Category: Theory

The theory of Improvement Science

Posted on

The Rubik Cube Problem

Look what popped out of Santa’s sack!

I have not seen one of these for years and it brought back memories of hours of frustration and time wasted in attempting to solve it myself; a sense of failure when I could not; a feeling of envy for those who knew how to; and a sense of indignation when they jealously guarded the secret of their “magical” power.

The Rubik Cube got me thinking – what sort of problem is this?

At first it is easy enough but it becomes quickly apparent that it becomes more difficult the closer we get to the final solution – because our attempts to reach perfection undo our previous good work.  It is very difficult to maintain our initial improvement while exploring new options. 

This insight struck me as very similar to many of the problems we face in life and the sense of futility that creates a powerful force that resists further attempts at change.  Fortunately, we know that it is possible to solve the Rubik cube – so the question this raises is “Is there a way to solve it in a rational, reliable and economical way from any starting point?”

One approach is to try every possible combination of moves until we find the solution. That is the way a computer might be programmed to solve it – the zero intelligence or brute force approach.

The problem here is that it works in theory but fails in practice because of the number of possible combinations of moves. At each step you can move one of the six faces in one of two directions – that is 12 possible options; and for each of these there are 12 second moves or 12 x 12 possible two-move paths; 12 x 12 x 12 = 1728 possible three-move paths; about 3 million six-move paths; and nearly half a billion eight-move paths!

You get the idea – solving it this way is not feasible unless you are already very close to the solution.

So how do we actually solve the Rubik Cube?  Well, the instructions that come with a new one tells you – a combination of two well-known ingredients: strategy and tactics. The strategy is called goal-directed and in my instructions the recommended strategy is to solving each layer in sequence. The tactics are called heuristics: tried-tested-and-learned sequences of actions that are triggered by specific patterns.

At each step we look for a small set of patterns and when we find one we follow the pre-designed heuristic and that moves us forward along the path towards the next goal. Of the billions of possible heuristics we only learn, remember, use and teach the small number that preserve the progress we have already made – these are our magic spells.

So where do these heuristics come from?

Well, we can search for them ourselves or we can learn them from someone else.  The first option holds the opportunity for new insights and possible breakthroughs – the second option is quicker!  Someone who designs or discovers a better heuristic is assured a place in history – most of us only ever learn ones that have been discovered or taught by others – it is a much quicker way to solve problems.  

So, for a bit of fun I compared the two approaches using a computer: the competitive-zero-intelligence-brute-force versus the collaborative-goal-directed-learned-and-shared-heuristics.  The heuristic method won easily every time!

The Rubik Cube is an example of a mechanical system: each of the twenty-six parts are interdependent, we cannot move one facet independently of the others, we can only move groups of nine at a time. Every action we make has nine consequences – not just one.  To solve the whole Rubik Cube system problem we must be mindful of the interdependencies and adopt methods that preserve what works while improving what does not.

The human body is a complex biological system. In medicine we have a phrase for this concept of preserving what works while improving what does not: “primum non nocere” which means “first of all do no harm”.  Doctors are masters of goal-directed heuristics; the medical model of diagnosis before prognosis before treatment is a goal-directed strategy and the common tactic is to quickly and accurately pattern-match from a small set of carefully selected data. 

In reality we all employ goal-directed-heuristics all of the time – it is the way our caveman brains have evolved.  Relative success comes from having a more useful set of heuristics – and these can be learned.  Just as with the Rubik Cube – it is quicker to learn what works from someone who can demonstrate that it works and can explain how it works – than to always laboriously work it out for ourselves.

An organisation is a bio-psycho-socio-economic system: a set of interdependent parts called people connected together by relationships and communication processes we call culture.  Improvement Science is a set of heuristics that have been discovered or designed to guide us safely and reliably towards any goal we choose to select – preserving what has been shown to work and challenging what does not.  Improvement Science does not define the path it only helps us avoid getting stuck, or going around in circles, or getting hopelessly lost while we are on the life-journey to our chosen goal.

And Improvement Science is learnable.

Posted on

Inborn Errors of Management

There is a group of diseases called “inborn errors of metabolism” which are caused by a faulty or missing piece of DNA – the blueprint of life that we inherit from our parents. DNA is the chemical memory that stores the string of instructions for how to build every living organism – humans included. If just one DNA instruction becomes damaged or missing then we may lose the ability to make or to remove one specific chemical – and that can lead to a deficiency or an excess of other chemicals – which can then lead to dysfunction – which can then make us feel unwell – and can then limit both our quality and quantity of life.  We are a biological system of interdependent parts. If an inborn error of metabolism is lethal it will not be passed on to our offspring because we don’t live long enough – so the ones we see are the ones which and not lethal.  We treat the symptoms of an inborn error of metabolism by artificially replacing the missing chemical – but the way to treat the cause is to repair, replace or remove the faulty DNA.

The same metaphor can be applied to any social system. It too has a form of DNA which is called culture – the inherited set of knowledge, beliefs, attitudes and behaviours that the organisation uses to conduct itself in its day-to-day business of survival. These patterns of behaviour are called memes – the social equivalent to genes – and are passed on from generation to generation through language – body language and symbolic language; spoken words – stories, legends, myths, songs, poems and books – the cultural collective memory of the human bio-psycho-social system. All human organisations share a large number of common memes – just as we share a large number of common genes with other animals and plants and even bacteria. Despite this much larger common cultural heritage – it is the differences rather than the similarities that we notice – and it is these differences that spawn the cultural conflict that we observe at all levels of society.

If, by chance alone, an organisation inherits a depleted set of memes it will appear different to all the others and it will tend to defend that difference rather than to change it. If an organisation has a meme defect, a cultural mutation that affects a management process, then we have the organisational condition called an Inborn Error of Management – and so long as the mutation is not lethal to the organisation it will tend to persist and be passed largely unnoticed from one generation of managers to the next!

The NHS was born in 1948 without a professional management arm, and while it survived and grew initally, it became gradually apparent that the omisson of the professional management limb was a problem; so in the 1980’s, following the Griffiths Report, a large dose professional management was grafted on and a dose of new management memes were injected. These included finance, legal and human resource management memes but one important meme was accidentally omitted – process engineering – the ability to design a process to meet a specific quality, time and cost specification.  This omission was not noticed initially because the rapid development of new medical technologies and new treatments was delivering improvements that obscured the inborn error of management. The NHS became the envy of many other countries – high quality healthcare available to all and free at the point of delivery.  Population longevity improved, public expectation increased, demand for healthcare increased and inevitably the costs increased.  In the 1990’s the growing pains of the burgeoning NHS led to a call for more funding, quoting other countries as evidence, and at the turn of the New Millenium a ten year plan to pump billions of pounds per year into the NHS was hatched.  Unfortunately, the other healthcare services had inherited the same meme defect – so the NHS grew 40% bigger but no better – and the evidence is now accumulatung that productivity (the ratio of output quality to input cost) has actally fallen by more than 10% – there are more people doing more work but less well.  The UK along with many other countries has hit an economic brick wall and the money being sucked into the NHS cannot increase any more – even though we have created a legacy of an increasing proportion of retired and elderly members of society to support. 

The meme defect that the NHS inherited in 1948 and that was not corrected in the transplant operation  1980’s is now exerting it’s influence – the NHS has no capability for process engineering – the theory, techniques, tools and training required to design processes are not on the curriculum of either the NHS managers or the clinicians. The effect of this defect is that we can only treat the symptoms rather than the cause – and we only have blunt and ineffective instruments such as a budget restriction – the management equivalent of a straight jacket – and budget cuts – the management equivalent of a jar of leeches. To illustrate the scale of the effect of this inborn error of management we only need to look at other organisations that do not appear to suffer from the same condition – for example the electronics manufacturing industry. The almost unbelieveable increase in the performance, quality and value for money of modern electronics over the last decade (mobile phones, digital cameras, portable music players, laptop computers, etc) is because these industries have invested in developing both their electrical and process engineering capabilities. The Law of the Jungle has weeded out the companies who did not – they have gone out of business or been absorbed – but publically funded service organisations like the NHS do not have this survival pressure – they are protected from it – and trying to simulate competition with an artificial internal market and applying stick-and-carrot top-down target-driven management is not a like-for-like replacement.    

The challenge for the NHS is clear – if we want to continue to enjoy high quality health care, free at the point of delivery, and that we can afford then we will need to recognise and correct our inborn error of management. If we ignore the symptoms, deny the diagnosis and refuse to take the medicine then we will suffer a painful and lingering decline – not lethal and not enjoyable – and it is has a name: purgatory.

The good news is that the treatment is neither expensive, nor unpleasant nor dangerous – process engineering is easy to learn, quick to apply, and delivers results almost immediately – and it can be incorporated into the organisational meme-pool quite quickly by using the see-do-teach vector. All we have to do is to own up to the symptoms, consider the evidence, accept the diagnosis, recognise the challenge and take our medicine. The sooner the better!

 

Posted on

The Drama Triangle

Have you ever had the experience of trying to help someone with a problem, not succeeding, and being left with a sense of irritation, disappointment, frustration and even anger?

Was the dialog that led up to this unhappy outcome something along the lines of:

A: I have a problem with …
B: What about trying …
A: Yes, but ….
B: What about trying ….
A: Yes, but …

… and so on until you run out of ideas, patience or both.

If this sounds familiar then it is likely that you have been unwittingly sucked into a Drama Triangle – an unconscious, habitual pattern of behaviour that we all use to some degree.

This endemic behaviour has a hidden purpose: to feed our belonging need for social interaction.

The theory goes something like this – we are social animals and we need social interaction just as much as we need oxygen, water and food.  Without it we become psychologically malnourished and this insight explains why prolonged solitary confinement is such an effective punishment – it is the psychological equivalent to starvation.

The emotional sustenance we want most is unconditional love (UCL) – the sort we usually get from our parents, family and close friends.  Repeated affirmation that we are ‘OK’ with no strings attached.

The downside of our unconscious desire for UCL is that it offers a way for others to control our behaviour and those who choose to abuse that power are termed ‘manipulative’.  This control is done by adding conditions: “I will give you the affirmation you crave IF you do what I want“.  This is conditional love (CL).

When we are born we are completely powerless, and completely dependent on our parents – in particular our mother.  As we get older and start to exert our free will we learn that our society has rules – we cannot just follow every selfish desire.

Our parents unconsciously employ CL as a form of behavioural control and it is surprisingly effective: “If you are a good boy/girl then …“.  So, as children, we learn the technique from our parents.

This in itself  is not a problem; but it can become a problem when CL is the only sort available and when the intention is to further only the interests of the giver.  When this happens it becomes … manipulation.

The apparently harmless playground threat of “If you don’t do what I want then I won’t be your friend anymore” is the practice script of a future manipulator – and it feeds on a limiting-belief in the unconscious mind of the child – the belief that there is a limited supply of UCL and that someone else controls it.

And because we make this assumption at the pre-verbal stage of child development, it becomes unconscious, habitual, unspoken and second nature.

Our invalid childhood belief has a knock-on effect; we learn to survive on CL because “No Love” is the worst of all options; it is the psychological equivalent of starvation.

And we learn to put up with second best, and because CL offers inferior emotional nourishment we need a way of generating as much as we want, on-demand.

So we employ the behaviour we were unwittingly taught by our patents – and the Drama Triangle becomes our on-demand-generator-of-second-rate-emotional-sustenance.

The tangible evidence of this “programming” is an observable behaviour that is called “game playing” and was first described by Eric Berne in the famous book “Games People Play“.

Berne described many different Games and they all have a common pattern and a common objective – to generate second-rate emotional food (or ‘transactions’ to use Berne’s language).  But our harvest comes at a price – the transactions are unhealthy – not enough to harm us immediately – but enough to leave us feeling dissatisfied and unhappy.

But what choice do we believe we have?

If we were given the options of breathing stale air or suffocating what would we do?

If we assume our options are to die of thirst or drink stagnant pond-water what would we do?

If we believe our only options are to starve or eat rubbish what would we do?

Our survival instinct is much stronger than our belonging need, so we choose unhealthy over deadly and eventually we become so habituated to game-playing that we do not notice it any more.

Excessive and prolonged exposure to the Drama Triangle is the psychological equivalent of alcoholic liver cirrhosis.  Permanent and irreversible psychological scarring called cynicism.

It is important to remember that this is learned behaviour – and therefore it can be unlearned – or rather overwritten with a healthier habit.

Just by becoming aware of the problem, and understanding the root cause of the Drama Triangle, an alternative pathway appears.

We can challenge our untested assumption that UCL is limited and that someone else controls the supply.  We can consider the alternative hypothesis: that the supply of UCL is unlimited and that we control the supply.

Q: How easy is it for us to offer someone else UCL?

Easy – we see it all the time. How do you feel when someone gives a genuine “Thank You”, cheers you on, celebrates your success, seeks your opinion, and recommends you to others – with no strings attached.  These are all forms of UCL that anyone can practice; by making a conscious choice to give with no expectation of a return.

For many people it feels uncomfortable at first because the game-playing behaviour is so deeply ingrained – and game-playing is particularly prevalent in the corridors of power where it is called “politics”.

Game-free behaviour gets easier with practice because UCL benefits both the giver and the receiver – it feels healthier – there is no need for a payback, there is no score to be kept, no emotional account to balance.  It feels like a breath of fresh air.

So, next time you feel that brief flash of irritation at the start of a conversation or are left with a negative feeling after a conversation just stop and ask yourself  “Was I just sucked into a Drama Triangle?”

Anyone who is able to “press your button” is hooking you into a game, and it takes two to play.

Now consider the question “And to what extent was I unconsciously colluding?“

The tactic to avoid the Drama Triangle is to learn to sense the emotional “hook” that signals the invitation to play the Game; and to consciously deflect it before it embeds into your unconscious mind and triggers an unconscious, habitual, reflex, emotional reaction.

One of the most potent barriers to change is when we unconsciously compute that our previously reliable sources of CL are threatened by the change.  We have no choice but to oppose the change – and that choice is made unconsciously. So, we unwittingly undermine the plan.

The symptoms of this unconscious behaviour are obvious when you know what to look for … and the commonest reaction is:

“Yes … but …”

and the more intelligent and invested the person the more cogent and rational the argument will sound.

The most effective response is to provide evidence that disproves the defensive assertion – not the person’s opinion – and before taking on this challenge we need to prepare the evidence.

By demonstrating that their game-playing behaviour no longer leads to the expected payoff, and at the same time demonstrating that game-free behaviour is both possible and better – we demonstrate that the underlying, unconscious, limiting belief is invalid.

And by that route we develop our capability for game-free social interactions.

Simple enough in theory, and it does works in practice, though it can be difficult to learn because game-playing is such an ingrained behaviour.  It does get easier with practice and the ultimate reward is worth the investment  – a healthier emotional environment.  And that is transformational.

Posted on

Lies, Damned Lies and Statistics!

Most people are confused by statistics and because of this experts often regard them as ignorant, stupid or both.  However, those who claim to be experts in statistics need to proceed with caution – and here is why.

The people who are confused by statistics are confused for a reason – the statistics they see presented do not make sense to them in their world.  They are not stupid – many are graduates and have high IQ’s – so this means they must be ignorant and the obvious solution is to tell them to go and learn statistics. This is the strategy adopted in medicine: Trainees are expected to invest some time doing research and in the process they are expected to learn how to use statistics in order to develop their critical thinking and decision making.  So far so good, so what  is the outcome?

Well, we have been running this experiment for decades now – there are millions of peer reviewed papers published – each one having passed the scrutiny of a statistical expert – and yet we still have a health care system that is not delivering what we need at a cost we can afford.  So, there must be someone else at fault – maybe the managers! They are not expected to learn or use statistics so that statistically-ignorant rabble must be the problem -so the next plan is “Beat up the managers” and “Put statistically trained doctors in charge”.

Hang on a minute! Before we nail the managers and restructure the system let us step back and consider another more radical hypothesis. What if there is something not right about the statistics we are using? The medical statistics experts will rise immediately and state “Research statistics is a rigorous science derived from first principles and is mathematically robust!”  They are correct. It is. But all mathematical derivations are based on some initial fundamental assumptions so when the output does not seem to work in all cases then it is always worth re-examining the initial assumptions. That is the tried-and-tested path to new breakthroughs and new understanding.

The basic assumption that underlies research statistics is that all measurements are independent of each other which also implies that order and time can be ignored.  This is the reason that so much effort, time and money is invested in the design of a research trial – to ensure that the statistical analysis will be correct and the conclusions will be valid. In other words the research trial is designed around the statistical analysis method and its founding assumption. And that is OK when we are doing research.

However, when we come to apply the output of our research trials to the Real World we have a problem.

How do we demonstrate that implementing the research recommendation has resulted in an improvement? We are outside the controlled environment of research now and we cannot distort the Real World to suit our statistical paradigm.  Are the statistical tools we used for the research still OK? Is the founding assumption still valid? Can we still ignore time? Our answer is clearly “NO” because we are looking for a change over time! So can we assume the measurements are independent – again our answer is “NO” because for a process the measurement we make now is influenced by the system before, and the same system will also influence the next measurement. The measurements are NOT independent of each other.

Our statistical paradigm suddenly falls apart because the founding assumption on which it is built is no longer valid. We cannot use the statistics that we used in the research when we attempt to apply the output of the research to the Real World. We need a new and complementary statistical approach.

Fortunately for us it already exists and it is called improvement statistics and we use it all the time – unconsciously. No doctor would manage the blood pressure of a patient on Ward A  based on the average blood pressure of the patients on Ward B – it does not make sense and would not be safe.  This single flash of insight is enough to explain our confusion. There is more than one type of statistics!

New insights also offer new options and new actions. One action would be that the Academics learn improvement statistics so that they can understand better the world outside research; another action would be that the Pragmatists learn improvement statistics so that they can apply the output of well-conducted research in the Real World in a rational, robust and safe way. When both groups have a common language the opportunities for systemic improvment increase. 

BaseLine© is a tool designed specifically to offer the novice a path into the world of improvement statistics.

Posted on

More than the Sum or Less?

It is often assumed that if you combine world-class individuals into a team you will get a world-class team.

Meredith Belbin showed 30 years ago that you do not and it was a big shock at the time!

So, if world class individuals are not enough, what are the necessary and sufficient conditions for a world-class team?

The late Russell Ackoff described it perfectly – he said that if you take the best parts of all the available cars and put them together you do not get the best car – you do not even get a car. The parts are necessary but they are not sufficient – how the parts connect to each other and how they influence each other is more important.  These interdependencies are part of the system – and to understand a system requires understanding both the parts and their relationships.

A car is a mechanical system; the human body is a biological system; and a team is a social system. So to create a high performance, healthy, world class team requires that both the individuals and their relationships with each other are aligned and resonant.

When the parts are aligned we get more than the sum of the parts; and when they are not we get less.

If we were to define intelligence quotient as “an ability to understand and solve novel problems” then the capability of a team to solve novel problems is the collective intelligence.  Experience suggests that a group can appear to be less intelligent than any of the individual members.  The problem here is with the relationships between the parts – and the term that is often applied is “dysfunctional”.

The root cause is almost always distrustful attitudes which lead from disrespectful prejudices and that lead to discounting behaviour.  We learn these prejudices, attitudes and behaviours from each other and we reinforce them with years of practice.  But if they are learned then they can be un-learned. It is simple in theory, and it is possible in practice, but it is not easy.

So if we want to (dis)solve complex, novel problems thenwe need world-class problem solving teams; and to transform our 3rd class dysfunctional teams we must first learn to challenge respectfully our disrespectful behaviour.

The elephant is in the room!

Posted on

Does More Efficient equal More Productive?

It is often assumed that efficiency and productivity are the same thing – and this assumption leads to the conclusion that if we use our resources more efficiently then we will automatically be more productive. This is incorrect. The definition of productivity is the ratio of what we expect to get out divided by what we put in – and the important caveat to remember is that only the output which meets expectation is counted – only output that passes the required quality specification.

This caveat has two important implications:

1. Not all activity contributes to productivity. Failures do not.
2. To measure productivity we must define a quality specification.

Efficiency is how resources are used and is often presented as metric called utilisation – the ratio of how much time a resource was used to how much time a resource was available.  So, utilisation includes time spent by resources detecting and correcting avoidable errors.

Increasing utilisation does not always imply increasing productivity: It is possible to become more efficient and less productive by making, checking, detecting and fixing more errors.

For example, if we make more mistakes we will have more output that fails to meet the expected quality, our customers complain and productivity has gone down. Our standard reaction to this situation is to put pressure on ourselves to do more checking and to correct the erros we find – which implies that our utilisation has gone up but our productivity has remained down: we are doing more work to achieve the same outcome.

However, if we remove the cause of the mistakes then more output will meet the quality specification and productivity will go up (better outcome with same resources); and we also have have less re-work to do so utilisation goes down which means productivity goes up even further (remember: productivity = success out divided by effort in). Fixing the root case of errors delivers a double-productivity-improvement.

In the UK we have become a victim of our own success – we have a population that is living longer (hurray) and that will present a greater demand for medical care in the future – however the resources that are available to provide healthcare cannot increase at the same pace (boo) – so we have a problem looming that is not going to go away just by ignoring it. Our healthcare system needs to become more productive. It needs to deliver more care with the same cash – and that implies three requirements:
1. We need to specify our expectation of required quality.
2. We need to measure productivity so that we can measure improvement over time.
3. We need to diagnose the root-causes of errors rather than just treat their effects.

Improved productivity requires improved quality and lower costs – which is good because we want both!

Posted on

How Do We Measure the Cost of Waste?

There is a saying in Yorkshire “Where there’s muck there’s brass” which means that muck or waste is expensive to create and to clean up. 

Improvement science provides the theory, techniques and tools to reduce the cost of waste and to re-invest the savings in further improvement.  But how much does waste cost us? How much can we expect to release to re-invest?  The answer is deceptively simple to work out and decidedly alarming when we do.

We start with the conventional measurement of cost – the expenses – be they materials, direct labour, indirect labour, whatever. We just add up all the costs for a period of time to give the total spend – let us call that the stage cost. The next step requires some new thinking – it requires looking from the perspective of the job or customer – and following the path backwards from the intended outcome, recording what was done, how much resource-time and material it required and how much that required work actually cost.  This is what one satisfied customer is prepared to pay for; so let us call this the required stream cost. We now just multiply the output or activity for the period of time by the required stream cost and we will call that the total stream cost. We now just compare the stage cost and the stream cost – the difference is the cost of waste – the cost of all the resources consumed that did not contribute to the intended outcome. The difference is usually large; the stream cost is typically only 20%-50% of the stage cost!

This may sound unbelieveable but it is true – and the only way to prove it to go and observe the process and do the calculation – just looking at our conventional finanical reports will not give us the answer.  Once we do this simple experiment we will see the opportunity that Improvement Science offers – to reduce the cost of waste in a planned and predictable manner.

But if we are not prepared to challenge our assumptions by testing them against reality then we will deny ourselves that opportunity. The choice is ours.

One of the commonest assumptions we make is called the Flaw of Averages: the assumption that it is always valid to use averages when developing business cases. This assumption is incorrect.  But it is not immediately obvious why it is incorrect and the explanation sounds counter-intuitive. So, one way to illustrate is with a real example and here is one that has been created using a process simulation tool – virtual reality:

Posted on

When Is Seeing Believing?

One of the problems with our caveman brains is that they are a bit slow. It may not feel that way but they are – and if you don’t believe me try this experiment: Stand up, get a book, hold it in your left hand open it at any page, hold a coin in your right hand between finger and thumb so that it will land on the floor when you drop it. Then close your eyes and count to three. Open your eyes, drop the coin, and immediately start reading the book. How long is it before you are consciously aware of the meaning of the words. My guess is that the coin hits the floor about the same time that you start to making sense of what is on the page. That means it takes about half a second to start perceiving what you are seeing. That long delay is a problem because the world around us is often changing much faster than that and, to survive, we need to keep up. So what we do is fill in the gaps – what we perceive is a combination of what we actually see and what we expect to see – the process is seamless, automatic and unconscious. And that is OK so long as expectation and reality stay in tune – but what happens when they don’t? We experience the “Eh?” effect which signals that we are temporarily confused – an uncomfortable and scary feeling which resolves when we re-align our perception with reality. Over time we all learn to avoid that uncomfortable confusion feeling with a simple mind trick – we just filter out the things we see that do not fit our expectation. Psychologists call this “perceptual distortion” and the effect is even greater when we look with our minds-eye rather than our real eyes – then we only perceive  what we expect to see and we avoid the uncomfortable “Eh?” effect completely.  This unconscious behaviour we all demonstrate is called self-delusion and it is a powerful barrier to improvement – because to improve we have to first accept that what we have is not good enough and that reality does not match our expectation.

To become a master of improvement it is necessary to learn to be comfortable with the “eh?” feeling – to disconnect it from the negative emotion of fear that drives the denial reaction and self-justifying behaviour – and instead to reconnect it to the positive emotion of excitement that drives the curiosity action and exploratory behaviour.  One ewasy way to generate the “eh?” effect is to perform reality checks – to consciously compare what we actually see with what we expect to see.  That is not easy because our perception is very slippery – we are all very,very good at perceptual distortion. A way around this is to present ourselves with a picture of realilty over time, using the past as a baseline, and our understanding of the system, we can predict what we believe will happen in the near future. We then compare what actually happens with our expectation.  Any significant deviations are “eh?” effects that we can use to focus our curiosity – for there hide the nuggets of new knowledge.  But how do we know what is a “signifcant” deviation? To answer that we must avoid using our slippery self-delusional perception system – we need a tool that is designed to do this interpretation safely, easily, and quickly.  Click here for an example of such a tool.

Posted on

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

Posted on

Are there Three Languages?

When we are in “heated agreement” with each other it feels like we are talking different languages and this is a sign that we need to explore further and deeper. With patience and persistence we realise they are just dialects of the same language. Our challenge now is to learn to speak clearly in one language at a time and in the same language as the person(s) we are communicating with. Improvement Science has three primary languages – the language of quality (100% qualitative) , the language of money (100% quantitative) and the language of time (100% qualitative or quantitative depending on our perspective).  Learning to speak all three languages fluently – dreams are painted in the language of quality, processes are described in the language of time, and survival is a story told in the language of money which is the universal currency that we exchange for our physical needs (water, food, warmth, shelter, security, etc).

The engagement is emotional – through the subjective language of quality – and once engaged we have to master the flow of time in order to influence the flow of money. Our higher purpose is necessary but it is not sufficient – it is our actions that converts our passion into reality – and uncoordinated or badly designed action just dissipates passion and leads to exhaustion, disappointment and cynicism.

Posted on

Reactive or Proactive?

Improvement Science is about solving problems – so looking at how we solve problems is a useful exercise – and there is a continuous spectrum from 100% reactive to 100% proactive.

The reactive paradigm implies waiting until the problem is real and urgent and then acting quickly and decisively – hence the picture of the fire-fighter.  Observe the equipment that the fire-fighter needs:  a hat and suit to keep him safe and a big axe! It is basically a destructive and unsafe job based on the “our purpose is to stop the problem getting worse”.

The proactive paradigm implies looking for the earliest signs of the problem and planning the minimum action required to prevent the problem – hence the picture of the clinician. Observe the equipment that the clinician needs: a clean white coat to keep her patients safe and a stethoscope – a tool designed to increase her sensitivity so that subtle diagnostic sounds can be detected.

If we never do the proactive we will only ever do the reactive – and that is destructive and unsafe. If we never do the reactive we run the risk of losing everything – and that is destructive and unsafe too.

To practice safe and effective Improvement Science we must be able to do both in any combination and know which and when: we need to be impatient, decisive and reactive when a system is unstable, and we need to be patient, reflective and proactive when the system is stable.  To choose our paradigm we must listen to the voice of the process. It will speak to us if we are prepared to listen and if we are prepared to learn it’s language.

Posted on

What do We Mean by Capacity?

I often hear the statement “Our problem is caused by lack of capacity?” and this is usually followed by a heated debate (i.e. an arugment) about how to get more resources to solve the “capacity problem”: The protagonists are usually Governance who start the debate by raising a safety or quality problem; Operations who are tasked to resolve the problem and Finance who are expected to pay.

But what are they talking about? What exactly is “Capacity”? The reason I ask is because the word is ambiguous – it has several meanings – and unless the precise meaning is made explicit then individuals may unconsciously assume different interpretations and crossed-wires, confusion and conflict will ensue.

From the perspective of a process there are at least two distinct meanings that must not be confused: one is flow capacity and the other is inventory capacity.  To give an example of the distinction consider your household plumbing system: the hot water tank has a capacity that is measured in the volume of the tank – e.g. in litres; the pipe that leads from the tank to your tap has a capacity that is measured by the flow through the pipe – e.g. in litres per minute.  These are clearly NOT the same; they are related by time: A 50 litre capacity tank connected to a 5 litre per minute capacity pipe will empty in 10 minutes. So when you are talking about “capacity” be sure to be explicit about which form you mean … volume or flow; static or dynamic; inventory or activity.  It will avoid a LOT of confusion!!

Posted on

Can Chance make Us a Killer?

Imagine you are a hospital doctor. Some patients die. But how many is too many before you or your hospital are labelled killers? If you check out the BBC page

Posted on

Is this just a Clash of Personality?

Have you ever have the experience of trying to work on a common challenge with a team member and it just feels like you are on different planets?  You are using the same language yet are not communicating – they go off at apparently random tangents while you are trying to get a decision; they deluge you with detail when you ask about the big picture; you get upset when their cold logic threatens to damage team unity. The list is endless.  If you experience this sort of confusion and frustration then you may be experiencing a personality clash – or to be more accurate a pyschological type mismatch.

Carl Jung described a theory of psychological types that was later developed into the Myers-Briggs Type Indictator (MBTI).  This extensively validated method classifies people into sixteen broad groups based on four dimensions that are indicated by a letter code. It is important to appreciate that there are no good/bad types or right/wrong types – each describes a mode of thinking: a model of how we gather information, make decisions and act on those decisions.  Everyone uses all the modes of thinking to some degree – we just prefer some more than others and so we get more practice with them.  The purpose of MBTI is not to “correct” someone elses psychologcial type – it is to gain a conscious and shared awareness of the effect of psychological types on interpersonal and team dynamics. For example, some tasks and challenges suit some psychological types better than others – they resonate – and when this happens these tasks are achieved more easily and with greater satisfaction.  “One’s meat is another’s poison” sums the idea up.  Just having insight into this dynamic is helpful because it offers new options to avoid frustrating, futile and wasteful conflict.  So if you are curious find out your MBTI – you can do it on line in a few minutes (for example http://www.personalitytest.net/types/index.htm) and with that knowledge you can learn what your psychological type implies.  Mine is INFJ …

Posted on

Are we Stuck in a Toxic Emotional Waste Swamp?

Have you ever had the uncomfortable experience of joining a new group of people and discovering that your usual modus operandi does not seem to fit?  Have you ever experienced the pain of a behavioural expectation mismatch – a clash of culture? What do we do when that happens? Do we keep quiet, listen and try to work out the expected behaviours by observing others and then mimic their behaviour to fit in? Do we hold our ground, stay true to our norms and habits and challenge the group? Do we just shrug, leave and not return?

The other side of this common experience is the effect on the group of a person who does not match the behavioural norms of the group.  Are they regarded as a threat or an opportunity? Usually a threat. But a threat to whom? It depends. And it primarily depends on the emotional state of the chief, chair or boss of the group – the person who holds the social power. We are social animals and we have evolved over millions of years to be hard-wired to tune in to the emotional state of the pack leader – because it is a proven survival strategy!

If the chief is in a negative emotional state then the group will be too and a newcomer expressing a positive emotional outlook will create an emotional tension. People prefer leaders who broadcast a positive emotional state because it makes them feel happier; and leaders are attracted by power – so in this situation the chief will perceive a challenge to the balance of power and will react by putting the happy newcomer firmly in their place in the pecking order. The group observe the mauling and learn that a positive emotional attitude is an unsuccessful strategy to gain favour with the chief – and so the status quo is maintained. The toxic emotional waste swamp gets a bit deeper, the sides get a bit more slippery, and the emotional crocodiles who lurk in the murk get a tasty snack. Yum yum – that’ll teach you to be happy around here!

If the chief has a uniformly positive emotional approach then the group will echo that and a newcomer expressing a negative emotional state creates a different tension. The whole group makes it clear that this negative behaviour is unwelcome – they don’t want someone spoiling their cosy emotional oasis! And the status quo is maintained again. Unfortunately, the only difference between this and the previous example is that this only-happy-people-allowed-here group is drowning in emotional treacle rather than emotional turds. It is still an emotional swamp and the outcome is the same – you get stuck in it.

This either-or model is not a successful long-term strategy because it does not foster learning – it maintains the status quo – tough-minded or touch-feely – pessimistic or optimistic – but not realistic.

Effective learning only happens when the status quo is challenged in a way that respects both the power and authority of the chief and of the group – and the safest way to do that is to turn to reality for feedback and to provide the challenge to the group.  To do this in practice requires a combination of confidence and humility by both the chief and the group: the confidence to reject complacency and to face up to reality and the humility to employ what is discovered to keep moving on, to keep learning, to keep improving.

Reality will provide both positive and negative feedback (“Nuggets” and “Niggles”) and the future will hold both positive and negative challenges (“Nice-Ifs” and “Noo-Noos”).  Effective leaders know this and are able to maintain the creative tension. For those of us who are learning to be more effective leaders perhaps the routes out of our Toxic Emotional Waste Swamps are drawn on our 4N charts?

Posted on

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?

Posted on

But Why?

Just two, innocent-looking, three-letter words.

So what is the big deal? If you’ve been a parent of young children you’ll recognise the feeling of desperation that happens when your pre-schooler keeps asking the “But why?” question. You start off patiently attempting to explain in language that you hope they will understand, and the better you do that the more likely you are to get the next “But why?” response. Eventually you reach the point where you’re down to two options: “I don’t know!” or “Just because!”.  How are you feeling now about yourself and your young interrogator?

The troublemaker word is “but”. A common use of the word “but” in normal conversation is “Yes … but …” such as in “I hear what you are saying but …”.

What happens inside your head when you hear that?  Does it niggle? Does the red mist start to rise?

Used in this way the word “but” reveals a mental process called discounting – and the message that you registered unconsciously is closer to “I don’t care about you and your opinion, I only care about me and my opinion and here it comes so listen up!”.  This is a form of disrespectful behaviour that often stimulates a defensive response – even an argument – which only serves to further polarise the separate opinions, to deepen the mutual disrespect, and to erode trust.

It is a self-reinforcing negative-outcome counter-productive behaviour.

The trickster word is “why?”  When someone asks you this open-ended question they are often just using it as a shortcut for a longer series of closed, factual questions such as “how, what, where, when, who …”.  We are tricked because we often unconsciously translate “why?” into “what are your motives for …” which is an emotive question and can unconsciously trigger a negative emotional response. We then associate the negative feeling with the person and that hardens prejudices, erodes trust, reinforces resistance and fuels conflict.

My intention in this post is only to raise conscious awareness of this niggle.

If you are curious to test this youself – try consciously tuning in to the “but” and “why” words in conversation and in emails.  See if you can consciously register your initial emotional response – the one that happens in the split second before your conscious thoughts catch up. Then ask youself the question “Did I just have a positive or a negative feeling?

Posted on

How might some people be offended by performance charting?

Some fabulous new SPC software, called BaseLine© is now available – it’s designed for organizations and individuals who see the advantages in having people use a standard performance charting tool that’s statistically robust yet straight forward to use even for the uninitiated. As well as being highly accessible, at under £50 it is easily the most inexpensive option now available.

There is even a time-unlimited FREE version.

BaseLine© is obtainable via http://www.valuesystemdesign.com

How might some people be offended by performance charting?

The idea behind BaseLine© is that most every organisation is these days awash with time-series data, usually held in spreadsheet form, yet very little of it is used to diagnose systemic change. Even people who are held accountable for performance are often unaware of the gold that lies beneath their feet – or if they are aware, are for some reason reluctant to make use of it. Because BaseLine© is so accessible – there really is no longer any reason to avoid using SPC, but wait ..

.. observing those who are taking the plunge it’s becoming clearer to me where this reluctance might be coming from. Whilst some of it is due undoubtedly to low organisational expectation, I’m detecting that some of it is also due to low self-perception of capability, and some might even be because BaseLine© somehow confronts the personal value-set of particular managers. Let me refer to these value sets and capabilities as “memes”(1) and allow myself the luxury of speculatively labelling each one – so that I can treat each as a hypothesis that might later be tested – to see if the accumulating evidence either supports or refutes it. So here goes ..

1. The “Accountability-avoidance” meme – Those comfortable and skilled enough to hold a senior position may still however be inhabited by this meme, which can actually apply at any level in an organisational hierarchy. To most people it is an essential underpinning of their self-esteem to be able to feel that they’ve personally made a contribution whilst at work. It’s safer therefore (at least unconsciously) to be able to avoid roles for which any direct or personal performance measurement is attached – and there are plenty of such roles.
2. The “anti-Management” meme – According to this meme there’s something dehumanising about asking anyone to manage a process that delivers an outcome to someone who might appreciate it. Those who embody this value-set may also think that Management sounds altogether too boring when compared to Leadership since not much good happens unless people can feel good about it, and people have to be led to achieve anything meaningful and lasting. If there’s any management to be done it should be done by the followers.
3. The “anti-Control freak” meme – People holding this meme tend to dislike the whole idea of control, unless it’s the empowering of others to be in control – and even this may be considered too dangerous since the power to control anything can so easily be abused.
4. The “anti-Determinism” meme – Inside this meme Albert Einstein is considered as having completely supplanted the Newtonian “predict and control paradigm” as opposed to having merely built upon it. Life is viewed as inherently uncertain, and there’s a preference for believing that little can be reliably predicted, so it’s best to adopt an “act first/ ask questions later” approach. Deepak Chopra fans for example will know that “the past is history, and the future a mystery” and that therefore almost any form of planning is repellent – instead, emergence is the thing most highly valued.
5. The “Numerophobia” meme – so widespread is the tendency to avoid numbers, it may be easier to think of this as a syndrome rather than a meme – indeed, in the extreme it is a medical condition called “dyscalculia.” Whilst few people readily admit to being illiterate, there are many who are relatively happy to announce that they “don’t do numbers” – and some have even learned that it pays to be proud of it. In one recent UK study 11% were designated illiterate, but 40% innumerate.
6. The “iNtuitives rule” meme – People who are inhabited by this meme are those who may well feel comfortable weaving (even spinning) their story without the benefit of data that’s been fully “sensed”. The Myers Briggs Type Indicator – scores around 25% of people as N (iNtuitive), the remaining 75% being Sensors – who prefer to look for and absorb data via their 5 senses, data that to them feels tangibly “real.” On average around 12% people score as having N/T (intuitive thinking) preferences – yet exec teams & boards often score at more than 50%. Is this because they have had to become comfortable feeling disconnected from the customer interface, or because they were always that way inclined and therefore gravitated towards the apex of the hierarchy?
7. The “anti-Science” meme – According to this meme even the fact that I’m labelling these value-sets/ memes at all, will be seen as being antithetical – regardless of whether it might in some way prove to be a useful scientific device for advancing knowledge. People in organisations may behave in a way that’s anti-science in that tasks and projects are typically carried out in a Plan-Do-Review sequence – unaware that Plan-Do-Study-Act represents the scientific method in action, and is an entirely different paradigm.
8. the “protect my group or profession” meme – According to this meme, people are confident that they know what they know – and have spent several years of their life being trained to acquire that knowledge. They less aware of the extent to which this has formed their mental maps and how these in turn direct their opinions. When in doubt, reference is made to the writings and utterances of their personal or professional gurus – and quoted verbatim, frequently out of context. When a new tool arrives, the default position is: if I don’t recognise it, it should be rejected – until one of the gurus authenticates it.

Wow, when I started the list I didn’t think there would be as many as eight.

Individuals and organizations that are already, or can become, comfortable with applying the scientific method in their organisations – and personally – as a system, will see the profundity in a tool like BaseLine©. Others will miss it altogether, and one or more of the memes listed above could be preventing them seeing it. I’ll continue to collect more data, both sensed and intuited, and report on my findings in a future blog.

One source of test data will of course be the comments I solicit from readers of this blog, so having read these labels and descriptions, do you notice any reactive feelings? If so, can you accurately describe what you feel most confronted by? I’d be delighted to hear from you.

(1) Richard Dawkins coined (or adapted) the word “meme” in The Selfish Gene (1976) as a value set, or a postulated unit of cultural ideas, symbols or practices – which can be transmitted from one mind to another through writing, speech, gestures, rituals or other imitable phenomena. It’s sometimes used synonymously with the phrase “world view.” Clare Graves then made the Value meme (vMeme) a core concept in his Spiral Dynamics model – see Beck D.E & Cowan C.C. : “Spiral Dynamics – Mastering Values, Leadership, and Change” – 1996

Posted on

To Push or Not to Push? Is that the Question?

Improvement implies change;

… change implies learning;

… learning implies asking questions;

… and asking questions implies listening with both humility and confidence.

The humility of knowing that their are many things we do not yet understand; and the confidence of knowing that there are many ways we can grow our understanding.

Change is a force – and when we apply a force to a system we meet resistance.

The natural response to feeling resistance is to push harder; and when we do that the force of resistance increases. With each escalation the amount of effort required for both sides to maintain the stalemate increases and the outcome of the trial is decided by the strength and stamina of the protagonists.

One may break, tire or give up …. eventually.

The counter-intuitive reaction to meeting resistance is to push less and to learn more; and it is more effective strategy.

We can observe this principle in the behaviour of a system that is required to deliver a specific performance – such as a delivery time.  The required performance is often labelled a “target” and is usually enforced with a carrot-flavoured-stick wrapped in a legal contract.

The characteristic sign on the performance chart of pushing against an immovable target is the Horned Gaussian – the natural behaviour of the system painfully distorted by the target.

Our natural reaction is to push harder; and initially we may be rewarded with some progress.  And with a Herculean effort we may actually achieve the target – though at what cost?

Our front-line fighters are engaged in a never-ending trial of strength, holding back the Horn that towers over them and that threatens to tip over the target at any moment.

The effort, time, and money expended is out of all proportion to the improvement gained and just maintaining the status quo is exhausting.

Our unconscious belief is that if we weather the storm and push hard enough we will “break” the resistance, and after that it will be plain sailing. This strategy might work in the affairs of Man – it doesn’t work with Nature.

We won’t break the Laws of Nature by pushing harder. They will break us.

So, consider what might happen if we did the opposite?

When we feel resistance we pull back a bit; we ask questions; we seek to see from the opposite perspective and to broaden our own perspective; we seek to expand our knowledge and to deepen our understanding.

When we redirect our effort, time and money into understanding the source of the resistance we uncover novel options; we get those golden “eureka!” moments that lead to synergism rather than to antagonism; to win-win rather than lose-lose outcomes.

Those options were there all along – they were just not visible with our push mindset.

Change is a force – so “May the 4th be with you“.

Posted on

Are your Targets a Pain in the #*&!?

If your delivery time targets are giving you a pain in the #*&! then you may be sitting on a Horned Gaussian and do not realise it. What is a Horned Gaussian? How do you detect one? And what causes it?  To establish the diagnosis you need to gather the data from the most recent couple of hundred jobs and from it calculate the interval from receipt to delivery. Next create a tally chart with Delivery Time on the vertical axis and Counts on the horizontal axis; mark your Delivery Time Target as a horizontal line about two thirds of the way up the vertical axis; draw ten equally spaced lines between it and the X axis and five more above the Target. Finally, sort your delivery times into these “bins” and look at the profile of the histogram that results. If there is a clearly separate “hump” and “horn” and the horn is just under the target then you have confirmed the diagnosis of a Horned Gaussian. The cause is the Delivery Time Target, or more specifically its effect on your behaviour.  If the Target is externally imposed  and enforced using either a reward or a punishment then when the delivery time for a request approaches the Target, you will increase the priority of the request and the job leapfrogs to the front of the queue, pushing all the other jobs back. The order of the jobs is changing and in a severe case the large number of changing priorities generates a lot of extra work to check and reschedule the jobs.  This extra work exacerbates the delays and makes the problem worse, the horn gets taller and sharper, and the pain gets worse. Does that sound a familiar story? So what is the treatment? Well, to decide that you need to create a graph of delivery times in time order and look at the pattern (using charting tool such as BaseLine© www.valuesystemdesign.com makes this easier and quicker). What you do depends on what the chart says to you … it is the Voice of the Process.  Improvement Science is learning to understand the voice of the process.

Posted on

Are We in Heated Agreement?

Do you ever feel that during a heated debate you are actually arguing the same point? You are in agreement, or rather “heated agreement”. Why does that happen and how can you distinguish this from an real disagreement? Some years ago I came across the concept of “worldviews” while looking for guidance on managing conflict. The idea is that two different people can look at the same thing and see something different; or rather perceive something different. The apparent difference leads to the debate or argument, which if carried to its conclusion demonstrates the zones of both agreement and difference.  When this is done both protagonists can learn from each other and expand their worldviews and their common ground.  If the debate never takes place then their views remain polarised, no exchange happens, no learning takes place and the common ground does not grow. So is heated debate a good thing? Well it depends on the outcome you want.  If you want to improve, learn, change and expand your perspective then “yes”; if you want to change someone else’s opinion to match yours then “no”.  Improvement implies change; change imples learning; and learning implies an altered perspective.  So engaging in heated debate and achieving heated agreement is a sensible improvement strategy!

Posted on

Anyone Heard of Henry Gantt?

Most managers have heard of Gantt charts and associate them with project management where they are widely used to help coordinate the separate threads of work so that the project finishes on time.

How many know about the man who invented them and why?

Henry Laurence Gantt (1861-1919) was an engineer and he invented the chart for a very different purpose – so that the workers and the managers could see at a glance the progress of the work and to see what was impairing the flow.  Decades before the invention of the computer, Henry Gantt created a simple and incredibly powerful visual tool for enabling workers and managers to improve processes together.

I know how simple and powerful the original Gantt chart is because I use it all the time for capturing the behaviour of a process in a visual form that stimulates constructive conversations which result in win-win-win improvements.  All you need is some squared paper, a pencil, a clock, a Mark I Eyeball or two, and a bit of practice.

Posted on

Can the Finance tail wag the Quality dog?

Money is the “fuel” that all organisations need to survive because all endeavours incur costs. It is the flow of money that is important – static money is just a number.  Money is used to buy time – more specifically LIFE-time.  We trade our life-time for money which we then use to buy the goods and services that we need to survive in the modern world.  These goods and services are delivered by processes that require people’s time to design, implement, operate and improve.  So we all want the best value-for-money that we can get; the best value-for-lifetime. So what happens when the flow of money is constrained? Value, Lifetime and Money are interdependent – restrict the flow of any of the three and all three slow down. It is inevitable. With this perspective it does appear that the finance tail can wag the quality dog; and the lifetime tail can wag the quality dog too. So when you experience low quality goods or services try asking this question: “Is it the flow of money, motivation or both that is the root cause?” Stories please ….

Posted on

What Blocks Improvement?

Learning LoopsMy focus this week has been to ask the question “What blocks improvement?”. The answers that I found most interesting were “I didn’t realise there was a problem.” and “I feel there is a problem but I don’t know where to focus my attention.” This set me pondering and eventually I had a bit of an “eureka” moment.  It isn’t something that is present that creates this blindness – it is something that is missing. And the only way you can see what isn’t there is by comparison with when it is there – just like the game of “Spot the Difference”. When I compared what I saw with what I know is possible the thing I didn’t see was a fast-feedback loop. Hence the doodle.  It appears that there are at least four dimensions to feedback – sign, magnitude, accuracy and timing.  The speed of the feedback needs to be appropriate to the speed of the improvement; so if we want rapid improvement we need a fast-and-accurate feedback loop – a learning loop.  A slow or inaccurate learning loop not only doesn’t work – it can actually make the problem worse.  So, my take-home this week is to actively search for the learning loops and if I don’t see one then I have something to focus on improving.

Posted on

What do you do when you don’t know what to do?

One of the scariest feelings I experience is when I am asked “What should we do?” or “What would you do?” and there is an expectation that I should know what to do … and I don’t.

Do I say “I don’t know” or do I play for time and spout some b*****t and hope my lack of knowledge is not exposed?

Reflecting on this uncomfortable, and oft repeated, experience I am led to some questions:

1. Where does the expectation come from? The person asking, myself or both?

2. Where does the feeling of fear come from? What am I scared of? Who am I scared of?

Pondering these questions I have the fleeting impression that my fear comes from me.  I am afraid of disappointing myself.  It is me that I am scared of.

Then the impression is replaced by a conscious process of looking for evidence that proves that it can’t be me – it must be someone else making me feel scared – and to feel better I have to shift the blame from myself.

Oooooo … that’s a bit of an “Eureka” moment!

And now I have a new option. Choose to behave like of a victim of myself and shift the blame; or choose to address the problem – my deep fear of part of myself.

Phew!  I feel better already – I have a new opportunity to explore …

Posted on

The Effect of Feedback?

Feedback?I find that I have to draw pictures when I am thinking – it seems to help.

One thing I have been thinking about this week is how to predict the outcome of an action; because I don’t want to do something that has a negative outcome that I did not anticipate.

I know that whatever I do will change the “system” and may have an ongoing effect that may be positive and negative; and once I have set the ball rolling even reversing my action may not change the course.

So the problem I have is this: although I can work out what I feel is the best thing to do now, I do not seem to be able to predict the knock-on effects of my actions.  I know from experience that I may be the recipient of the future effect of my actions today. I will get feedback one way or the other.

So how do we work out what is the best thing to do now? How do we get good feedback?

Posted on

Improvement costs more doesn’t it?

We all know the phrase “you get what you pay for” and we all know from experience that higher quality goods and services cost more. So, it follows that if we improve the quality of our product or service then we are always going to have to charge our customers more for it. But is that always the case?

If we add extra value to the product then it is likely that it will cost us more to do that and we may have to pass that cost on; but improvement often comes from removing something that was preventing a higher quality output.

When we remove something our costs are likely to go down and this reduction in cost can be passed on to the customer. Unfortunately the idea that lower costs mean lower quality is also deeply engrained into our thinking – so if a supplier offers what appears to be higher quality at a lower price we get suspicious. There must be a catch or a trick.

So, to avoid disappointing your customers when you make an improvement by removing an impediment to quality – just increase the price a bit.  That way your costs go down, the price goes up, the customers expectation is met and everyone is happy; your customers and especially your accountant! It can’t be that easy surely. There must be catch?

Posted on

Errors of Omission and Commission

I like doodling on Post-It® Notes and playing with two-by-two tables and recently I came across one that triggered a bit of an “Eureka” moment.

The two dimensions were Action (Nothing-to-Something) and Outcome (Worse-to-Better).  We are all familiar with the good feeling that comes from doing something and seeing things get better; and the not-so-good feeling of doing something and seeing things get worse!  I discovered that this latter option is called the “Error of Commission” and is the one we fear most because we leave an audit trail of evidence that can be traced back to our action. It does not seem to matter that we did not intend the outcome to be worse.

However, the 2 x 2 table also suggests that there are two other combinations. How do we feel when we do nothing and things get better? What do we learn from that experience? And how do we feel when we do nothing and things get worse? This, I discovered, is called the “Error of Omission” and is an error that is more difficult to learn from because there is no audit trail of cause-and-effect evidence. It is also the error that generates the greatest sadness – a feeling of loss of what might have been.

Both the Error of Commission and the Error of Omission can lead to unintended negative consequences.  It appears that our systems are better designed to manage the Errors of Commission. I wonder if we could learn to better protect ourselves from the Errors of Omission?