we see are also shrouded in ambiguity it is even harder to make a decision!

<Bob>Yes. We cannot see past the barrier of uncertainty – so we stop and debate because it feels safer.

<Leslie>Which is why so many really clever people seem get stuck in the paralysis of analysis and valueless discussion.

<Bob>Yes.

<Leslie>So all we need to do is switch to the counter-intuitive Right-2-Left thinking and the path becomes clear?

<Bob>Not quite. The choices become a lot easier so the Tyranny of Choice disappears. We still have choices. There are still many possible paths. But it does not matter which we choose because they all lead to the common goal.

<Leslie>Thank you Bob. I am going to have to mull this one over for a while – red wine may help.

<Bob>Yes – mulled wine is a favorite of mine too. Ching-ching!

15/04/2013

Burn Your Bridges and Boats

There are many stories from history on the theme of famous leaders symbolically burning bridges and boats.

They do this because they know that when they have no way back to the past then they are forced to face the future.

When we have no run-away option we have to overcome the challenges that face us – and we surprise and delight ourselves when we learn what we were always capable of achieving!

Our fear of change coupled with a too-easy escape route leads to giving up when the going gets a bit too tough. We choose to fail.

Then we erode our confidence a bit more and are even less likely to try next time.

It is not our ability to succeed or the possibility of success that is the issue. The issue is that we continually create self-fulfilling-failure-prophesies. Or some of us do.

Fortunately there are a some tenacious, courageous and optimistic innovators who keep getting back on the horse. They are a bit angry – mainly at themselves.

And there is a Chinese proverb that says:

“Those who say it cannot be done should not interrupt the person doing it.“

Burning the bridges and the boats can be the bravest and wisest decision that an effective leader can make. It broadcasts a powerful message. It says: “We are all in this together and I believe we can succeed“.

The NHS has just burned its bridges and boats.

The old wooden PCTs and SHAs have gone up in smoke – and the cash is now held by an innovative new design called Clinical Commissioning Groups.

This change was made final on 1st April 2013 (April Fool’s Day sneer the cynics) – and it is now essentially irreversible. We are all in it together.

What is most interesting to observe is how quiet it seems to have gone. We now have to sink or swim with the new system. And what seems to be happening is that people are getting on with it – and surprising themselves with what they can achieve.

Wasting time complaining reduces our chance of survival and the whiners have become a liability.

Which is good because we will see what is possible when our leaders torch our bridges and boats and we are forced to listen to our inner innovative voices! The ones that we have been drowning out with whining, wailing and complaining for years.

And there is another cultural dimension to this symbolic pyre metaphor. It is important to say “goodbye” to the past and to do so with respect. It is important to mourn the loss of what was good and to acknowledge the passing of what was bad. It was not all good and it was not all bad. Both sadness and relief are natural parts of change and improvement. They are part of the emotional transition process. The Nerve Curve.

And I know just how this sort of transition feels because this week I went through a major one. I upgraded my old push-button mobile phone to a phablet. Wow! What a transition! I’m going to call it a “fablet”.

I have to say that I have been looking forward to it with a mixture of anticipation and anxiety. I felt a sad to finally say goodbye to my trusted Blackberry and I felt relieved to say goodbye to its Niggles. The deed is done. The phone number and contacts have been transferred. There is no going back. The boat and bridge are burned. And it was done seamlessly, quickly and with minimal pain. The trigger was the sand running out on my old phone contract. Thank you Car Phone Warehouse – you provided a fabulous service!

And the new fablet feels like an old friend already.

So, onwards and forwards … and so many new and exciting opportunities to explore! And two days after getting the fablet I am writing Android apps in Java (that is geek-speak just to be extra-super-nerdy) – I would never have done that with the old phone!

09/02/2013

The Writing On The Wall – Part I

The writing is on the wall for the NHS.

It is called the Francis Report and there is a lot of it. Just the 290 recommendations runs to 30 pages. It would need a very big wall and very small writing to put it all up there for all to see.

So predictably the speed-readers have latched onto specific words – such as “Inspectors“.

Recommendation 137 “Inspection should remain the central method for monitoring compliance with fundamental standards.”

And it goes further by recommending “A specialist cadre of hospital inspectors should be established …”

A predictable wail of anguish rose from the ranks “Not more inspectors! The last lot did not do much good!”

The word “cadre” is not one that is used in common parlance so I looked it up:

Cadre: 1. a core group of people at the center of an organization, especially military; 2. a small group of highly trained people, often part of a political movement.

So it has a military, centralist, specialist, political flavour. No wonder there was a wail of anguish! Perhaps this “cadre of inspectors” has been unconsciously labelled with another name? Persecutors.

Of more interest is the “highly trained” phrase. Trained to do what? Trained by whom? Clearly none of the existing schools of NHS management who have allowed the fiasco to happen in the first place. So who – exactly? Are these inspectors intended to be protectors, persecutors, or educators?

And what would they inspect?

And how would they use the output of such an inspection?

Would the fear of the inspection and its possible unpleasant consequences be the stick to motivate compliance?

Is the language of the Francis Report going to create another brick wall of resistance from the rubble of the ruins of the reputation of the NHS? Many self-appointed experts are already saying that implementing 290 recommendations is impossible.

They are incorrect.

The number of recommendations is a measure of the breadth and depth of the rot. So the critical-to-success factor is to implement them in a well-designed order. Get the first few in place and working and the rest will follow naturally. Get the order wrong and the radical cure will kill the patient.

So where do we start?

Let us look at the inspection question again. Why would we fear an external inspection? What are we resisting? There are three facets to this: first we do not know what is expected of us; second we do not know if we can satisfy the expectation; and third we fear being persecuted for failing to achieve the impossible.

W Edwards Deming used a very effective demonstration of the dangers of well-intended but badly-implemented quality improvement by inspection: it was called the Red Bead Game. The purpose of the game was to illustrate how to design an inspection system that actually helps to achieve the intended goal. Sustained improvement.

This is applied Improvement Science and I will illustrate how it is done with a real and current example.

I am assisting a department in a large NHS hospital to improve the quality of their service. I have been sent in as an external inspector. The specific quality metric they have been tasked to improve is the turnaround time of the specialist work that they do. This is a flow metric because a patient cannot leave hospital until this work is complete – and more importantly it is a flow and quality metric because when the hospital is full then another patient, one who urgently needs to be admitted, will be waiting for the bed to be vacated. One in one out.

The department have been set a standard to meet, a target, a specification, a goal. It is very clear and it is easily measurable. They have to turnaround each job of work in less than 2 hours. This is called a lead time specification and it is arbitrary. But it is not unreasonable from the perspective of the patient waiting to leave and for the patient waiting to be admitted. Neither want to wait.

The department has a sophisticated IT system that measures their performance. They use it to record when each job starts and when each job is finished and from those two events the software calculates the lead time for each job in real-time. At the end of each day the IT system counts how many jobs were completed in less than 2 hours and compares this with how many were done in total and calculates a ratio which it presents as a percentage in the range of 0 and 100. This is called the process yield. The department are dedicated and they work hard and they do all the work that arrives each day the same day – no matter how long it takes. And at the end of each day they have their score for that day. And it is almost never 100%. Not never. Almost never. But it is not good enough and they are being blamed for it. In turn they blame others for making their job more difficult. It is a blame-game and it has been going on for years.

So how does an experienced Improvement Science-trained Inspector approach this sort of “wicked” problem?

First we need to get the writing on the wall – we need to see the reality – we need to “plot the dots” – we need to see what the performance is doing over time – we need to see the voice of the process. And that requires only their data, a pencil, some paper and for the chart to be put on the on the wall where everyone can see it.

This is what their daily % yield data for three consecutive weeks looked like as a time-series chart. The thin blue line is the 100% yield target.

The 100% target was only achieved on three days – and they were all Sundays. On the other Sunday it was zero (which may mean that there was no data to calculate a ratio from).

There is wide variation from one day to the next and it is the variation as well as the average that is of interest to an improvement scientist. What is the source of the variation it? If 100% yield can be achieved some days then what is different about those days?

So our Improvement science-trained Inspector will now re-plot the data in a different way – as rational groups. This exposes the issue clearly. The variation on Weekends is very wide and the performance during the Weekdays is much less variable. What this says is that the weekend system and the weekday system are different. This means that it is invalid to combine the data for both.

It also raises the question of why there is such high variation in yield only at weekends? The chart cannot answer the question, so our IS-trained Inspector digs a bit deeper and discovers that the volume of work done at the weekend is low, the staffing of the department is different, and that the recording of the events is less reliable. In short – we cannot even trust the weekend data – so we have two reasons to justify excluding it from our chart and just focusing on what happens during the week.

We re-plot our chart, marking the excluded weekend data as not for analysis.

We can now see that the weekday performance of our system is visible, less variable, and the average is a long way from 100%.

The team are working hard and still only achieving mediocre performance. That must mean that they need something that is missing. Motivating maybe. More people maybe. More technology maybe. But there is no more money for more people or technology and traditional JFDI motivation does not seem to have helped.

This looks like an impossible task!

So what does our Inspector do now? Mark their paper with a FAIL and put them on the “To Be Sacked for Failing to Meet an Externally Imposed Standard“ heap?

Nope.

Our IS-trained Inspector calculates the limits of expected performance from the data and plots these limits on the chart – the red lines. The computation is not difficult – it can be done with a calculator and the appropriate formula. It does not need a sophisticated IT system.

What this chart now says is “The current design of this process is capable of delivering between 40% and 85% yield. To expect it do do better is unrealistic”. The implication for action is “If we want 100% yield then the process needs to be re-designed.” Persecution will not work. Blame will not work. Hoping-for-the-best will not work. The process must be redesigned.

Our improvement scientist then takes off the Inspector’s hat and dons the Designer’s overalls and gets to work. There is a method to this and it is called 6M Design®.

First we need to have a way of knowing if any future design changes have a statistically significant impact – for better or for worse. To do this the chart is extended into the future and the red lines are projected forwards in time as the black lines called locked-limits. The new data is compared with this projected baseline as it comes in. The weekends and bank holidays are excluded because we know that they are a different system. On one day (20/12/2012) the yield was surprisingly high. Not 100% but more than the expected upper limit of 85%.

The alerts us to investigate and we found that it was a ‘hospital bed crisis’ and an ‘all hands to the pumps’ distress call went out.

Extra capacity was pulled to the process and less urgent work was delayed until later. It is the habitual reaction-to-a-crisis behaviour called “expediting” or “firefighting”. So after the crisis had waned and the excitement diminished the performance returned to the expected range. A week later the chart signals us again and we investigate but this time the cause was different. It was an unusually quiet day and there was more than enough hands on the pumps.

Both of these days are atypically good and we have an explanation for each of them. This is called an assignable cause. So we are justified in excluding these points from our measure of the typical baseline capability of our process – the performance the current design can be expected to deliver.

An inexperienced manager might conclude from these lessons that what is needed is more capacity. That sounds and feels intuitively obvious and it is correct that adding more capacity may improve the yield – but that does not prove that lack of capacity is the primary cause. There are many other causes of long lead times just as there are many causes of headaches other than brain tumours! So before we can decide the best treatment for our under-performing design we need to establish the design diagnosis. And that is done by inspecting the process in detail. And we need to know what we are looking for; the errors of design commission and the errors of design omission. The design flaws.

Only a trained and experienced process designer can spot the flaws in a process design. Intuition will trick the untrained and inexperienced.

Once the design diagnosis is established then the redesign stage can commence. Design always works to a specification and in this case it was clear – to significantly improve the yield to over 90% at no cost. In other words without needing more people, more skills, more equipment, more space, more anything. The design assignment was made trickier by the fact that the department claimed that it was impossible to achieve significant improvement without adding extra capacity. That is why the Inspector had been sent in. To evaluate that claim.

The design inspection revealed a complex adaptive system – not a linear, deterministic, production-line that manufactures widgets. The department had to cope with wide variation in demand, wide variation in quality of request, wide variation in job complexity, and wide variation in urgency – all at the same time. But that is the nature of healthcare and acute hospital work. That is the expected context.

The analysis of the current design revealed that it was not well suited for this requirement – and the low yield was entirely predictable. The analysis also revealed that the root cause of the low yield was not lack of either flow-capacity or space-capacity.

This insight led to the suggestion that it would be possible to improve yield without increasing cost. The department were polite but they did not believe it was possible. They had never seen it, so why should they be expected to just accept this on faith?

So, the next step was to develop, test and demonstrate a new design and that was done in three stages. The final stage was the Reality Test – the actual process design was changed for just one day – and the yield measured and compared with the predicted improvement.

This was the validity test – the proof of the design pudding. And to visualise the impact we used the same technique as before – extending the baseline of our time-series chart, locking the limits, and comparing the “after” with the “before”.

The yellow point marks the day of the design test. The measured yield was well above the upper limit which suggested that the design change had made a significant improvement. A statistically significant improvement. There was no more capacity than usual and the day was not unusually quiet. At the end of the day we held a team huddle.

Our first question was “How did the new design feel?” The consensus was “Calmer, smoother, fewer interruptions” and best of all “We finished on time – there was no frantic catch up at the end of the day and no one had to stay late to complete the days work!”

The next question was “Do we want to continue tomorrow with this new design or revert back to the old one?” The answer was clear “Keep going with the new design. It feels better.”

The same chart was used to show what happened over the next few days – excluding the weekends as before. The improvement was sustained – it did not revert to the original because the process design had been changed. Same work, same capacity, different process – higher yield. The red flags on the charts mark the statistically significant evidence of change and the cluster of red flags is very strong statistical evidence that the improvement is not due to chance.

The next phase of the 6M Design® method is to continue to monitor the new process to establish the new baseline of expectation. That will require at least twelve data points and it is in progress. But we have enough evidence of a significant improvement. This means that we have no credible justification to return to the old design, and it also implies that it is no longer valid to compare the new data against the old projected limits. Our chart tells us that we need to split the data into before-and-after and to calculate new averages and limits for each segment separately. We have changed the voice of the process by changing the design.

And when we split the data at the point-of-change then the red flags disappear – which means that our new design is stable. And it has a new capability – a better one. We have moved closer to our goal of 100% yield. It is still early days and we do not really have enough data to calculate the new capability.

What we can say is that we have improved average quality yield from 63% to about 90% at no cost using a sequence of process diagnose, design, deliver. Study-Plan-Do.

And we have hard evidence that disproves the impossibility hypothesis.

And that was the goal of the first design change – it was not to achieve 100% yield in one jump. Our design simulation had predicted an improvement to about 90%. And there are other design changes to follow that need this stable foundation to build on. The order of implementation is critical – and each change needs time to bed in before the next change is made. That is the nature of the challenge of improving a complex adaptive system.

The cost to the department was zero but the benefit was huge. The bigger benefit to the organisation was felt elsewhere – the ‘customers’ saw a higher quality, quicker process – and there will be a financial benefit for the whole system. It will be difficult to measure with our current financial monitoring systems but it will be real and it will be there – lurking in the data.

The improvement required a trained and experienced Inspector/Designer/Educator to start the wheel of change turning. There are not many of these in the NHS – but the good news is that the first level of this training is now available.

What this means for the post-Francis Report II NHS is that those who want to can choose to leap over the wall of resistance that is being erected by the massing legions of noisy cynics. It means we can all become our own inspectors. It means we can all become our own improvers. It means we can all learn to redesign our systems so that they deliver higher safety, better quality, more quickly and at no extra one-off or recurring cost. We all can have nothing to fear from the Specialist Cadre of Hospital Inspectors.

The writing is on the wall.

15/02/2013 – Two weeks in and still going strong. The yield has improved from 63% to 92% and is stable. Improvement-by-design works.

10/03/2013 – Six weeks in and a good time to test if the improvement has been sustained.

The chart is the weekly performance plotted for 17 weeks before the change and for 5 weeks after. The advantage of weekly aggregated data is that it removes the weekend/weekday 7-day cycle and reduces the effect of day-to-day variation.

The improvement is obvious, significant and has been sustained. This is the objective improvement. More important is the subjective improvement.

Here is what Chris M (departmental operational manager) wrote in an email this week (quoted with permission):

Hi Simon

It is I who need to thank you for explaining to me how to turn our pharmacy performance around and ultimately improve the day to day work for the pharmacy team (and the trust staff). This will increase job satisfaction and make pharmacy a worthwhile career again instead of working in constant pressure with a lack of achievement that had made the team feel rather disheartened and depressed. I feel we can now move onwards and upwards so thanks for the confidence boost.

Best wishes and many thanks

Chris

This is what Improvement Science is all about!

02/02/2013

Kicking the Habit

It is not easy to kick a habit. We all know that. And for some reason the ‘bad’ habits are harder to kick than the ‘good’ ones. So what is bad about a ‘bad habit’ and why is it harder to give up? Surely if it was really bad it would be easier to give up?

Improvement is all about giving up old ‘bad’ habits and replacing them with new ‘good’ habits – ones that will sustain the improvement. But there is an invisible barrier that resists us changing any habit – good or bad. And it is that barrier to habit-breaking that we need to understand to succeed. Luck is not a reliable ally.

What does that habit-breaking barrier look like?

The problem is that it is invisible – or rather it is emotional – or to be precise it is chemical.

Our emotions are the output of a fantastically complex chemical system – our brains. And influencing the chemical balance of our brains can have a profound effect on our emotions. That is how anti-depressants work – they very slightly adjust the chemical balance of every part of our brains. The cumulative effect is that we feel happier. Nicotine has a similar effect.

And we can achieve the same effect without resorting to drugs or fags – and we can do that by consciously practising some new mental habits until they become ingrained and unconscious. We literally overwrite the old mental habit.

So how do we do this?

First we need to make the mental barrier visible – and then we can focus our attention on eroding it. To do that we need to remove the psychological filter that we all use to exclude our emotions. It is rather like taking off our psychological sunglasses.

When we do that the invisible barrier jumps into view: illuminated by the glare of three negative emotions. Sadness, fear, and anxiety. So whenever we feel any of these we know there is a barrier to improvement hiding the emotional smoke. This is the first stage: tune in to our emotions.

The next step is counter-intuitive. Instead of running away from the negative feeling we consciously flip into a different way of thinking. We actively engage with our negative feelings – and in a very specific way. We engage in a detached, unemotional, logical, rational, analytical ‘What caused that negative feeling?’ way.

We then focus on the causes of the negative emotions. And when we have the root causes of our Niggles we design around them, under them, and over them. We literally design them out of our heads.

The effect is like magic.

And this week I witnessed a real example of this principle in action.

One team I am working with experienced the Power of Improvementology. They saw the effect with their own eyes. There were no computers in the way, no delays, no distortion and no deletion of data to cloud the issue. They saw the performance of their process jump dramatically – from a success rate of 60% to 96%! And not just the first day, the second day too. “Surprised and delighted” sums up their reaction.

So how did we achieve this miracle?

We just looked at the process through a different lens – one not clouded and misshapen by old assumptions and blackened by ignorance of what is possible. We used the 6M Design® lens – and with the clarity of insight it brings the barriers to improvement became obvious. And they were dissolved. In seconds.

Success then flowed as the Dam of Disbelief crumbled and was washed away.

The chaos has gone. The interruptions have gone. The expediting has gone. The firefighting has gone. The complaining has gone. These chronic Niggles have have been replaced by the Nuggets of calm efficiency, new hope and visible excitement.

And we know that others have noticed the knock-on effect because we got an email from our senior executive that said simply “No one has moaned about TTOs for two days … something has changed.”

That is Improvementology-in-Action.

12/01/2013

Quality First or Time First?

Before we explore this question we need to establish something. If the issue is Safety then that always goes First – and by safety we mean “a risk of harm that everyone agrees is unacceptable”.

Many Improvement Zealots state dogmatically that the only way reach the Nirvanah of “Right Thing – On Time – On Budget” is to focus on Quality First.

This is incorrect. And what makes it incorrect is the word only.

Experience teaches us that it is impossible to divert people to focus on quality when everyone is too busy just keeping afloat. If they stop to do something else then they will drown. And they know it.

The critical word here is busy.

‘Busy’ means that everyone is spending all their time doing stuff – important stuff – the work, the checking, the correcting, the expediting, the problem solving, and the fire-fighting. They are all busy all of the time.

So when a Quality Zealot breezes in and proclaims ‘You should always focus on quality first … that will solve all the problems’ then the reaction they get is predictable. The weary workers listen with their arms-crossed, roll-their eyes, exchange knowing glances, sigh, shrug, shake their heads, grit their teeth, and trudge back to fire-fighting. Their scepticism and cynicism has been cut a notch deeper. And the weary workers get labelled as ‘Not Interested In Quality’ and ‘Resisting Change’ and ‘Laggards’ by the Quality Zealot who has spent more time studying and regurgitating rhetoric than investing time in observing and understanding reality.

The problem here is the seemingly innocuous word ‘always’. It is too absolute. Too black-and-white. Too dogmatic. Too simple.

Sometimes focussing on Quality First is a wise decision. And that situation is when there is low-quality and idle-time. There is some spare capacity to re-invest in understanding the root causes of the quality issues, in designing them out of the process, and in implementing the design changes.

But when everyone is busy – when there is no idle-time – then focussing on quality first is not a wise decision because it can actually make the problem worse!

[The Quality Zealots will now be turning a strange red colour, steam will be erupting from their ears and sparks will be coming from their finger-tips as they reach for their keyboards to silence the heretical anti-quality lunatic. “Burn, burn, burn” they rant].

When everyone is busy then the first thing to focus on is Time.

And because everyone is busy then the person doing the Focus-on-Time stuff must be someone else. Someone like an Improvementologist. The Quality Zealot is a liability at this stage – but they become an asset later when the chaos has calmed.

And what our Improvementologist is looking for are queues – also known as Work-in-Progress or WIP.

Why WIP? Why not where the work is happening? Why not focus on resource utilisation? Isn’t that a time metric?

Yes, resource utilisation is a time-related metric but because everyone is busy then resource utilisation will be high. So looking at utilisation will only confirm what we already know. And everyone is busy doing important stuff – they are not stupid – they are busy and they are doing their best given the constraints of their process design.

The queue is where an Improvementologist will direct attention first. And the specific focus of their attention is the cause of the queue.

This is because there is only one cause of a queue: a mismatch-over-time between demand and activity.

So, the critical first step to diagnosing the cause of a queue is to make the flow visible – to plot the time-series charts of demand, activity and WIP. Until that is done then no progress will be made with understanding what is happening and it wil be impossible to decide what to do. We need a diagnosis before we can treat. And to get a diagnosis we need data from an examination of our process; and we need data on the history of how it has developed. And we need to know how to convert that data into information, and then into understanding, and then into design options, and then into a wise decision, and then into action, and then into improvement.

And we now know how to spot an experienced Improvementologist because the first thing they will look for are the Queues not the Quality.

But why bother with the flow and the queues at all? Customers are not interested in them! If time is the focus then surely it is turnaround times and waiting times that we need to measure! Then we can compare our performance with our ‘target’ and if it is out of range we can then apply the necessary ‘pressure’!

This is indeed what we observe. So let us explore the pros and cons of this approach with an example.

We are the manager of a support department that receives requests, processes them and delivers the output back to the sender. We could be one of many support departments in an organisation: human resources, procurement, supplies, finance, IT, estates and so on. We are the Backroom Brigade. We are the unsung heros and heroines.

The requests for our service come in different flavours – some are easy to deal with, others are more complex. They also come with different priorities – urgent, soon and routine. And they arrive as a mixture of dribbles and deluges. Our job is to deliver high quality work (i.e. no errors) within the delivery time expected by the originator of the request (i.e. on time). If we do that then we do not get complaints (but we do not get compliments either).

From the outside things look mostly OK. We deliver mostly on quality and mostly on time. But on the inside our department is in chaos! Every day brings a new fire to fight. Everyone is busy and the pressure and chaos are relentless. We are keeping our head above water – but only just. We do not enjoy our work-life. It is not fun. Our people are miserable too. Some leave – others complain – others just come to work, do stuff, take the money and go home – like Zombies. They comply.

Once in the past we were were seduced by the sweet talk of a Quality Zealot. We were promised Nirvanah. We were advised to look at the quality of the requests that we get. And this suggestion resonated with us because we were very aware that the requests were of variable quality. Our people had to spend time checking-and-correcting them before we could process them. The extra checking had improved the quality of what we deliver – but it had increased our costs too. So the Quality Zealot told us we should work more closely with our customers and to ‘swim upstream’ to prevent the quality problems getting to us in the first place. So we sent some of our most experienced and most expensive Inspectors to paddle upstream. But our customers were also very busy and, much as they would have liked, they did not have time to focus on quality either. So our Inspectors started doing the checking-and-correcting for our customers. Our people are now working for our customers but we still pay their wages. And we do not have enough Inspectors to check-and-correct all the requests at source so we still need to keep a skeleton crew of Inspectors in the department. And these stay-at-home Inspectors are stretched too thin and their job is too pressured and too stressful. So no one wants to do it.And given the choice they would all rather paddle out to the customers first thing in the morning to give them as much time as possible to check-and-correct the requests so the days work can be completed on time. It all sounds perfectly logical and rational – but it does not seem to have worked as promised. The stay-at-home Inspectors can only keep up with the more urgent work, delivery of the less urgent work suffers and the chronic chaos and fire-fighting are now aggravated by a stream of interruptions from customers asking when their ‘non-urgent’ requests will be completed.

The Quality Zealot insisted we should always answer the phone to our customers – so we take the calls – we expedite the requests – we solve the problems – and we fight-the-fire. Day, after day, after day.

We now know what Purgatory means. Retirement with a pension or voluntary redundancy with a package are looking more attractive – if only we can keep going long enough.

And the last thing we need is more external inspection, more targets, and more expensive Quality Zealots telling us what to do!

And when we go and look we see a workplace that appears just as chaotic and stressful and angry as we feel. There are heaps of work in progress everywhere – the phone is always ringing – and our people are running around like headless chickens, expediting, fire-fighting and getting burned-out: physically and emotionally. And we feel powerless to stop it. So we hide.

Does this fictional fiasco feel familiar? It is called the Miserable Job Purgatory Vortex.

Now we know the characteristic pattern of symptoms and signs: constant pressure of work, ever present threat of quality failure, everyone busy, just managing to cope, target-stick-and-carrot management, a miserable job, and demotivated people.

The issue here is that the queues are causing some of the low quality. It is not always low quality that causes all of the queues.

Queues create delays, which generate interruptions, which force investigation, which generates expediting, which takes time from doing the work, which consumes required capacity, which reduces activity, which increases the demand-activity mismatch, which increases the queue, which increases the delay – and so on. It is a vicious circle. And interruptions are a fertile source of internally generated errors which generates even more checking and correcting which uses up even more required capacity which makes the queues grow even faster and longer. Round and round. The cries for ‘we need more capacity’ get louder. It is all hands to the pump – but even then eventually there is a crisis. A big mistake happens. Then Senior Management get named-blamed-and shamed, money magically appears and is thrown at the problem, capacity increases, the symptoms settle, the cries for more capacity go quiet – but productivity has dropped another notch. Eventually the financial crunch arrives.

One symptom of this ‘reactive fire-fight design’ is that people get used to working late to catch up at the end of the day so that the next day they can start the whole rollercoaster ride again. And again. And again. At least that is a form of stability. We can expect tomorrow to be just a s miserable as today and yesterday and the day before that. But TOIL (Time Off In Lieu) costs money.

The way out of the Miserable Job Purgatory Vortex is to diagnose what is causing the queue – and to treat that first.

And that means focussing on Time first – and that means Focussing on Flow first. And by doing that we will improve delivery, improve quality and improve cost because chaotic systems generate errors which need checking and correcting which costs more. Time first is a win-win-win strategy too.

And we already have everything we need to start. We can easily count what comes in and when and what goes out and when.

The first step is to plot the inflow over time (the demand), the outflow over time (the activity), and from that we work out and plot the Work-in-Progress over time. With these three charts we can start the diagnostic process and by that path we can calm the chaos.

And then we can set to work on the Quality Improvement.

13/01/2013 – Newspapers report that 17 hospitals are “dangerously understaffed” Sound familiar?

Next week we will explore how to diagnose the root cause of a queue using Time charts.

For an example to explore please play the SystemFlow Game by clicking here

05/01/2013

The Management of Victimosis

One of the commonest psycho-socio-economic diseases is Victimosis.

This disease has a characteristic set of symptoms and signs. The symptoms are easy to detect – and the easiest way is to close your eyes and listen to the language being used. There is a characteristic vocabulary. ‘Yes but’ is common as is ‘If only’ and ‘They should’ and ‘Not my’ and ‘Too busy’. Hearing these phrases used frequently is good evidence that the subject is suffering from Victimosis.

Everyone suffers from Acute Victimosis occasionally, especially if they are tired and suffer a series of emotional set backs. With the support of relatives and friends our psychoimmune system is able to combat the cause and return us to healthy normality. We are normally able to heal our emotional wounds.

Unfortunately Victimosis is an infectious and highly contagious condition and with a large enough innoculum it can spread until almost everyone in the organisation is affected to some degree. When this happens the Victimosis behaviour can become the norm and awareness of the symptoms slips from consciousness. Victimosis then becomes the unspoken dominant culture and the transition to the Chronic Victimosis phase is complete.

Research has shown that Victimosis is an acquired disease linked to a transmissable meme that is picked up early in life. The meme can be transmitted person-to-person and also through mass communication systems which then leads to rapid dissemination. Typical channels are newspapers, television, the internet and now social media. Just sample the daily news and observe how much Victimosis language is in circulation.

Those more susceptible to infection can develop into chronic carriers who constantly infect and reinfect others. The outward mainfestations of the chronic form are incessant complaining, criticising, irrational decisions, ineffective actions, blaming and eventually depression, hopelessness and terminal despair. The chronically infected may aggregate into like-minded groups as a safety-in-numbers reflex response. These groups are characterised by having a high proportion of people with the same temperament; particularly the Guardian preference (the Supervisors, Inspectors, Providers and Protectors who make up two thirds of the population).

Those able to resist infection find the context and culture toxic and they take action. They leave.

The outward manifestations of Chronic Victimosis are GroupThink and Silosis. GroupThink is where collectives start to behave as one and their group-rhetoric becomes progressively less varied and more dogmatic. Silosis is a form of organisational tribalism where Departments become separated from each other, conceptually, emotionally, physically and financially. Both natural reactions only aggravate the condition and accelerate the decline.

One of the effects of the Victimosis-meme is Agnostic Hyper-Reactivity. This is where both the Individuals and their Silos develop a thick emotional protective membrane that distorts their perception. It is not that they do not sense what is happening – it is that they do not perceive it or that they perceive it in a distorted way. This is the Agnosia part – literally ‘not knowing’.

Unfortunately being ignorant of Reality does not help and eventually the pressure of Reality builds up and punches a hole through the emotional barrier. Something exceptionally bad happens that cannot be discounted or ignored. This is the ‘crisis‘ stage and it elicits a characteristic reflex reaction. An emotional knee-jerk. Unfortunately the reflex is an over-reaction and is poorly focussed and badly coordinated – so it does more harm than good.

This is the hyper-reactivity part.

The blind reflex reaction further destabilises an already unstable situation and accelerates the decline. It creates a positive feedback loop that can quickly escalate to verbal, written and then psychological and physical conflict. The Lose-Lose-Lose of Self-Destructive behaviour that is characteristic of the late phase. And that is not all. Over time the reflex reaction gets less effective as the Victimosis Membrane thickens. The reflex fades out. This is a dangerous development because on the surface it looks like things are improving, there is less conflict, but in reality the patient is slipping into pre-terminal Victimosis.

Fortunately there is a treatment for Victimosis.

It is called Positivicillin.

This is not a new wonder drug, it is a natural product. We all produce Positivicillin and some of us produce more than others: they are called Optimists. Positivicillin works by channelling the flow of emotional energy into the reflection-and-action pathways. Naturally occurring Positivicillin has a long-half life: the warm glow of success lasts a long time. Unfortunately Positivicillin is irreversibly deactivated by the emotional toxin generated by the Victimosis meme: a toxin called Discountin. So in the presence of Discountin the affected person needs to generate more Positivicillin and to do so continuously and this leads to emotional exhaustion. The diffusion of Positivicillin is impeded by the Victimosis Membrane so if subject has a severe case of Chronic Victimosis then they may need extrinsic Positivicillin treatment at high dose and for a long time to prevent terminal decline. The primary goal of emergency treatment is to neutralise the excess Discountin for long enough that the natural production of Positivicillin can start to work.

So where can we get supplies of extrinsic Positivicillin from?

In its pure form Positivicillin is rare and expensive. The number of naturally occurring Eternal Optimist Exporters is small and their collective Positivicillin production capability is limited. Healthy organisations value and attract them; unhealthy ones discount and reject them.

So we are forced to resort to using more abundant, cheaper but inferior drugs. One is called Alcoholimycin and another is Tobaccomycin. They are both widely available and affordable but they have long term irreversible toxic side effects.

Chronic Victimosis is endemic so chronic abuse of Tobaccomycin and Alcoholimycin is common and, in an attempt to restrict their negative long term effects, both drugs are heavily taxed by the Authorities.

Unfortunately this only aggravates the spread of Chronic Victimosis which some report is a sign of the same condition affecting the Authorties! These radicals are calling for de-regulation of the more potent variants such a Cannabisimycin but the Authorities have opted for a tightly regulated supply of symptom-suppressants such as Anxiolytin and Antidepressin. These are now freely available and do help those who want to learn to cure themselves.

The long term goal of the Victimosis Research Council is to develop ways to produce pure Positivicillin and to treat the most severe cases of Chronic Victimosis; and to find ways to boost the natural production of Positivicillin within less seriously affected individuals and organisations.

Chronic Victimosis is not a new disease – it has been described in various forms throughout recorded history – so the search for a cure starts with the historical treatments – one of which is Confessmycin. This has been used for centuries and appears to work well for some but not others and this idiosyncratic response is believed to be due to the presence (or not) of the Rel-1-Gion meme. Active dissemination of a range of Rel-1-Gion meme variants (and the closely linked Pol-1-Tic meme variants) has been tried with considerable success but does not appear to be a viable long term option.

A recent high-tech approach is called a Twimplant. This is an example of the Social-Media class of biopsychosocial feedback loops that uses the now ubiquitous mobiphonic symbiont to connect the individual to a regular supply of positive support, ideas and evidence called P-Tweets. It is important to tune the Twimplant correctly because the same device can also pick up distress signals broadcast by sufferers of Chronic Victimosis who are attempting to dilute their Discountin by digitising it and exporting it to everyone else. These are called N-Tweets and are easily identifiable by their Victimosis vocabulary. N-tweets can be avoided by adopting an Unfollow policy.

One promising line of new research is called R2LM probe therapy. This is an unconventional and innovative way of curing Chronic Victimosis. The R2LM probe is designed to identify the gaps in the organisational memetic code and to guide delivery of specific meme transplants that fill the gaps it reveals. One common gap is called the OM-meme deletion and one effective treatment for this is called FISH. Taking a course of FISH injections or using a FISH immersion technique leads to a rapid and sustained improvement in emotional balance. That in-turn leads to an increase in the natural production of Positivicillin. From that point on the individual and can dissolve the Victimosis Membrance and correct their perceptual distortion. The treatment is sometimes uncomfortable but those who completed the course will vouch for its effectiveness.

For the milder forms of Victimosis it is possible to self-diagnose and to self-treat.

The strategy here is to actively reduce the production of Discountin and to boost the natural production of Positivicillin. These have a synergistic effect. The first step is to practice listening for the Victimosis vocabulary using a list of common phrases. The patient is taught to listen for these in spoken communication and to look for them in written communication. Spoken communication includes their Internal Voice. The commonest phrases are:

1. “Yes but …”
2. “If only …”
3. “I/You/We/They should …”
4. “I/We can’t …”
5. “I/We hope …”
6. “Not My/Our fault …”
7. “Constant struggle …”
8. “I/We do not know …”
9. “I am too busy to …”

The negative emotional impact of these phrases is caused by the presence of the Discountin toxin.

The second step is to substitute the contaminated phrase with an equivalent one where the Discountin is deactivated using Positivicillin. This deliberate and conscious substitution is easiest in written communication, then externally spoken and finally the Internal Voice. The replacements for the above are …

1. “Yes, and …”
2. “Next time …”
3. “I/We could …”
4. “I/We can …”
5. “I/We know …”
6. “My/Our responsibility …”
7. “Endless opportunity …”
8. “I/We will learn …”
9. “It is too important not to …”

The system-wide benefits of the prompt and effective management of Chronic Victimosis are enormous. There is more reflective consideration and more effective action. There is success and celebration where before there was failure and frustration. The success stimulates natural release of more Positivicillin which builds a positive reinforcement feedback loop. In addition the other GA-memes become progressively switched off and the signs of Passive Persecutitis and Reactive Rescuopathy resolve.

The combined effect leads to the release of Curiositonin, the natural inquisitiveness hormone, and Excitaline – the hormone that causes the addictive feeling of eager anticipation. The racing heart and the dry mouth.

From then on the ex-patient is able to maintain their emotional balance, to further develop their emotional resilience, and to assist other sufferers. And that is a win for everyone.

22/12/2012

Shifting, Shaking and Shaping

Stop Press: For those who prefer cartoons to books please skip to the end to watch the Who Moved My Cheese video first.

In 1962 – that is half a century ago – a controversial book was published. The title was “The Structure of Scientific Revolutions” and the author was Thomas S Kuhn (1922-1996) a physicist and historian at Harvard University. The book ushered in the concept of a ‘paradigm shift’ and it upset a lot a people.

In particular it upset a lot of scientists because it suggested that the growth of knowledge and understanding is not smooth – it is jerky. And Kuhn showed that the scientists were causing the jerking.

Kuhn described the process of scientific progress as having three phases: pre-science, normal science and revolutionary science. Most of the work scientists do is normal science which means exploring, consolidating, and applying the current paradigm. The current conceptual model of how things work. Anyone who argues against the paradigm is regarded as ‘mistaken’ because the paradigm represents the ‘truth’. Kuhn draws on the history of science for his evidence, quoting examples of how innovators such as Galileo, Copernicus, Newton, Einstein and Hawking radically changed the way that we now view the Universe. But their different models were not accepted immediately and ethusiastically because they challenged the status quo. Galileo was under house arrest for much of his life because his ‘heretical’ writings challenged the Church.

Each revolution in thinking was both disruptive and at the same time constructive because it opened a door to allow rapid expansion of knowledge and understanding. And that foundation of knowledge that has been built over the centuries is one that we all take for granted. It is a fragile foundation though. It could be all lost and forgotten in one generation because none of us are born with this knowledge and understanding. It is not obvious. We all have to learn it. Even scientists.

Kuhn’s book was controversial because it suggested that scientists spend most of their time blocking change. This is not necessarily a bad thing. Stability for a while is very useful and the output of normal science is mostly positive. For example the revolution in thinking introduced by Isaac Newton (1643-1727) led directly to the Industrial Revolution and to far-reaching advances in every sphere of human knowledge. Most of modern engineering is built on Newtonian mechanics and it is only at the scales of the very large, the very small and the very quick that it falls over. Relativistic and quantum physics are more recent and very profound shifts in thinking and they have given us the digital computer and the information revolution. This blog is a manifestation of the quantum paradigm.

Kuhn concluded that the progess of change is jerky because scientists create resistance to change to create stability while doing normal science experiments. But these same experiments produce evidence that suggest that the current paradigm is flawed. Over time the pressure of conflicting evidence accumulates, disharmony builds, conflict is inevitable and intellectual battle lines are drawn. The deeper and more fundamental the flaw the more bitter the battle.

In contrast, newcomers seek harmony in the cacophony and propose new theories that explain both the old and the new. New paradigms. The stage is now set for a drama and the public watch bemused as the academic heavyweights slug it out. Eventually a tipping point is reached and one of the new paradigms becomes dominant. Often the transition is triggered by one crucial experiment.

There is a sudden release of the tension and a painful and disruptive conceptual lurch – a paradigm shift. Then the whole process starts over again. The creators of the new paradigm become the consolidators and in time the defenders and eventually the dogmatics! And it can take decades and even generations for the transition to be completed.

It is said that Albert Einstein (1879-1955) never fully accepted quantum physics even though his work planted the seeds for it and experience showed that it explained the experimental observations better. [For more about Einstein click here].

The message that some take from Kuhn’s book is that paradigm shifts are the only way that knowledge can advance. With this assumption getting change to happen requires creating a crisis – a burning platform. Unfortunatelty this is an error of logic – it is a unverified generalisation from an observed specific. The evidence is growing that this we-always-need-a-burning-platform assumption is incorrect. It appears that the growth of knowledge and understanding can be smoother, less damaging and more effective without creating a crisis.

So what is the evidence that this is possible?

Well, what pattern would you look for to illustrate that it is possible to improve smoothly and continually? A smooth growth curve of some sort? Yes – but it is more than that. It is a smooth curve that is steeper than anyone else’s and one that is growing steeper over time. Evidence that someone is learning to improve faster than their peers – and learning painlessly and continuously without crises; not painfully and intermittently using crises.

Two examples are Toyota and Apple.

Toyota is a Japanese car manufacturer that has out-performed other car manufacturers consistently for 40 years – despite the global economic boom-bust cycles. What is their secret formula for their success?

We need a bit of history. In the 1980’s a crisis-of-confidence hit the US economy. It was suddenly threatened by higher-quality and lower-cost imported Japanese products – for example cars.

The switch to buying Japanese cars had been triggered by the Oil Crisis of 1973 when the cost of crude oil quadrupled almost overnight – triggering a rush for smaller, less fuel hungry vehicles. This is exactly what Toyota was offering.

This crisis was also a rude awakening for the US to the existence of a significant economic threat from their former adversary. It was even more shocking to learn that W Edwards Deming, an American statistician, had sown the seed of Japan’s success thirty years earlier and that Toyota had taken much of its inspiration from Henry Ford. The knee-jerk reaction of the automotive industry academics was to copy how Toyota was doing it, the Toyota Production System (TPS) and from that the school of Lean Tinkering was born.

This knowledge transplant has been both slow and painful and although learning to use the Lean Toolbox has improved Western manufacturing productivity and given us all more reliable, cheaper-to-run cars – no other company has been able to match the continued success of Japan. And the reason is that the automotive industry academics did not copy the paradigm – the intangible, subjective, unspoken mental model that created the context for success. They just copied the tangible manifestation of that paradigm. The tools. That is just cynically copying information and knowledge to gain a competitive advantage – it is not respecfully growing understanding and wisdom to reach a collaborative vision.

Apple is now one of the largest companies in the world and it has become so because Steve Jobs (1955-2011), its Californian, technophilic, Zen Bhuddist, entrepreneurial co-founder, had a very clear vision: To design products for people. And to do that they continually challenged their own and their customers paradigms. Design is a logical-rational exercise. It is the deliberate use of explicit knowledge to create something that delivers what is needed but in a different way. Higher quality and lower cost. It is normal science.

Continually challenging our current paradigm is not normal science. It is revolutionary science. It is deliberately disruptive innovation. But continually challenging the current paradigm is uncomfortable for many and, by all accounts, Steve Jobs was not an easy person to work for because he was future-looking and demanded perfection in the present. But the success of this paradigm is a matter of fact:

“In its fiscal year ending in September 2011, Apple Inc. hit new heights financially with $108 billion in revenues (increased significantly from $65 billion in 2010) and nearly $82 billion in cash reserves. Apple achieved these results while losing market share in certain product categories. On August 20, 2012 Apple closed at a record share price of $665.15 with 936,596,000 outstanding shares it had a market capitalization of $622.98 billion. This is the highest nominal market capitalization ever reached by a publicly traded company and surpasses a record set by Microsoft in 1999.”

And remember – Apple almost went bust. Steve Jobs had been ousted from the company he co-founded in a boardroom coup in 1985. After he left Apple floundered and Steve Jobs proved it was his paradigm that was the essential ingredient by setting up NeXT computers and then Pixar. Apple’s fortunes only recovered after 1998 when Steve Jobs was invited back. The rest is history so click to see and hear Steve Jobs describing the Apple paradigm.

So the evidence states that Toyota and Apple are doing something very different from the rest of the pack and it is not just very good product design. They are continually updating their knowledge and understanding – and they are doing this using a very different paradigm. They are continually challenging themselves to learn. To illustrate how they do it – here is a list of the five principles that underpin Toyota’s approach:

Challenge
Improvement
Go and see
Teamwork
Respect

This is Win-Win-Win thinking. This is the Science of Improvement. This is Improvementology®.

So what is the reason that this proven paradigm seems so difficult to replicate? It sounds easy enough in theory! Why is it not so simple to put into practice?

The requirements are clearly listed: Respect for people (challenge). Respect for learning (improvement). Respect for reality (go and see). Respect for systems (teamwork).

In a word – Respect.

Respect is a big challenge for the individualist mindset which is fundamentally disrespectful of others. The individualist mindset underpins the I-Win-You-Lose Paradigm; the Zero-Sum -Game Paradigm; the Either-Or Paradigm; the Linear-Thinking Paradigm; the Whole-Is-The-Sum-Of-The-Parts Paradigm; the Optimise-The-Parts-To-Optimise-The-Whole Paradigm.

Unfortunately these are the current management paradigms in much of the private and public worlds and the evidence is accumulating that this paradigm is failing. It may have been adequate when times were better, but it is inadequate for our current needs and inappropriate for our future needs.

So how can we avoid having to set fire to the current failing management paradigm to force a leap into the cold and uninviting reality of impending global economic failure? How can we harness our burning desire for survival, security and stability? How can we evolve our paradigm pro-actively and safely rather than re-actively and dangerously?

We need something tangible to hold on to that will keep us from drowning while the old I-am-OK-You-are-Not-OK Paradigm is dissolved and re-designed. Like the body of the caterpillar that is dissolved and re-assembled inside the pupa as the body of a completely different thing – a butterfly.

We need a robust and resilient structure that will keep us safe in the transition from old to new and we also need something stable that we can steer to a secure haven on a distant shore.

We need a conceptual lifeboat. Not just some driftwood, a bag of second-hand tools and no instructions! And we need that lifeboat now.

But why the urgency?

The answer is basic economics.

The UK population is growing and the proportion of people over 65 years old is growing faster. Advances in healthcare means that more of us survive age-related illnesses such as cancer and heart disease. We live longer and with better quality of life – which is great.

But this silver-lining hides a darker cloud.

The proportion of elderly and very elderly will increase over the next 20 years as the post WWII baby-boom reaches retirement age. The number of people who are living on pensions is increasing and the demands on health and social services is increasing. Pensions and public services are not paid out of past savings they are paid out of current earnings. So the country will need to earn more to pay the bills. The UK economy will need to grow.

But the UK economy is not growing. Our Gross Domestic Product (GDP) is currently about £380 billion and flat as a pancake. This sounds like a lot of dosh – but when shared out across the population of 56 million it gives a more modest figure of just over £100 per person per week. And the time-series chart for the last 20 years shows that the past growth of about 1% per quarter took a big dive in 2008 and went negative! That means serious recession. It recovered briefly but is now sagging towards zero.

So we are heading for a big economic crunch and hiding our heads in the sand and hoping for the best is not a rational strategy. The only way to survive is to cut public services or for tax-funded services to become more productive. And more productive means increasing the volume of goods and services for the same cost. These are the services that we will need to support the growing population of dependents but without increasing the cost to the country – which means the taxpayer.

The success of Toyota and Apple stemmed from learning how to do just that: how to design and deliver what is needed; and how to eliminate what is not; and how to wisely re-invest the released cash. The difference can translate into higher profit, or into growth, or into more productivity. It just depends on the context. Toyota and Apple went for profit and growth. Tax-funded public services will need to opt for productivity.

And the learning-productivity-improvement-by-design paradigm will be a critical-to-survival factor in tax-payer funded public services such as the NHS and Social Care. We do not have a choice if we want to maintain what we take for granted now. We have to proactively evolve our out-of-date public sector management paradigm. We have to evolve it into one that can support dramatic growth in productivity without sacrificing quality and safety.

We cannot use the burning platform approach. And we have to act with urgency.

We need a lifeboat!

Our current public sector management paradigm is sinking fast and is being defended and propped up by the old school managers who were brought up in it. Unfortunately the evidence of 500 years of change says that the old school cannot unlearn. Their mental models go too deep. The captains and their crews will go down with their ships. [Remember the Titanic the unsinkable ship that sank in 1912 on the maiden voyage. That was a victory of reality over rhetoric.]

Those of us who want to survive are the ‘rats’. We know when it is time to leave the sinking ship. We know we need lifeboats because it could be a long swim! We do not want to freeze and drown during the transition to the new paradigm.

So where are the lifeboats?

One possibility is an unfamiliar looking boat called “6M Design”. This boat looks odd when viewed through the lens of the conventional management paradigm because it combines three apparently contradictiry things: the rational-logical elements of system design; the respect-for-people and learning-through-challenge principles embodied by Toyota and Apple; and the counter-intuitive technique of systems thinking.

Another reason it feel odd is because “6M Design” is not a solution; it is a meta-solution. 6M Design is a way of creating a good-enough-for-now solution by changing the current paradigm a bit at a time. It is a-how-to-design framework; it is not the-what-to-do solution. 6M Design is a paradigm shaper – not a paradigm shaker or a paradigm shifter.

And there is yet another reason why 6M Design does not float the current management boat. It does not need to be controlled by self-appointed experts. Business schools and management consultants, who have a vested interest in defending the current management paradigm, cannot make a quick buck from it because they are irrelevant. 6M Design is intended to be used by anyone and everyone as a common language for collectively engaging in respectful challenge and lifelong learning. Anyone can learn to use it. Anyone.

We do not need a crisis to change. But without changing we will get the crisis we do not want. If we choose to change then we can choose a safer and smoother path of change.

The choice seems clear. Do you want to go down with the ship or stay afloat aboard an innovation boat?

And we will need something to help us navigate our boat.

If you are a reflective, conceptual learner then you might ike to read a synopsis of Thomas Kuhn’s book. You can download a copy here. [There is also a 50 year anniversary edition of the original that was published this year].

And if you prefer learning from stories then there is an excellent one called “Who Moved My Cheese” that describes the same challenge of change. And with the power of the digital paradigm you can watch the video here.

16/12/201207/09/2024

Defusing Trust Eroders – Part III

Leslie’s computer heralded the arrival of yet another email! They were coming in faster and faster – now that the word had got out on the grapevine about Improvementology.

Leslie glanced at the sender.

It was from Bob. That was a surprise. Bob had never emailed out-of-the-blue before. Leslie was too impatient to wait until later to read the email.

Leslie was consumed with curiosity. What could Bob possibly want advice on? It was Leslie who sought advice from Bob – not the other way around.

Leslie could not wait and emailed back immediately that it was OK to talk now.

L: Hello Bob, what a pleasant surprise! I am very curious to know what you need my advice about.

B: Thank you Leslie. What I would like your counsel on is how to engage in learning the science of improvement.

L: Wow! That is a surprising question. I am really confused now. You helped me to learn this new thinking and now you are asking me to teach you?

B: Yes. On the surface it seems counter-intuitive. It is a genuine request though. I need to learn and understand what works for you and what does not.

L: OK. I think I am getting an idea of what you are asking. But I am only just getting grips with the basics. I do not know how to engage others yet and I certainly would not be able to teach anyone!

B: I must apologise. I was not clear in my request. I need to understand how you engaged yourself in learning. I only provided the germ of the idea – it was you who added what was needed for it to develop into something tangible and valuable for you. I need to understand how that happened.

L: Ahhhh! I see what you mean. Yes. Let me think. Would it help if I describe my current mental metaphor?

B: That sounds like an excellent idea.

L: OK. Well your phrase ‘germ of an idea’ was a trigger. I see the science of improvement as a seed of information that grows into a sturdy tree of understanding. Just like the ‘tiny acorn into the mighty oak’ concept. Using that seed-to-tree metaphor helped me to appreciate that the seed is necessary but it is not sufficient. There are other things that are needed too. Soil, water, air, sunlight, and protection from hazards and predators.

I then realised that the seed-to-tree metaphor goes deeper. One insight that I had was when I realised that the first few leaves are critical to success – because they provide the ongoing energy and food to support the growth of more leaves, and the twigs, branches, trunk, and roots that support the leaves and supply them with water and nutrients. I see the tree as synergistic system that has a common purpose: to become big enough and stable enough to be able to survive the inevitable ups-and-downs of reality. To weather the winter storms and survive the summer droughts.

It seemed to me that the first leaf needed to be labelled ‘safety’ because in our industry if we damage our customers or our staff we do not get a second chance! The next leaf to grow is labelled ‘quality’ and that means quality-by-design. Doing the right thing and doing it right first time without needing inspection-and-correction. The safety and quality leaves provide the resources needed to grow the next leaf which I labelled ‘delivery’. Getting the work done in time, on time, every time. Together these three leaves support the growth of the fourth – ‘economy’ which means using only what is necessary and also having just enough reserve to ride over the inevitable rocks and ruts in the road of reality.

I then reflected on what the water and the sunshine would represent when applying improvement science in the real world.

It occurred to me that the water in the tree is like money in a real system. It is required for both growth and health; it must flow to where it is needed, when it is needed and as much as needed. Too little will prevent growth, and too much water at the wrong time and wrong place is just as unhealthy. I did some reading about the biology of trees and I learned that the water is pulled up the tree! The ‘suck’ is created by the water evaporating from the leaves. The plant does not have a committee that decides where the available water should go! It is a simple self-adjusting, auto-regulating system.

The sunshine for the tree is like feedback for people. In a plant the suns energy provides the motive force for the whole system. In our organisations we call it motivation and the feedback loop is critical to success. Keeping people in the dark about what is required and how they are doing is demotivating. Healthy organisations are feedback-fuelled!

B: I see the picture in my mind clearly. That is a powerful metaphor. How did it help overcome the natural resistance to change?

L: Well using the 6M Design method and taking the desire to create a ‘sturdy tree of understanding’ as the goal of the seed-to-tree process, I then considered what the possible ways it could fail – the failure modes and effects analysis method that you taught me.

B: OK. Yes I see how that approach would help – approaching the problem from the far side of the invisible barrier. What insights did that lead to?

L: Well it highlighted that just having enough water and enough sunshine was not sufficient – it had to be clean water and the right sort of sunshine. The quality is as critical as the quantity. A toxic environment will kill tender new shoots of improvement long before they can get established. Cynicism is like cyanide! Non-specific cost cutting is like blindly wielding a pair of sharp secateurs. Ignoring the competition from wasteful weeds and political predators is a guaranteed recipe-for-failure too.

This seed-to-tree metaphor really helped because it allowed me to draw up a checklist of necessary conditions for successful growth of knowledge and understanding. Rather like the shopping list that a gardener might have. Viable seeds, fertile soil, clean water, enough sunlight, and protection from threats and hazards, especially in the early stages. And patience and perseverance. Growing from seed takes time. Not all seeds will germinate. Not all seeds can thrive in the context our gardener is able to create. And the harsher the elements the fewer the types of seed that have any chance of survival. The conditions select the successful seeds. Deserts select plants that hoard water so the desert remains a desert. If money is too tight the miserly will thrive at the expense of the charitable – and money remains hoarded and fought over as the rest of the organisation withers. And the timing is crucial – the seeds need to be planted at the right time in the cycle of change. Too early and they cannot germinate, too late and they do not have time to become strong enough to survive in the real world winter storms.

B: Yes. I see. The deeper you dig into your seeds-to-trees metaphor, the more insightful it becomes.

L: Bob, you just said something really profound then that has unlocked something for me.

B: Did I? What was it?

L: You said ‘seeds-to-trees’. Up until you said that I was unconsciously limiting myself to one-seed-to-one-tree. Of course! If it works for the individual it can work for the collective. Woods and forests are collectives. The best example I can think of is a tropical rainforest. With ample water and sunshine the plant-collective creates a synergistic system that has endured millions of years of global climate change. And one of the striking features of the tropical rain forest is the diversity of species. It is as if that diversity is an important part of the design. Competition is ever present though – all the trees compete for sunlight – but it is healthy competition. Trees do not succeed individually by hunting each other down. And the diversity seems to be an important component of healthy competition too. It is as if they are in a shared race to the sun and their differences are an asset rather than a liability. If all the trees were the same the forest would be at greater risk of all making the same biological blunder and suddenly becoming extinct if their environment changes unpredictably. Uniformity only seems to work in harsh conditions.

B: That is a profound observation Leslie. I had not consciously made that distinction.

L: So have I answered your question? Have I helped you? It has certainly helped me by being asked to putting my thoughts into words. I see it clearer too now.

B: Yes. You are a good teacher. I believe others will resonate with your seeds-to-trees metaphor just as I have.

L: Thank you Bob. I believe I am beginning to understand something you said in a previous conversation – “the teacher is the person who learns the most”. I am going to test our seeds-to-trees metaphor on the real world! And I will feedback what I learn – because in doing that I will amplify and clarify my own learning.

B: Thank you Leslie. I look forward to learning with you.

15/12/201207/09/2024

Defusing Trust Eroders – Part II

B: Hello Leslie. How are you today?

L: Hi Bob – I am OK. Thank you for your time today. Is 15 minutes going to be enough?

B: Yes. There is evidence that the ideal chunk of time for effective learning is around 15 minutes.

L: OK. I said I would read the material you sent me and reflect on it.

B: Yes. Can you retell your Nerve Curve experience as a storyboard and highlight your ‘ah ha’ moments?

L: OK. And that was the first ‘ah ha’. I found the storyboard format a really effective way to capture my sequence of emotional states.

B: Yes. There are close links between stories, communication, learning and improvement. Before we learned to write we used campfire stories to pass collective knowledge from generation to generation. It is an ancient, in-built skill we all have and we all enjoy a good story.

L: Yes. My first reaction was to the way you described the Victim role. It really resonated with how I was feeling and how I was part of the dynamic. You were spot on with the feelings that dominated my thinking – anxiety and fear. The big ‘ah ha’ for me was to understand the discount that I was making. Not of others – of myself.

B: OK. What was the image that you sketched on your storyboard?

L: I am embarrased to say – you will think I am silly.

B: I will not think you are silly.

I know. And I knew that as soon as I said it. I think I was actually saying it to myself – or part of myself. Like I was trying to appease part of myself. Anyway, the picture I sketched was me as a small child at school standing with my head down, hands by my sides, and being told off in front of the whole class for getting a sum wrong. I was crying. I was not very good at maths and even now my mind sort of freezes and I get tears in my eyes and feel scared whenever someone tries to explain something using equations! I can feel the terror starting to well up just talking about it.

B: OK. No need to panic. Take a long breath and exhale slowly. The story you have told is very common. Many of our fears of failure originate from early memories of experiencing ‘education by humiliation’. It is a blunt and ineffective motivational tool that causes untold and long lasting damage. It is a symptom of a low quality education system design. Education is an exercise in improvement of knowledge, understanding, capability and confidence. The unintended outcome of this clumsy teaching tactic is a belief that we cannot solve problems ourselves and it is that invalid belief that creates the self-fulfilling prophecy of repeated failure.

L: Yes! And I know I can solve maths problems – I do it all the time – and I help my children with their maths homework. So, it is not the maths that is triggering my fear. What is it?

B: The answer to your question will become clear. What is the next picture on your storyboard?

The next picture was of the teacher who was telling me off. Or rather the face of the teacher. It was a face of frustration and anger. I drew a thought bubble and wrote in it “This small, irritating child cannot solve even a simple maths problem and is slowing down the whole lesson by bursting into tears everytime they get stuck. I blame the parents who are clearly too soft. They all need to learn some discipline – the hard way.“

L: Does this shed any light on your question?

B: Wow! Yes! It is not the maths that I am reacting to – it is the behaviour of the teacher. I am scared of the behaviour. I feel powerless. They are the teacher, I am just a small, incompetent, stupid, blubbing child. They do not care that I do not understand the question, and that I am in distress, and that I am scared that I will be embarassed in front of the whole class, and that I am scared that my parents will see a bad mark on my school report. And I feel trapped. I need to rationalise this. To make sense of it. Maybe I am stupid? That would explain why I cannot solve the mths problem. Maybe I should just give in and accept that I am a failure and too stupid to do maths?

There was a pause. Then Leslie continued in a different tone. A more determined tone.

L: But I am not a failure. This is just my knee jerk habitual reaction to an authority figure displaying anger towards me. I can decide how I react. I have complete control over that. I can disconnect the behaviour I experience and my reaction to it. I can choose. Wow!

B: OK. How are you feeling right now? Can you describe it using a visual metaphor?

ready_to_launch_PA_150_wht_5052 L: Um – weird. Mixed feelings. I am picturing myself sitting on a giant catapault. The ends of the huge elastic bands are anchored in the present and I am sitting in the loop but it is stretched way back into the past. There is something formless in the past that has been holding me back and the tension has been slowly building over time. And it feels that I have just cut that tie to the past, and I am free, and I am now being accelerated into the future. I did that. I am in control of my own destiny and it suddenly feels fun and exciting.

B: OK. How do you feel right now about the memory of the authority figure from the past?

L: OK actually. That is really weird. I thought that I would feel angry but I do not. I just feel free. It was not them that was the problem. Their behaviour was not my fault – and it was my reaction to their behaviour that was the issue. My habitual behaviour. No, wait a second. Our habitual behaviour. It is a dynamic. It takes both people to play the game.

There was a pause. Leslie sensed that Bob knew that some time was needed to let the emotions settle a bit.

B: Are you OK to continue with your storyboard?

L: Yes. The next picture is of the faces of my parents. They are looking at my school report. They look sad and are saying “We always dreamed that Leslie would be a doctor or something like that. I suppose we will have to settle for something less ambitious. Do not worry Leslie, it is not your fault, it will be OK, we will help you.” I felt like I had let them down and I had shattered their dream. I felt so ashamed. They had given me everything I had ever asked for. I also felt angry with myself and with them. And that is when I started beating myself up. I no longer needed anyone else to do that! I could persecute myself. I could play both parts of the game in my own head. That is what I did just now when it felt like I was talking to myself.

B: OK. You have now outlined the three roles that together create the dynamic for a stable system of learned behaviour. A system that is very resistant to change. It is like a triangular role-playing-game. We pass the role-hats as we swap places in the triangle and we do it in collusion with others and ourselves and we do it unconsciously. The purpose of the game is to create opportunities for social interaction – which we need and crave – the process has a clear purpose. The unintended outcome of this design is that it generates bad feelings, it erodes trust and it blocks personal and organisational development and improvement. We get stuck in it – rather like a small boat in a whirlpool. And we cannot see that we are stuck in it. We just feel bad as we spin around in an emotional maelstrom. And we feel cheated out of something better but we do not know what it is and how to get it.

There was a long pause. Leslie’s mind was racing. The world had just changed. The pieces had been blown apart and were now re-assembling in a different configuration. A simpler, clearer and more elegant design.

L: So, tell me if I have this right. Each of the three roles involves a different discount?

B: Yes.

And each discount requires a different – um – tactic to defuse?

B: Yes.

So, the way to break out of this trust eroding behavioural hamster-wheel is to learn to recognise which role we are in and to consciously deploy the discount defusing tactic.

B: Yes.

And by doing that enough times we learn how to spot the traps that other people are creating and avoid getting sucked into them.

B: Yes. And we also avoid starting them ourselves.

L: Of course! And by doing that we develop growing respect for ourselves and for each other and a growing level of trust in ourselves and in others? We have started to defuse the trust eroding behaviour and that lowers the barrier to personal and organisational development and improvement.

B: Yes.

L: So what are the three discount defusing tactics?

There was a pause. Leslie knew what was coming next. It would be a question.

B: What role are you in now?

L: Oh! Yes. I see. I am still feeling like that small school child at school but now I am asking for the answer and I am discounting myself by assuming that I cannot solve this problem myself. I am assuming that I need you to rescue me by telling me the answer. I am still in the trust eroding game, I do not trust myself and I am inviting you to play too, and to reinforce my belief that I cannot solve the problem.

B: And do you need me to tell you the answer?

L: No. I can probably work this out myself. And if I do get stuck then I can ask for hints or nudges – not for the answer. I need to do the learning work and I want to do it.

B: OK. I will commit to hinting and nudging if asked, and if I do not know the answer I will say so.

L: Phew! That was definitely an emotional rollercoaster ride on the Nerve Curve. Looking back it all makes complete sense and I now know what to do – but at the start it felt like I was heading into the Dark Unknown. You are right. It is liberating and exhilarating!

B: That feeling of clarity-of-hindsight and exhilaration from learning is what we always strive for. Both as teachers and students.

L: You mean it is the same for you? You are still riding the Nerve Curve? Still feeling surprised, confused, scared, resolved, enlightened then delighted?

B: Ha ha! Yes. Every day. It is fun. I believe that there is No Limit to Learning so there is an inexhaustible Font of Fun.

L: Wow! I am off to have more Fun from Learning. Thank you so much yet again.

B: Thank you Leslie.

13/12/201207/09/2024

Defusing Trust Eroders – Part I

Bob heard the beep and looked at his phone. There was a text message from Leslie, one of his Improvementology coachees.

It said:

“Hi Bob, Do you have time to help me with a behaviour barrier that I keep hitting and cannot see a way around?”

Bob thumbed his reply:

“Yes. I am free at the moment – please feel free to call.”

B: Hello Leslie. What’s on your mind?

L: Hi Bob. I really hope you can help me with this recurring Niggle. I have looked through my Foundation notes and I cannot see where it is described and it does not seem to be a Nerve Curve problem.

B: I will do my best. Can you outline the context or give me an example?

L: It is easier to give you an example. This week I was working with a team in my organisation who approached me to help them with recurring niggles in their process. I went to see for myself and I mapped their process and identified where their Niggles were and what was driving them. That was the easy bit. But when I started to make suggestions of what they could do to resolve their problems they started to give me a hard time and kept saying ‘Yes, but …”. It was as if they were asking for help but did not really want it. They kept emphasising that all their problems were caused by other people outside their department and kept asking me what I could do about it. I felt as if they were pushing the problem onto me and I was also feeling guilty for not being able to sort it out for them.

There was a pause. Then Bob said.

B: You are correct Leslie. This is not a Nerve Curve issue. It is a different people-related system issue. It is ubiquitous and it is a potentially deadly organisational disease. We call it Trust Eroding Behaviour.

L: That sounds exactly how it felt for me. I went to help in good faith and quickly started to feel distrustful of their motives. It was not a good feeling and I do not know if I want to go back. One part of me says “Keep going – you have made a commitment” and another part of me says “Stop – you are being suckered”. What is happening?

B: Do you remember that the Improvement Science framework has three parts – Processes, People and Systems?

L: Yes.

B: OK. This is part of the People component and it is similar to but different from the Nerve Curve. The Nerve Curve is a hard-wired emotional response to any change. The Fright, Freeze, Fight, Flight response. It is just the way we are and it is not ‘correctable’. This is different. This is a learned behaviour. Which means it can be unlearned.

L: Unlearned? That is not a concept that I am familiar with. Can you explain? Is it the same as forgetting?

B: Forgetting means that you cannot bring something to conscious awareness. Unlearning is different – it operates at a deeper psychological and emotional level. Have you ever tried to change a bad habit?

L: Yes, I have! I used to smoke which is definitely a bad habit and I managed to give up but it was really tough.

B: What you did was to unlearn the smoking habit and replaced it with a healthier one. You did not forget about smoking. You could not because you are repeatedly reminded by other people who still indulge in the habit.

L: Ah ha! I see what you mean. Yes – after I kicked the habit I became a bit of a Stop-Smoking evangelist. It did not seem to make much impact on the still-smokers though. If anything my behaviour seemed to make them more determined to keep doing it – just to spite me!

B: Yes. What you describe is what many people report. It is part if the same learned behaviour patterns. The habit that is causing the issue is rather like smoking because it causes short-term pleasure and long-term pain. It is both attractive and destructive. The reactive behaviour generates a positive feeling briefly but it is toxic to trust over the longer term, which is why we call it a Trust Eroding Behaviour.

L: What is the bad habit? I do not recognise the behaviour that you are referring to.

B: The habit is called discounting. The reason we are not aware of it is because we do it unconsciously.

L: What is it that we do?

B: I will give you some examples. How do you feel when all the feedback you get is silence? How do you feel when someone complains that their mistake was not their fault? How do you feel when you try to help but you hit invisible barriers that block your progess?

L: Ouch! Those are uncomfortable questions. When I get no feedback I feel anxious and even fearful that I have made a mistake, and no one is telling me. There is a conspiracy of silence and a nasty surprise is on its way. When someone keeps complaining that even though they made the mistake they are not to blame I feel angry. When I try to help others and I fail to then I feel anxious and sad because my reputation, credibility and self-confidence is damaged.

B: OK. No need to panic. These negative emotional reactions are the normal reaction to discounting behaviour. Another word for discounting is disrespect. The three primary emotions we feel are sadness, anger and fear. Fear is the sense of impending loss; anger is the sense of present loss; and sadness is the sense of past loss. They are the same emotions that we feel on the Nerve Curve. What is different is the cause. Discounting is a disrepectful behaviour that is learned. So, it can be unlearned.

L: Oooo! That really resonates with me. Just reflecting on one day at work I can think of lots of examples of all of those negative feelings. So, when and how do we learn this discounting habit?

B: It is believed that we learn this behaviour when we are very young – before the age of seven. And because we learn it so young we internalise it and we become unaware of it. It then becomes a habit that is reinforced with years of experience and practice.

L: Wow! That rings true for me – and it may explain why I actively avoided some people at school – they were just toxic. But they had friends, went to college, got jobs, married and started families – just like me. Does that mean we grow out of it?

B: Most people unlearn some of these behavioural habits because life-experience teaches them that they are counter-productive. We all carry some of them though, and they tend to emerge when we are tired and under pressure. Some people get sort of stuck and carry these behaviours into their adult life. Their behaviour can be toxic to their relationships and their organisations.

L: I definitely resonate with that statement! Is there a way to unlearn this discounting habit?

B: Yes – just becoming aware of its existence is the first step. There are some strategies that we can learn, practice and use to defuse the discounting behaviour and over time our bad habit can be “kicked”.

L: Wow! That sounds really useful. And not just at work – I can see benefits in other areas of my life too.

B: Yes. Improvement science is powerful medicine.

L: So what do I need to do?

B: You have learned the 6M Design framework for resolving process niggles. There is an equivalent one for dissolving people niggles. I will send you some links to material to read and then we can talk again.

L: Will it help me resolve the problem that I have with the department that asked for my help who are behaving like Victims?

B: Yes.

L: OK – please send me the material. I promise to read it, reflect on it and I will arrange another conversation. I cannot wait to learn how to nail this niggle! I can see a huge win-win-win opportunity here.

B: OK. The email is on its way. I look forward to our next conversation.

08/12/201207/09/2024

The Six Dice Game

<Ring Ring><Ring Ring>

Hello, you are through to the Improvement Science Helpline. How can we help?

This is Leslie, one of your apprentices. Could I speak to Bob – my Improvement Science coach?

Yes, Bob is free. I will connect you now.

<Ring Ring><Ring Ring>

B: Hello Leslie, Bob here. What is on your mind?

L: Hi Bob, I have a problem that I do not feel my Foundation training has equipped me to solve. Can I talk it through with you?

B: Of course. Can you outline the context for me?

L: OK. The context is a department that is delivering an acceptable quality-of-service and is delivering on-time but is failing financially. As you know we are all being forced to adopt austerity measures and I am concerned that if their budget is cut then they will fail on delivery and may start cutting corners and then fail on quality too. We need a win-win-win outcome and I do not know where to start with this one.

B: OK – are you using the 6M Design method?

L: Yes – of course!

B: OK – have you done The 4N Chart for the customer of their service?

L: Yes – it was their customers who asked me if I could help and that is what I used to get the context.

B: OK – have you done The 4N Chart for the department?

L: Yes. And that is where my major concerns come from. They feel under extreme pressure; they feel they are working flat out just to maintain the current level of quality and on-time delivery; they feel undervalued and frustrated that their requests for more resources are refused; they feel demoralized; demotivated and scared that their service may be ‘outsourced’. On the positive side they feel that they work well as a team and are willing to learn. I do not know what to do next.

B: OK. Dispair not. This sounds like a very common and treatable system illness. It is a stream design problem which may be the reason your Foundations training feels insufficient. Would you like to see how a Practitioner would approach this?

L: Yes please!

B: OK. Have you mapped their internal process?

L: Yes. It is a six-step process for each job. Each step has different requirements and are done by different people with different skills. In the past they had a problem with poor service quality so extra safety and quality checks were imposed by the Governance department. Now the quality of each step is measured on a 1-6 scale and the quality of the whole process is the sum of the individual steps so is measured on a scale of 6 to 36. They now have been given a minimum quality target of 21 to achieve for every job. How they achieve that is not specified – it was left up to them.

B: OK – do they record their quality measurement data?

L: Yes – I have their report.

B: OK – how is the information presented?

L: As an average for the previous month which is reported up to the Quality Performance Committee.

B: OK – what was the average for last month?

L: Their results were 24 – so they do not have an issue delivering the required quality. The problem is the costs they are incurring and they are being labelled by others as ‘inefficient’. Especially the departments who are in budget and they are annoyed that this failing department keeps getting ‘bailed out’.

B: OK. One issue here is the quality reporting process is not alerting you to the real issue. It sounds from what you say that you have fallen into the Flaw of Averages trap.

L: I don’t understand. What is the Flaw of Averages trap?

B: The answer to your question will become clear. The finance issue is a symptom – an effect – it is unlikely to be the cause. When did this finance issue appear?

L: Just after the Safety and Quality Review. They needed to employ more agency staff to do the extra work created by having to meet the new Minimum Quality target.

B: OK. I need to ask you a personal question. Do you believe that improving quality always costs more?

L: I have to say that I am coming to that conclusion. Our Governance and Finance departments are always arguing about it. Governance state ‘a minimum standard of safety and quality is not optional’ and finance say ‘but we are going out of business’. They are at loggerheads. The service departments get caught in the cross-fire.

B: OK. We will need to use reality to demonstrate that this belief is incorrect. Rhetoric alone does not work. If it did then we would not be having this conversation. Do you have the raw data from which the averages are calculated?

L: Yes. We have the data. The quality inspectors are very thorough!

B: OK – can you plot the quality scores for the last fifty jobs as a BaseLine chart?

L: Yes – give me a second. The average is 24 as I said.

B: OK – is the process stable?

L: Yes – there is only one flag for the fifty. I know from my Foundations training that is not a cause for alarm.

B: OK – what is the process capability?

L: I am sorry – I don’t know what you mean by that?

B: My apologies. I forgot that you have not completed the Practitioner training yet. The capability is the range between the red lines on the chart.

L: Um – the lower line is at 17 and the upper line is at 31.

L: OK – how many points lie below the target of 21.

B: None of course. They are meeting their Minimum Quality target. The issue is not quality – it is money.

There was a pause. Leslie knew from experience that when Bob paused there was a surprise coming.

B: Can you email me your chart?

A cold-shiver went down Leslie’s back. What was the problem here? Bob had never asked to see the data before.

Sure. I will send it now. The recent fifty is on the right, the data on the left is from after the quality inspectors went in and before the the Minimum Quality target was imposed. This is the chart that Governance has been using as evidence to justify their existence because they are claiming the credit for improving the quality.

B: OK – thanks. I have got it – let me see. Oh dear.

Leslie was shocked. She had never heard Bob use language like ‘Oh dear’.

There was another pause.

B: Leslie, what is the context for this data? What does the X-axis represent?

Leslie looked at the chart again – more closely this time. Then she saw what Bob was getting at. There were fifty points in the first group, and about the same number in the second group. That was not the interesting part. In the first group the X-axis went up to 50 in regular steps of five; in the second group it went from 50 to just over 149 and was no longer regularly spaced. Eventually she replied.

Bob, that is a really good question. My guess it is that this is the quality of the completed work.

B: It is unwise to guess. It is better to go and see reality.

You are right. I knew that. It is drummed into us during the Foundations training! I will go and ask. Can I call you back?

B: Of course. I will email you my direct number.

<Ring Ring><Ring Ring>

B: Hello, Bob here.

L: Bob – it is Leslie. I am so excited! I have discovered something amazing.

B: Hello Leslie. That is good to hear. Can you tell me what you have discovered?

L: I have discovered that better quality does not always cost more.

B: That is a good discovery. Can you prove it with data?

L: Yes I can! I am emailing you the chart now.

B: OK – I am looking at your chart. Can you explain to me what you have discovered?

L: Yes. When I went to see for myself I saw that when a job failed the Minimum Quality check at the end then the whole job had to be re-done because there was no time to investigate and correct the causes of the failure. The people doing the work said that they were helpless victims of errors that were made upstream of them – and they could not predict from one job to the next what the error would be. They said it felt like quality was a lottery and that they were just firefighting all the time. They knew that just repeating the work was not solving the problem but they had no other choice because they were under enormous pressure to deliver on-time as well. The only solution they could see is was to get more resources but their requests were being refused by Finance on the grounds that there is no more money. They felt completely trapped.

B: OK. Can you describe what you did?

L: Yes. I saw immediately that there were so many sources of errors that it would be impossible for me to tackle them all. So I used the tool that I had learned in the Foundations training: the Niggle-o-Gram. That focussed us and led to a surprisingly simple, quick, zero-cost process design change. We deliberately did not remove the Inspection-and-Correction policy because we needed to know what the impact of the change would be. Oh, and we did one other thing that challenged the current methods. We plotted every attempt, both the successes and the failures, on the BaseLine chart so we could see both the the quality and the work done on one chart. And we updated the chart every day and posted it chart on the notice board so everyone in the department could see the effect of the change that they had designed. It worked like magic! They have already slashed their agency staff costs, the whole department feels calmer and they are still delivering on-time. And best of all they now feel that they have the energy and time to start looking at the next niggle. Thank you so much! Now I see how the tools and techniques I learned in Foundations are so powerful and now I understand better the reason we learned them first.

B: Well done Leslie. You have taken an important step to becoming a fully fledged Practitioner. You have learned some critical lessons in this challenge.

This scenario is fictional but realistic.

And it has been designed so that it can be replicated easily using a simple game that requires only pencil, paper and some dice.

If you do not have some dice handy then you can use this little program that simulates rolling six dice.

The Six Digital Dice program (for PC only).

Instructions
1. Prepare a piece of A4 squared paper with the Y-axis marked from zero to 40 and the X-axis from 1 to 80.
2. Roll six dice and record the score on each (or roll one die six times) – then calculate the total.
3. Plot the total on your graph. Left-to-right in time order. Link the dots with lines.
4. After 25 dots look at the chart. It should resemble the leftmost data in the charts above.
5. Now draw a horizontal line at 21. This is the Minimum Quality Target.
6. Keep rolling the dice – six per cycle, adding the totals to the right of your previous data.

But this time if the total is less than 21 then repeat the cycle of six dice rolls until the score is 21 or more. Record on your chart the output of all the cycles – not just the acceptable ones.

7. Keep going until you have 25 acceptable outcomes. As long as it takes.

Now count how many cycles you needed to complete in order to get 25 acceptable outcomes. You should find that it is about twice as many as before you “imposed” the Inspect-and-Correct QI policy.

This illustrates the problem of an Inspection-and-Correction design for quality improvement. It does improve the quality of the final output – but at a higher cost.

We are treating the symptoms (effects) and ignoring the disease (causes).

The internal design of the process is unchanged so it is still generating mistakes.

How much quality improvement you get and how much it costs you is determined by the design of the underlying process – which has not changed. There is a Law of Diminishing returns here – and a big risk.

The risk is that if quality improves as the result of applying a quality target then it encourages the Governance thumbscrews to be tightened further and forces those delivering the service further into cross-fire between Governance and Finance.

The other negative consequence of the Inspect-and-Correct approach is that it increases both the average and the variation in lead time which also fuels the calls for more targets, more sticks, calls for more resources and pushes costs up even further.

The lesson from this simple exercise seems clear.

The better strategy for improving quality is to design the root causes of errors out of the processes because then we will get improved quality and improved delivery and improved productivity and we will discover that we have improved safety as well. Win-win-win-win.

The Six Dice Game is a simpler version of the famous Red Bead Game that W Edwards Deming used to explain why, in the modern world, the arbitrary-target-driven-command-and-control-stick-and-carrot style of performance management creates more problems than it solves.

The illusion is of short-term gain but the reality is of long-term pain.

And if you would like to see and hear Deming talking about the science of improvement there is a video of him speaking in 1984. He is at the bottom of the page. Click here.

24/11/2012

The Three R’s

Processes are like people – they get poorly – sometimes very poorly.

Poorly processes present with symptoms. Symptoms such as criticism, complaints, and even catastrophes.

Poorly processes show signs. Signs such as fear, queues and deficits.

So when a process gets very poorly what do we do?

We follow the Three R’s

1-Resuscitate
2-Review
3-Repair

Resuscitate means to stabilize the process so that it is not getting sicker.

Review means to quickly and accurately diagnose the root cause of the process sickness.

Repair means to make changes that will return the process to a healthy and stable state.

So the concept of ‘stability’ is fundamental and we need to understand what that means in practice.

Stability means ‘predictable within limits’. It is not the same as ‘constant’. Constant is stable but stable is not necessarily constant.

Predictable implies time – so any measure of process health must be presented as time-series data.

We are now getting close to a working definition of stability: “a useful metric of system performance that is predictable within limits over time”.

So what is a ‘useful metric’?

There will be at least three useful metrics for every system: a quality metric, a time metric and a money metric.

Quality is subjective. Money is objective. Time is both.

Time is the one to start with – because it is the easiest to measure.

And if we treat our system as a ‘black box’ then from the outside there are three inter-dependent time-related metrics. These are external process metrics (EPMs) – sometimes called Key Performance Indicators (KPIs).

Flow in – also called demand
Flow out – also called activity
Delivery time – which is the time a task spends inside our system – also called the lead time.

But this is all starting to sound like rather dry, conceptual, academic mumbo-jumbo … so let us add a bit of realism and drama – let us tell this as a story …

[reveal heading=”Click here to reveal the story …“]

Picture yourself as the manager of a service that is poorly. Very poorly. You are getting a constant barrage of criticism and complaints and the occasional catastrophe. Your service is struggling to meet the required delivery time performance. Your service is struggling to stay in budget – let alone meet future cost improvement targets. Your life is a constant fire-fight and you are getting very tired and depressed. Nothing you try seems to make any difference. You are starting to think that anything is better than this – even unemployment! But you have a family to support and jobs are hard to come by in austere times so jumping is not an option. There is no way out. You feel you are going under. You feel are drowning. You feel terrified and helpless!

In desperation you type “Management fire-fighting” into your web search box and among the list of hits you see “Process Improvement Emergency Service”. That looks hopeful. The link takes you to a website and a phone number. What have you got to lose? You dial the number.

It rings twice and a calm voice answers.

?“You are through to the Process Improvement Emergency Service – what is the nature of the process emergency?”

“Um – my service feels like it is on fire and I am drowning!”

The calm voice continues in a reassuring tone.

?“OK. Have you got a minute to answer three questions?”

“Yes – just about”.

?“OK. First question: Is your service safe?”

“Yes – for now. We have had some catastrophes but have put in lots of extra safety policies and checks which seems to be working. But they are creating a lot of extra work and pushing up our costs and even then we still have lots of criticism and complaints.”

?“OK. Second question: Is your service financially viable?”

“Yes, but not for long. Last year we just broke even, this year we are projecting a big deficit. The cost of maintaining safety is ‘killing’ us.”

?“OK. Third question: Is your service delivering on time?”

“Mostly but not all of the time, and that is what is causing us the most pain. We keep getting beaten up for missing our targets. We constantly ask, argue and plead for more capacity and all we get back is ‘that is your problem and your job to fix – there is no more money’. The system feels chaotic. There seems to be no rhyme nor reason to when we have a good day or a bad day. All we can hope to do is to spot the jobs that are about to slip through the net in time; to expedite them; and to just avoid failing the target. We are fire-fighting all of the time and it is not getting better. In fact it feels like it is getting worse. And no one seems to be able to do anything other than blame each other.”

There is a short pause then the calm voice continues.

?“OK. Do not panic. We can help – and you need to do exactly what we say to put the fire out. Are you willing to do that?”

“I do not have any other options! That is why I am calling.”

The calm voice replied without hesitation.

?“We all always have the option of walking away from the fire. We all need to be prepared to exercise that option at any time. To be able to help then you will need to understand that and you will need to commit to tackling the fire. Are you willing to commit to that?”

You are surprised and strangely reassured by the clarity and confidence of this response and you take a moment to compose yourself.

“I see. Yes, I agree that I do not need to get toasted personally and I understand that you cannot parachute in to rescue me. I do not want to run away from my responsibility – I will tackle the fire.”

?“OK. First we need to know how stable your process is on the delivery time dimension. Do you have historical data on demand, activity and delivery time?”

“Hey! Data is one thing I do have – I am drowning in the stuff! RAG charts that blink at me like evil demons! None of it seems to help though – the more data I get sent the more confused I become!”

?“OK. Do not panic. The data you need is very specific. We need the start and finish events for the most recent one hundred completed jobs. Do you have that?”

“Yes – I have it right here on a spreadsheet – do I send the data to you to analyse?”

?“There is no need to do that. I will talk you through how to do it.”

“You mean I can do it now?”

?“Yes – it will only take a few minutes.”

“OK, I am ready – I have the spreadsheet open – what do I do?”

?“Step 1. Arrange the start and finish events into two columns with a start and finish event for each task on each row.

You copy and paste the data you need into a new worksheet.

“OK – done that”.

?“Step 2. Sort the two columns into ascending order using the start event.”

“OK – that is easy”.

?“Step 3. Create a third column and for each row calculate the difference between the start and the finish event for that task. Please label it ‘Lead Time’”.

“OK – do you want me to calculate the average Lead Time next?”

There was a pause. Then the calm voice continued but with a slight tinge of irritation.

?“That will not help. First we need to see if your system is unstable. We need to avoid the Flaw of Averages trap. Please follow the instructions exactly. Are you OK with that?”

This response was a surprise and you are starting to feel a bit confused.

“Yes – sorry. What is the next step?”

?“Step 4: Plot a graph. Put the Lead Time on the vertical axis and the start time on the horizontal axis”.

“OK – done that.”

?“Step 5: Please describe what you see?”

“Um – it looks to me like a cave full of stalagtites. The top is almost flat, there are some spikes, but the bottom is all jagged.”

?“OK. Step 6: Does the pattern on the left-side and on the right-side look similar?”

“Yes – it does not seem to be rising or falling over time. Do you want me to plot the smoothed average over time or a trend line? They are options on the spreadsheet software. I do that use all the time!”

The calm voice paused then continued with the irritated overtone again.

?“No. There is no value is doing that. Please stay with me here. A linear regression line is meaningless on a time series chart. You may be feeling a bit confused. It is common to feel confused at this point but the fog will clear soon. Are you OK to continue?”

An odd feeling starts to grow in you: a mixture of anger, sadness and excitement. You find yourself muttering “But I spent my own hard-earned cash on that expensive MBA where I learned how to do linear regression and data smoothing because I was told it would be good for my career progression!”

?“I am sorry I did not catch that? Could you repeat it for me?”

“Um – sorry. I was talking to myself. Can we proceed to the next step?”

?”OK. From what you say it sounds as if your process is stable – for now. That is good. It means that you do not need to Resuscitate your process and we can move to the Review phase and start to look for the cause of the pain. Are you OK to continue?”

An uncomfortable feeling is starting to form – one that you cannot quite put your finger on.

“Yes – please”.

?Step 7: What is the value of the Lead Time at the ‘cave roof’?”

“Um – about 42”

?“OK – Step 8: What is your delivery time target?”

“42”

?“OK – Step 9: How is your delivery time performance measured?”

“By the percentage of tasks that are delivered late each month. Our target is better than 95%. If we fail any month then we are named-and-shamed at the monthly performance review meeting and we have to explain why and what we are going to do about it. If we succeed then we are spared the ritual humiliation and we are rewarded by watching others else being mauled instead. There is always someone in the firing line and attendance at the meeting is not optional!”

You also wanted to say that the data you submit is not always completely accurate and that you often expedite tasks just to avoid missing the target – in full knowkedge that the work had not been competed to the required standard. But you hold that back. Someone might be listening.

There was a pause. Then the calm voice continued with no hint of surprise.

?“OK. Step 10. The most likely diagnosis here is a DRAT. You have probably developed a Gaussian Horn that is creating the emotional pain and that is fuelling the fire-fighting. Do not panic. This is a common and curable process illness.”

You look at the clock. The conversation has taken only a few minutes. Your feeling of panic is starting to fade and a sense of relief and curiosity is growing. Who are these people?

“Can you tell me more about a DRAT? I am not familiar with that term.”

?“Yes. Do you have two minutes to continue the conversation?”

“Yes indeed! You have my complete attention for as long as you need. The emails can wait.”

The calm voice continues.

?“OK. I may need to put you on hold or call you back if another emergency call comes in. Are you OK with that?”

“You mean I am not the only person feeling like this?”

?“You are not the only person feeling like this. The process improvement emergency service, or PIES as we call it, receives dozens of calls like this every day – from organisations of every size and type.”

“Wow! And what is the outcome?”

There was a pause. Then the calm voice continued with an unmistakeable hint of pride.

?“We have a 100% success rate to date – for those who commit. You can look at our performance charts and the client feedback on the website.”

“I certainly will! So can you explain what a DRAT is?”

And as you ask this you are thinking to yourself ‘I wonder what happened to those who did not commit?’

The calm voice interrupts your train of thought with a well-practiced explanation.

?“DRAT stands for Delusional Ratio and Arbitrary Target. It is a very common management reaction to unintended negative outcomes such as customer complaints. The concept of metric-ratios-and-performance-specifications is not wrong; it is just applied indiscriminately. Using DRATs can drive short-term improvements but over a longer time-scale they always make the problem worse.”

One thought is now reverberating in your mind. “I knew that! I just could not explain why I felt so uneasy about how my service was being measured.” And now you have a new feeling growing – anger. You control the urge to swear and instead you ask:

“And what is a Horned Gaussian?”

The calm voice was expecting this question.

?“It is easier to demonstrate than to explain. Do you still have your spreadsheet open and do you know how to draw a histogram?”

“Yes – what do I need to plot?”

?“Use the Lead Time data and set up ten bins in the range 0 to 50 with equal intervals. Please describe what you see”.

It takes you only a few seconds to do this. You draw lots of histograms – most of them very colourful but meaningless. No one seems to mind though.

“OK. The histogram shows a sort of heap with a big spike on the right hand side – at 42.”

The calm voice continued – this time with a sense of satisfaction.

?“OK. You are looking at the Horned Gaussian. The hump is the Gaussian and the spike is the Horn. It is a sign that your complex adaptive system behaviour is being distorted by the DRAT. It is the Horn that causes the pain and the perpetual fire-fighting. It is the DRAT that causes the Horn.”

“Is it possible to remove the Horn and put out the fire?”

?“Yes.”

This is what you wanted to hear and you cannot help cutting to the closure question.

“Good. How long does that take and what does it involve?”

The calm voice was clearly expecting this question too.

?“The Gaussian Horn is a non-specific reaction – it is an effect – it is not the cause. To remove it and to ensure it does not come back requires treating the root cause. The DRAT is not the root cause – it is also a knee-jerk reaction to the symptoms – the complaints. Treating the symptoms requires learning how to diagnose the specific root cause of the lead time performance failure. There are many possible contributors to lead time and you need to know which are present because if you get the diagnosis wrong you will make an unwise decision, take the wrong action and exacerbate the problem.”

Something goes ‘click’ in your head and suddently your fog of confusion evaporates. It is like someone just switched a light on.

“Ah Ha! You have just explained why nothing we try seems to work for long – if at all. How long does it take to learn how to diagnose and treat the specific root causes?”

The calm voice was expecting this question and seemed to switch to the next part of the script.

?“It depends on how committed the learner is and how much unlearning they have to do in the process. Our experience is that it takes a few hours of focussed effort over a few weeks. It is rather like learning any new skill. Guidance, practice and feedback are needed. Just about anyone can learn how to do it – but paradoxically it takes longer for the more experienced and, can I say, cynical managers. We believe they have more unlearning to do.”

You are now feeling a growing sense of urgency and excitement.

“So it is not something we can do now on the phone?”

?“No. This conversation is just the first step.”

You are eager now – sitting forward on the edge of your chair and completely focussed.

“OK. What is the next step?”

There is a pause. You sense that the calm voice is reviewing the conversation and coming to a decision.

?“Before I can answer your question I need to ask you something. I need to ask you how you are feeling.”

That was not the question you expected! You are not used to talking about your feelings – especially to a complete stranger on the phone – yet strangely you do not sense that you are being judged. You have is a growing feeling of trust in the calm voice.

You pause, collect your thoughts and attempt to put your feelings into words.

“Er – well – a mixture of feelings actually – and they changed over time. First I had a feeling of surprise that this seems so familiar and straightforward to you; then a sense of resistance to the idea that my problem is fixable; and then a sense of confusion because what you have shown me challenges everything I have been taught; and then a feeling distrust that there must be a catch and then a feeling of fear of embarassement if I do not spot the trick. Then when I put my natural skepticism to one side and considered the possibility as real then there was a feeling of anger that I was not taught any of this before; and then a feeling of sadness for the years of wasted time and frustration from battling something I could not explain. Eventually I started to started to feel that my cherished impossibility belief was being shaken to its roots. And then I felt a growing sense of curiosity, optimism and even excitement that is also tinged with a feeling of fear of disappointment and of having my hopes dashed – again.”

There was a pause – as if the calm voice was digesting this hearty meal of feelings. Then the calm voice stated:

?“You are experiencing the Nerve Curve. It is normal and expected. It is a healthy sign. It means that the healing process has already started. You are part of your system. You feel what it feels – it feels what you do. The sequence of negative feelings: the shock, denial, anger, sadness, depression and fear will subside with time and the positive feelings of confidence, curiosity and excitement will replace them. Do not worry. This is normal and it takes time. I can now suggest the next step.”

You now feel like you have just stepped off an emotional rollercoaster – scary yet exhilarating at the same time. A sense of relief sweeps over you. You have shared your private emotional pain with a stranger on the phone and the world did not end! There is hope.

“What is the next step?”

This time there was no pause.

?“To commit to learning how to diagnose and treat your process illnesses yourself.”

“You mean you do not sell me an expensive training course or send me a sharp-suited expert who will come tell me what to do and charge me a small fortune?”

There is an almost sarcastic tone to your reply that you regret as soon as you have spoken.

Another pause. An uncomfortably long one this time. You sense the calm voice knows that you know the answer to your own question and is waiting for you to answer it yourself.

You answer your own question.

“OK. I guess not. Sorry for that. Yes – I am definitely up for learning how! What do I need to do.”

?“Just email us. The address is on the website. We will outline the learning process. It is neither difficult nor expensive.”

The way this reply was delivered – calmly and matter-of-factly – was reassuring but it also promoted a new niggle – a flash of fear.

“How long have I got to learn this?”

This time the calm voice had an unmistakable sense of urgency that sent a cold prickles down your spine.

?”Delay will add no value. You are being stalked by the Horned Gaussian. This means your system is on the edge of a catastrophe cliff. It could tip over any time. You cannot afford to relax. You must maintain all your current defenses. It is a learning-by-doing process. The sooner you start to learn-by-doing the sooner the fire starts to fade and the sooner you move away from the edge of the cliff.”

“OK – I understand – and I do not know why I did not seek help a long time ago.”

The calm voice replied simply.

?”Many people find seeking help difficult. Especially senior people”.

Sensing that the conversation is coming to an end you feel compelled to ask:

“I am curious. Where do the DRATs come from?”

?“Curiosity is a healthy attitude to nurture. We believe that DRATs originated in finance departments – where they were originally called Fiscal Averages, Ratios and Targets. At some time in the past they were sucked into operations and governance departments by a knowledge vacuum created by an unintended error of omission.”

You are not quite sure what this unfamiliar language means and you sense that you have strayed outside the scope of the “emergency script” but the phrase ‘error of omission sounds interesting’ and pricks your curiosity. You ask:

“What was the error of omission?”

?“We believe it was not investing in learning how to design complex adaptive value systems to deliver capable win-win-win performance. Not investing in learning the Science of Improvement.”

“I am not sure I understand everything you have said.”

?“That is OK. Do not worry. You will. We look forward to your email. My name is Bob by the way.”

“Thank you so much Bob. I feel better just having talked to someone who understands what I am going through and I am grateful to learn that there is a way out of this dark pit of despair. I will look at the website and send the email immediately.”

?”I am happy to have been of assistance.”

[/reveal]

27/10/2012

The First Step Looks The Steepest

Getting started on improvement is not easy.

It feels like we have to push a lot to get anywhere and when we stop pushing everything just goes back to where it was before and all our effort was for nothing.

And it is easy to become despondent. It is easy to start to believe that improvement is impossible. It is easy to give up. It is not easy to keep going.

One common reason for early failure is that we often start by trying to improve something that we have little control over. Which is natural because many of the things that niggle us are not of our making.

But not all Niggles are like that; there are also many Niggles over which we have almost complete control.

It is these close-to-home Niggles that we need to start with – and that is surprisingly difficult too – because it requires a bit of time-investment.

The commonest reason for not investing time in improvement is: “I am too busy.”

Q: Too busy doing what – specifically?

This simple question is a good place to start because just setting aside a few minutes each day to reflect on where we have been spending our time is a worthwhile task.

And the output of our self-reflection is usually surprising.

We waste lifetime every day doing worthless work.

Then we complain that we are too busy to do the worthwhile stuff.

Q: So what are we scared of? Facing up to the uncomfortable reality of knowing how much lifetime we have wasted already?

We cannot change the past. We can only influence the future. So we need to learn from the past to make wiser choices.

Lifetime is odd stuff. It both is and is not like money.

We can waste lifetime and we can waste money. In that respect they are the same. Money we do not use today we can save for tomorrow, but lifetime not used today is gone forever.

We know this, so we have learned to use up every last drop of lifetime – we have learned to keep ourselves busy.

And if we are always busy then any improvement will involve a trade-off: dis-investing and re-investing our lifetime. This implies the return on our lifetime re-investment must come quickly and predictably – or we give up.

One tried-and-tested strategy is to start small and then to re-invest our time dividend in the next cycle of improvement. An if we make wise re-investment choices, the benefit will grow exponentially.

Successful entrepreneurs do not make it big overnight.

If we examine their life stories we will find a repeating cycle of bigger and bigger business improvement cycles.

The first thing successful entrepreneurs learn is how to make any investment lead to a return – consistently. It is not luck. They practice with small stuff until they can do it reliably.

Successful entrepreneurs are disciplined and they only take calculated risks.

Unsuccessful entrepreneurs are more numerous and they have a different approach.

They are the get-rich-quick brigade. The undisciplined gamblers. And the Laws of Probability ensure that they all will fail eventually.

Sustained success is not by chance, it is by design.

The same is true for improvement. The skill to learn is how to spot an opportunity to release some valuable time resource by nailing a time-sapping-niggle; and then to reinvest that time in the next most promising cycle of improvement – consistently and reliably. It requires discipline and learning to use some novel tools and techniques.

This is where Improvement Science helps – because the tools and techniques apply to any improvement. Safety. Flow. Quality. Productivity. Stability. Reliability.

In a nutshell … trustworthy.

The first step looks the steepest because the effort required feels high and the benefit gained looks small. But it is climbing the first step that separates the successful from the unsuccessful. And successful people are self-disciplined people.

After a few invest-release-reinvest cycles the amount of time released exceeds the amount needed to reinvest. It is then we have time to spare – and we can do what we choose with that.

Ask any successful athlete or entrepreneur – they keep doing it long after they need to – just for the “rush” it gives them.

The tool I use, because it is quick, easy and effective, is called The 4N Chart®. And it has a helpful assistant called a Niggle-o-Gram®. Together they work like a focusing lens – they show where the most fertile opportunity for improvement is – the best return on an investment of time and effort.

And when we have proved to yourself that the first step of improvement is not as steep as you believed – then we have released some time to re-invest in the next cycle of improvement – and in sharing what we have discovered.

That is where the big return comes from.

10/11/2012: Feedback from people who have used The 4N Chart and Niggle-o-Gram for personal development is overwhelmingly positive.