Category: Stories

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Predictable and Explainable – or Not

It is a common and intuitively reasonable assumption to believe that if something is explainable then it is predictable; and if it is not explainable then it is not predictable. Unfortunately this beguiling assumption is incorrect.  Some things are explainable but not predictable; and some others are predictable but not explainable.  Believe me? Of course not. We are all skeptics when our intuitively obvious assumptions and conclusions are challenged! We want real and rational evidence not rhetorical exhortation.

OK.  Explainable means that the principles that guide the process are conceptually simple. We can explain the parts in detail and we can explain how they are connected together in detail. Predictable implies that if we know the starting point in detail, and the intervention in detail, then we can predict what the outcome will be – in detail.

Let us consider an example. Say we know how much we have in our bank account, and we know how much we intend to spend on that new whizzo computer, then we can predict what will be left in out bank account when the payment has been processed. Yes. This is an explainable and predictable system. It is called a linear system.

Let us consider another example. Say we know we have six dice each with numbers 1 to 6 printed on them and we throw them at the same time. Can we predict where they will land and what the final sum will be? No. We can say that it will be between 6 and 36 but that is all. And after we have thrown the dice we will not be able to explain, in detail, how they came to rest exactly where they did.  This is an unpredictable and unexplainable system. It is called a random system.

This is a picture of a conceptually simple system. It is a novelty toy and it comprises two thin sheets of glass held a few millimetres apart by some curved plastic spacers. The narrow space is filled with green coloured oil, some coarse black volcanic sand, and some fine white coral sand. That is all. It is a conceptually simple toy. I have (by some magical means) layered the sand so that the coarse black sand is at the bottom and the fine white sand is on top. It is stable arrangement – and explainable. I then tipped the toy on its side – I rotated it through 90 degrees. It is a simple intervention – and explainable.

My intervention has converted a stable system to an unstable one and I confidently predict that the sand and oil will flow under the influence of gravity. There is no randomness here – I do not jiggle the toy – so the outcome should be predictable because I can explain all the parts in detail before we start;  and I can explain the process in detail; and I can explain precisely what my intervention will be. So I should be able to predict the final configuration of the sand when this simple and explainable system finally settles into a new stable state again. Yes?

Well, I cannot. I can make some educated guesses – some plausible projections. But the only way to find out precisely what will happen is by doing the experiment and observing what actually happens.

This is what happened.

The final, stable configuration of the coarse black and fine white sand has a strange beauty in the way the layers are re-arranged. The result is not random – it has structure. And with the benefit of hindsight I feel I can work backwards and understand how it might have come about. It is explainable in retrospect but I could not predict it in prospect – even with a detailed knowledge of the starting point and the process.

This is called a non-linear system. Explainable in concept but difficult to predict in practice. The weather is another example of a non-linear system – explainable in terms of the physics but not precisely predictable. How reliable are our long range weather forecasts – or the short range ones for that matter?

Non-linear systems exhibit complex and unpredictable  behaviour – even though they may be simple in concept and uncomplicated in construction.  Randomness is usually present in real systems but it is not the cause of the complex behaviour, and making our systems more complicated seems likely to result in more unpredictable behaviour – not less.

If we want the behaviour of our system to be predictable and our system has non-linear parts and relationships in it – then we are forced to accept two Universal Truths.

1. That our system behaviour will only be predictable within limits (even if there is little or no randomness in it).

2. That to keep the behaviour within acceptable limits then we need to be careful how we arrange the parts and how they relate to each other.

This challenge of creating a predictable-within-acceptable-limits system from non-linear parts is called resilient design.

We have a fourth option to consider: a system that has a predictable outcome but an unexplainable reason.

We make predictions two ways – by working out what will happen or by remembering what has happened before. The second method is much easier so it is the one we use most of the time: it is called re-cognition. We call it knowledge.

If we have a black box with inputs on one side and outputs on the other, and we observe that when we set the inputs to a specific configuration we always get the same output – then we have a predicable system. We cannot explain how the inputs result in the output because the inner workings are hidden. It could be very simple – or it could be fiendishly complicated – we do not know.

It this situation we have no choice but to accept the status quo – and we have to accept that to get a predictable outcome we have to follow the rules and just do what we have always done before. It is the creed of blind acceptance – the If you always do what you have always done you will always get what you always got. It is knowledge but it is not understanding.  New knowledge  can only be found by trial and error.  It is not wisdom, it is not design, it is not curiosity and it is not Improvement Science.

If our systems are non-linear (which they are) and we want predictable and acceptable performance (which we do) then we must strive to understand them and then to design them to be as simple as possible (which is difficult) so that we have the greatest opportunity to improve their performance by design (which is called Improvement Science).

This is a snapshot of the evolving oil-and-sand system. Look at that weird wine-glass shaped hole in the top section caused by the black sand being pulled down through the gap in the spacer then running down the slope of the middle section to fill a white sand funnel and then slip through the next hole onto the top of the white sand pyramid created by the white sand in the middle section that slipped through earlier onto the top of the sliding sand in the lowest section. Did you predict that? I suspect not. Me neither. But I can explain it – with the benefit of hindsight.

So what is it that is causing this complex behaviour? It is the spacers – the physical constraints to the flow of the sand and oil. And the same is true of systems – when the process hits a constraint then the behaviour suddenly changes and complex behaviour emerges.  And there is more to it than even this. It is the gaps between the spacers that is creating the complex behaviour. The flow from one compartment leaking into the next and influencing its behaviour, and then into the next.  This is what happens in all systems – the more constraints that are added to force the behaviour into predictable channels, and the more gaps that exist in the system of constraints then the more complex and unpredictable the system behaviour becomes. Which is exactly the opposite of the intended outcome.

The lesson that this simple toy can teach us is that if we want stable and predictable (i.e. non-complex) behaviour from our complicated systems then we must design them to operate inside the constraints so that they just never quite touch them. That requires data, information, knowledge, understanding and wise design. That is called Improvement Science.

But if, in an act of desperation, we force constraints onto the system we will make the system less stable, less predictable, less safe, less productive, less enjoyable and less affordable. That is called tampering.

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The Pragmatist and the Three Fears

The term Pragmatist is a modern one – it was coined by Charles Sanders Pierce (1839-1914) – a 19th century American polymath and iconoclast. In plain speak he was a tree-shaker and a dogma-breaker; someone who regarded rules created by people as an opportunity for innovation rather than a source of frustration.

A tree-shaker reframes the Three Fears that block change and improvement; the Fear of Ambiguity; the Fear of Ridicule and the Fear of Failure. A tree-shaker re-channels their emotional energy from fear into innovation and exploration. They feel the fear but they do it anyway. But how do they do it?

To understand this we first need to explore how we learn to collectively suppress change by submitting to peer-fear.

In the 1960’s there was an experiment done with Rhesus monkeys that sheds light on a possible mechanism: the monkeys appeared to learn from each other by observing the emotional responses of other monkeys to threats. The story of the Five Monkeys and the Banana Experiment first appeared in a management textbook in 1996  but there is no evidence that this particular experiment was ever performed. With this in mind here is a version of the story:

Five naive monkeys were offered a banana but it required climbing a ladder to get it.  Monkeys like bananas and are good at climbing. The ladder was novel. And every time any of the monkeys started to climb the ladder all the monkeys were sprayed with cold water. Monkeys do not like cold water. It was a classic conditioning experiment and after just a few iterations the monkeys stopped trying to climb the ladder to get the banana. They had learned to fear the ladder and their natural desire for the banana was suppressed by their new fear: a learned association between climbing the ladder and the unpleasant icy shower. Next the psychologists replaced one of the monkeys with a new naive monkey – who immediately started to climb the ladder to get the banana. What happened next is interesting. The other four monkeys pulled the new monkey back. They did not want to get another cold shower. After a while the new monkey learned because his fear of social rejection was greater than his desire for the banana. He stopped trying to get the banana. This cycle was repeated four more times until all the original monkeys had been replaced. None of the five remaining monkeys had any personal experience of the cold shower – but the ladder-avoiding behaviour remained and was enforced by the group, even though the original reason for shunning the ladder was unknown.

Here is the quoted reference to the experiment on which the story is based.

Stephenson, G. R. (1967). Cultural acquisition of a specific learned response among rhesus monkeys. In: Starek, D., Schneider, R., and Kuhn, H. J. (eds.), Progress in Primatology, Stuttgart: Fischer, pp. 279-288.

So it would appear that a very special type of monkey would be needed to break a culturally enforced behavioural norm. One that is curious, creative and courageous, and one that does not fear ridicule or failure. One that is immune to peer-fear.

We could extrapolate from this story and reflect on how peer pressure might impede change and improvement in the workplace.  When well-intended, innocent, creativity and innovation are met with the emotional ice-bath of dire warnings, criticism, ridicule and cynicism then the unconfident innovator may eventually give up trying and start to believe that improvement is impossible.  The Hans Christian Anderson’s short tale of the Emporer’s New Clothes is a well known example – the one innocent child says what all the experienced adults have learned to deny. A culture of peer-fear can become self-sustaining and this change-avoiding-culture appears to be a common state of affairs in many organisations; in particular ones of an academic and bureaucratic leaning.

At the other end of the change spectrum from Bureaucracy sits Chaos. It is also resisted but the behaviour is fuelled by a different fear – the Fear of Ambiguity. We prefer the known and the predictable. We follow ingrained habits. We prevaricate even when our rationality says we should change.  We dislike the feeling of ambiguity and uncertainty because it leaves us with a sense of foreboding and dread. Change is strongly associated with confusion and we appear hard-wired to avoid it. Except that we are not. This is learned behaviour and we learned it when we were very young. As adults we reinforce it; as adults we replicate it; and as adults impose it on others – including our next generation. The generation that will inherit our world and who will look after us when we are old and frail. We will reap what we sow. But if we learned it and teach it then are we able to unlearn it and unteach it?

Enter the Pragmatists. They have learned to harness the Three Fears. Or rather they have unlearned their association of Fear with Change. Sometimes this unlearning came from a crisis – they were forced to change by external factors. Doing nothing was not an option. Sometimes their unlearning came from inspiration – they saw someone else demonstrate that other options were possible and beneficial. Sometimes their insight came by surprise – an unexpected change of perspective exposed the hidden opportunity. An eureka moment.

Whatever the route the Pragmatist discovers a new tool: a tool labelled “Heuristics”.  A heuristic is a “rule of thumb” – an empirically derived good-enough-for-now guideline. Heuristics include some uncertainty, some ambiguity and some risk. Just enough uncertainty and ambiguity to build a flexible conceptual framework that is strong enough, resilient enough and modifiable enough to facilitate learning and improvement. And with it a pinch of risk to spice the sauce – because we all like a bit of risk.

The Improvement Scientist is a Pragmatist and a Practitioner of Heuristics – both of which can be learned.

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The Skeptics, The Cynics and The Sphere of Influence

All intentional improvement implies change. Change requires deliberate action – thinking about change is not enough. Action implies control of physical objects and, despite what we might like to believe, the only things that are under our personal control are our beliefs, our attitudes, our behaviours and our actions. Everything else can only be changed through some form of indirect influence.

Our Circle of Control appears to extends only to our skin – beyond that is our Sphere of Influence – and beyond that is our Region of Concern.

Very few of us live a solitary existence as a hermit. The usual context for improvement is social and therefore to achieve improvement outside ourselves we need to influence the beliefs, attitudes, behaviours and actions of others. And we can only do that through our own behaviour and actions. We cannot do telepathy or mind-control.  And remember, we are being influenced by others – it is a two-way street.

So when we receive a push-back to our attempted change-for-the-better action, we have failed to influence in a positive sense and the intended improvement cannot happen.  Those who oppose our innovation usually belong to one of two tribes – the Skeptics and the Cynics – and they have much in common.  They both operate from a position of doubt and a belief that they are being deliberately deceived. They distrust, discount, question, analyse, critique and they challenge. They do not blindly believe our rhetoric.

This is not new. These two tribes are thousands of years old – the Ancient Greeks knew them well and gave them the names Skeptics and Cynics. They were the Lords of the Dark Ages but they survived the Renaissance and the first skeptical hypothesis in modern Western philosophy is attributed to Rene Descartes who wrote “I will suppose … that some evil demon of the utmost power and cunning has employed all his energies to deceive me.”

The two tribes present the Innovator and Improvement Scientist with a dilemma. Before action there is only rhetoric, only an idea, only a belief that better is possible. There is no evidence of improvement yet – so no reality to support the rhetoric. And if the action requires the engagement or permission of either of the two tribes then the change will not happen because it is impossible to influence their belief and behaviour without evidence. We have crashed into the wall of resistance – and the harder we push the harder they push back.  So let us conserve our energy, step back from the wall, reflect for a moment and ask “Does the wall surround us completely – or are there gaps?”

Could we find a region of the Sphere of Influence that has few or no Skeptics and Cynics? Is there a place where they do not like to live because the cultural climate is not to their taste? We have an option – we can explore the Sphere of Influence.

At one pole we discover a land called Apathy. It is a barren place where nothing changes; it is devoid of ideas and innovation; it is passionless, monotonous, stable, predictable, safe and boring.  The Skeptics and Cynics do not like it there because there is none of their favourite food – Innovator Passion – which is where they derive their energy and their sport.

At the other pole we discover a land called Assertion – and we discover that the Skeptics and Cynics do not like it there either but for a different reason. In Assertion there is abundant passion and innovation, but also experimentation and reflection and the ideas are fewer but come packaged with a tough shell of hard evidence. This makes them much less palatable to the Skeptics because  they have to chew hard for little gain. The Cynics shun the place.

At the end of our journey we have learned that the two tribes prefer to live in the temperate zone between Apathy and Assertion where there is an abundant supply of innocent, passionate, innovators with new ideas and no evidence. The Skeptics and Cynics frustrate the inexperienced Innovators who become inflamed with passion which is what the two tribes feed on, and when finally exhausted the Innovators fall easy prey to the Cynics – who convert and enslave them. It is a veritable feeding frenzy – and the ultimate casuality is improvement.

So what is the difference between the Skeptics and the Cynics?

Despite their behaviour the Skeptics do care – they are careful. They are the guardians of stability and their opinion is respected because they help to keep the Sphere safe. They are willing to be convinced – but they want explanation and evidence. Rhetoric is not enough.

The Cynics follow a different creed. Their name derives from the Greek for dog and it is not a term of endearment. They have lost their dreams. They blame others for it and their goal is vengeance. They are remorseless, and shameless. They shun social norms and reasonable behaviour and they are not respected by others. They do not care. They are indifferent.

So the wise Improvement Scientist needs to be able to distinguish the Skeptics from the Cynics – and to learn to value the strengths of the Skeptics and to avoid the Cynics. The deal they negotiate with the Skeptics is: “In return for a steady supply of ideas and enthusiasm we ask only for an explanation of the rejections”. It is a fair trade. The careful and considered feedback of the Skeptics is valuable to the Improvement Scientist because it helps to sharpen the idea and harden the shell of evidence. Once the Innovator, Improvement Scientist and the Skeptic have finished their work any ideas that have survived the digestive process are worthy of investment.  It is a a win-win-win arrangement – everyone gets what they want.

The Cynics scavenge the scraps. And that is OK – it is their choice.

 

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The Nerve Curve

The Nerve Curve is the emotional roller-coaster ride that everyone who engages in Improvement needs to become confident to step onto.

Just like a theme park ride it has ups and downs, twists and turns, surprises and challenges, an element of danger and a splash of excitement.  If it did not have all of those components then it would not be fun and there would not be queues of people wanting to ride, again and again.  And the reason that theme parks are so successful is because their rides have been very carefully designed – to be challenging, exciting, fun and safe – all at the same time.

So, when we challenge others to step aboard our Improvement Nerve Curve then we need to ensure that our ride is safe – and to do that we need to understand where the emotional dangers lurk, to actively point them out and then avoid them.

A big danger hides right at the start.  To get aboard the Nerve Curve we have to ask questions that expose the Elephant-in-the-Room issues.  Everyone knows they are there – but no one wants to talk about them.   The biggest one is called Distrust – which is wrapped up in all sorts of different ways and inside the nut is the  Kernel of Cynicism.  The inexperienced improvement facilitator may blunder straight into this trap just by using one small word … the word “Why”?  Arrrrrgh!  Kaboom!  Splat!  Game Over.

The “Why” question is like throwing a match into a barrel of emotional gunpowder – because it is interpreted as “What is your purpose?” and in a low-trust climate no one will want to reveal what their real purpose or intention is.  They have learned from experience to keep their cards close to their chest – it is safer to keep agendas hidden.

A much safer question is “What?”  What are the facts?  What are the effects? What are the causes? What works well? What does not? What do we want? What don’t we want? What are the constraints? What are our change options? What would each deliver? What are everyone’s views?  What is our decision?  What is our first action? What is the deadline?

Sticking to the “What” question helps to avoid everyone diving for the Political Panic Button and pulling the Emotional Emergency Brake before we have even got started.

The first part of the ride is the “Awful Reality Slope” that swoops us down into “Painful Awareness Canyon” which is the emotional low-point of the ride.  This is where the elephants-in-the-room roam for all to see and where passengers realise that, once the issues are in plain view, there is no way back.

The next danger is at the far end of the Canyon and is called the Black Chasm of Ignorance and the roller-coaster track goes right to the edge of it.  Arrrgh – we are going over the edge of the cliff – quick grab the Wilful Blindness Goggles and Denial Bag from under the seat, apply the Blunder Onwards Blind Fold and the Hope-for-the-Best Smoke Hood.

So, before our carriage reaches the Black Chasm we need to switch on the headlights to reveal the Bridge of How:  The structure and sequence that spans the chasm and that is copiously illuminated with stories from those who have gone before.  The first part is steep though and the climb is hard work.  Our carriage clanks and groans and it seems to take forever but at the top we are rewarded by a New Perspective and the exhilarating ride down into the Plateau of Understanding where we stop to reflect and to celebrate our success.

Here we disembark and discover the Forest of Opportunity which conceals many more Nerve Curves going off in all directions – rides that we can board when we feel ready for a new challenge.  There is danger lurking here too though – hidden in the Forest is Complacency Swamp – which looks innocent except that the Bridge of How is hidden from view.   Here we can get lured by the pungent perfume of Power and the addictive aroma of Arrogance and we can become too comfortable in the Zone.   As we snooze in the Hammock of Calm from we do not notice that the world around us is changing.  In reality we are slipping backwards into Blissful Ignorance and we do not notice – until we suddenly find ourselves in an unfamiliar Canyon of Painful Awareness.  Ouch!

Being forewarned is our best defense.  So, while we are encouraged to explore the Forest of Opportunity,  we learn that we must also return regularly to the Plateau of Understanding to don the Habit of Humility.  We must  regularly refresh ourselves from the Fountain of New Knowledge by showing others what we have learned and learning from them in return.  And when we start to crave more excitement we can board another Nerve Curve to a new Plateau of Understanding.

The Safety Harness of our Improvement journey is called See-Do-Teach and the most important part is Teach.  Our educators need to have more than just a knowledge of how-to-do, they also need to have enough understanding to be able to explore the why-to -do. The Quest for Purpose.

To convince others to get onboard the Nerve Curve we must be able to explain why the Issues still exist and why the current methods are not sufficient.  Those who have been on the ride are the only ones who are credible because they understand.  They have learned by doing.

And that understanding grows with practice and it grows more quickly when we take on the challenge of learning how to explore purpose and explain why.  This is Nerve Curve II.

All aboard for the greatest ride of all.

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The Power of the Positive Deviants

It is neither reasonable nor sensible to expect anyone to be a font of all knowledge.

And gurus with their group-think are useful but potentially dangerous when they suppress competitive paradigms.

So where does an Improvement Scientist seek reliable and trustworthy inspiration?

Guessing is a poor guide; gut-instinct can seriously mislead; and mind-altering substances are illegal, unreliable or both!

So who are the sources of tested ideas and where do we find them?

They are called Positive Deviants and they are everywhere.

But, the phrase positive deviant does not feel quite right does it? The word “deviant” has a strong negative emotional association. We are socially programmed from birth to treat deviations from the norm with distrust and for good reason. Social animals view conformity and similarity as security – it is our herd instinct. Anyone who looks or behaves too far from the norm is perceived as odd and therefore a potential threat and discounted or shunned.

So why consider deviants at all? Well, because anyone who behaves significantly differently from the majority is a potential source of new insight – so long as we know how to separate the positive deviants from the negative ones.

Negative deviants display behaviours that we could all benefit from by actively discouraging!  The NoNo or thou-shalt-not behaviours that are usually embodied in Law.  Killing, stealing, lying, speeding, dropping litter – that sort of thing. The anti-social trust-eroding conflict-generating behaviour that poisons the pond that we all swim in.

Positive deviants display behaviours that we could all benefit from actively encouraging! The NiceIf behaviours. But we are habitually focussed more on self-protection than self-development and we generalise from specifics. So we treat all deviants the same – we are wary of them. And by so doing we miss many valuable opportunities to learn and to improve.

How then do we identify the Positive Deviants?

The first step is to decide the dimension we want to improve and choose a suitable metric to measure it.

The second step is to measure the metric for everyone and do it over time – not just at a point in time. Single point-in-time measurements (snapshots) are almost useless – we can be tricked by the noise in the system into poor decisions.

The third step is to plot our measure-for-improvement as a time-series chart and look at it.  Are there points at the positive end of the scale that deviate significantly from the average? If so – where and who do they come from? Is there a pattern? Is there anything we might use as a predictor of positive deviance?

Now we separate the data into groups guided by our proposed predictors and compare the groups. Do the Positive Deviants now stick out like a sore thumb? Did our predictors separate the wheat from the chaff?

If so we next go and investigate.  We need to compare and contrast the Positive Deviants with the Norms. We need to compare and contrast both their context and their content. We need to know what is similar and what is different. There is something that is causing the sustained deviation and we need to search until we find it – and then we need know how and why it is happening.

We need to separate associations from causations … we need to understand the chains of events that lead to the better outcomes.

Only then will a new Door to Opportunity magically appear in our Black Wall of Ignorance – a door that leads to a proven path of improvement. A path that has been trodden before by a Positive Deviant – or by a whole tribe of them.

And only we ourselves can choose to open the door and explore the path – we cannot be pushed through by someone else.

When our system is designed to identify and celebrate the Positive Deviants then the negative deviants will be identified too! And that helps too because they will light the path to more NoNos that we can all learn to avoid.

For more about positive deviance from Wikipedia click here

For a case study on positive deviance click here

NB: The terms NiceIfs  and NoNos are two of the N’s on The 4N Chart® – the other two are Nuggets and Niggles.

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Seeing Is Believing or Is It?

Do we believe what we see or do we see what we believe?  It sounds like a chicken-and-egg question – so what is the answer? One, the other or both?

Before we explore further we need to be clear about what we mean by the concept “see”.  I objectively see with my real eyes but I subjectively see with my mind’s eye. So to use the word see for both is likely to result in confusion and conflict and to side-step this we will use the word perceive for seeing-with-our-minds-eye.   

When we are sure of our belief then we perceive what we believe. This may sound incorrect but psychologists know better – they have studied sensation and perception in great depth and they have proved that we are all susceptible to “perceptual bias”. What we believe we will see distorts what we actually perceive – and we do it unconsciously. Our expectation acts like a bit of ancient stained glass that obscures and distorts some things and paints in a false picture of the rest.  And that is just during the perception process: when we recall what we perceived we can add a whole extra layer of distortion and can can actually modify our original memory! If we do that often enough we can become 100% sure we saw something that never actually happened. This is why eye-witness accounts are notoriously inaccurate! 

But we do not do this all of the time.  Sometimes we are open-minded, we have no expectation of what we will see or we actually expect to be surprised by what we will see. We like the feeling of anticipation and excitement – of not knowing what will happen next.   That is the psychological basis of entertainment, of exploration, of discovery, of learning, and of improvement science.

An experienced improvement facilitator knows this – and knows how to create a context where deeply held beliefs can be explored with sensitivity and respect; how to celebrate what works and how and why it does; how to challenge what does not; and how to create novel experiences; foster creativity and release new ideas that enhance what is already known, understood and believed.

Through this exploration process our perception broadens, sharpens and becomes more attuned with reality. We achieve both greater clarity and deeper understanding – and it is these that enable us to make wiser decisions and commit to more effective action.

Sometimes we have an opportunity to see for real what we would like to believe is possible – and that can be the pivotal event that releases our passion and generates our commitment to act. It is called the Black Swan effect because seeing just one black swan dispels our belief that all swans are white.

A practical manifestation of this principle is in the rational design of effective team communication – and one of the most effective I have seen is the Communication Cell – a standardised layout of visual information that is easy-to-see and that creates an undistorted perception of reality.  I first saw it many years ago as a trainee pilot when we used it as the focus for briefings and debriefings; I saw it again a few years ago at Unipart where it is used for daily communication; and I have seen it again this week in the NHS where it is being used as part of a service improvement programme.

So if you do not believe then come and see for yourself.

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Is Our System Constipated?

There are some very common system ailments that we do not talk about in public – they are not socially acceptable topics of conversation.

We all know they exist because we all suffer from them at sometime or other – and some more than others.

Our problem is “how do we solve sometheng that no one wants to own up to and talk about?”  Grin-and-bear it? Trial-and-error? Or seek competent, confidential, professional assistance?

One such ailment is chronic system constipation. Yes – I said it!

The usual symptoms are recurrent, severe pains in the middle management area associated with ominous rumblings, intermittent eruptions of unpleasant hot “air” and accompanied by infrequent, unpredictable and often inconsequential output.

The signs are also characterstic: bloated budgets, capital distention and a strained and pained appearance of the executive visage.

The commonest findings on further investigation are accumulation of work in progress inside the organisation that is caused by functional bottlenecks, accumulation of undigestable red-tape, and process paralysis.  These findings confirm the diagnosis.

The more desperate organisations may seek help from corporate quacks who confidently prescribe untested yet expensive remedies such as mangement purges and corporate restructure.  These harsh treatments only serve to impoverish the patient and exacerbate the problem. They are also sometimes fatal. 

The patient who avoids or survives the quacks may seek competent help – and reluctantly submit themselves to a more intimate examination of their orifices.  This proceeds in a back-office to front-of-house order looking for accumulations of work-in-progress (WIP) and their associated causes.  The usual finding is apathetic and demoralised staff burned out by over-complicated, error-prone processes and pushing against turgid bureaucracy. 

The first stage of treatment is to relieve the obstruction that is closest to the discharge orifice first.

Often the intimate examination itself is sufficient to stimulate spontaneous ejection of the offending obstruction; sometimes a corporate-level enema is required to facilitate the process.  Either way the relief is immediate, dramatic and welcomel and is usually followed by vigorous expulsion of the remaining offensive material and restoration of both regular flow and disspiation of the gaseous bloating.

The timid or inexperienced corporoproctologist may be tempted to try exogenous stimulants instead – an inspiring podcast or an executive awayday perhaps.  This well-interntioned palliative treatment may distract attention and sooth the discomfort but the effect is short-lived and the symptoms soon return; often with a vengeance.

The more courageous and experienced Improvement Science practitioner knows that “if you don’t put your finger in it you will put your foot in it” and they come prepared with the organisational equivalent of rubber gloves and lubricating gel: flip charts and hot coffee.

So to avoid the squirming discomfort of the probing questions it is better to seek enematic advice well before this stage. And you may not be surprised to hear that it is all common-sense:

  • Avoid all high-bureaucracy diets.
  • Steer clear of  high-technology quick-fixes.
  • Stimulate the flow of creativity with regular service improvement exercises.
  • Monitor continuously for corporate complacency.
  • Treat early and vigorously with a high-challenge dialog.

But we know all this – don’t we? It is just common sense. 

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Steps, Streams, Silos and Swamps.

The late Steve Jobs created a world class company called Apple – which is now the largest and most successful technology company – eclipsing Microsoft.  The secret of the success of Apple is laid out in Steve Jobs biography – and can be stated in one word. Design.

Apple designs, develops and delivers great products and services  – ones that people want to own and to use.  That makes them cool. What is even more impressive is that Steve Jobs has done this in more than once and has reinvented more than one market: Apple Computers and the graphical personal computer;  Pixar and animated films; and Apple again with digital music, electronic publishing; and mobile phones.

The common themes are digital technology and end-to-end seamless integrated design of chips, devices, software, services and shops. Full vertical integration rather like Henry Ford’s verically integrated iron-ore to finished cars production line.  The Steve Jobs design paradigm is simplicity. It is much more difficult to design simplicity than to evolve complexity and his reputation was formidable. He was a uncompromising perfectionist who sacrificed feelings on the alter of design perfection. His view of the world was binary – it was either great or crap – meaning it was either moving towards perfection or away from it.

What Steve Jobs created was a design stream out of which must-have products and services flowed – and he did it by seeing all the steps as part of one system and aligned with one purpose.  He did not allow physical or psychological silos to form and he did this by challenging anything and everything.  Many could not work in this environment and left, many others thrived and delivered far beyond what they believed they could do.

Other companies were swamps. Toxic emotional waste swamps of silos, politics and turf wars.  Apple computers itself when through a phase when Steve Jobs was “ejected” and without its spiritual leader the company slipped downhill. He was enticed back and Apple was reborn and went on to create the iMac, iPod, iTunes, iPhone, iPad and now iCloud. Revolutioning the world of digital commnication.

The image above is a satellite view of a delta – a complex network of interconnected streams created by a river making its way to the sea through a swamp.  The structure of the delta is constantly changing and evolving so it is easy to get lost it in, to get caught in a dead-end, or stuck in the mud. Only travel by small boat is possible and that is often both ineffective and inefficient.

Many organistions are improvement science swamps. The stream of innovative ideas gets fragmented by the myriad of everchanging channels; caught in political dead-ends; and stuck in the mud of bureaucracy.  Only small, skillfully steered ideas will trickle  through – but this trickle is not enough to keep the swamp from silting up. Eventually the resistance to change reaches a critical level and the improvement stream is forced to change course – diverting the flow of change away from the swamp – and marooning the stick-in-the-muds to slowly sink and expire in the bureaucratic gloop that they spawned.

Steve Jobs’ legacy to us is a lesson. To create a system that continues to deliver and delight we need to start by learning how to design the steps, then to design the streams of steps to link seamlessly, and finally to design the system of streams to synergise as sophisticated simplicity.

Improvement cannot be left to chance in the blind hope that excellence will evolve spontaneously. Evolution is both ineffective and inefficient and is more likely to lead to dissipated and extravagant complexity than aligned and elegant simplicity.

Improvement is a science that sits at the cross-roads of humanity and technology.

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The Frozen Planet

This is a picture of one of the vast Antarctic ice shelves breaking up and fracturing into huge icebergs that then float northwards and melt. This happens every Antarctic summer as the frozen surface of the sea thaws. It refreezes in the winter and completes a natural cycle that is driven by the rotation of the Earth around the Sun.  Clever as we see ourselves we have no influence at the solar scale. The Earth has been circling the Sun for 4.5 billion years so what is the issue?

The issue is that the ice shelves are getting smaller each year.

When they refreeze in winter they do not freeze as far; and when they thaw in the summer the melting edge creeps ever closer to the dry and barren land. This has immediate, direct and dire implications for the life that finds its food in the well-stocked acquatic larder under the ice.  It has delayed, indirect, yet equally dire implications for life that does not live there – and that includes us. 

As each iceberg melts the liberated water has to go somewhere – into the sea – so the average sea level rises a fraction. If enough volume of polar ice melts then the sea level may rise enough to flood low-lying land and displace the people who make their living there. Is there enough ice in the melting shelf to do this? No. That isn’t the problem. The problem is that the ice shelf does something else – it acts as a “plug” that holds back the vast ice sheet that covers the Antarctic continent. And there is a lot of it – about 5 million square miles with an average depth of 1 mile; that is about 5 million cubic miles of  water-in-progress (WIP). The surface area of our oceans is around 140 million square miles – so if  all the Antarctic ice slid down the hill into the sea, broke off as icebergs, floated north and melted then the sea level would rise by 5/140 ths of a mile which is 63 yards or 188 feet.  Oh dear! A large proportion of our most densely populated areas lie below that new sea level.

But let us not not worry about that too much – it won’t happen in the next ten or twenty years. The idealistic-optimist-academics can always hope that Science will come to the rescue and provide innovative solutions that will avert the disaster. That is what we pay our scientists to do after all. The realistic-pessimist-pragmatists have a Plan B: we will just up sticks and move as the waters rise slowly higher. We could do with some new beach side real estate opportunities anyway!  We just need to plot the 60 yard contour line and stake our claim on it early! What is all the fuss about?

It is not only the rising level of water that we need to worry about – it is something else – something that is much less tangible. We need to worry about the rising level of expectation.  And we need to worry because it happens over a much short time scale and by a much greater degree.

On the global scale we have short lives and even shorter memories.  We see what others have and we want the same: we want e-quality and we want it now. In the affluent countries we expect universal health, education and welfare almost as a right – in the less afflunet these are all luxuries. Those we assign the power to make it happen, our elected politicians, have the same expectations – so they get what they want. As we race to grow our economies, anyone who cannot keep up is labelled as a loser.  Flat economic growth is perceived as a warning sign; and a shrinking economy is treated as a failure. The growth-at-any-cost merchants fuel the national fear with emotionally charged words such as “recession”, “depression” and “disaster”.  We are brainwashed to believe that the only way to meet rising expectation is to grow bigger BUT we are doing it by squandering our future needs to satisfy our immediate wants. We are borrowing our future wealth and spending it now – with no coherent plan for settling the loan.  We are living in hope and in denial. Greece, Italy and Ireland are tangible examples. 

This is not sustainable: there is economic chaos that threatens to drown Europe in a rising tide of national structural debt, doubt, confusion and legally enforced austerity measures. It takes a brave person to stand up and say – this is not sustainable.

If feels as though we are at a crossroads and we appear to  have only three choices:

1. Discount the issue; huddle to gether for security on our melting iceberg and hope that someone or something comes to our rescue;

2. Panic and adopt the every-man-for-himself approach, leap into the sea and swim off in all directions in the hope that some of use find unknown dry land before we drown;

3. Learn to preserve what we have and to search for new paradigms that are sustainable into the future. Learn to grow better rather than bigger and learn to meet rising expectation within the limits of the finite global resources. Learn how to improve.

Option 3 gets my vote!

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NIGYYSOB

This is the image of an infamous headline printed on May 4th 1982 in a well known UK newspaper.  It refers to the sinking of the General Belgrano in the Falklands war.

It is the clarion call of revenge – the payback for past grievances.

The full title is NIGYYSOB which stands for Now I Gotcha You Son Ofa B**** and is the name of one of Eric Berne’s Games that People Play.  In this case it is a Level 4 Game – played out on the global stage by the armed forces of the protagonists and resulting in both destruction and death.

The NIGYYSOB game is played out much more frequently at Level 1 – in the everyday interactions between people – people who believe that revenge has a sweet taste.

The reason this is important to the world of Improvement Science is because sometimes a well-intentioned improvement can get unintentionally entangled in a game of NIGYYSOB.

Here is how the drama unfolds.

Someone complains frequently about something that is not working, a Niggle, that they believe that they are powerless to solve. Their complaints are either ignored, discounted or not acted upon because the person with the assumed authority to resolve it cannot do so because they do not know how and will not admit that.  This stalemate can fester for a long time and can build up a Reservoir of Resentment. The Niggle persists and keeps irritating the emotional wound which remains an open cultural sore.  It is not unusual for a well-intentioned third party to intervene to resolve the standoff but as they too are unable to resolve the underlying problem – and all that results is either meddling or diktat which can actually make the problem worse.

The outcome is a festering three-way stalemate with a history of failed expectations and a deepening Well of Cynicism.

Then someone with an understanding of Improvement Science appears on the scene – and the stage is set for a new chapter of the drama because they risk of being “hooked” into The Game.  The newcomer knows how to resolve the problem and, with the grudging consent of the three protagonists, as if by magic, the Niggle is dissolved.  Wow!   The walls of the Well of Cynicism are breached by the new reality and the three protagonists suddenly realise that they may need to radically re-evaluate their worldviews.  That was not expected!

What can happen next is an emotional backlash – rather like a tight elastic band being released at one end. Twang! Snap! Ouch!

We all have a the same psychological reaction to a sudden and surprising change in our reality – be it for the better or for the worse. It takes time to adjust to a new worldview and that transition phase is both fragile and unstable; so there is a risk of going off course.

Experience teaches us that it does not take much to knock the tentative improvement over.

The application of Improvement Science will generate transitions that need to be anticipated and proactively managed because if this is not done then there is a risk that the emotional backlash will upset the whole improvement apple-cart.

What appears to occur is: after reality shows that the improvement has worked then the realisation dawns that the festering problem was always solvable, and the chronic emotional pain was avoidable. This comes as a psychological shock that can trigger a reflex emotional response called anger: the emotion that signals the unconscious perception of sudden loss of the old, familiar, worldview. The anger is often directed externally and at the perceived obstruction that blocked the improvement; the person who “should” have known what to do; often the “boss”.  This backlash, the emotional payoff, carries the implied message of “You are not OK because you hold the power, and you could not solve this, and you were too arrogant to ask for help and now I have proved you wrong and that I was right all the time!”  Sweet-tasting revenge?

Unfortunately not. The problem is that this emotional backlash damages the fragile, emerging, respectful relationship and can effectively scupper any future tentative inclinations to improve. The chronic emotional pain returns even worse than before; the Well of Cynicism deepens; and the walls are strengthened and become less porous.

The improvement is not maintained and it dies of neglect.

The reality of the situation was that none of the three protagonists actually knew what to do – hence the stalemate – and the only way out of that situation is for them all to recognise and accept the reality of their collective ignorance – and then to learn together.

Managing the improvement transition is something that an experienced facilitator needs to understand. If there is a them-and-us cultural context; a frustrated standoff; a high pressure store of accumulated bad feeling; and a deep well of cynicism then that emotional abscess needs to diagnosed, incised and drained before any attempt at sustained improvement can be made.

If we apply direct pressure on an emotional abscess then it is likely to rupture and squirt you with cynicide; or worse still force the emotional toxin back into the organisation and poison the whole system. (Email is a common path-of-low-resistance for emotional toxic waste!).

One solution is to appreciate that the toxic emotional pressure needs to be released in a safe and controlled way before the healing process can start.  Most of the pain goes away as soon as the abscess is lanced – the rest dissipates as the healing process engages.

One model that is helpful in proactively managing this dynamic is the Elizabeth Kubler-Ross model of grief which describes the five stages: denial, anger, bargaining, depression, and acceptance.  Grief is the normal emotional reaction to a sudden change in reality – such as the loss of a loved one – and the same psychological process operates for all emotionally significant changes.  The facilitator just needs to provide a game-free and constructive way to manage the anger by reinvesting the passion into the next cycle of improvement.  A more recent framework for this is the Lewis-Parker model which has seven stages:

  1. Immobilisation – Shock. Overwhelmed mismatch: expectations vs reality.
  2. Denial of Change – Temporary retreat. False competence.
  3. Incompetence – Awareness and frustration.
  4. Acceptance of Reality – ‘Letting go’.
  5. Testing – New ways to deal with new reality.
  6. Search for Meaning – Internalisation and seeking to understand.
  7. Integration – Incorporation of meanings within behaviours.

An effective tool for getting the emotional rollercoaster moving is The 4N Chart® – it allows the emotional pressure and pain to be released in a safe way. The complementary tool for diagnosing and treating the cultural abscess is called AFPS (Argument Free Problem Solving) which is a version of Edward De Bono’s Six Thinking Hats®.

The two are part of the improvement-by-design framework called 6M Design® which in turn is a rational, learnable, applicable and teachable manifestation of Improvement Science.

 

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Argument-Free-Problem-Solving

I used to be puzzled when I reflected on the observation that we seem to be able to solve problems as individuals much more quickly and with greater certainty than we could as groups.

I used to believe that having many different perspectives of a problem would be an asset – but in reality it seems to be more of a liability.

Now when I receive an invitation to a meeting to discuss an issue of urgent importance my little heart sinks as I recall the endless hours of my limited life-time wasted in worthless, unproductive discussion.

But, not to be one to wallow in despair I have been busy applying the principles of Improvement Science to this ubiquitous and persistent niggle.  And I have discovered something called Argument Free Problem Solving (AFPS) – or rather that is my name for it because it does what it says on the tin – it solves problems without arguments.

The trick was to treat problem-solving as a process; to understand how we solve problems as individuals; what are the worthwhile bits; and how we scupper the process when we add-in more than one person; and then how to design-to-align the  problem-solving workflow so that it …. flows. So that it is effective and efficient.

The result is AFPS and I’ve been testing it out. Wow! Does it work or what!

I have also discovered that we do not need to create an artificial set of Rules or a Special Jargon – we can  apply the recipe to any situation in a very natural and unobtrusive way.  Just this week I have seen it work like magic several times: once in defusing what was looking like a big bust up looming; once t0 resolve a small niggle that had been magnified into a huge monster and a big battle – the smoke of which was obscuring the real win-win-win opportunity; and once in a collaborative process improvement exercise that demonstrated a 2000% improvement in system productivity – yes – two thousand percent!

So AFPS  has been added to the  Improvement Science treasure chest and (because I like to tease and have fun) I have hidden the key in cyberspace at coordinates  http://www.saasoft.com/moodle

Mwah ha ha ha – me hearties! 

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Cutting The Cost Cake

We are in now in cost cake cutting times! We are being forced by financial reality to tighten the fiscal belt until our eyeballs water – and then more so.

The cost cake is a mixture of three ingredients – the worthwhile, the necessary, and the rest – the stuff that is worthless and not wanted – the worthless stuff, the unhealthy stuff, the waste.  But it costs just as much per morsel as the rest. And there is a problem – all three ingredients are mixed up together and our weighing scales can not say how much of each is in there – it just tells us the total weight and cost.

If we are forced to cut the cost of the cake we have to cut all three. Our cake gets smaller – not better – which means that we all go a bit hungrier. Or as is more likely – the hand that weilds the knife will cut themselves a full slice and someone else will starve.

Would it not be better if we could separate out the ingredients and see them for what the are – worthy (green), necessary (yellow) and the worthless waste (red) – and then use the knife to slice off the waste?  Then we could mix up what is left and share out a smaller but healthier meal.  We might even re-invest our savings in buying more of the better ingredients and bake ourselves a healthier cake. We would have a choice. 

If we translate this culinary metaphor into the real world then we will see the need for a way of separating and counting the cost of time spent on worthy, necessary and worthless work. If we can do that then we can remove just the worthless stuff and either reduce the cost or  reinvest the resource in something more worthwhile.

The problem we find when we try to do this is that our financial accounting systems do not work this way.

The closed door to a healthier future is staring us in the face – it is barn-door obvious – we just need to design our accounting methods so that they can do what we need them to do.

What are we waiting for?  Let us work together to find a way to open that closed door. It is in all of our interests! 

 

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Three Blind Men and an Elephant

The Blind Men and the Elephant Story   – adapted from the poem by John Godfrey Saxe.

 “Three blind men were discussing exactly what they believed an elephant to be, since each had heard how strange the creature was, yet none had ever seen one before. So the blind men agreed to find an elephant and discover what the animal was really like. It did not take the blind men long to find an elephant at a nearby market. The first blind man approached the animal and felt the elephant’s firm flat side. “It seems to me that an elephant is just like a wall,” he said to his friends. The second blind man reached out and touched one of the elephant’s tusks. “No, this is round and smooth and sharp – an elephant is like a spear.” Intrigued, the third blind man stepped up to the elephant and touched its trunk. “Well, I can’t agree with either of you; I feel a squirming writhing thing – surely an elephant is just like a snake.” All three blind men continued to argue, based on their own individual experiences, as to what they thought an elephant was like. It was an argument that they were never able to resolve. Each of them was concerned only with their own experience. None of them could see the full picture, and none could appreciate any of the other points of view. Each man saw the elephant as something quite different, and while each blind man was correct they could not agree.”

The Elephant in this parable is the NHS and the three blind men are Governance, Operations and Finance. Each is blind because he does not see reality clearly – his perception is limited to assumptions and crippled by distorted data. The three blind men cannot agree because they do not share a common understanding of the system; its parts and its relationships. Each is looking at a multi-dimensional entity from one dimension only and for each there is no obvious way forward. So while they appear to be in conflict about the “how” they are paradoxically in agreement about the “why”. The outcome is a fruitless and wasteful series of acrimonious arguments, meaningless meetings and directionless discussions.  It is not until they declare their common purpose that their differences of opinion are seen in a realistic perspective and as an opportunity to share and to learn and to create an collective understanding that is greater than the sum of the parts.

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Reality trumps Rhetoric

One of the biggest challenges posed by Improvement is the requirement for beliefs to change – because static beliefs imply stagnated learning and arrested change.  We all display our beliefs for all to hear and see through our language – word and deed – our spoken language and our body language – and what we do not say and do not do is as important as what we do say and what we do do.  Let us call the whole language thing our Rhetoric – the external manifestation of our internal mental model.

Disappointingly, exercising our mental model does not seem to have much impact on Reality – at least not directly. We do not seem to be able to perform acts of telepathy or telekinesis. We are not like the Jedi knights in the Star Wars films who have learned to master the Force – for good or bad. We are not like the wizards in the Harry Potter who have mastered magical powers – again for good or bad. We are weak-minded muggles and Reality is spectacularly indifferent to our feeble powers. No matter what we might prefer to believe – Reality trumps Rhetoric.

Of course we can side step this uncomfortable feeling by resorting to the belief of One Truth which is often another way of saying My Opinion – and we then assume that if everyone else changed their belief to our belief then we would have full alignment, no conflict, and improvement would automatically flow.  What we actually achieve is a common Rhetoric about which Reality is still completely indifferent.  We know that if we disagree then one of us must be wrong or rather un-real-istic; but we forget that even if we agree then we can still both be wrong. Agreement is not a good test of the validity of our Rhetoric. The only test of validity is Reality itself – and facing the unfeeling Reality risks bruising our rather fragile egos – so we shy away from doing so.

So one way to facilitate improvement is to employ Reality as our final arbiter and to do this respectfully.  This is why teachers of improvement science must be masters of improvement science. They must be able to demonstrate their Improvenent Science Rhetoric by using Reality and their apprentices need to see the IS Rhetoric applied to solving real problems. One way to do this is for the apprentices to do it themselves, for real, with guidance of an IS master and in a safe context where they can make errors and not damage their egos. When this is done what happens is almost magical – the Rhetoric changes – the spoken language and the body language changes – what is said and what is done changes – and what is not said and not done changess too. And very often the change is not noticed at least by those who change.  We only appear to have one mental model: only one view of Reality so when it changes we change.

It is also interesting to observe is that this evolution of Rhetoric does not happen immediately or in one blinding flash of complete insight. We take small steps rather than giant leaps. More often the initial emotional reaction is confusion because our experience of the Reality clashes with the expectation of our Rhetoric.  And very often the changes happen when we are asleep – it is almost as if our minds work on dissolving the confusion when it is not distracted with the demands of awake-work; almost like we are re-organising our mental model structure when it is offline. It is a very common to have a sleepless night after such an Reality Check and to wake with a feeling of greater clarity – our updated mental model declaring itself as our New Rhetoric. Experienced facilitators of Improvement Science understand this natural learning process and that it happens to everyone – including themselves. It is this feeling of increased clarity, deeper understanding, and released energy that is the buzz of Improvement Science – the addictive drug.  We learn that our memory plays tricks on us; and what was conflict yesterday becomes confusion today and clarity tomorrow. One behaviour that often emerges spontaneously is the desire to keep a journal – sometimes at the bedside – to capture the twists and turns of the story of our evolving Rhetoric.

This blog just such a journal.

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Low-Tech-Toc

Beware the Magicians who wave High Technology Wands and promise Miraculous Improvements if you buy their Black Magic Boxes!

If a Magician is not willing to open the box and show you the inner workings then run away – quickly.  Their story may be true, the Miracle may indeed be possible, but if they cannot or will not explain HOW the magic trick is done then you will be caught in their spell and will become their slave forever.

Not all Magicians have honourable intentions – those who have been seduced by the Dark Side will ensnare you and will bleed you dry like greedy leeches!

In the early 1980’s a brilliant innovator called Eli Goldratt created a Black Box called OPT that was the tangible manifestation of his intellectual brainchild called ToC – Theory of Constraints. OPT was a piece of complex computer software that was intended to rescue manufacturing from their ignorance and to miraculously deliver dramatic increases in profit. It didn’t.

Eli Goldratt was a physicist and his Black Box was built on strong foundations of Process Physics – it was not Snake Oil – it did work.  The problem was that it did not sell: Not enough people believed his claims and those who did discovered that the Black Box was not as easy to use as the Magician suggested.  So Eli Goldratt wrote a book called The Goal in which he explained, in parable form, the Principles of ToC and the theoretical foundations on which his Black Box was built.  The book was a big success but his Black Box still did not sell; just an explanation of how his Black Box worked was enough for people to apply the Principles of ToC and to get dramatic results. So, Eli abandoned his plan of making a fortune selling Black Boxes and set up the Goldratt Institute to disseminate the Principles of ToC – which he did with considerably more success. Eli Goldratt died in June 2011 after a short battle with cancer and the World has lost a great innovator and a founding father of Improvement Science. His legacy lives on in the books he wrote that chart his personal journey of discovery.

The Principles of ToC are central both to process improvement and to process design.  As Eli unintentionally demonstrated, it is more effective and much quicker to learn the Principles of ToC pragmatically and with low technology – such as a book – than with a complex, expensive, high technology Black Box.  As many people have discovered – adding complex technology to a complex problem does not create a simple solution! Many processes are relatively uncomplicated and do not require high technology solutions. An example is the challenge of designing a high productivity schedule when there is variation in both the content and the volume of the work.

If our required goal is to improve productivity (or profit) then we want to improve the throughput and/or to reduce the resources required. That is relatively easy when there is no variation in content and no variation in volume – such as when we are making just one product at a constant rate – like a Model-T Ford in Black! Add some content and volume variation and the challenge becomes a lot trickier! From the 1950’s the move from mass production to mass customisation in the automobile industry created this new challenge and spawned a series of  innovative approaches such as the Toyota Production System (Lean), Six Sigma and Theory of Constraints.  TPS focussed on small batches, fast changeovers and low technology (kanbans or cards) to keep inventory low and flow high; Six Sigma focussed on scientifically identifying and eliminating all sources of variation so that work flows smoothly and in “statistical control”; ToC focussed on identifying the “constraint steps” in the system and then on scheduling tasks so that the constraints never run out of work.

When applied to a complex system of interlinked and interdependent processes the ToC method requires a complicated Black Box to do the scheduling because we cannot do it in our heads. However, when applied to a simpler system or to a part of a complex system it can be done using a low technology method called “paper and pen”. The technique is called Template Scheduling and there is a real example in the “Three Wins” book where the template schedule design was tested using a computer simulation to measure the resilience of the design to natural variation – and the computer was not used to do the actual scheduling. There was no Black Box doiung the scheduling. The outcome of the design was a piece of paper that defined the designed-and-tested template schedule: and the design testing predicted a 40% increase in throughput using the same resources. This dramatic jump in productivity might be regarded as  “miraculous” or even “impossible” but only to someone who was not aware of the template scheduling method. The reality is that that the designed schedule worked just as predicted – there was no miracle, no magic, no Magician and no Black Box.

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Where is the Rotten Egg?

Have you ever had the experience of arriving home from a holiday – opening the front door and being hit with the rancid smell of something that has gone rotten while you were away.

Phwooorrrarghhh!

When that happens we open the windows to let the fresh-air blow the smelly pong out and we go in search of the offending source of the horrible whiff. Somewhere we know we will find the “rotten egg” and we know we need to remove it because it is now beyond repair.

What happened here is that our usual, regular habit of keeping our house clean was interrupted and that allowed time for something to go rotten and to create a nasty stink. It may also have caused other things to go rotten too – decay  spreads. Usually we maintain an olfactory vigilance to pick up the first whiff of a problem and we act before the rot sets in – but this only works if we know what fresh air smells like, if we remove the peg from our nose, and if we have the courage to remove all of the rot. Permfuing the pig is not an effective long term strategy.

The rotten egg metaphor applies to organisations. The smell we are on the alert for is the rancid odour of a sour relationship, the signal we sense is the dissonance of misery, and the behaviours we look for are those that erode trust. These behaviours have a name – they are called discounts – and they come in two types.

Type 1 discounts are our deliberate actions that lead to erosion of trust – actions like interrupting, gossiping, blaming, manipulation, disrespect, intimidation, and bullying.

Type 2 discounts are the actions that we deliberately omit to do that also cause erosion of trust – like not asking for and not offering feedback, like not sharing data, information and knowledge, like not asking for help, like not saying thank you, like not challenging assumptions, like not speaking out when we feel things are not right, like not getting the elephant out in the room. These two types of discounts are endemic in all organisations and the Type 2 discounts are the more difficult to see because it was what we didn’t do that led to the rot. We must all maintain constant vigilance to sniff out the first whiff of misery and to act immediately and effectively to sustain a pong-free organisational atmosphere.

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Watch Out for the Overshoot!

In 1972 a group called the Club of Rome published a report entitled “The Limits to Growth” that examined the possible global impact of our current obsession with competition and growth. They used Jay W Forrester’s computer models described in World Dynamics – models of global stocks and flows of natural resources, capital and people – and explored the range future possibilities based on the best understanding of current reality. Their conclusions were not encouraging – the most likely outcome they predicted if current behaviours continued would be global natural, economic and population collapse before 2100!

Their conclusions were discounted by governments, corporations and individuals as doom-preaching but it struck a chord with many and helped to fuel the growth of the global environmental movement.

Thirty years later the original work has been revised, updated and the original predictions compared with actual changes.

The original forecast proved to be prophetic – and revealed an alarming conclusion – that we may already be past the point of no return. It is now forty years since the original work and we have enjoyed the predicted boom years of the 1980’s and ignored the warnings so many options for avoiding a future global collapse have already been squandered. Even if we corrected all the errors of commission and errors of omission today it may be too late because we over-estimate our ability to solve problems and underestimate the effect of “overshoot”.

Suppose you are driving at night in freezing fog and you want to get to your destination as soon as possible so you press on the accelerator and your speed grows. You have not been on this particular road before but you have been driving for years and you trust your experience, skills, and reactions. Suddenly a red light appears out of the gloom – it is a stop light and it is close, too close, so you hit the brakes! You don’t stop immediately though – you are slowing down but not fast enough. The road is slippery, your tyres do not grip as well as usual, and your momentum carries you on. You are burning up the remaining tarmac fast and now you see other lights – white lights – coming from the right. A juggernaut is nearly at the crossroads and it has the green light and is not slowing down.  You are on a crash course – and there is nothing you can do – you have no options. The awful realisation dawns that you have made a fatal error of judgement and this is the end as you overshoot the red light and are crushed to a mangled pulp of metal and flesh under the wheels of the juggernaut!

The accident was avoidable – in retrospect. Was it avoidable in prospect? Of course – but only
– IF we were able to challenge our blind trust in our own capability and
– IF we were able to anticipate what could happen and
– IF we had set up trustworthy early warning signals and
– IF we had prepared contingency plans of what we would do if any of the warning bells rang.

Easy enough for an individual to do perhaps – but much more difficult for a group of individuals who have low regard for each other and who are competing to grow bigger and faster. Our mastery of  nature has given us the means to change global system dynamics – so our collective fate is sealed by our collective behaviour. We have the ability to achieve mutually assured destruction (MAD) without dropping a single bomb – and we are on course to do so not because we set out to – but because we did not set out not to. The error of omission is the stealth killer.

Is this global disaster scenario realistic? Is there anything that can be done? Are we collectively capable of doing it? The evidence suggests “yes” to all three questions – there is hope – but it will require a paradigm shift in thinking rather than a breakthrough in technology.

The laws of physics will seal our fate unless the laws of people adapt – and it may already be too late to avoid some degree of catastrophic decline – which implies billions of lives will be lost needlessly. Those of us in positions of most influence are already to old to expect to live to see the fruits of our collective error of omission – our children will bear the pain of our ignorance and arrogance.  What do you want carved on your gravestone … “Here lies X – who saw but did not act. Sorry.”

Limits to Growth – the 30 year update. ISBN 978-1-84407-144-9

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Anyone for more Boiled Frog?

There is a famous metaphor for the dangers of denial and complacency called the boiled frog syndrome.

Apparently if you drop a frog into hot water it will notice and jump out  but if you put a frog in water at a comfortable temperature and then slowly heat it up it will not jump out – it does not notice the slowly rising temperature until it is too late – and it boils.

The metaphor is used to highlight the dangers of not being aware enough of our surroundings to notice when things are getting “hot” – which means we do not act in time to prevent a catastrophe.

There is another side to the boiled frog syndrome – and this when improvements are made incrementally by someone else and we do not notice those either. This is the same error of complacency and there is no positive feedback so the improvement investment fizzles out – without us noticing that either.  This is a disadvantage of incremental improvement – we only notice the effect if we deliberately measure at intervals and compare present with past. Not many of us appear to have the foresight or fortitude to do that. We are the engineers of our own mediocrity.

There is an alternative though – it is called improvement-by-design. The difference from improvement-by-increments is that with design you deliberately plan to make a big beneficial change happen quickly – and you can do this by testing the design before implementing it so that you know it is feasible.  When the change is made the big beneficial difference is noticed – WOW! – and everyone notices: supporters and cynics alike.  Their responses are different though – the advocates are jubilant and the cynics are shocked. The cynics worldview is suddenly challenged – and the feeling is one of positive confusion. They say “Wow! That’s a miracle – how did you do that?”.

So when we understand enough to design a change then we should use improvement-by-design; and when we don’t understand enough we have no choice but to do use improvement-by-discovery.

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July 5th 2018 – The old NHS is dead.

Today is the last day of the old NHS – ironically on the 70th anniversary of its birth. Its founding principles are no more – care is no longer free at the point of delivery and is no longer provided according to needs rather than means. SickCare®, as it is now called, is a commodity just like food, water, energy, communications, possessions, housing, transport, education and leisure – and the the only things we get free-of-charge are air, sunlight, rain and gossip.  SickCare® is now only available from fiercely competitive service conglomerates – TescoHealth and VirginHealth being the two largest.  We now buy SickCare® like we buy groceries – online and instore.

Gone forever is the public-central-tax-funded-commissioner-and-provider market. Gone forever are the foundation trusts, the clinical commissioning groups and the social enterprises. Gone is the dream of cradle-to-grave equitable health care  – and all in a terrifyingly short time!

The once proud and independent professionals are now paid employees of profit-seeking private providers. Gone is their job-for-life security and gone is their gold-plated index-linked-final-salary-pensions.  Everyone is now hired and fired on the basis of performance, productivity and profit. Step out of line or go outside the limits of acceptability and it is “Sorry but you have breached your contract and we have to let you go“.

So what happened? How did the NHS-gravy-train come off the taxpayer-funded-track so suddenly?

It is easy to see with hindsight when the cracks started to appear. No-one and every-one is to blame.

We did this to ourselves. And by the time we took notice it was too late.

The final straw was when the old NHS became unaffordable because we all took it for granted and we all abused it.  Analysts now agree that there were two core factors that combined to initiate the collapse and they are unflatteringly referred to as “The Arrogance of Clinicians” and “The Ignorance of Managers“.  The latter is easier to explain.

When the global financial crisis struck 10 years ago it destabilised the whole economy and drastic “austerity” measures had to be introduced by the new coalition government. This opened the innards of the NHS to scrutiny by commercial organisations with an eager eye on the £100bn annual budget. What they discovered was a massive black-hole of management ignorance!

Protected for decades from reality by their public sector status the NHS managers had not seen the need to develop their skills and experience in Improvement Science and, when the chips were down, they were simply unable to compete.

Thousands of them hit the growing queues of the unemployed or had to settle for painful cuts in their pay and conditions before they really knew what had hit them. They were ruthlessly replaced by a smaller number of more skilled and more experienced managers from successful commercial service companies – managers who understood how systems worked and how to design them to deliver quality, productivity and profit.

The medical profession also suffered.

With the drop in demand for unproven treatments, the availability of pre-prescribed evidence-based standard protocols for 80% of the long-term conditions, and radically redesigned community-based delivery processes – a large number of super-specialised doctors were rendered “surplus to requirement”. This skill-glut created the perfect buyers market for their specialist knowledge – and they were forced to trade autonomy for survival. No longer could a GP or a Consultant choose when and how they worked; no longer were they able to discount patient opinion or patient expectation; and no longer could they operate autonomous empires within the bloated and bureaucratic trusts that were powerless to performance manage them effectively. Many doctors tried to swim against the tide and were lost – choosing to jump ship and retire early. Many who left it too late to leap failed to be appointed to their previous jobs because of “lack of required team-working and human-factor skills”.

And the public have fared no better than the public-servants. The service conglomerates have exercised their considerable financial muscle to create low-cost insurance schemes that cover only the most expensive and urgent treatments because, even in our Brave New NHS, medical bankruptcy is not politically palatable.  State subsidised insurance payouts provide a safety net  – but they cover only basic care. The too-poor-to-pay are not left to expire on the street as in some countries – but once our immediate care needs are met we have to leave or start paying the going rate.  Our cashless society and our EzeeMonee cards now mean that we pay-as-we-go for everything. The cash is transferred out of our accounts before the buy-as-you-need drug has even started to work!

A small yet strident band of evangelical advocates of the Brave New NHS say it is long overdue and that, in the long term, the health of the nation will be better for it. No longer able to afford the luxury of self-abuse through chronic overindulgence of food, cigarettes, and alcohol – and faced with the misery of the outcome of their own actions –  many people are shepherded towards healthier lifestyles. Those who comply enjoy lower insurance premiums and attractive no-claims benefits.  Healthier in body perhaps – but what price have we paid for our complacency? “

On July 15th 2012 the following headline appeared in one Sunday paper: “Nurses hired at £1,600 a day to cover shortages” and in another “Thousands of doctors face sack: NHS staff contracts could be terminated unless they agree to drastic changes to their pay and conditions“.  We were warned and it is not too late.

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Synigence

The “Qualigence, Quantigence and Synergence” blopic has generated some interesting informal feedback and since being more attuned to this concept I have seen evidence of it at work in practice. My own reflection is that synergence does not quite hit the spot because syn-erg-gence can be translated as “knowing how to work together” and from this small niggle a new word was born – synigence – which I feel captures the concept better. It is an improvement. 

Improvement Science always considers a challenge from three perspectives – quality, delivery and quantity. The delivery dimension involves time and can be viewed both qualitatively and quantitatively.  The pure qualitative dimension is the subjective experience (feelings) and the pure quanitative dimension is the objective evidence (facts) – very often presented in the Universal Language of Money (ULM). The diagram attempts to capture this idea of three perspectives and that there is common ground between all three;  the soil in which the seeds of improvement take root. There is more to it though – this common ground/vision/goal/sense does not look the same from different perspectives and for synergy to develop the synigent facilitator needs to be capable of translating the one vision into three languages. It is rather like the Rosetta Stone an ancient Egyptian grandiorite stele inscribed with a decree issued at Memphis, Egypt in 196 BC on behalf of King Ptolemy V. The decree appears in three scripts: Ancient Egyptian hieroglyphs, Demotic Egyptian script, and Ancient Greek and, as it presents essentially the same text in all three scripts, it provided the key to the modern understanding of Egyptian hieroglyphs.  With this key the wisdom of the Ancient Egyptians was unlocked.

My learning this week is that this is less on an exercise in how to influence others and more of an exercise in how to influence oneself and by that route the sum can become greater than the parts.  Things that looked impossible for either working alone (or more often in conflict) now become not only possible but also inevitable.  Once we have seen we cannot forget – and once we believe we cannot understand that it is not obvious to everyone else: and there lurks a trap for the unsynigent – it is not obvious – if it were we would have seen it sooner ourselves.

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Do You Have A Miserable Job?

If you feel miserable at work and do not know what to do then then take heart because you could be suffering from a treatable organisational disease called CRAP (cynically resistant arrogant pessimism).

To achieve a healthier work-life then it is useful to understand the root cause of CRAP and the rationale of how to diagnose and treat it.

Organisations have three interdependent dimensions of performance: value, time and money.  All organisations require both the people and the processes to be working in synergy to reliably deliver value-for-money over time.  To create a productive system it is necessary to understand the relationships between  value, money and time. Money is easier because it is tangible and durable; value is harder because it is intangible and transient. This means that the focus of attention is usually on the money – and it is often assumed that if the money is OK then the value must be OK too.  This assumption is incorrect.

Value and money are interdependent but have different “rates of change”  and can operate in different “directions”.  A common example is when a dip in financial performance triggers an urgent “drive” to improve the “bottom line”.  Reactive revenue generation and cost cutting results in a small, quick, and tangible improvement on the money dimension but at the same time sets off a large, slow, and intangible deterioration on the value dimension.  Money, time and  value are interdependent and the inevitable outcome is a later and larger deterioration in the money – as illustrated in the doodle. If only money is measured the deteriorating value is not detected, and by the time the money starts to falter the momentum of the falling value is so great that even heroic efforts to recover are futile. As the money starts to fall the value falls even further and even faster – the lose-lose-lose spiral of organisational failure is now underway.

People who demonstrate in their attitude and behaviour that they are miserable at work provide the cardinal sign of falling system value. A miserable, sceptical and cynical employee poisons the emotional atmosphere for everyone around them. Misery is both defective and infective.  The primary cause of a miserable job is the behaviour exhibited by people in positions of authority – and the more the focus is only on money the more misery their behaviour generates.

Fortunately there is an antidote; a way to break out of the vicious tail spin – measure both value and money, focus on improving value and observe the positive effect on the money.  The critical behaviour is to actively test the emotional temperature and to take action to keep it moving in a positive direction.  “The Three Signs of a Miserable Job” by Patrick Lencioni tells a story of how an experienced executive learns that the three things a successful managerial leader must do to achieve system health are:
1) ensure employees know their unique place, role and value in the whole system;
2) ensure employees can consciously connect their work with a worthwhile system goal; and
3) ensure employees can objectively measure how they are doing.

Miserable jobs are those where the people feel anonymous, where people feel their work is valueless, and where people feel that they get no feedback from their seniors, peers or juniors. And it does not matter if it is the cleaner or the chief executive – everyone needs a role, a goal and to know all their interdependencies.

We do not have to endure a Miserable Job – we all have the power to transform it into Worthwhile Work.

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In Whom and in What do We Trust?

The issue of trust has been a recurring theme again this week – and it has appeared in many guises.  In one situation it was a case of distrust – I observed an overt display of suspicious, sceptical, and cynical behaviour. In another situation it was a case of mistrust – a misplaced confidence in my own intuition. My illogical and irrational heart said one thing but when my mind worked through the problem logically and rationally my intuition was proved incorrect. In another it was a case of rewarded-trust: positive feedback that showed a respectful challenge had resulted in a win-win-win outcome. And in yet another a case of extended-trust: an expression of delighted surprise from someone whose default position was to distrust.

Improvement Science rests on two Foundation stones Trust and Capability. First to trust oneself to have the confidence and humility to challenge, to learn, to change, to improve, to celebrate and to share; second to extend trust to others with a clear explanation of the consequences of betraying that trust; and third in building collective trust by having the courage to challenge trust-eroding behaviour.

At heart we are all curious, friendly, social animals – our natural desire is to want to trust. Distrust is a learned behaviour that, ironically, is the result of the instinctive trust and respect that, as children, we have for our parents.  We are taught to distrust by observing and copying distrustful and disrepectful behaviour by our role models. So with this insight we gain access to an antidote to the emotional poison of distrust: our innate child-like curiosity, desire to explore, appetite for fun, and thirst for knowledge and meaning. To dissolve distrust we only need to reconnect to our own inner child: One half of the foundation of Improvement Science.

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The Six Learning Pebbles

Yesterday I had the great pleasure of taking Alice and Sophie to school. When I am doing the school run we often play a game of “interesting conversations” and we talked about what were were planning to do today.  “I am going to demonstrate the Six Thinking Hats method of solving problems” I said and gave a thumbnail sketch of Edward De Bono’s inspired invention. “That sounds like our Six Pebbles of Learning that we learned in SEAL” said Alice. “What is SEAL”?  I asked. “Social and Emotional Aspects of Learning” she replied “it is one of our lessons”.  My curiosity was pricked. “Wow! And what are the Six Pebbles? ” I asked.  Alice reeled them off immediately “Watching, Asking, Listening, Thinking Carefully, Perseverence and Learning from Mistakes”.  I was speechless – they didn’t teach that stuff when I was at school!  There are many organisations that invest small fortunes on “Team Development Programmes” which sounded to me like the same stuff – schools seem to have moved on a bit!

So, after a thoroughly enjoyable afternoon juggling the Six Hats I looked up the Six Pebbles on the Internet and here is what I found …
              
One stormy night, far, far away, a woman gave birth to four healthy sons. She wrapped them up and laid them in a row next to her. What would happen to them? She prayed to the magic spirit of her family. There was a flash and a beautiful spirit appeared. The spirit looked at the first baby. Out of her golden bag she drew a shiny purple stone and sang, ‘You will be a talented musician.’ To the second baby she gave a green stone and sang, ‘You will be a fantastic farmer.’ To the third baby she gave a red stone and sang, ‘You will be a talented artist.’ When she came to the fourth baby, she drew out of her bag six ugly brown pebbles. ‘And you will be a good learner’, she sang. There was a fearful bang and a flash of light and the spirit disappeared.

What did she mean?’ the woman asked herself. She looked at the pebbles. ‘It can’t be very important’, she thought. Even so she carefully put the pebbles in a small bag and hung them round the baby’s neck.

As soon as the first three sons could walk they showed their talents. People always asked to hear the first son sing. If one of their animals was sick, they brought it to the second son and he immediately knew what was wrong. The third son drew pictures so beautiful that when he was still young people asked him to decorate their houses and clothes. When the woman looked at the fourth son she kissed him on the forehead and smiled, and thought that it was a good job he had such talented brothers.The fourth son looked at the six pebbles and wondered what they meant. He was very proud of his three brothers. He wanted to be like them, so he looked carefully at what they did. He asked them questions and listened carefully to what they said. He thought about what he saw and heard. He imitated what they did and when it didn’t work he didn’t give up, but learned from it. The brothers loved him dearly and, because he was so helpful and good to be with, they spent lots of time with him. When the four sons were nearly grown up the woman said to the first three sons, ‘Go off and make your fortunes. You have all the talents you need.’ They left the farm. The fourth son asked if he could go too but the woman said, ‘You haven’t any special talents so perhaps you had better stay here. What have you got to offer the world?’

That evening she was feeling sad. ‘I wish someone was here to cheer me up,’ she said. The fourth son opened his mouth and sang a song. It was beautiful – as beautiful as the songs of the first son. The next day one of the animals was sick. The fourth son looked at the animal and knew what to do. The next day it was better, just like the animals that the second son had looked after. When the woman woke up the next day she saw a lovely new picture on the wall, as beautiful as the pictures painted by the third son.

She took the small bag from round fourth son’s neck and looked at them. She remembered what the spirit had said: ’And you will be a good learner.’

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Must We Unlearn First?

In the famous “Star Wars” films when Luke Skywalker is learning to master the Force – his trainer, Jedi Master Yoda, says the famous line:

“You must unlearn what you have learned“.

These seven words capture a fundamental principle of Improvement Science – that very often we have to unlearn before we can improve.

Unlearning is not the same as forgetting – because much of what we have learned is unconscious – so to unlearn we first have to make our assumptions conscious.

Unlearning is not just erasing a memory, it is preparing the mental ground to replace the learning with something else.

And we do not want to unlearn everything – we want to keep the nexus of knowledge nuggets that form the solid foundation of new learning.  We only want to unlearn what is preventing us adding new understanding, concepts and skills – the invisible layer of psychological grease that smears our vision and leaves our minds slippery and unable to grasp new concepts.

We need to apply some cognitive detergent and ad some heated debate to strip off the psycho-slime.  The best detergent is I have found is called Reality and the good news is that Reality is widely available, completely free and supplies will never run out.

Watch the video on YouTube

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Will the Cuts Cure the Problem or Kill the Patient?

Times are hard. Severe austerity measures are being imposed to plug the hole in the national finances. Cuts are being made.  But will these cuts cure the problem or kill the patient?  How would we know before it is too late? Is there an alternative to sticking the fiscal knife in and hoping we don’t damage a vital part of the system? Is a single bold slash or a series of planned incisions a better strategy?  How deep, how far and how fast is it safe to cut? The answer to these questions is “we don’t know” – or rather that we find it very hard to predict with confidence what will happen.  The reason for this is that we are dealing with a complex system of interdependent parts that connect to each other through causal links; some links are accelerators, some are brakes, some work faster and some slower.  Our caveman brains were not designed to solve this sort of predicting-the-future-behaviour-of-a-complex-system problem: our brains evolved to spot potential danger quickly and to manage a network of social relationships.  So to our caveman way of thinking complex systems behave in counter-intuitive ways.  However, all physical systems are constrained by the Laws of Nature – so if we don’t understand how they behave then the limitation is with the caveman wetware between our ears.

We do have an amazing skill though – we have the ability to develop tools that extend our limited biological capabilites. We have mastered technology – in particular the technology of data and information. We have  learned how to recode and record our expereince and our understanding so that each generation can build on the knowledge of the previous ones.  The tricky problems we are facing are ones that we have never encountered before so we have to learn as we go.

So our current problem of understanding the dynamics of our economic and social system is this: we cannot do this unconsciously and intuitively in our heads. Instead we have developed tools that can extend our predictive capability. Our challenge is to learn how to use these tools – how to wield the fiscal scalpel so that it is quick, safe and effective. We need to excise the cancer of waste while preserving our vital social and economic structures and processes.  We need the best tools available – diagnostic tools, decision tools, treatment planning tools, and progress monitoring tools.  These tools exist – we just need to learn to use them.

A perfect example of this is the reining in of public spending and the impact of cutting social service budgets.  One thing that these budgets provide are services that some people need to maintain independent living in the community.  Very often elderly people are only just coping and even a minor illness can be enough to tip them over the edge and into hospital – where they can get stuck because to discharge them safely requires extra social support – support that if provided earlier might have prevented a hospital admission. So boldly slashing the social care budget will not magically excise the waste – it means that there will be less social support capacity and patients will get stuck in the hospital part of the health and social care system. This is not good for them – or anyone else. Hospitals are not hotels and getting stuck in one is not a holiday! Hospitals are for people who are very ill – and if the hospital is full of not-so-ill people who are stuck then we have an even bigger problem – because the very ill people get even more ill – and then they need even more resources to get them well again. Some do not make it. A bold slash in just one part of the health and  social care system can, unintentionally, bring the whole health and social care system crashing down.

Fortunately there is a way to avoid this – and it is counter-intuitive – otherwise we would have done it already. And because it is counter-intuitive I cannot just explain it – the only way to understand it is to discover and demonstrate  it to ourselves.  And in the process of learning to master the tools we need we will make a lot of errors. Clearly, we do not want to impose those errors on the real system – so we need something to practice with that is not the real system yet behaves realistically enough to allow us to develop our skills. That something is a system simulation. To experience an example of a healthcare system simulation and to play the game please follow the link: click here to play the game

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The Plague of Niggles

Historians tell us that in the Middle Ages about 25 million people, one third of the population of Europe, were wiped out by a series of Plagues! We now know that the cause was probably a bacteria called Yersinia Pestis that was spread by fleas when they bite their human hosts to get a meal of blood. The fleas were carried by rats and ships carried the rats from one country to another.  The unsanitary living conditions of the ports and towns at the time provided the ideal conditions for rats and fleas and, with a superstitious belief that cats were evil, without their natural predator the population of rats increased, so the population of fleas increased, so the likehood of transmission of the lethal bacteria increased, and the number of people decreased. A classic example of a chance combination of factors that together created an unstable and deadly system.

The Black Death was not eliminated by modern hi-tech medicine; it just went away when some of the factors that fuelled the instability were reduced. A tangible one being the enforced rebuilding of London after the Great Fire in Sept 1666 which gutted the medieval city and which followed the year after the last Great Plague in 1665 that killed 20% of the population. 

The story is an ideal illustration of how apparently trivial, albeit  annoying, repeated occurences can ultimately combine and lead to a catastrophic outcome.  I have a name for these apparently trivial, annoying and repeated occurences – I call them Niggles – and we are plagued by them. Every day we are plagued by junk mail, unpredictable deliveries, peak time traffic jams, car parking, email storms, surly staff, always-engaged call centres, bad news, bureaucracy, queues, confusion, stress, disappointment, depression. Need I go on?  The Plague of Niggles saps our spirit just as the Plague of Fleas sucked our ancestors blood.  And the Plague of Niggles infect us with a life-limiting disease – not a rapidly fatal one like the Black Death – instead we are infected with a slow, progressive, wasting disease that affects our attitude and behaviour and which manifests itself as criticism, apathy and cynicism.  A disease that seems as terifying, mysterious and incurable to us today as the Plague was to our ancestors. 

History repeats itself and we now know that complex systems behave in characteristic ways – so our best strategy may the same – prevention. If we use the lesson of history as our guide we should be proactive and focus our attention on the Niggles. We should actively seek them out; see them for what they really are; exercise our amazing ability to understand and solve them; and then share the nuggets of new knowledge that we generate.

Seek-See-Solve-Share.

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Do We have a Wealth of Data and a Dearth of Information?

Sustained improvement only follows from effective actions; which follow from well-informed decisions – not from blind guessing.  A well-informed decision imples good information – and good information is not just good data. Good information implies that good data is presented in a format that is both undistorted and meaningful to the recipient.  How we present data is, in my experience, one of the weakest links in the improvement process.  We rarely see data presented in a clear, undistorted, and informative way and commonly we see it presented in a way that obscures or distorts our perception of reality. We are presented with partial facts quoted without context – so we unconsciously fill in the gaps with our own assumptions and prejudices and in so doing distort our perception further.  And the more emotive the subject the more durable the memory that we create – which means it continues to distort our future perception even more.

The primary purpose of the news media is survival – by selling news – so the more emotive and memorable the news the better it sells.  Accuracy and completeness can render news less attractive: by generating the “that’s obvious, it is not news” response.  Catchy headlines sell news and to do that they need to generate a specific emotional reaction quickly – and that emotion is curiosity! Once alerted, they must hold the readers attention by quickly creating a sense of drama and suspense – like a good joke – by being just ambiguous enough to resonate with many different pepole – playing on their prejudices to build the emotional intensity.

The purpose of politicians is survival – to stay in power long enough to achieve their goals – so the less negative press they attract the better – but Politicians and the Press need each other because their purpose is the same – to survive by selling an idea to the masses – and to do that they must distort reality and create ambiguity.  This has the unfortunate side effect of also generating less-than-wise decisions.

So if our goal is to cut through the emotive fog and get to a good decision quickly so that we can act effectively we need just the right data presented in context and in an unambiguous format that we, the decision-maker, can interpret quickly. The most accessible format is as a picture that tells a story – the past, the present and the likely future – a future that is shaped by the actions that come from the decisions we make in the present that we make using information from the past.  The skill is to convert data into a story … and one simple and effective tool for doing that is a process behaviour chart.

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Which Checkout do We Choose?

When we are approaching the checkout in the supermarket how do we decide which queue to join?  Is it the shortest? Is it the one with the fewest number of full trollies? Is it the one that is staffed by the most competent looking operative? Or is it the new-fangled computerised one that technophobes like me avoid like the plague? If our goal is to get out of the shop as quickly as possible then this is an important yet tricky decision. Once we have committed to a specific queue then we are bound by the social norms to stick it out.

Technically speaking the queue to join is not the shortest one, or the one with the where there are the smallest number of individual items that need to be scanned, or the one with the fastest operative – it is the queue with the smallest load – the cumulative product of the number of items and cycle time of the operative. Hence our quick mental calculation of length of queue * average size of trollies * speed of operative.  Even then it can go wrong if someone throws a spanner in – such as picking up the only item on the shelf with a missing barcode – triggering the need to call a “supervisor”!

Are we completely powerless in this process? Not at all – we each can ensure all our purchases have barcodes and we can also influence the cycle time of the operative. Observe what they are doing – picking up each item in turn, finding the bar code, and turning the item so that the bar code can be easily scanned by the computer.  To shorten the cycle time all we have to do is make the work for the operative as easy as possible by placing each item on the moving belt in the correct orientation and spaced so that the speed of the belt delivers the items at the same rate that the operative can scan.  This sounds counter-intuitive but it works!  It is just like the variable speed limits on some motorways – by slowing down you get there faster because the flow is smoother – there is less “turbulence” created.

There are two potential flaws in this counter-intuitive strategy though – the people in the queue behind you may start “tutting” because they believe you are playing childish games and slowing the process down (which is incorrect but we are social animals and we copy other people’s behaviour and react to “social deviants”).  The other flaw is that, if I am shopping alone I cannot both stream my purchases for optimal scanning and also pack my scanned purchases into my reusable shopping bag!  So, I may only be able to use this strategy when accompanied by a trained assistant and have access to my fast getaway car!  Of course I might get even more radical – and offer to stream the shopping for the person in front of me while they pack their scanned items. But that would mean that we work together to achieve a common goal – to reduce the (life)time we all spend waiting in the shopping queue. This way we do not need an assistant or a getaway car and shopping might even become more sociable.  Everyone wins. What everyone? How is that possible?

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Can We See the Wood for the Trees?

“The Map is not the Territory” but it is a very useful because it provides a sense of perspective; the bigger picture; where you are; and what you would need to do to get from A to B.  A map can also provide the the fine detail, they way-points on your journey, and what to expect to see along the way.  I remember the first computer programs that would find a route from A to B for me and present it as a printed recipe for the journey; how far it was and, best of all, how long it would take – so I knew when to set off to be reasonably confident I could arrive on time.  Of course, there might always be unexpected holdups along the way but it was a big step forward. One problem was using the recipe as I drove, and another was when I accidently took a wrong turn, which is easy in unfamiliar surroundings with only a list of instructions to go by.  If I came off the intended track I would get lost – so I still needed the paper map as a backup. The trouble now was I did not alwasy know where I was on the map – because I was lost.  Two steps forward and one step backwards.  Now we have Google Maps and we can see what we will actually see on the way – before we even leave home!  And with SatNav we can get this map-reading-and-route-planning done for us in real time so if we choose to, are forced to, or accidentially take a wrong turn it can get us back-on-track. The days of heated debate between the map reader and the map needer have gone and it seems the only need we have for a map now is as a backup if the SatNav breaks down. (This did happen to me once, I didn’t have a map in the car and the only information I had was the postcode of my destination. I was pressed for time so I drove around randomly until I passed a shop that sold SatNavs and bought a new/spare one – entered the postcode and arrived at my intended destination just in time!).

So is the map dead?  Not at all – the value of a map in providing a sense of perspective, context and location is just as useful as ever. And there are many sorts of maps apart from the static, structural, geographical maps ones we are used to.  The really exciting maps are the dynamic ones – the functional maps.  These are maps that show how things are working and flowing, not only where they are.  Imagine if your SatNav had both a static map and was able to access a real time dynamic map of traffic flow. Just think how much more useful it could be? However, to achieve that implies that each person on the road would have to contribute both their position and their intended destination to a central system – isn’t that Big Brother back. Air traffic control (ATC) systems have done this for years for a very good reason: aeroplanes full of passengers are perishable goods – they can’t land anywhere they like and they can’t stay up there waiting to land for ever.  You can’t afford to have traffic jams with aeroplanes – so every pilot has to file a flight plan and will only be given ATC clearance to take off if their destination is capable of offering them a landing slot in an acceptable time frame – i.e. before the plane runs out of fuel! Static maps will always be needed to provide us with a sense of perspective – and in the future dynamic maps will revolutionise the way that we do everything – but only if we are prepared to behave collectively and share our data.  We want to see the wood, the trees and even the breeze through the leaves!

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Is this Second Nature or Blissful Ignorance?

Four stages of learningI haven’t done a Post-It doodle for a while so here is one of my favourites that I was reminded of this week.  Recently my organisation has mandated that we complete a 360-feedback exercise – which for me generated some anxiety – even fear. Why? What am I scared of? Could it be that I am unconsciously aware that there are things I am not very good – I just don’t know what they are – and by asking for feedback I will become painfully aware of my limitations? What then? Will I able to address those weaknesses or do I have to live with them? And even more painful to consider; what if I believed I was good at something because I have been doing it so long it has become second nature – and I discover that what I was good at is not longer appropriate or needed? Wow! That is not going to feel much fun.  I think I’ll avoid the whole process by keeping too busy to complete the online questionnaire.  That strategy did not work of course – a head-in-the-sand approach often doesn’t.  So I completed it and await my fate with trepidation.

The model of learning that I have sketched is called the Conscious-Competence model or – as I prefer to call it – Capability Awareness.  We all start bottom left – not aware of our lack of capablity – let’s call that Blissful Ignorance.  Then something happens that challenges our complacency – we become aware of our lack of capability – ouch! That is Painful Awareness.  From there we have three choices – retreat (denial), stay where we are (distress) or move forward (discovery).  If we choose the path of discovery we must actively invest time and effort to develop our capability to get to the top right position – where we are aware of what we can do – the state of Know How.  Then as we practice or new capability and build our experience we gradually become less aware of out new capability – it becomes Second Nature.  We can now do it without thinking – it becomes sort of hard-wired.  Of course, this is a very useful place to get to: it does conceal a danger though – we start to take our capability for granted as we focus our attention on new challenges. We become complacent – and as the world around us is constantly changing we may be unaware our once-appropriate capability may be growing less useful.  Being a wizard with a set of log-tables and a slide-rule became an unnecessary skill when digital calculators appeared – that was fairly obvious.  The silent danger is that we slowly slide from Second-Nature to Blissful-Ignorance; usually as we get older, become more senior, acquire more influence, more money and more power.  We now have the dramatic context for a nasty shock when, as a once capable and respected leader, we suddenly and painfully become aware of our irrelevance. Many leaders do not survive the shock and many organisations do not survive it either – especially if a once-powerful leader switches to self-justifying denial and the blame-others behaviour.

To protect ourselves from this unhappy fate just requires that we understand the dynamic of this deceptively simple model; it requires actively fostering a curious mindset; it requires a willingness to continuously challenge ourselves; to openly learn from a wide network of others who have more capability in the area we want to develop; and to be open to sharing with others what we have learned.  Maybe 360 feedback is not such a scary idea?

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Can an Old Dog learn New Tricks?

I learned a new trick this week and I am very pleased with myself for two reasons. Firstly because I had the fortune to have been recommended this trick; and secondly because I had the foresight to persevere when the first attempt didn’t work very well.  The trick I learned was using a webinar to provide interactive training. “Oh that’s old hat!” I hear some of you saying. Yes, teleconferencing and webinars have been around for a while – and when I tried it a few years ago I was disappointed and that early experience probably raised my unconscious resistance. The world has moved on – and I hadn’t. High-speed wireless broadband is now widely available and the webinar software is much improved.  It was a breeze to set up (though getting one’s microphone and speakers to work seems a perennial problem!). The training I was offering was for the BaseLine process behaviour chart software – and by being able to share the dynamic image of the application on my computer with all the invitees I was able to talk through what I was doing, how I was doing it and the reasons why I was doing it.  The immediate feedback from the invitees allowed me to pace the demonstration, repeat aspects that were unclear, answer novel queries and to demonstrate features that I had not intended to in my script.  The tried and tested see-do-teach method has been reborn in the Information Age and this old dog is definitely wagging his tail and looking forward to his walk in the park (and maybe a tasty treat, huh?)

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What is so Funny?

One line from the Simpson’s Movie that made me laugh was when Bart says “Dad, this is the worst day of my life!” to which Homer replies “Worst day <dramatic pause> so far!”.  If Bart had said “Dad, this is the best day of my life!” and Homer had replied “Best day <dramatic pause> so far!” it would not have been funny – it would have sounded cheesy. Why is that?  What does this tell us about how we can sometimes confuse humour and pleasure?  If we laugh when we are unexpectedly confronted with someone else’s emotional distress (the basis of slapstick humour); and we also laugh when we see other people laughing; and we also laugh when we have our expectations exceeded (the basis of surprise parties) then by simple association of the feeling (pleasure) with the behaviour (laughter) we have a recipe for collectively laughing at someone else’s distress.  More sinister is that we can unconsciously plan to derive laughter (and by association pleasure) by deliberately engineering distress for others.  Humour, like any process, can become sick.

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Can We See a Story in the Data?

I often hear the comments “I cannot see the wood for the trees”, “I am drowning in an ocean of data” and “I cannot identify the cause of the problem”.  We have data, we know there is a problem and we sense there is a soluton; the gap seems to be using the data to find a solution to the problem.

Most quantitative data is presented as tables of columns and rows of numbers; and is indigestable by the majority of people.  Numbers are a recent invention on a biological timescale and we have not yet evolved to effortlessly process data presented in that format. We are visual animals and we have evolved to be very good at seeing patterns in pictures – because it was critical to survival.  Another recent invention is spoken language and, long before writing was invented, accumulated knowledge and wisdom was passed down by word of mouth as legends, myths and stories. Stories are general descriptions that suggest specific solutions. So why do we have such difficulty in extracting the story from the data? Perhaps it is because we use our ears to hear stories that are communicated in words and we use our eyes to see patterns in pictures.  Presenting quantitative data as streams of printed symbols just doesn’t work as well.  To see the story in the data we need to present it as a picture and then talk about what we perceive.

Here are some data – a series of numbers recorded over a period of time – what is the story?

47, 55, 40, 52, 55, 70, 60, 43, 51, 41, 73, 73, 79, 89, 83, 86, 78, 85, 71, 70

Here is the same data converted into a picture.  You can see the message in the data … something changed between measurement 10 and 11.  The chart does not tell us why it changed – it only tells us when it happened and sugegsts what to look for – anything that is capable of causing the effect we can see.  We now have a story and our curiosity is aroused. We want an explanation; we want to understand; we want to learn; and we want to improve.  (For source of data and image visit www.valuesystemdesign.com).

A picture can save a thousand words and ten thousand numbers!

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What is the Quickest way to Paralyse a System?

Create confusion by introducing a new factor that the system has little experience of how to manage. And to get the message to spread make it really scary; life-threatening-for-innocent-bystanders-scary; because bad news travels faster than good news. What happens next is predictable; a safety alarm goes off, someone hits the brakes and everything stops. We need time to focus on the new factor, to observe it, investigate it, work out what it is, how it behaves and what to do. We have switched from doing to learning. There is a perfect example of this principle operating on a global scale as I write – a volcano in Iceland that has been dormant since 1821 suddenly spews a cloud of dust high into the sky. There are volcanic eruptions all the time so why is this different? Well, because of a combination of factors that when they combine creates a BIG system-wide impact. First the location of the volcano – on the north-west corner of Europe; then the weather – the prevailing winds are carrying the volcanic plume south and east over the whole of Europe; then the effect – to create a hazard for high altitude commercial jets. Europe is one of the most congested airspaces in the world with around 28,000 flights per day – mostly short haul – but the large European hubs serve as the end points of the trans-global long haul routes. If you want to paralyse global air travel for a completely reversible yet uncontrollable and unpredictable length of time then you probably couldn’t come up with a better plan! The trouble is that the longer the paralysis persists the greater and more irreversible the long term damage. Air travel is an essential component of many industries; so loss of flying capacity not only means loss of revenue and increased costs for airlines – the effects will be felt in every corner of commerce. What triggered this chaos was not just a volcano – it required something else – fear of the unknown. Limited, accidental experience of the interaction of high altitude volcanic plumes and commercial jets shows that all the engines of the jet can shut down – clogged by the volcanic ash. Not an attractive option for anyone. The problem is we simply do not know what the limits of safety are? We are on the horns of an uncomfortable dilemma. The experts and the press who normally feed off each other are uncharacteristically quiet at the moment … everyone is watching, waiting and hoping it will just blow away and we can get back to normal. It won’t and we can’t. Our worldview has just been changed and there is no going back – we have to evolve.

Update 25/04/2010 – I got stranded abroad for a week. It could have been much worse and what was interesting to observe was how the situation was managed. After the initial shock everyone just watched and waited. After a few days it was clear that the problem wasn’t just blowing away. The airlines were haemorrhaging money and were forced to act – by testing if the fear of engine failure was justified. It appeared not to be. A reduction in the volcanic ash being generated, and a shift of the wind, and increasing confidence led to flight activity begin resumed after 7 days. Long before the Authorities could gain any meaningful “scientific” data. The current tasks are to sort out the backlog of displaced passengers; find someone to blame and to sue for compensation. If past behaviour is anything to go by the Authorities will be blamed and the Taxpayers will pick up the bill.  Have we learned anything of lasting benefit from this experience? If not then the same lesson will be repeated; sometime, somewhere, somehow – until we do.

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Delusional Ratios and Arbitrary Targets

This week a friend of mine shared an interesting story.

They were told that their recent performance data showed that performance was improving. “That sounds good” they thought as they started to look at the data which was presented as a table of numbers, one number per time period, as a percentage ratio, and colour coded red, amber or green. The last number in the sequence was green; the previous ones were either red or amber. “See! Our performance has improved and is now acceptable“.

But it did not feel quite right to my friend who did not want to dampen the celebration without good reason, so enquired further “What is the ratio measuring exactly?” “H’mm, let me check, the number of failures divided by the number of customer requests.”  “And what does the red, amber and green signify?” “Oh that’s easy, whether we are above, near or below our target.” “And how was the target set and by whom?” “Um, I don’t know how it was set, we were just told what the target is and the consequences if we don’t meet it.” “And what are the consequences?” No answer – just a finger-across-the-throat gesture.  “Can I see the raw data used to calculate this ratio?” “Eh? I think so, but no one has ever asked us for that before.”

My friend could now see the origin of his niggle of doubt.  The raw data showed that the number of customer requests was falling progressively over time while the number of successful requests was not changing.  They were calculating failures from the difference between demand and activity and then dividing the result by the demand to give a percentage that was intended to show their performance. And then setting an arbitrary target for acceptability.

The raw data told a very different story – their customers were going elsewhere – which meant their future income was progressively walking away.  They were blind to it; their ratio was deluding them.

And by setting an arbitrary target for this “delusional ratio” implied that so long as they were “in the green” they didn’t need to do anything, they could sit back and relax. They could not see the nasty surprise coming.

This story led me to wonder how many organsiations get into trouble by following delusional ratios linked to arbitrary targets? How many never see the storm coming until it is too late to avoid it?  Where do these delusional ratios and arbitrary targets come from?  Do they have a valid and useful purpose? And if so, how do we know when to use a ratio or a target and when not to?

It also gave me a new acronym – D.R.A.T. – which seems rather appropriate.

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What Can We Learn From Fish?

A few weeks ago we were asked to look after the class fish during the half-term school holiday. Easy enough, just feed it daily and change the water when it gets murky was our handed-down knowledge of fish-management.  So when we observed the fish swimming at the surface apparently gulping air, even our limited grasp of fish-biology suggested that something was not quite right.  After a short web-surf our anxiety was confirmed: our fish was exhibiting high stress behaviour – it was being poisoned by toxic waste – the waste it makes itself.  We learned that a fish-tank is a delicate and complex eco-system.  Too big a fish in too small a tank, over-feeding, stagnation and infrequent complete water changes with toxic (chlorinated) tap-water are the commonest ways we upset this delicate balance. We were unintentionally killing the fish! The remedy was obvious: we had to learn about fish and learn how to maintain the fish-tank-eco-system. And fast! The fish was delivered back to school in a much bigger tank, complete with light, filter, pump, and the output of our learning – written instructions. The reaction was: “Wow! We can’t believe this is the same fish. It looks and behaves completely differently. It looks happy”.

This life-lesson reminded me of a book that I read some years ago called “Fish!” which involves the Pike Place Fish Market in Seattle and a story of how the fish-mongers inspired others to dramatically improve their own toxic work places.  The message in the story is that we all swim in the emotional toxic waste that we ourselves create; each of us has the choice to commit to reducing our toxic emotional waste emissions; we can contract to hold each other to account on this commitment; and collectively we have the power to drain our own toxic emotional waste swamps. This led to an “eureka” moment: Improvement can not happen in a toxic emotional environment. So how do we know we have one? What are the symptoms and signs? With this insight I believe we can answer that question by just looking and listening.

And if you fancy a diet of near-pure toxic emotional waste all you have to do is read a daily newspaper. Yeuk!