Pride and Joy

stick_figure_superhero_anim_150_wht_1857Have you heard the phrase “Pride comes before a fall“?

What does this mean? That the feeling of pride is the reason for the subsequent fall?

So by following that causal logic, if we do not allow ourselves to feel proud then we can avoid the fall?

And none of us like the feeling of falling and failing. We are fearful of that negative feeling, so with this simple trick we can avoid feeling bad. Yes?

But we all know the positive feeling of achievement – we feel pride when we have done good work, when our impact matches our intent.  Pride in our work.

Is that bad too?

Should we accept under-achievement and unexceptional mediocrity as the inevitable cost of avoiding the pain of possible failure?  Is that what we are being told to do here?

The phrase comes from the Bible, from the Book of Proverbs 16:18 to be precise.


And the problem here is that the phrase “pride comes before a fall” is not the whole proverb.

It has been simplified. Some bits have been omitted. And those omissions lead to ambiguity and the opportunity for obfuscation and re-interpretation.

In the fuller New International Version we see a missing bit … the “haughty spirit” bit.  That is another way of saying “over-confident” or “arrogant”.

But even this “authorised” version is still ambiguous and more questions spring to mind:

Q1. What sort of pride are we referring to? Just the confidence version? What about the pride that follows achievement?

Q2. How would we know if our feeling of confidence is actually justified?

Q3. Does a feeling of confidence always precede a fall? Is that how we diagnose over-confidence? Retrospectively? Are there instances when we feel confident but we do not fail? Are there instances when we do not feel confident and then fail?

Q4. Does confidence cause the fall or it is just a temporal association? Is there something more fundamental that causes both high-confidence and low-competence?

There is a well known model called the Conscious-Competence model of learning which generates a sequence of four stages to achieving a new skill. Such as one we need to achieve our intended outcomes.

We all start in the “blissful ignorance” zone of unconscious incompetence.  Our unknowns are unknown to us.  They are blind spots.  So we feel unjustifiably confident.


In this model the first barrier to progress is “wrong intuition” which means that we actually have unconscious assumptions that are distorting our perception of reality.

What we perceive makes sense to us. It is clear and obvious. We feel confident. We believe our own rhetoric.

But our unconscious assumptions can trick us into interpreting information incorrectly.  And if we derive decisions from unverified assumptions and invalid analysis then we may do the wrong thing and not achieve our intended outcome.  We may unintentionally cause ourselves to fail and not be aware of it.  But we are proud and confident.

Then the gap between our intent and our impact becomes visible to all and painful to us. So we are tempted to avoid the social pain of public failure by retreating behind the “Yes, But” smokescreen of defensive reasoning. The “doom loop” as it is sometimes called. The Victim Vortex. “Don’t name, shame and blame me, I was doing my best. I did not intent that to happen. To err is human”.

The good news is that this learning model also signposts a possible way out; a door in the black curtain of ignorance.  It suggests that we can learn how to correct our analysis by using feedback from reality to verify our rhetorical assumptions.  Those assumptions which pass the “reality check” we keep, those which fail the “reality check” we redesign and retest until they pass.  Bit by bit our inner rhetoric comes to more closely match reality and the wisdom of our decisions will improve.

And what we then see is improvement.  Our impact moves closer towards our intent. And we can justifiably feel proud of that achievement. We do not need to be best-compared-with-the-rest; just being better-than-we-were-before is OK. That is learning.


And this is how it feels … this is the Learning Curve … or the Nerve Curve as we call it.

What it says is that to be able to assess confidence we must also measure competence. Outcomes. Impact.

And to achieve excellence we have to be prepared to actively look for any gap between intent and impact.  And we have to be prepared to see it as an opportunity rather than as a threat. And we will need to be able to seek feedback and other people’s perspectives. And we need to be to open to asking for examples and explanations from those who have demonstrated competence.

It says that confidence is not a trustworthy surrogate for competence.

It says that we want the confidence that flows from competence because that is the foundation of trust.

Improvement flows at the speed of trust and seeing competence, confidence and trust growing is a joyous thing.

Pride and Joy are OK.

Arrogance and incompetence comes before a fall would be a better proverb.

A Recipe for Chaos

growing_workload_anim_6858There is an easy and quick-to-cook recipe for chaos.

All we have to do is to ensure that the maximum number of jobs that we can do in a given time is set equal to the average number of jobs that we are required to do in the same period of time.


That does not make sense.  Our intuition says that looks like the perfect recipe for a hyper-efficient, zero-waste, zero idle-time design which is what we want.

I know it does, but it isn’t.  Our intuition is tricking us.

It is the recipe for chaos – and to prove it all we will have to do a real world experiment – because to prove it using maths is really difficult. So difficult in fact that the formula was not revealed until 1962 – by a mathematician called John Kingman while a postgraduate student at Pembroke College, Cambridge.

The empirical experiment is very easy to do – all we need is a single step process – and a stream of jobs to do.

And we could do it for real, or we can simulate it using an Excel spreadsheet – which is much quicker.

So we set up our spreadsheet to simulate a new job arriving every X minutes and each job taking X minutes to complete.

Our operator can only do one job at a time so if a job arrives and the operator is busy the job joins the back of a queue of jobs and waits.

When the operator finishes a job it takes the next one from the front of the queue, the one that has been waiting longest.

And if there is no queue the operator will wait until the next job arrives.


And when we run simulation the we see that there is indeed no queue, no jobs waiting and the operator is always busy (i.e. 100% utilised). Perfection!

BUT ….

This is not a realistic scenario.  In reality there is always some random variation.  Not all jobs require the same length of time, and jobs do not arrive at precisely the right intervals.

No matter, our confident intuition tells us. It will average out.  Swings-and-roundabouts. Give-and-take.

It doesn’t.

And if you do not believe me just build the simple Excel model outlined above, verify that it works, then add some random variation to the time it takes to do each job … and observe what happens to the average waiting time.

What you will discover is that as soon as we add even a small amount of random variation we get a queue, and waiting and idle resources as well!

But not a steady, stable, predictable queue … Oh No! … We get an unsteady, unstable and unpredictable queue … we get chaos.

Try it.

So what? How does this abstract ‘queue theory’ apply to the real world?

Well, suppose we have a single black box system called ‘a hospital’ – patients arrive and we work hard to diagnose and treat them.  And so long as we have enough resource-time to do all the jobs we are OK. No unstable queues. No unpredictable waiting.

But time-costs-money and we have an annual cost improvement target (CIP) that we are required to meet so we need to ‘trim’ resource-time capacity to push up resource utilisation.  And we will call that an ‘efficiency improvement’ which is good … yes?

It isn’t actually.  I can just as easily push up my ‘utilisation’ by working slower, or doing stuff I do not need to, or by making mistakes that I have to check for and then correct.  I can easily make myself busier and delude myself I am working harder.

And we are also a victim of our own success … the better we do our job … the longer people live and the more workload they put on the health and social care system.

So we have the perfect storm … the perfect recipe for chaos … slowly rising demand … slowly shrinking budgets … and an inefficient ‘business’ design.

And that in a nutshell is the reason the NHS is descending into chaos.

So what is the solution?

Reduce demand? Stop people getting sick? Or make them sicker so they die quicker?

Increase budgets? Where will the money come from? Beg? Borrow? Steal? Economic growth?

Improve the design?  Now there’s a thought. But how? By using the same beliefs and behaviours that have created the current chaos?

Maybe we need to challenge some invalid beliefs and behaviours … and replace those that fail the Reality Test with some more effective ones.

What is Transformation?


It has been another interesting week.  A bitter-sweet mixture of disappointment and delight. And the central theme has been ‘transformation’.

The source of disappointment was the newsreel images of picket lines of banner-waving junior doctors standing in the cold watching ambulances deliver emergencies to hospitals now run by consultants.

So what about the thousands of elective appointments and operations that were cancelled to release the consultants? If the NHS was failing elective delivery time targets before it is going to be failing them even more now. And who will pay for the “waiting list initiatives” needed to just catch up? Depressing to watch.

The mercurial Roy Lilley summed up the general mood very well in his newsletter on Thursday, the day after the strike.


What he is saying is we do not have a health care system, we have a sick care system.  Which is the term coined by the acclaimed systems thinker, the late Russell Ackoff (see the video about half way down).

We aspire to a transformation-to-better but we only appear to be able to achieve a transformation-to-worse. That is depressing.

My source of delight was sharing the stories of those who are stepping up and are transforming themselves and their bits of the world; and how they are doing that by helping each other to learn “how to do it” – a small bite at a time.

Here is one excellent example: a diagnostic study looking at the root cause of the waiting time for school-age pupils to receive a health-protecting immunisation.

So what sort of transformation does the NHS need?

A transformation in the way it delivers care by elimination of the fragmentation that is the primary cause of the distrust, queues, waits, frustration, chaos and ever-increasing costs?

A transformation from purposeless and reactive; to purposeful and proactive?

A transformation from the disappointment that flows from the mismatch between intent and impact; to the delight that flows from discovering that there is a way forward; that there is a well understood science that underpins it; and a growing body of evidence that proves its effectiveness.  The Science of Improvement.

In  a recent blog I shared the story of how it is possible to ‘melt queues‘ or more specifically how it is possible to teach anyone, who wants to learn, how to melt queues.

It is possible to do this for an outpatient clinic in one day.

So imagine what could happen if just 1% of consultants decided improve their outpatient clinics using this quick-and-easy-to-learn-and-apply method?  Those courageous and innovative consultants who are not prepared to drown in the  Victim Vortex of despair and cynicism.  And what could happen if they shared their improvement stories with their less optimistic colleagues?  And what could happen if a just a few of them followed the lead of the innovators?

Would that be a small transformation?  Or the start of a much bigger one? Or both?

The Improvement Gearbox

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

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

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

Organisations appear to behave in much the same way.

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

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

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

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

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

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

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

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

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

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

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

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

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

Job done?

Unfortunately not.

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

So what about those organisations stuck in third gear?

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

But expectation is changing.

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

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

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

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

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

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

Our Iceberg Is Melting

hold_your_ground_rope_300_wht_6223[Dring Dring] The telephone soundbite announced the start of the coaching session.

<Bob> Good morning Leslie. How are you today?

<Leslie> I have been better.

<Bob> You seem upset. Do you want to talk about it?

<Leslie> Yes, please. The trigger for my unhappiness is that last week I received an email demanding that I justify the time I spend doing improvement work and  a summons to a meeting to ‘discuss some issues that have been raised‘.

<Bob> OK. I take it that you do not know what or who has triggered this inquiry.

<Leslie> You are correct. My working hypothesis is that it is the end of the financial year and budget holders are looking for opportunities to do some pruning – to meet their cost improvement program targets!

<Bob> So what is the problem? You have shared the output of your work. You have demonstrated significant improvements in safety, flow, quality and productivity and you have described both them and the methodology clearly.

<Leslie> I know. That us why I was so upset to get this email. It is as if everything that we have achieved has been ignored. It is almost as if it is resented.

<Bob> Ah! You may well be correct.  This is the nature of paradigm shifts. Those who have the greatest vested interest in the current paradigm get spooked when they feel it start to wobble. Each time you share the outcome of your improvement work you create emotional shock-waves. The effects are cumulative and eventually there will be is a ‘crisis of confidence’ in those who feel most challenged by the changes that you are demonstrating are possible.  The whole process is well described in Thomas Kuhn’s The Structure of Scientific Revolutions. That is not a book for an impatient reader though – for those who prefer something lighter I recommend “Our Iceberg is Melting” by John Kotter.

<Leslie> Thanks Bob. I will get a copy of Kotter’s book – that sounds more my cup of tea. Will that tell me what to do?

<Bob> It is a parable – a fictional story of a colony of penguins who discover that their iceberg is melting and are suddenly faced with a new and urgent potential risk of not surviving the storms of the approaching winter. It is not a factual account of a real crisis or a step-by-step recipe book for solving all problems  – it describes some effective engagement strategies in general terms.

<Leslie> I will still read it. What I need is something more specific to my actual context.

<Bob> This is an improvement-by-design challenge. The only difference from the challenges you have done already is that this time the outcome you are looking for is a smooth transition from the ‘old’ paradigm to the ‘new’ one.  Kuhn showed that this transition will not start to happen until there is a new paradigm because individuals choose to take the step from the old to the new and they do not all do that at the same time.  Your work is demonstrating that there is a new paradigm. Some will love that message, some will hate it. Rather like Marmite.

<Leslie> Yes, that make sense.  But how do I deal with an unseen enemy who is stirring up trouble behind my back?

<Bob> Are you are referring to those who have ‘raised some issues‘?

<Leslie> Yes.

<Bob> They will be the ones who have most invested in the current status quo and they will not be in senior enough positions to challenge you directly so they are going around spooking the inner Chimps of those who can. This is expected behaviour when the relentlessly changing reality starts to wobble the concrete current paradigm.

<Leslie> Yes! That is  exactly how it feels.

<Bob> The danger lurking here is that your inner Chimp is getting spooked too and is conjuring up Gremlins and Goblins from the Computer! Left to itself your inner Chimp will steer you straight into the Victim Vortex.  So you need to take it for a long walk, let it scream and wave its hairy arms about, listen to it, and give it lots of bananas to calm it down. Then put your put your calmed-down Chimp into its cage and your ‘paradigm transition design’ into the Computer. Only then will you be ready for the ‘so-justify-yourself’ meeting.  At the meeting your Chimp will be out of its cage like a shot and interpreting everything as a threat. It will disable you and go straight to the Computer for what to do – and it will read your design and follow the ‘wise’ instructions that you have put in there.

<Leslie> Wow! I see how you are using the Chimp Paradox metaphor to describe an incredibly complex emotional process in really simple language. My inner Chimp is feeling happier already!

<Bob> And remember that you are in all in the same race. Your collective goal is to cross the finish line as quickly as possible with the least chaos, pain and cost.  You are not in a battle – that is lose-lose inner Chimp thinking.  The only message that your interrogators must get from you is ‘Win-win is possible and here is how we can do it‘. That will be the best way to soothe their inner Chimps – the ones who fear that you are going to sink their boat by rocking it.

<Leslie> That is really helpful. Thank you again Bob. My inner Chimp is now snoring gently in its cage and while it is asleep I have some Improvement-by-Design work to do and then some Computer programming.

The Shredder

figure_snowblowing_150_wht_13606It is the time of year when our minds turn to self-improvement.

New Year.

We re-affirm our Resolutions from last year and we vow to try harder this year. As we did last year. And the year before that. And we usually fail.

So why do we fail to keep our New Year Resolutions?

One reason is because we do not let go of the past. We get pulled back into old habits too easily. To get a new future we have to do some tidying up. We need to get The Shredder. We need to make the act of letting go irreversible.

Bzzzzzzz …. Aaaaah. That feels better.

Why does this work?

First, because it feels good to be taking definitive action.  We know that resolutions are just good intentions. It is not until we take action that change happens.  Many of us are weak on the Activist dimension. We talk a lot about what we should do but we do not walk as much as we could do.

Second, because  we can see the evidence of the improvement immediately. We get immediate, visual, positive feedback. That heap of old bills and emails and reports that we kept ‘just in case’ is no longer cluttering up our desks, our eyes, our minds and our lives.  And we have ‘recycled’ it which feels even better.

Third, because we have challenged our own Prevarication Policy. And if we can do that for ourselves we can, with some credibility, do the same for others. We feel more competent and more confident.

Fourth, because we have freed up valuable capacity to invest.  More space. More time (our prevarication before kept us busy but wasted our limited time). More motivation (trying to work around a pile of rubbish day-in and day-out is emotionally draining).

So all we need to do in the New Year is stay inside our circle of control and shred some years of accumulated rubbish.

figure_picking_up_trash_150_wht_11857And it is not just tangible rubbish we can dispose of.  We can shred some emotional garbage too. The list of “Yes … But” excuses that we cling on to.  The sack of guilt for past failures that weighs us down. The flag of fear that we wave when we surrender our independence and adopt the Victim role.  The righteous indignation that we use to hide our own self-betrayal.

And just by putting that lot through The Shredder we release the opportunity for improvement.

The rest just happens – as if by magic.

Three Essentials

There are three necessary parts before ANY improvement-by-design effort will gain traction. Omit any one of them and nothing happens.


1. A clear purpose and an outline strategic plan.

2. Tactical measurement of performance-over-time.

3. A generic Improvement-by-Design framework.

These are necessary minimum requirements to be able to safely delegate the day-to-day and week-to-week tactical stuff the delivers the “what is needed”.

These are necessary minimum requirements to build a self-regulating, self-sustaining, self-healing, self-learning win-win-win system.

And this is not a new idea.  It was described by Joseph Juran in the 1960’s and that description was based on 20 years of hands-on experience of actually doing it in a wide range of manufacturing and service organisations.

That is 20 years before  the terms “Lean” or “Six Sigma” or “Theory of Constraints” were coined.  And the roots of Juran’s journey were 20 years before that – when he started work at the famous Hawthorne Works in Chicago – home of the Hawthorne Effect – and where he learned of the pioneering work of  Walter Shewhart.

And the roots of Shewhart’s innovations were 20 years before that – in the first decade of the 20th Century when innovators like Henry Ford and Henry Gantt were developing the methods of how to design and build highly productive processes.

Ford gave us the one-piece-flow high-quality at low-cost production paradigm. Toyota learned it from Ford.  Gantt gave us simple yet powerful visual charts that give us an understanding-at-a-glance of the progress of the work.  And Shewhart gave us the deceptively simple time-series chart that signals when we need to take more notice.

These nuggets of pragmatic golden knowledge have been buried for decades under a deluge of academic mud.  It is nigh time to clear away the detritus and get back to the bedrock of pragmatism. The “how-to-do-it” of improvement. Just reading Juran’s 1964 “Managerial Breakthrough” illustrates just how much we now take for granted. And how ignorant we have allowed ourselves to become.

Acquired Arrogance is a creeping, silent disease – we slip from second nature to blissful ignorance without noticing when we divorce painful reality and settle down with our own comfortable collective rhetoric.

The wake-up call is all the more painful as a consequence: because it is all the more shocking for each one of us; and because it affects more of us.

The pain is temporary – so long as we treat the cause and not just the symptom.

The first step is to acknowledge the gap – and to start filling it in. It is not technically difficult, time-consuming or expensive.  Whatever our starting point we need to put in place the three foundation stones above:

1. Common purpose.
2. Measurement-over-time.
3. Method for Improvement.

Then the rubber meets the road (rather than the sky) and things start to improve – for real. Lots of little things in lots of places at the same time – facilitated by the Junior Managers. The cumulative effect is dramatic. Chaos is tamed; calm is restored; capability builds; and confidence builds. The cynics have to look elsewhere for their sport and the skeptics are able to remain healthy.

Then the Middle Managers feel the new firmness under their feet – where before there were shifting sands. They are able to exert their influence again – to where it makes a difference. They stop chasing Scotch Mist and start reporting real and tangible improvement – with hard evidence. And they rightly claim a slice of the credit.

And the upwelling of win-win-win feedback frees the Senior Managers from getting sucked into reactive fire-fighting and the Victim Vortex; and that releases the emotional and temporal space to start learning and applying System-level Design.  That is what is needed to deliver a significant and sustained improvement.

And that creates the stable platform for the Executive Team to do Strategy from. Which is their job.

It all starts with the Three Essentials:

1. A Clear and Common Constancy of Purpose.
2. Measurement-over-time of the Vital Metrics.
3. A Generic Method for Improvement-by-Design.

The Victim Vortex

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

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

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

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

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

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

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

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

<Lesley>The Victim Vortex?

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

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

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

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

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

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

<Bob>Frustrating for whom?

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

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

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

tornada_150_wht_10155<Bob>Yes. Visualize a cultural tornado.  The energy that drives it is the emotional  currency spent in playing the OK – Not OK Games.  It is a self-fueling system, a stable design, very destructive and very resistant to change.

<Lesley>That metaphor works really well for me!

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

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

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

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

<Bob>Yes.  It does not solve the problem either.  The Vortex is always hoovering up new Victims.  It is insatiable.

<Lesley> And another option would be to swim with the flow to avoid being “got” from behind.  That would be seem sensible and is possible; and at least I would feel better for doing something. I might even escape if I swim fast enough!

<Bob>That is indeed what some try.  The movers and shakers.  The pace setters.  The optimists.  The extrovert leaders.  The problem is that it makes the Vortex spin even faster.  It actually makes the Vortex bigger,  more chaotic and more dangerous than before.

<Lesley>Yes – I can see that.  So my other option is to swim against the flow in an attempt to slow the Vortex down.  Would that work?

<Bob>If everyone did that at the same time it might but that is unlikely to happen spontaneously.  If you could achieve that degree of action alignment you would not have a Victim Vortex in the first place.  Trying to do it alone is ineffective, you tire very quickly, the other Victims bash into you, you slow them down, and then you all get sucked down the Plughole of Despair.

<Lesley>And I suppose a small group of like-minded champions who try to swim-against the flow might last longer if they stick together but even then eventually they would get bashed up and broken up too.  I have seen that happen.  And that is probably where our team are heading at the moment.  I am out of options.  Is it impossible to escape the Victim Vortex?

<Bob>There is one more direction you can swim.

<Lesley>Um?  You mean across the flow heading directly away from the center?

<Bob>Exactly.  Consider that option.

<Lesley>Well, it would still be hard work and I would still be going around with the Vortex and I would still need to watch out for flotsam but every stroke I make would take me further from the center.  The chaos would get gradually less and eventually I would be in clear water and out of danger.  I could escape the Victim Vortex!

<Bob>Yes. And what would happen if others saw you do that and did the same?

<Lesley>The Victim Vortex would dissipate!

<Bob>Yes.  So that is your best strategy.  It is a win-win-win strategy too. You can lead others out of the Victim Vortex.

<Lesley>Wow!  That is so cool!  So how would I apply that metaphor to the Information System niggle?

<Bob>I will leave you to ponder on that.  Think about it as a design assignment.  The design of the system that generates IT solutions that are fit-for-purpose.

<Lesley> Somehow I knew you were going to say that!  I have my squared-paper and sharpened pencil at the ready.  Yes – an improvement-by-design assignment.  Thank you once again Bob.  This ISP course is the business!

Fear and Fuel

stick_figure_open_cupboard_150_wht_8038Improvement implies change.

Change requires motivation.

And there are two flavours of motivation juice – Fear and Fuel

Fear is the emotion that comes from anticipated loss in the future.  Loss means some form of damage. Physical, psychological or social harm.  We fear loss of peer-esteem and we fear loss of self-esteem … almost more than we fear physical harm.

Our fear of anticipated loss may be based on reality. Our experience of actual loss in the past.  We remember the emotional pain and we learn from past pain to fear future loss.

Our fear of anticipated loss may also be fueled by rhetoric.  The doom-mongering of the Shroud-Wavers, the Nay-Sayers, the Skeptics and the Cynics.

And there are examples where the rhetorical fear is deliberately generated to drive the fear-of-reality to “the solution” – which of course we have to pay dearly for. This is Machiavellian mass manipulation for commercial gain.

“Fear of germs, fear of fatness, fear of the invisible enemies outside and inside”.

Generating and ameliorating fear is big business. It is a Burn-and-Scrape design.

What we are seeing here is the Drama Triangle operating on a massive scale. The Persecutors create the fear, the Victims run away and the Persecutors then switch role to Rescuers and offer to sell the terrified-and-now-compliant Victims “the  solution” to their fear.  The Victims do not learn.  That is not the purpose – because that would end the Game and derail the Gravy Train.

So fear is not an effective way to motivate for sustained improvement,  and we have ample evidence to support that statement!  It might get us started, but it won’t keep us going.

The Burn-and-Scrape design that we see everywhere is a fear-driven-design.

Any improvements are transitory and usually only achieved at the emotional expense of a passionate idealist. When they get too tired to push any more the toast gets burnt again because the toaster is perfectly designed to burn toast.  Not intentionally designed to burn the toast but perfectly designed to nevertheless.

The use of Delusional Ratios and Arbitrary Targets (DRATs) is a fear-based-design-strategy. It ensures the Fear Game and Gravy Train continue.

And fear has a frightening cost. The cost of checking-and-correcting. The cost of the defensive-bureaucracy that may catch errors before too much local harm results but which itself creates unmeasurable global harm in a different way – by hoovering up the priceless human resource of life-time – like an emotional black hole.

The cost of errors. The cost of queues. The list of fear-based-design costs is long.

A fear-based-design for delivering improvement is a poor design.

So we need a better design.

And a better one is based on a positive-attractive-emotional force pulling us forwards into the future. The anticipation of gains for all. A win-win-win design.

Win-win-win design starts with the Common Purpose: the outcomes that everyone wants; and the outcomes that no-one wants.  We need both.  This balance creates alignment of effort on getting the NiceIfs (the wants) while avoiding the NoNos (the do not wants).

Then we ask the simple question: “What is preventing us having our win-win-win outcome now?

The blockers are the parts of our current design that we need to change: our errors of omission and our errors of commission.  Our gaps and our gaffes.

And to change them we need to be clear what they are; where they are and how they came to be there … and that requires a diagnostic skill that is one of our errors of omission. We have never learned how to diagnose our process design flaws.

Another common blocker is that we believe that a win-win-win outcome is impossible. This is a learned belief. And it is a self-fulfilling prophesy.

We may also believe that all swans are white because we have never seen a black swan – even though we know, in principle, that a black swan could be possible.

Rhetoric and Reality are not the same thing.  Feeling it could be possible and knowing that it actually is possible are different emotions. We need real evidence to challenge our life-limiting rhetoric.

Weary and wary skeptics crave real evidence not rhetorical exhortation.

So when that evidence is presented – and the Impossibility Hypothesis is disproved – then an emotional shock is inevitable.  We are now on the emotional roller-coaster called the Nerve Curve.  And the deeper our skepticism the bigger the shock.

After the shock we characteristically do one of three things:

1. We discount the evidence and go into denial.  We refuse to challenge our own rhetoric. Blissful ignorance is attractive.  The gap between intent and impact is scary.

2. We go quiet because we are now stuck in the the painful awareness of the transition zone between the past and the future. The feelings associated with the transition are anxiety and depression. We don’t want to go back and we don’t know how to go forwards.

3. We sit up, we take notice, we listen harder, we rub our chins, our minds race as we become more and more excited. The feelings associated with the stage of resolution are curiosity, excitement and hope.

It is actually a sequence and it is completely normal.

And those who reach Stage 3 of the Nerve Curve say things like “We have food for thought;  we feel inspired; our passion is re-ignited; we now have a beacon of hope for the future.

That is the flavour of motivation-juice that is needed to fuel the improvement-by-design engine and to deliver win-win-win designs that are both surprising and self-sustaining.

And what actually changes our belief of what is possible is when we learn to do it for ourselves. For real.

That is Improvement Science in action. It is a pragmatic science.

Find and Fill

Many barriers to improvement are invisible.

This is because they are caused by what is not present rather than what is.  They are gaps or omissions.

Some gaps are blindingly obvious.  This is because we expect to see something there so we notice when it is missing. We would notice the gap if a rope bridge across chasm is obviously missing because only end posts are visible.

Many gaps are not obvious. This is because we have no experience or expectation.  The gap is invisible.  We are blind to the omission.

These are the gaps that we accidentally stumble into. Such as a gap in our knowledge and understanding that we cannot see. These are the gaps that create the fear of failure. And the fear is especially real because the gap is invisible and we only know when it is too late.

minefieldIt is like walking across an emotional minefield.  At any moment we could step on an ignorance mine and our confidence would be blasted into fragments.

So our natural and reasonable reaction is to stay outside the emotional minefield and inside our comfort zones – where we feel safe.  We give up trying to learn and trying to improve. Every-one hopes that Some-one or Any-one will do it for us.  No-one does.

The path to Improvement is always across an emotional minefield because improvement implies unlearning. So we need a better design than blundering about hoping not to fall into an invisible gap.  We need a safer design.

There are a number of options:

Option 1. Ask someone who knows the way across the minefield and can demonstrate it. Someone who knows where the mines are and knows how to avoid them. Someone to tell us where to step and where not to.

Option 2. Clear a new path and mark it clearly so others can trust that it is safe.  Remove the ignorance mines. Find and Fill the knowledge map.

Option 1 is quicker but it leaves the ignorance mines in place.  So sooner or later someone will step on one. Boom!

We need to be able to do Option 2.

The obvious  strategy for Option 2 is to clear the ignorance mines.  We could do this by deliberately blundering about setting off the mines. We could adopt the burn-and-scrape or learn-from-mistakes approach.

Or we could detect, defuse and remove them.

The former requires people willing to take emotional risks; the latter does not require such a sacrifice.

And “learn-by-mistakes” only works if people are able to make mistakes visibly so everyone can learn. In an adversarial, competitive, distrustful context this can not happen: and the result is usually for the unwilling troops to be forced into the minefield with the threat of a firing-squad if they do not!

And where a mistake implies irreversible harm it is not acceptable to learn that way. Mistakes are covered up. The ignorance mines are re-set for the next hapless victim to step on. The emotional carnage continues. Any change 0f sustained, system-wide improvement is blocked.

So in a low-trust cultural context the detect-defuse-and-remove strategy is the safer option.

And this requires a proactive approach to finding the gaps in understanding; a proactive approach to filling the knowledge holes; and a proactive approach to sharing what was learned.

Or we could ask someone who knows where the ignorance mines are and work our way through finding and filling our knowledge gaps. By that means any of us can build a safe, effective and efficient path to sustainable improvement.

And the person to ask is someone who can demonstrate a portfolio of improvement in practice – an experienced Improvement Science Practitioner.

And we can all learn to become an ISP and then guide others across their own emotional minefields.

All we need to do is take the first step on a well-trodden path to sustained improvement.

Taming the Wicked Bull and the OH Effect

bull_by_the_horns_anim_150_wht_9609Take the bull by the horns” is a phrase that is often heard in Improvement circles.

The metaphor implies that the system – the bull – is an unpredictable, aggressive, wicked, wild animal with dangerous sharp horns.

“Unpredictable” and “Dangerous” is certainly what the newspapers tell us the NHS system is – and this generates fear.  Fear-for-our-safety and fear drives us to avoid the bad tempered beast.

It creates fear in the hearts of the very people the NHS is there to serve – the public.  It is not the intended outcome.

Bullish” is a phrase we use for “aggressive behaviour” and it is disappointing to see those accountable behave in a bullish manner – aggressive, unpredictable and dangerous.

We are taught that bulls are to be  avoided and we are told to not to wave red flags at them! For our own safety.

But that is exactly what must happen for Improvement to flourish.  We all need regular glimpses of the Red Flag of Reality.  It is called constructive feedback – but it still feels uncomfortable.  Our natural tendency to being shocked out of our complacency is to get angry and to swat the red flag waver.  And the more powerful we are,  the sharper our horns are, the more swatting we can do and the more fear we can generate.  Often intentionally.

So inexperienced improvement zealots are prodded into “taking the executive bull by the horns” – but it is poor advice.

Improvement Scientists are not bull-fighters. They are not fearless champions who put themselves at personal risk for personal glory and the entertainment of others.  That is what Rescuers do. The fire-fighters; the quick-fixers; the burned-toast-scrapers; the progress-chasers; and the self-appointed-experts. And they all get gored by an angry bull sooner or later.  Which is what the crowd came to see – Bull Fighter Blood and Guts!

So attempting to slay the wicked bullish system is not a realistic option.

What about taming it?

This is the game of Bucking Bronco.  You attach yourself to the bronco like glue and wear it down as it tries to throw you off and trample you under hoof. You need strength, agility, resilience and persistence. All admirable qualities. Eventually the exhausted beast gives in and does what it is told. It is now tamed. You have broken its spirit.  The stallion is no longer a passionate leader; it is just a passive follower. It has become a Victim.

Improvement requires spirit – lots of it.

Improvement requires the spirit-of-courage to challenge dogma and complacency.
Improvement requires the spirit-of-curiosity to seek out the unknown unknowns.
Improvement requires the spirit-of-bravery to take calculated risks.
Improvement requires the spirit-of-action to make  the changes needed to deliver the improvements.
Improvement requires the spirit-of-generosity to share new knowledge, understanding and wisdom.

So taming the wicked bull is not going to deliver sustained improvement.  It will only achieve stable mediocrity.

So what next?

What about asking someone who has actually done it – actually improved something?

Good idea! Who?

What about someone like Don Berwick – founder of the Institute of Healthcare Improvement in the USA?

Excellent idea! We will ask him to come and diagnose the disease in our system – the one that lead to the Mid-Staffordshire septic safety carbuncle, and the nasty quality rash in 14 Trusts that Professor Sir Bruce Keogh KBE uncovered when he lifted the bed sheet.

[Click HERE to see Dr Bruce’s investigation].

We need a second opinion because the disease goes much deeper – and we need it from a credible, affable, independent, experienced expert. Like Dr Don B.

So Dr Don has popped over the pond,  examined the patient, formulated his diagnosis and delivered his prescription.

[Click HERE to read Dr Don’s prescription].

Of course if you ask two experts the same question you get two slightly different answers.  If you ask ten you get ten.  This is because if there was only one answer that everyone agreed on then there would be no problem, no confusion, and need for experts. The experts know this of course. It is not in their interest to agree completely.

One bit of good news is that the reports are getting shorter.  Mr Robert’s report on the failing of one hospital is huge and has 209 recommendations.  A bit of a bucketful.  Dr Bruce’s report is specific to the Naughty Fourteen who have strayed outside the statistical white lines of acceptable mediocrity.

Dr Don’s is even shorter and it has just 10 recommendations. One for each finger – so easy to remember.

1. The NHS should continually and forever reduce patient harm by embracing wholeheartedly an ethic of learning.

2. All leaders concerned with NHS healthcare – political, regulatory, governance, executive, clinical and advocacy – should place quality of care in general, and patient safety in particular, at the top of their priorities for investment, inquiry, improvement, regular reporting, encouragement and support.

3. Patients and their carers should be present, powerful and involved at all levels of healthcare organisations from wards to the boards of Trusts.

4. Government, Health Education England and NHS England should assure that sufficient staff are available to meet the NHS’s needs now and in the future. Healthcare organisations should ensure that staff are present in appropriate numbers to provide safe care at all times and are well-supported.

5. Mastery of quality and patient safety sciences and practices should be part of initial preparation and lifelong education of all health care professionals, including managers and executives.

6. The NHS should become a learning organisation. Its leaders should create and support the capability for learning, and therefore change, at scale, within the NHS.

7. Transparency should be complete, timely and unequivocal. All data on quality and safety, whether assembled by government, organisations, or professional societies, should be shared in a timely fashion with all parties who want it, including, in accessible form, with the public.

8. All organisations should seek out the patient and carer voice as an essential asset in monitoring the safety and quality of care.

9. Supervisory and regulatory systems should be simple and clear. They should avoid diffusion of responsibility. They should be respectful of the goodwill and sound intention of the vast majority of staff. All incentives should point in the same direction.

10. We support responsive regulation of organisations, with a hierarchy of responses. Recourse to criminal sanctions should be extremely rare, and should function primarily as a deterrent to wilful or reckless neglect or mistreatment.

The meat in the sandwich are recommendations 5 and 6 that together say “Learn Improvement Science“.

And what happens when we commit and engage in that learning journey?

Steve Peak has described what happens in this this very blog. It is called the OH effect.

OH stands for “Obvious-in-Hindsight”.

Obvious means “understandable” which implies visible, sensible, rational, doable and teachable.

Hindsight means “reflection” which implies having done something and learning from reality.

So if you would like to have a sip of Dr Don’s medicine and want to get started on the path to helping to create a healthier healthcare system you can do so right now by learning how to FISH – the first step to becoming an Improvement Science Practitioner.

The good news is that this medicine is neither dangerous nor nasty tasting – it is actually fun!

And that means it is OK for everyone – clinicians, managers, patients, carers and politicians.  All of us.


The Five-and-Two Improvement Plan

Fish!One of the reasons that many people find improvement difficult is because they are told that they will undergo a “transformational” change and they will have a “Road-To-Damascus Moment” when the “penny drops” and the “light bulb goes on”.

This is rubbish advice.

The unstated implication is that “and if you do not then there is something wrong with you“.

There is no Improvementologist I know who ever had a massive “ah ha” moment – the insight was gained gradually, bit-by-bit, over a long period of time.

And that is for a good reason.

We are all very weak-willed.

We all very easily slip back into Victim role, and I’m Not OK or They’re not OK thinking.  Especially when bad news is so plentiful and so cheap.

The “Eureka Mantra”  does not work with trying to improve physical health by losing weight so why should it work for anything else?  Diets do not work – if they did we would all be a healthy weight.

A few months ago I ran an experiment – to see if I could lose a significant amount of weight without much effort – certainly without doing any extra exercise.  How?  By “not burning the toast” on the first place. By ingesting fewer carbs.

That experiment has shown it is possible – I have the evidence – hard facts not just fuzzy feelings.

The most surprising lesson was that all I had to do was to reduce carb intake for two days a week. I just skipped the sugar, biscuits, bread, potatoes, crisps etc for two days a week. It was not difficult. In fact it was so easy I am not surprised that the Five-and-Two weight reduction plan is going viral.

So I wonder what would happen if we try the same experiment for other areas of improvement – psychological.  What if we just change the “diet” from “carbs” to “cants”.  What if for two days a week we just restrict our “cant” intake.  What if we turn down the volume of our inner voice that tells us what we cant do?  What if we just ignore the people whose response to every improvement suggestion is “yes …but”?  What if we just do this and measure what happens?

For only two days a week though.

I’m not interested in being suddenly transformed – a gradual metamorphosis is OK by me.  My intuition is that it will be important to maintain a normal diet of whining and denying for the other five days – because I need variation and I do seem to get pleasure from wallowing in my own toxic emotional swamp.

That sounds doable.

I could probably maintain a “negative thought filter” for two days a week – and then return to my curmudgeonly comfort zone for the other five.

I’ll need to choose which days wisely though …  and I had better wear a special hat, tie or badge that indicates which mode I am in – a pessimistic Black Hat five days a week and an optimistic Yellow Hat for the other two perhaps.

I wonder if anyone will notice?

And the idea of choosing your attitude for a day reminds me of a little book called FISH!

Closing the Two Loops

Over the past few weeks I have been conducting an Improvement Science Experiment (ISE).  I do that a lot.  This one is a health improvement experiment. I do that a lot too.  Specifically – improving my own health. Ah! Not so diligent with that one.

The domain of health that I am focusing on is weight – for several reasons:
(1) because a stable weight that is within “healthy” limits is a good idea for many reasons and
(2) because weight is very easy to measure objectively and accurately.

But like most people I have constraints: motivation constraints, time constraints and money constraints.  What I need is a weight reduction design that requires no motivation, no time, and no money.  That sounds like a tough design challenge – so some consideration is needed.

Design starts with a specific purpose and a way of monitoring progress.  And I have a purpose – weight within acceptable limits; a method for monitoring progress – a dusty set of digital scales. What I need is a design for delivering the improvement and a method for maintaining it. That is the challenge.

So I need a tested design that will deliver the purpose.  I could invent something here but it is usually quicker to learn from others who have done it, or something very similar.  And there is lots of knowledge and experience out there.  And they fall into two broad schools – Eat Healthier or Exercise More and usually Both.

Eat Healthier is sold as  Eat Less of the Yummy Bad Stuff and more of the Yukky Good Stuff. It sounds like a Puritanical Policy and is not very motivating. So with zero motivation as  a constraint this is a problem.  And Yukky Good Stuff seems to come with a high price tag. So with zero budget as a constraint this is a problem too.

Exercise More is sold as Get off Your Bottom and Go for a Walk. It sounds like a Macho Man Mantra. Not very motivating either. It takes time to build up a “healthy” sweat and I have no desire to expose myself as a health-desperado by jogging around my locality in my moth-eaten track suit.  So with zero time as a constraint this is a problem. Gym subscriptions and the necessary hi-tech designer garb do not come cheap.  So with a zero budget constraint this is another problem.

So far all the conventional wisdom is failing to meet any of my design constraints. On all dimensions.

Oh dear!

The rhetoric is not working.  That packet of Chocolate Hob Nobs is calling to me from the cupboard. And I know I will feel better if I put them out of their misery. Just one will not do any harm. Yum Yum.  Arrrgh!!!  The Guilt. The Guilt.

OK – get a grip – time for Improvement Scientist to step in – we need some Science.

[Improvement Science hat on]

The physics and physiology are easy on this one:

(a) What we eat provides us with energy to do necessary stuff (keep warm, move about, think, etc). Food energy  is measured in “Cals”; work energy is measured in “Ergs”.
(b) If we eat more Cals than we burn as Ergs then the difference is stored for later – ultimately as blubber (=fat).
(c) There are four contributors to or weight: dry (bones and stuff), lean (muscles and glands of various sorts), fluid (blood, wee etc), and blubber (fat).
(d) The sum of the dry, lean, and fluids should be constant – we need them – we do not store energy there.
(e) The fat component varies. It is stored energy. Work-in-progress so to speak.
(f) One kilogram of blubber is equivalent to about 9000 Cals.
(g) An adult of average weight, composition, and activity uses between 2000 and 2500 Cals per day – just to stay at a stable weight.

These facts are all we need to build an energy flow model.

Food Cals = Energy In.
Work Ergs = Energy Out.
Difference between Energy In and Energy Out is converted to-and-from blubber at a rate of 1 gram per 9 Cal.
Some of our weight is the accumulated blubber – the accumulated difference between Cals-In and Ergs-Out

The Laws Of Physics are 100% Absolute and 0% Negotiable. The Behaviours of People are 100% Relative and 100% Negotiable.  Weight loss is more about behaviour. Habits. Lifestyle.

Bit more Science needed now:

Which foods have the Cals?

(1) Fat (9 Cal per gram)
(2) Carbs (4 Cal per gram)
(3) Protein (4 Cal per gram)
(4) Water, Vitamins, Minerals, Fibre, Air, Sunshine, Fags, Motivation (0 Cal per gram).

So how much of each do we get from the stuff we nosh?

It is easy enough to work out – but it is very tedious to do so.  This is how calorie counting weight loss diets work. You weigh everything that goes in, look up the Cal conversions per gram in a big book, do some maths and come up with a number.  That takes lots of time. Then you convert to points and engage in a pseudo-accounting game where you save points up and cash them in as an occasional cream cake.  Time is a constraint and Saving-the-Yummies-for-Later is not changing a habit – it is feeding it!

So it is just easier for me to know what a big bowel of tortilla chips translates to as Cals. Then I can make an informed choice. But I do not know that.

Why not?

Because I never invested time in learning.  Like everyone else I gossip, I guess, and I generalise.  I say “Yummy stuff is bad because it is Hi-Cal; Yukky stuff is good because it is Lo-Cal“.  And from this generalisation I conclude “Cutting Cals feels bad“. Which is a problem because my motivation is already rock bottom.  So I do nothing,  and my weight stays the same, and I still feel bad.

The Get-Thin-Quick industry knows this … so they use Shock Tactics to motivate us.  They scare us with stories of fat young people having heart attacks and dying wracked with regret. Those they leave behind are the real victims. The industry bludgeons us into fearful submission and into coughing up cash for their Get Thin Quick Panaceas.  Their real goal is the repeat work – the loyal customers. And using scare mongering and a few whale-to-waif conversions as rabble-rousing  zealots they cook up the ideal design to achieve that.  They know that, for most of us, as soon as the fear subsides, the will weakens, the chips are down (the neck), the blubber builds, and we are back with our heads hung low and our wallets open.

I have no motivation – that is a constraint.  So flogging an over-weight and under-motivated middle-aged curmudgeon will only get a more over-weight, ego-bruised-and-depressed, middle-aged cynic. I may even seek solace in the Chocolate Hob Nob jar.

Nah! I need a better design.

[Improvement Scientist hat back on]

First Rule of Improvement – Check the Assumptions.

Assumption 1:
Yummy => Hi-Cal => Bad for Health
Yukky => Lo-Cal => Good for Health

It turns out this is a gross over-simplification.  Lots of Yummy things are Lo-Cal; lots of Yukky things are Hi-Cal. Yummy and Yukky are subjective. Cals are not.

OK – that knowledge is really useful because if I know which-is-which then I can made wiser decisions. I can do swaps so that the Yummy Score goes higher and the Cals Score goes lower.  That sounds more like it! My Motiv-o-Meter twitches.

Assumption 2:
Hi-Cal => Cheap => Good for Wealth
Lo-Cal => Expensive => Bad for Wealth

This is a gross over-simplification too. Lots of Expensive things are Hi-Cal; lots of Cheap things are Lo-Cal.

OK so what about the combination?

Bingo!  There are lots of Yummy+Cheap+Lo-Cal things out there !  So my process is to swap the Lose-Lose-Lose for the Win-Win-Win. I feel a motivation surge. The needle on my Motiv-o-Meter definitely moved this time.

But how much? And for how long? And how will I know if it is working?

[Improvement Science hat back on]

Second Rule of Improvement Science – Work from the Purpose

We need an output  specification.  What weight reduction in what time-scale?

OK – I work out my target weight – using something called the BMI (body mass index) which uses my height and a recommended healthy BMI range to give a target weight range. I plumb for 75 kg – not just “10% reduction” – I need an absolute goal. (PS. The BMI chart I used is at the end of the blog).

OK – I now I need a time-scale – and I know that motivation theory shows that if significant improvement is not seen within 15 repetitions of a behaviour change then it does not stick. It will not become a new habit. I need immediate feedback. I need to see a significant weight reduction within two weeks. I need a quick win to avoid eroding my fragile motivation.  And so long as a get that I will keep going. And how long to get to target weight?  One or two lunar cycles feels about right. Let us compromise on six weeks.

And what is a “significant improvement”?

Ah ha! Now I am on familiar ground – I have a tool for answering that question – a system behaviour chart (SBC).  I need to measure my weight and plot it on a time-series chart using BaseLine.  And I know that I need 9 points to show a significant shift, and I know I must not introduce variation into my measurements. So I do four things – I ensure my scales have high enough precision (+/- 0.1 kg); I do the weighing under standard conditions (same time of day and same state of dress);  I weigh myself every day or every other day; and I plot-the-dots.

OK – how am I doing on my design checklist?
1. Purpose – check
2. Process – check
3. Progress – check

Anything missing?

Yes – I need to measure the energy input – the Cals per day going in – but I need a easy, quick and low-cost way of doing it.

Time for some brainstorming. What about an App? That fancy new smartphone can earn its living for a change. Yup – lots of free ones for tracking Cals.  Choose one. Works OK. Another flick on the Motiv-o-Meter needle.

OK – next bit of the jigsaw. What is my internal process metric (IPM)?  How many fewer Cals per day on average do I need to achieve … quick bit of beer-mat maths … that many kg reduction times Cal per kg of blubber divided by 6 weeks gives  … 1300 Cals per day less than now (on average).  So what is my daily Cals input now?  I dunno. I do not have a baseline.  And I do not fancy measuring it for a couple of weeks to get one. My feeble motivation will not last that long. I need action. I need a quick win.

OK – I need to approach this a different way.  What if I just change the input to more Yummy+Cheap+Lo-Cal stuff and less Yummy+Cheap+Hi-Cal stuff and just measure what happens.  What if I just do what I feel able to? I can measure the input Cals accurately enough and also the output weight. My curiosity is now pricked too and my Inner Nerd starts to take notice and chips in “You can work out the rest from that. It is a simple S&F model” . Thanks Inner Nerd – you do come in handy occasionally. My Motiv-o-Meter is now in the green – enough emotional fuel for a decision and some action.

I have all the bits of the design jigsaw – Purpose, Process, Progress and Pieces.  Studying, and Planning over – time for Doing.

So what happened?

It is an ongoing experiment – but so far it has gone exactly as the design dictated (and the nerdy S&F model predicted).

And the experience has helped me move some Get-Thin-Quick mantras to the rubbish bin.

I have counted nine so far:

Mantra 1. Do not weight yourself every day –  rubbish – weigh yourself every day using a consistent method and plot the dots.
Mantra 2. Focus on the fatrubbish – it is Cals that count whatever the source – fat, carbs, protein (and alcohol).
Mantra 3. Five fresh fruit and veg a dayrubbish – they are just Hi-Cost+Low-Cal stocking fillers.
Mantra 4. Only eat balanced mealsrubbish –  it is OK to increase protein and reduce both carbs and fat.
Mantra 5. It costs money to get healthyrubbish – it is possible to reduce cost by switching to Yummy+Cheap+Lo-Cal stuff.
Mantra 6. Cholesterol is badrubbish – we make more cholesterol than we eat – just stay inside a recommended range.
Mantra 7. Give up all alcohol – rubbish – just be sensible – just stay inside a recommended range.
Mantra 8. Burn the fat with exercise rubbish – this is scraping-the-burnt-toast thinking – less Cals in first.
Mantra 9. Eat less every dayrubbish – it is OK to have Lo-Cal days and OK-Cal days – it is the average Cals that count.

And the thing that has made the biggest difference is the App.  Just being able to quickly look up the Cals in a “Waitrose Potato Croquette” when-ever and where-ever I want to is what I really needed. I have quickly learned what-is-in-what and that helps me make “Do I need that Chocolate Hob-Nob or not?” decisions on the fly. One tiny, insignificant Chocolate Hob-Nob = 95 Cals. Ouch! Maybe not.

I have been surprised by what I have learned. I now know that before I was making lots of unwise decisions based on completely wrong assumptions. Doh!

The other thing that has helped me build motivation is seeing the effect of those wiser design decisions translated into a tangible improvement – and quickly!  With a low-variation and high-precision weight measurement protocol I can actually see the effect of the Cals ingested yesterday on the Weight recorded today.  Our bodies obey the Laws of Physics. We are what we eat.

So what is the lesson to take away?

That there are two feedback loops that need to be included in all Improvement Science challenges – and both loops need to be closed so information flows if the Improvement exercise is to succeed and to sustain.

First the Rhetoric Feedback loop – where new, specific, knowledge replaces old, generic gossip. We want to expose the myths and mantras and reveal novel options.  Challenge assumptions with scientifically valid evidence. If you do not know then look it up.

Second the Reality Feedback loop – where measured outcomes verifies the wisdom of the decision – the intended purpose was achieved.  Measure the input, internal and output metrics and plot all as time-series charts. Seeing is believing.

So the design challenge has been achieved and with no motivation, no time and no budget.

Now where is that packet of Chocolate Hob Nobs. I think I have earned one. Yum yum.

[PS. This is not a new idea – it is called “double loop learning“.  Do not know of it? Worth looking it up?]


The Five Ages of Improvement

Improvement is not easy. If it were this blog would not attract any vistors.  The data says that the hit rate is increasing. So what questions are visitors asking?

What makes improvement so difficult?

In a word – disappointment.

Or rather the cumulative effect of repeated disappointments.

Over time we become emotionally damaged by disappointment. Our youthful mountain of optimism is slowly eroded and washed away by the stormy reality that life throws at us.

Is this emotional erosion inevitable? I believe not. Some seem to avoid it with innate ability – the rest of us have to learn how. To do that we need to understand how the emotional erosion happens and with that insight we can design an anti-disappointment defense for ourselves.

I see it as a time-dependent process with five phases. The divisions are somewhat artificial because it is a continuous process; the phases overlap and we do not all progress at the same rate. Each phase lasts about 10-15 years it seems.

The First Age – Tender Idealism


The natural child-like behaviour that we are born with is curious, playful, happy, and optimistic.  We arrive with no knowledge of the real world.  Our starting expectation is high because all we have experienced is the safe, warm, fuzzy redness of the womb. Birth is our first big disappointment! Ouch! It is cold out here and suddenly we have to do lots more for ourselves such as breathing, keeping warm, eating, weeing, and pooing. Waaaaaah!

Some claim that we spend our whole lives trying in vain to regain that wonderful, warm womb-like feeling of security and comfort.

But after our birthday surprise we activate our innate curiosity and we learn quickly as we explore the real world. We do not forget though –  we dream about how the world could be more womb-like. We are natural idealists. We all want to recreate a reliable comfort-zone. And anything that gets in our way needs to be removed! The old ideas and the old farts who cling on to them need to go! The problems and solutions are obvious; crystal clear; black-or-white; day-or-night; all-or-nothing; either-or. We start as Tender Idealists.

And we learn quickly that reality resists us.

The Second Age  – Tearful Optimism


As our experience grows the perfectly sharp edges of our idealism become smoothed off: eroded by the emotional impacts of numerous small disappointments. We remain optimists but our expectations are lowered and our frustrations are elevated. We are told by the Older-and-Wiser that when we fall off our bikes or horses we should brush ourselves down, get back on and try again. “No Pain No Gain” they preach. But it really hurts when we fall off – we graze our knees and we bruise our egos. We cry tears of frustration, pain and fear. But we strive to retain our optimism. We try again, and again, and again. And we are young so we have energy and stamina. We are not too damaged – not yet. We are Tearful Optimists.

The Third Age – Tired Realism

Tired_RealistBut reality is relentless. The battering by the sunshine and storms of life continue – apparently unaffected by our strenuous efforts to create calm.  And we keep slipping as the complexity mud gets thicker, deeper and stickier. We become more, and more tired. We try less and we sit on the fence more. It is less difficult, less tiring, less self-disappointing. We develop a taste for spectator sports. We adopt a team. We cheer when they win and we chide when they lose. Reality has eroded our optimism to the point where it has become so fragile that we dare not pit it against new challenges. We fear the seemingly inevitable failure and the consequent disappointment. Just one more tumble could break us completely. We have become Tired Realists.

The Fourth Age – Turgid Skepticism

Turgid_SkepticNow the rules of the life-game change. We must now protect the last precious vestiges of our hope and we must defend our life-dream from despair. So we build barriers that block the new Idealists and the new Optimists from blindly generating more disappointments for themselves – and for us.  We do not want to lose all hope. We exercise our intellect and our experience and we become experts in the “Yes … but” game.  We dispell new ideas and we say that they are not new and they are not worth trying. We say “Yes, but we tried that and it did not work“. We create a red-taped morass of bureaucracy to slow them down and to tire them out. And we can do that because by now we have gravitated to Positions of Authority. We write the Rules. And our rules all start with the word “No”.

The Tired Realists sit on the fence to watch the New Optimists battle with us Old Skeptics. Just as they had done when they still had the energy. It becomes their favourite spectator sport. A few optimists navigate the bureaucracy swamp and have their innovations implemented. Some even succeed and shine for a while. All fade and fail eventually. The emotional erosion continues relentlessly.

The skeptics are well-intentioned though – they want to prevent avoidable disappointment – but their strategy is non-specific. It blocks all innovation – both the worthwhile and the worthless. And their preferred tool is the simple question “Where is the evidence?” No evidence means “game over” but having evidence is no guarantor of success. Evidence means rich opportunities for nit-picking. The more academic skeptics discard what cannot be proved statistically beyond all reasonable doubt and unintentionally create an unwinnable game of Catch-22.  And over time their examination of the evidence becomes less and less rigorous. They become increasingly Turgid Skeptics.

The Fifth Age – Toxic Cynicism

Toxic_CynicThe final age starts when the skeptic suffers dream failure and enters the Land of the Hopeless. Here any idealism, optimism and realism are discounted by default and without respect. Their Pavlovian reflex is now fully established – every one and every thing is discounted without conscious thought. This is the Creed of the Cynics. The continuous discounting acts as an oily emotional toxin. It is called cynicide – and it poisons the whole organisation. It greases the slippery slope from Realist through Skeptic to Cynic – who may be a minority but the damage they create is disproportionately large. The Toxic Cynics create the waves that trigger the storms that drive the whole disappointment process.

And Toxic Cynics are indiscriminate. A Tender Idealiss can have their fragile and nascent curiosity and optimism destroyed by just one poisonous barb fired accurately but unwittingly by a habitually cynical parent figure.

stick_figure_drawing_three_check_marks_150_wht_5283So what does an experienced Improvement Scientist do to avoid the decline to Cynicism? What strategies do they employ to deflect and dissipate the storms and to defend themselves from their emotionally erosive action?

First they learn of the weathering process and the damage it does and they actively remove themselves from the most toxic parts of their organisations. Why be exposed to cynicide for no good reason? They avoid the cynics,  their congregations and their conversations. They avoid the emotional hooks-and-lines that cynics cast and use to draw others into the Drama Triangle – the negative emotional maelstrom from which the unwitting victims may never escape.

Second they learn to channel their own disappointment into improvement. They learn that after they have failed to meet their own expectation they must step back, reflect, understand what happened, formulate a new design, and then try again. Not just to blindly repeat the same action in the hope that just determination and repetition is sufficient. It is not. They also learn to do the same after a success – they reflect and understand what delivered the delight and how to make that happen more often.

Third they learn to engage the skeptics in a constructive dialog. Skeptics are useful – their sharp questions can help to improve an innovation as much as to destroy one. And they learn how to disarm the cynics. They learn how to neutralise the cynicide poison – by exposing it to the antidote – Respectful Challenge of the Cynical Behaviour.

leaderEffective leaders are de facto improvement scientists. Effective leaders carve an alternative groove for the Idealists, Optimists and Realists – the path to Capability, Credibility, and Sagacity. Effective leaders nurture the Idealists because they are the  future Optimists. Effective leaders support the Optimists because they are the future leaders. Effective leaders coax the Realists out of passive observation and into active participation. Effective leaders respect the Skeptics for their skills and restrict their bureaucracy.  Effective leaders block cynicide production by offering the Cynics a simple binary choice: healthy skepticism or The Door.

The Five Ages represent learned roles not inherited attributes. We can all choose our behaviour. We can all choose to play any of the five roles at any time. We are not Saints or Sinners. We are all fallible; we are all on the same life path and we all have the same choices:

Do we choose the path of continual improvement or do we choose the path of constant disappointment?

A wise decision is required.

And for the Optimists, Realists and Skeptics out there – hard evidence that Improvement Science works in practice – even when the participants are highly skeptical – the six week update on the real example described in The Writing On The Wall – Part I

The Writing on the Wall – Part II

Who_Is_To_BlameThe retrospectoscope is the favourite instrument of the forensic cynic – the expert in the after-the-event-and-I-told-you-so rhetoric. The rabble-rouser for the lynch-mob.

It feels better to retrospectively nail-to-a-cross the person who committed the Cardinal Error of Omission, and leave them there in emotional and financial pain as a visible lesson to everyone else.

This form of public feedback has been used for centuries.

It is called barbarism, and it has no place in a modern civilised society.

A more constructive question to ask is:

Could the evolving Mid-Staffordshire crisis have been detected earlier … and avoided?”

And this question exposes a tricky problem: it is much more difficult to predict the future than to explain the past.  And if it could have been detected and avoided earlier, then how is that done?  And if the how-is-known then is everyone else in the NHS using this know-how to detect and avoid their own evolving Mid-Staffs crisis?

To illustrate how it is currently done let us use the actual Mid-Staffs data. It is conveniently available in Figure 1 embedded in Figure 5 on Page 360 in Appendix G of Volume 1 of the first Francis Report.  If you do not have it at your fingertips I have put a copy of it below.


The message does not exactly leap off the page and smack us between the eyes does it? Even with the benefit of hindsight.  So what is the problem here?

The problem is one of ergonomics. Tables of numbers like this are very difficult for most people to interpret, so they create a risk that we ignore the data or that we just jump to the bottom line and miss the real message. And It is very easy to miss the message when we compare the results for the current period with the previous one – a very bad habit that is spread by accountants.

This was a slowly emerging crisis so we need a way of seeing it evolving and the better way to present this data is as a time-series chart.

As we are most interested in safety and outcomes, then we would reasonably look at the outcome we do not want – i.e. mortality.  I think we will all agree that it is an easy enough one to measure.

MS_RawDeathsThis is the raw mortality data from the table above, plotted as a time-series chart.  The green line is the average and the red-lines are a measure of variation-over-time. We can all see that the raw mortality is increasing and the red flags say that this is a statistically significant increase. Oh dear!

But hang on just a minute – using raw mortality data like this is invalid because we all know that the people are getting older, demand on our hospitals is rising, A&Es are busier, older people have more illnesses, and more of them will not survive their visit to our hospital. This rise in mortality may actually just be because we are doing more work.

Good point! Let us plot the activity data and see if there has been an increase.


Yes – indeed the activity has increased significantly too.

Told you so! And it looks like the activity has gone up more than the mortality. Does that mean we are actually doing a better job at keeping people alive? That sounds like a more positive message for the Board and the Annual Report. But how do we present that message? What about as a ratio of mortality to activity? That will make it easier to compare ourselves with other hospitals.

Good idea! Here is the Raw Mortality Ratio chart.

MS_RawMortality_RatioAh ha. See! The % mortality is falling significantly over time. Told you so.

Careful. There is an unstated assumption here. The assumption that the case mix is staying the same over time. This pattern could also be the impact of us doing a greater proportion of lower complexity and lower risk work.  So we need to correct this raw mortality data for case mix complexity – and we can do that by using data from all NHS hospitals to give us a frame of reference. Dr Foster can help us with that because it is quite a complicated statistical modelling process. What comes out of Dr Fosters black magic box is the Global Hospital Raw Mortality (GHRM) which is the expected number of deaths for our case mix if we were an ‘average’ NHS hospital.


What this says is that the NHS-wide raw mortality risk appears to be falling over time (which may be for a wide variety of reasons but that is outside the scope of this conversation). So what we now need to do is compare this global raw mortality risk with our local raw mortality risk  … to give the Hospital Standardised Mortality Ratio.

MS_HSMRThis gives us the Mid Staffordshire Hospital HSMR chart.  The blue line at 100 is the reference average – and what this chart says is that Mid Staffordshire hospital had a consistently higher risk than the average case-mix adjusted mortality risk for the whole NHS. And it says that it got even worse after 2001 and that it stayed consistently 20% higher after 2003.

Ah! Oh dear! That is not such a positive message for the Board and the Annual Report. But how did we miss this evolving safety catastrophe?  We had the Dr Foster data from 2001

This is not a new problem – a similar thing happened in Vienna between 1820 and 1850 with maternal deaths caused by Childbed Fever. The problem was detected by Dr Ignaz Semmelweis who also discovered a simple, pragmatic solution to the problem: hand washing.  He blew the whistle but unfortunately those in power did not like the implication that they had been the cause of thousands of avoidable mother and baby deaths.  Semmelweis was vilified and ignored, and he did not publish his data until 1861. And even then the story was buried in tables of numbers.  Semmelweis went mad trying to convince the World that there was a problem.  Here is the full story.

Also, time-series charts were not invented until 1924 – and it was not in healthcare – it was in manufacturing. These tried-and-tested safety and quality improvement tools are only slowly diffusing into healthcare because the barriers to innovation appear somewhat impervious.

And the pores have been clogged even more by the social poison called “cynicide” – the emotional and political toxin exuded by cynics.

So how could we detect a developing crisis earlier – in time to avoid a catastrophe?

The first step is to estimate the excess-death-equivalent. Dr Foster does this for you.MS_ExcessDeathsHere is the data from the table plotted as a time-series chart that shows that the estimated-excess-death-equivalent per year. It has an average of 100 (that is two per week) and the average should be close to zero. More worryingly the number was increasing steadily over time up to 200 per year in 2006 – that is about four excess deaths per week – on average.  It is important to remember that HSMR is a risk ratio and mortality is a multi-factorial outcome. So the excess-death-equivalent estimate does not imply that a clear causal chain will be evident in specific deaths. That is a complete misunderstanding of the method.

I am sorry – you are losing me with the statistical jargon here. Can you explain in plain English what you mean?

OK. Let us use an example.

Suppose we set up a tombola at the village fete and we sell 50 tickets with the expectation that the winner bags all the money. Each ticket holder has the same 1 in 50 risk of winning the wad-of-wonga and a 49 in 50 risk of losing their small stake. At the appointed time we spin the barrel to mix up the ticket stubs then we blindly draw one ticket out. At that instant the 50 people with an equal risk changes to one winner and 49 losers. It is as if the grey fog of risk instantly condenses into a precise, black-and-white, yes-or-no, winner-or-loser, reality.

Translating this concept back into HSMR and Mid Staffs – the estimated 1200 deaths are the just the “condensed risk of harm equivalent”.  So, to then conduct a retrospective case note analysis of specific deaths looking for the specific cause would be equivalent to trying to retrospectively work out the reason the particular winning ticket in the tombola was picked out. It is a search that is doomed to fail. To then conclude from this fruitless search that HSMR is invalid, is only to compound the delusion further.  The actual problem here is ignorance and misunderstanding of the basic Laws of Physics and Probability, because our brains are not good at solving these sort of problems.

But Mid Staffs is a particularly severe example and  it only shows up after years of data has accumulated. How would a hospital that was not as bad as this know they had a risk problem and know sooner? Waiting for years to accumulate enough data to prove there was a avoidable problem in the past is not much help. 

That is an excellent question. This type of time-series chart is not very sensitive to small changes when the data is noisy and sparse – such as when you plot the data on a month-by-month timescale and avoidable deaths are actually an uncommon outcome. Plotting the annual sum smooths out this variation and makes the trend easier to see, but it delays the diagnosis further. One way to increase the sensitivity is to plot the data as a cusum (cumulative sum) chart – which is conspicuous by its absence from the data table. It is the running total of the estimated excess deaths. Rather like the running total of swings in a game of golf.

MS_ExcessDeaths_CUSUMThis is the cusum chart of excess deaths and you will notice that it is not plotted with control limits. That is because it is invalid to use standard control limits for cumulative data.  The important feature of the cusum chart is the slope and the deviation from zero. What is usually done is an alert threshold is plotted on the cusum chart and if the measured cusum crosses this alert-line then the alarm bell should go off – and the search then focuses on the precursor events: the Near Misses, the Not Agains and the Niggles.

I see. You make it look easy when the data is presented as pictures. But aren’t we still missing the point? Isn’t this still after-the-avoidable-event analysis?

Yes! An avoidable death should be a Never-Event in a designed-to-be-safe healthcare system. It should never happen. There should be no coffins to count. To get to that stage we need to apply exactly the same approach to the Near-Misses, and then the Not-Agains, and eventually the Niggles.

You mean we have to use the SUI data and the IR1 data and the complaint data to do this – and also ask our staff and patients about their Niggles?

Yes. And it is not the number of complaints that is the most useful metric – it is the appearance of the cumulative sum of the complaint severity score. And we need a method for diagnosing and treating the cause of the Niggles too. We need to convert the feedback information into effective action.

Ah ha! Now I understand what the role of the Governance Department is: to apply the tools and techniques of Improvement Science proactively.  But our Governance Department have not been trained to do this!

Then that is one place to start – and their role needs to evolve from Inspectors and Supervisors to Demonstrators and Educators – ultimately everyone in the organisation needs to be a competent Healthcare Improvementologist.

OK – I now now what to do next. But wait a minute. This is going to cost a fortune!

This is just one small first step.  The next step is to redesign the processes so the errors do not happen in the first place. The cumulative cost saving from eliminating the repeated checking, correcting, box-ticking, documenting, investigating, compensating and insuring is much much more than the one-off investment in learning safe system design.

So the Finance Director should be a champion for safety and quality too.


Brill. Thanks. And can I ask one more question? I do not want to appear to skeptical but how do we know we can trust that this risk-estimation system has been designed and implemented correctly? How do we know we are not being bamboozled by statisticians? It has happened before!

That is the best question yet.  It is important to remember that HSMR is counting deaths in hospital which means that it is not actually the risk of harm to the patient that is measured – it is the risk to the reputation of hospital! So the answer to your question is that you demonstrate your deep understanding of the rationle and method of risk-of-harm estimation by listing all the ways that such a system could be deliberately “gamed” to make the figures look better for the hospital. And then go out and look for hard evidence of all the “games” that you can invent. It is a sort of creative poacher-becomes-gamekeeper detective exercise.

OK – I sort of get what you mean. Can you give me some examples?

Yes. The HSMR method is based on deaths-in-hospital so discharging a patient from hospital before they die will make the figures look better. Suppose one hospital has more access to end-of-life care in the community than another: their HSMR figures would look better even though exactly the same number of people died. Another is that the HSMR method is weighted towards admissions classified as “emergencies” – so if a hospital admits more patients as “emergencies” who are not actually very sick and discharges them quickly then this will inflated their estimated deaths and make their actual mortality ratio look better – even though the risk-of-harm to patients has not changed.

OMG – so if we have pressure to meet 4 hour A&E targets and we get paid more for an emergency admission than an A&E attendance then admitting to an Assessmen Area and discharging within one day will actually reward the hospital financially, operationally and by apparently reducing their HSMR even though there has been no difference at all to the care that patients actually recieve?

Yes. It is an inevitable outcome of the current system design.

But that means that if I am gaming the system and my HSMR is not getting better then the risk-of-harm to patients is actually increasing and my HSMR system is giving me false reassurance that everything is OK.   Wow! I can see why some people might not want that realisation to be public knowledge. So what do we do?

Design the system so that the rewards are aligned with lower risk of harm to patients and improved outcomes.

Is that possible?

Yes. It is called a Win-Win-Win design.

How do we learn how to do that?

Improvement Science.

Footnote I:

The graphs tell a story but they may not create a useful sense of perspective. It has been said that there is a 1 in 300 chance that if you go to hospital you will not leave alive for avoidable causes. What! It cannot be as high as 1 in 300 surely?

OK – let us use the published Mid-Staffs data to test this hypothesis. Over 12 years there were about 150,000 admissions and an estimated 1,200 excess deaths (if all the risk were concentrated into the excess deaths which is not what actually happens). That means a 1 in 130 odds of an avoidable death for every admission! That is twice as bad as the estimated average.

The Mid Staffordshire statistics are bad enough; but the NHS-as-a-whole statistics are cumulatively worse because there are 100’s of other hospitals that are each generating not-as-obvious avoidable mortality. The data is very ‘noisy’ so it is difficult even for a statistical expert to separate the message from the morass.

And remember – that  the “expected” mortality is estimated from the average for the whole NHS – which means that if this average is higher than it could be then there is a statistical bias and we are being falsely reassured by being ‘not statistically significantly different’ from the pack.

And remember too – for every patient and family that suffers and avoidable death there are many more that have to live with the consequences of avoidable but non-fatal harm.  That is called avoidable morbidity.  This is what the risk really means – everyone has a higher risk of some degree of avoidable harm. Psychological and physical harm.

This challenge is not just about preventing another Mid Staffs – it is about preventing 1000’s of avoidable deaths and 100,000s of patients avoidably harmed every year in ‘average’ NHS trusts.

It is not a mass conspiracy of bad nurses, bad doctors, bad managers or bad policians that is the root cause.

It is poorly designed processes – and they are poorly designed because the nurses, doctors and managers have not learned how to design better ones.  And we do not know how because we were not trained to.  And that education gap was an accident – an unintended error of omission.  

Our urgently-improve-NHS-safety-challenge requires a system-wide safety-by-design educational and cultural transformation.

And that is possible because the knowledge of how to design, test and implement inherently safe processes exists. But it exists outside healthcare.

And that safety-by-design training is a worthwhile investment because safer-by-design processes cost less to run because they require less checking, less documenting, less correcting – and all the valuable nurse, doctor and manager time freed up by that can be reinvested in more care, better care and designing even better processes and systems.

Everyone Wins – except the cynics who have a choice: to eat humble pie or leave.

Footnote II:

In the debate that has followed the publication of the Francis Report a lot of scrutiny has been applied to the method by which an estimated excess mortality number is created and it is necessary to explore this in a bit more detail.

The HSMR is an estimate of relative risk – it does not say that a set of specific patients were the ones who came to harm and the rest were OK. So looking at individual deaths and looking for the specific causes is to completely misunderstand the method. So looking at the actual deaths individually and looking for identifiable cause-and-effect paths is an misuse of the message.  When very few if any are found to conclude that HSMR is flawed is an error of logic and exposes the ignorance of the analyst further.

HSMR is not perfect though – it has weaknesses.  It is a benchmarking process the”standard” of 100 is always moving because the collective goal posts are moving – the reference is always changing . HSMR is estimated using data submitted by hospitals themselves – the clinical coding data.  So the main weakness is that it is dependent on the quality of the clinicial coding – the errors of comission (wrong codes) and the errors of omission (missing codes). Garbage In Garbage Out.

Hospitals use clinically coded data for other reasons – payment. The way hospitals are now paid is based on the volume and complexity of that activity – Payment By Results (PbR) – using what are called Health Resource Groups (HRGs). This is a better and fairer design because hospitals with more complex (i.e. costly to manage) case loads get paid more per patient on average.  The HRG for each patient is determined by their clinical codes – including what are called the comorbidities – the other things that the patient has wrong with them. More comorbidites means more complex and more risky so more money and more risk of death – roughly speaking.  So when PbR came in it becamevery important to code fully in order to get paid “properly”.  The problem was that before PbR the coding errors went largely unnoticed – especially the comorbidity coding. And the errors were biassed – it is more likely to omit a code than to have an incorrect code. Errors of omission are harder to detect. This meant that by more complete coding (to attract more money) the estimated casemix complexity would have gone up compared with the historical reference. So as actual (not estimated) NHS mortality has gone down slightly then the HSMR yardstick becomes even more distorted.  Hospitals that did not keep up with the Coding Game would look worse even though  their actual risk and mortality may be unchanged.  This is the fundamental design flaw in all types of  benchmarking based on self-reported data.

The actual problem here is even more serious. PbR is actually a payment for activity – not a payment for outcomes. It is calculated from what it cost to run the average NHS hospital using a technique called Reference Costing which is the same method that manufacturing companies used to decide what price to charge for their products. It has another name – Absorption Costing.  The highest performers in the manufacturing world no longer use this out-of-date method. The implication of using Reference Costing and PbR in the NHS are profound and dangerous:

If NHS hospitals in general have poorly designed processes that create internal queues and require more bed days than actually necessary then the cost of that “waste” becomes built into the future PbR tariff. This means average length of stay (LOS) is financially rewarded. Above average LOS is financially penalised and below average LOS makes a profit.  There is no financial pressure to improve beyound average. This is called the Regression to the Mean effect.  Also LOS is not a measure of quality – so there is a to shorten length of stay for purely financial reasons – to generate a surplus to use to fund growth and capital investment.  That pressure is non-specific and indiscrimiate.  PbR is necessary but it is not sufficient – it requires an quality of outcome metric to complete it.    

So the PbR system is based on an out-of-date cost-allocation model and therefore leads to the very problems that are contributing to the MidStaffs crisis – financial pressure causing quality failures and increased risk of mortality.  MidStaffs may be a chance victim of a combination of factors coming together like a perfect storm – but those same factors are present throughout the NHS because they are built into the current design.

One solution is to move towards a more up-to-date financial model called stream costing. This uses the similar data to reference costing but it estimates the “ideal” cost of the “necessary” work to achieve the intended outcome. This stream cost becomes the focus for improvement – the streams where there is the biggest gap between the stream cost and the reference cost are the focus of the redesign activity. Very often the root cause is just poor operational policy design; sometimes it is quality and safety design problems. Both are solvable without investment in extra capacity. The result is a higher quality, quicker, lower-cost stream. Win-win-win. And in the short term that  is rewarded by a tariff income that exceeds cost and a lower HSMR.

Radically redesigning the financial model for healthcare is not a quick fix – and it requires a lot of other changes to happen first. So the sooner we start the sooner we will arrive. 

The Management of Victimosis

erasable_sad_face_150_wht_6089One of the commonest psycho-socio-economic diseases is Victimosis.

This disease has a characteristic set of symptoms and signs. The symptoms are easy to detect – and the easiest way is to close your eyes and listen to the language being used. There is a characteristic vocabulary.  ‘Yes but’ is common as is ‘If only’ and ‘They should’ and ‘Not my’ and ‘Too busy’.  Hearing these phrases used frequently is good evidence that the subject is suffering from Victimosis.

Everyone suffers from Acute Victimosis occasionally, especially if they are tired and suffer a series of emotional set backs.  With the support of relatives and friends our psychoimmune system is able to combat the cause and return us to healthy normality. We are normally able to heal our emotional wounds.

Unfortunately Victimosis is an infectious and highly contagious condition and with a large enough innoculum it can spread until almost everyone in the organisation is affected to some degree.  When this happens the Victimosis behaviour can become the norm and awareness of the symptoms slips from consciousness. Victimosis then becomes the unspoken dominant culture and the transition to the Chronic Victimosis phase is complete.

dna_magnifying_glass_150_wht_8959Research has shown that Victimosis is an acquired disease linked to a transmissable meme that is picked up early in life. The meme can be transmitted person-to-person and also through mass communication systems which then leads to rapid dissemination. Typical channels are newspapers, television, the internet and now social media.  Just sample the daily news and observe how much Victimosis language is in circulation.

Those more susceptible to infection can develop into chronic carriers who constantly infect and reinfect others.  The outward mainfestations of the chronic form are incessant complaining, criticising, irrational decisions, ineffective actions, blaming and eventually depression, hopelessness and terminal despair.  The chronically infected may aggregate into like-minded groups as a safety-in-numbers reflex response.  These groups are characterised  by having a high proportion of people with the same temperament; particularly the Guardian preference (the Supervisors, Inspectors, Providers and Protectors who make up two thirds of the population).

Those able to resist infection find the context and culture toxic and they take action. They leave.

The outward manifestations of Chronic Victimosis are GroupThink and Silosis.  GroupThink is where collectives start to behave as one and their group-rhetoric becomes progressively less varied and more dogmatic. Silosis is a form of organisational tribalism where Departments become separated from each other, conceptually, emotionally, physically and financially. Both natural reactions only aggravate the condition and accelerate the decline.

patient_stumbling_with_bandages_150_wht_6861One of the effects of the Victimosis-meme is Agnostic Hyper-Reactivity. This is where both the Individuals and their Silos develop a thick emotional protective membrane that distorts their perception.  It is not that they do not sense what is happening – it is that they do not perceive it or that they perceive it in a distorted way.  This is the Agnosia part – literally ‘not knowing’.

Unfortunately being ignorant of Reality does not help and eventually the pressure of Reality builds up and punches a hole through the emotional barrier.  Something exceptionally bad happens that cannot be discounted or ignored. This is the ‘crisis‘ stage and it elicits a characteristic reflex reaction. An emotional knee-jerk. Unfortunately the reflex is an over-reaction and is poorly focussed and badly coordinated – so it does more harm than good.

This is the hyper-reactivity part.

The blind reflex reaction further destabilises an already unstable situation and accelerates the decline.  It creates a positive feedback loop that can quickly escalate to verbal, written and then psychological and physical conflict. The Lose-Lose-Lose of Self-Destructive behaviour that is characteristic of the late phase.  And that is not all.  Over time the reflex reaction gets less effective as the Victimosis Membrane thickens. The reflex fades out.  This is a dangerous development because on the surface it looks like things are improving, there is less conflict, but in reality the patient is slipping into pre-terminal Victimosis.

Fortunately there is a treatment for Victimosis.

It is called Positivicillin.

herbal_supplement_400_wht_8492This is not a new wonder drug, it is a natural product. We all produce Positivicillin and some of us produce more than others: they are called Optimists.  Positivicillin works by channelling the flow of emotional energy into the reflection-and-action pathways. Naturally occurring Positivicillin has a long-half life: the warm glow of success lasts a long time.  Unfortunately Positivicillin is irreversibly deactivated by the emotional toxin generated by the Victimosis meme: a toxin called Discountin. So in the presence of Discountin the affected person needs to generate more Positivicillin and to do so continuously and this leads to emotional exhaustion. The diffusion of Positivicillin is impeded by the Victimosis Membrane so if subject has a severe case of Chronic Victimosis then they may need extrinsic Positivicillin treatment at high dose and for a long time to prevent terminal decline. The primary goal of emergency treatment is to neutralise the excess Discountin for long enough that the natural production of Positivicillin can start to work.

So where can we get supplies of extrinsic Positivicillin from?

In its pure form Positivicillin is rare and expensive.  The number of naturally occurring Eternal Optimist Exporters is small and their collective Positivicillin production capability is limited. Healthy organisations value and attract them; unhealthy ones discount and reject them.

wine_toast_pc_400_wht_4449no_smoking_400_wht_6805So we are forced to resort to using more abundant, cheaper but inferior drugs.  One is called Alcoholimycin and another is Tobaccomycin.  They are both widely available and affordable but they have long term irreversible toxic side effects.

Chronic Victimosis is endemic so chronic abuse of Tobaccomycin and Alcoholimycin is common and, in an attempt to restrict their negative long term effects, both drugs are heavily taxed by the Authorities.

Unfortunately this only aggravates the spread of Chronic Victimosis which some report is a sign of the same condition affecting the Authorties! These radicals are calling for de-regulation of the more potent variants such a Cannabisimycin but the Authorities have opted for a tightly regulated supply of symptom-suppressants such as Anxiolytin and Antidepressin. These are now freely available and do help those who want to learn to cure themselves.

The long term goal of the Victimosis Research Council is to develop ways to produce pure Positivicillin and to treat the most severe cases of Chronic Victimosis; and to find ways to boost the natural production of Positivicillin within less seriously affected individuals and organisations.

Chronic Victimosis is not a new disease – it has been described in various forms throughout recorded history – so the search for a cure starts with the historical treatments – one of which is Confessmycin. This has been used for centuries and appears to work well for some but not others and this idiosyncratic response is believed to be due to the presence (or not) of the Rel-1-Gion meme. Active dissemination of a range of Rel-1-Gion meme variants (and the closely linked Pol-1-Tic meme variants) has been tried with considerable success but does not appear to be a viable long term option.

A recent high-tech approach is called a Twimplant.  This is an example of the Social-Media class of biopsychosocial feedback loops that uses the now ubiquitous mobiphonic symbiont to connect the individual to a regular supply of positive support, ideas and evidence called P-Tweets.  It is important to tune the Twimplant correctly because the same device can also pick up distress signals broadcast by sufferers of Chronic Victimosis who are attempting to dilute their Discountin by digitising it and exporting it to everyone else. These are called N-Tweets and are easily identifiable by their Victimosis vocabulary. N-tweets can be avoided by adopting an Unfollow policy.

heart_puzzle_piece_missing_pa_150_wht_4829One promising line of new research is called R2LM probe therapy.  This is an unconventional and innovative way of curing Chronic Victimosis. The R2LM probe is designed to identify the gaps in the organisational memetic code and to guide delivery of specific meme transplants that fill the gaps it reveals. One common gap is called the OM-meme deletion and one effective treatment for this is called FISH. Taking a course of FISH injections or using a FISH immersion technique leads to a rapid and sustained improvement in emotional balance.  That in-turn leads to an increase in the natural production of Positivicillin. From that point on the individual and can dissolve the Victimosis Membrance and correct their perceptual distortion. The treatment is sometimes uncomfortable but those who completed the course will vouch for its effectiveness.

For the milder forms of Victimosis it is possible to self-diagnose and to self-treat.

The strategy here is to actively reduce the production of Discountin and to boost the natural production of Positivicillin. These have a synergistic effect. The first step is to practice listening for the Victimosis vocabulary using a list of common phrases.  The patient is taught to listen for these in spoken communication and to look for them in written communication. Spoken communication includes their Internal Voice. The commonest phrases are:

1. “Yes but …”
2. “If only  …”
3. “I/You/We/They should …”
4. “I/We can’t …”
5. “I/We hope …”
6. “Not My/Our fault …”
7. “Constant struggle …”
8. “I/We do not know …”
9. “I am too busy to …”

The negative emotional impact of these phrases is caused by the presence of the Discountin toxin.

The second step is to substitute the contaminated phrase with an equivalent one where the Discountin is deactivated using Positivicillin. This deliberate and conscious substitution is easiest in written communication, then externally spoken and finally the Internal Voice. The replacements for the above are …

1. “Yes, and …”
2. “Next time …”
3. “I/We could …”
4. “I/We can …”
5. “I/We know …”
6. “My/Our responsibility …”
7. “Endless opportunity …”
8. “I/We will learn …”
9. “It is too important not to …”

figure_check_mark_celebrate_anim_150_wht_3617The system-wide benefits of the prompt and effective management of Chronic Victimosis are enormous. There is more reflective consideration and more effective action. There is success and celebration where before there was failure and frustration. The success stimulates natural release of more Positivicillin which builds a positive reinforcement feedback loop.  In addition the other GA-memes become progressively switched off and the signs of Passive Persecutitis and Reactive Rescuopathy resolve.

The combined effect leads to the release of Curiositonin, the natural inquisitiveness hormone, and Excitaline – the hormone that causes the addictive feeling of eager anticipation. The racing heart and the dry mouth.

From then on the ex-patient is able to maintain their emotional balance, to further develop their emotional resilience, and to assist other sufferers.  And that is a win for everyone.

Defusing Trust Eroders – Part II

line_figure_phone_400_wht_9858<Ring Ring><Ring Ring>

? Hello Leslie. How are you today?

Hi Bob – I am OK. Thank you for your time today. Is 15 minutes going to be enough?

? Yes. There is evidence that the ideal chunk of time for effective learning is around 15 minutes.

OK. I said I would read the material you sent me and reflect on it.

? Yes. Can you retell your Nerve Curve as a storyboard and highlight your ‘ah ha’ moments?

OK. And that was the first ‘ah ha’. I found the storyboard format a really effective way to capture my sequence of emotional states.

campfire_burning_150_wht_174?Yes.  There are very close links between stories, communication, learning and improvement. Before we learned to write we used campfire stories to pass collective knowledge from generation to generation.  It is an ancient, in-built skill we all have and we all enjoy a good story.

Yes. My first reaction was to the way you described the Victim role.  It really resonated with how I was feeling and how I was part of the dynamic. You were spot on with the feelings that dominated my thinking – anxiety and fear. The big ‘ah ha’ for me was to understand the discount that I was making. Not of others – of myself.

? OK. What was the image that you sketched on your storyboard?

I am embarrased to say – you will think I am silly.

? I will not think you are silly.

employee_diciplined_400_wht_5635Ouch! I know. And I knew that as soon as I said it. I think I was actually saying it to myself – or part of myself. Like I was trying to appease part of myself. Anyway, the picture I sketched was me as a small child at school standing with my head down, hands by my sides, and being told off in front of the whole class for getting a sum wrong. I was crying. I was not very good at maths and even now my mind sort of freezes and I get tears in my eyes and feel scared whenever someone tries to explain something using equations! I can feel the terror starting to well up just talking about it.

? OK. Do not panic. The story you have told is very common. Many of our fears of failure originate from early memories of experiencing ‘education by humiliation’. It is a blunt motivational tool that causes untold and long lasting damage. It is a symptom of a low quality education system design. Education is an exercise in improvement of knowledge and understanding. The unintended outcome of this clumsy educational tactic is a belief that we cannot solve problems ourselves and it is that invalid belief that creates the self-fulfilling prophecy of repeated failure.

Yes! And I know I can solve maths problems – I do it all the time – and I help my children with their maths homework. So it is not the maths that is triggering my fear. What is it?

? The answer to your question will become clear. What is the next picture on your storyboard?

emotion_head_mad_400_wht_7632The next picture was of the teacher who was telling me off. Or rather the face of the teacher. It was a face of frustration and anger. I drew a thought bubble and wrote in it “This small, irritating child cannot solve even a simple maths problem and is slowing down the whole lesson by bursting into tears everytime they get stuck. I blame the parents who are clearly too soft. They all need to learn some discipline – the hard way.

? Does this shed any light on your question?

Wow! Yes! It is not the maths that I am reacting to – it is the behaviour of the teacher. I am scared of the behaviour. I feel powerless. They are the teacher, I am just a small, incompetent, stupid, blubbing child. They do not care that I do not understand the question, and that I am in distress, and that I am scared that I will be embarassed in front of the whole class, and that I am scared that my parents will see a bad mark on my school report. And I feel trapped. I need to rationalise this. To make sense of it. Maybe I am stupid? That would explain why I cannot solve the mths problem. Maybe I should just give in and accept that I am a failure and to stupid to do maths?

There was a pause. Then Leslie continued in a different tone. A more determined tone.

But I am not a failure. This is just my knee jerk habitual reaction to an authority figure displaying anger towards me.  I can decide how I react. I have complete control over that.  I can disconnect the behaviour I experience and my reaction to it. I can choose.  Wow!         

? OK. How are you feeling right now? Can you describe it using a visual metaphor?

ready_to_launch_PA_150_wht_5052Um – weird. Mixed feelings. I am picturing myself sitting on a giant catapault. The ends of the huge elastic bands are anchored in the present and I am sitting in the loop but it is stretched way back into the past. There is something formless in the past that has been holding me back and the tension has been slowly building over time. And it feels that I have just cut that tie to the past, and I am free, and I am now being accelerated into the future. I did that. I am in control of my own destiny and it suddenly feels fun and exciting.

? OK. How do you feel right now about the memory of the authority figure from the past?

OK actually. That is really weird. I thought that I would feel angry but I do not. I just feel free. It was not them that was the problem. Their behaviour was not my fault – and it was my reaction to their behaviour that was the issue. My habitual behaviour. No, wait a second. Our habitual behaviour. It is a dynamic. It takes both people to play the game.

There was a pause.  Leslie sensed that Bob knew that some time was needed to let the emotions settle a bit.

? Are you OK to continue with your storyboard?

emotion_head_sad_frown_400_wht_7644Yes. The next picture is of the faces of my parents. They are looking at my school report. They look sad and are saying “We always dreamed that Leslie would be a doctor or something like that. I suppose we will have to settle for something less ambitious. Do not worry Leslie, it is not your fault, it will be OK, we will help you.” I felt like I had let them down and I had shattered their dream. I felt so ashamed. They had given me everything I had ever asked for. I also felt angry with myself and with them. And that is when I started beating myself up. I no longer needed anyone else to do that! I could persecute myself. I could play both parts of the game in my own head. That is what I did just now when it felt like I was talking to myself.  

? OK. You have now outlined the three roles that together create the dynamic for a stable system of learned behaviour. A system that is very resistant to change.  It is like a triangular role-playing-game. We pass the role-hats as we swap places in the triangle and we do it in collusion with others and ourselves and we do it unconsciously.  The purpose of the game is to create opportunities for social interaction – which we need and crave – the process has a clear purpose. The unintended outcome of this design is that it generates bad feelings, it erodes trust and it blocks personal and organisational development and improvement. We get stuck in it – rather like a small boat in a whirlpool. And we cannot see that we are stuck in it. We just feel bad as we spin around in an emotional maelstrom. And we feel cheated out of something better but we do not know what it is and how to get it.

There was a long pause. Leslie’s mind was racing. The world had just changed. The pieces had been blown apart and were now re-assembling in a different configuration. A simpler, clearer and more elegant design. 

So, tell me if I have this right. Each of the three roles involves a different discount?


And each discount requires a different – um – tactic to defuse?


So the way to break out of this trust eroding behavioural hamster-wheel is to learn to recognise which role we are in and to consciously deploy the discount defusing tactic.

? Yes.

And by doing that enough times we learn how to spot the traps that other people are creating and avoid getting sucked into them.

? Yes. And we also avoid starting them ourselves.

Of course! And by doing that we develop growing respect for ourselves and for each other and a growing level of trust in ourselves and in others? We have started to defuse the trust eroding behaviour and that lowers the barrier to personal and organisational development and improvement.

? Yes.

So what are the three discount defusing tactics?

There was a pause. Leslie knew what was coming next. It would be a question.

? What role are you in now?

Oh! Yes. I see. I am still feeling like that small school child at school but now I am asking for the answer and I am discounting myself by assuming that I cannot solve this problem myself. I am assuming that I need you to rescue me by telling me the answer. I am still in the trust eroding game, I do not trust myself and I am inviting you to play too, and to reinforce my belief that I cannot solve the problem.  

? And do you need me to tell you the answer?

No. I can probably work this out myself.  And if I do get stuck then I can ask for hints or nudges – not for the answer. I need to do the learning work.

? OK. I will commit to hinting and nudging if asked and if I do not know the answer I will say so.

Phew! That was definitely a rollercoaster ride on the Nerve Curve. Looking back it all makes complete sense and I now know what to do – but at the start it felt like I was heading into the Dark Unknown. You are right. It is liberating and exhilarating!

? That feeling of clarity of hindsight and exhilaration from learning is what we always strive for. Both as educators and educatees.

You mean it is the same for you? You are still riding the Nerve Curve? Still feeling surprised, confused, scared, resolved, enlightened then delighted?

? Yes. Every day. It is fun. I believe that there is No Limit to Learning so there is an inexhaustible Font of Fun.

Wow! I am off to have more Fun from Learning. Thank you so much yet again.

two_stickmen_shaking_hands_puzzle_150_wht_5229? Thank you Leslie.

Defusing Trust Eroders – Part I

Defusing Trust Eroders – Part III

Defusing Trust Eroders – Part I


Bob heard the beep and looked at his phone. There was a text message from Leslie, one of his Improvementology mentees.

It said:

Hi Bob, Do you have time to help me with a behaviour barrier that I keep hitting and cannot see a way around?

Bob thumbed his reply:

?Yes. I am free at the moment – please feel free to call.


?Hello Leslie. How can I help?

Hi Bob.  I really hope  you can help me with this recurring Niggle. I have looked through my Foundation notes and I cannot see where it is described and it does not seem to be a Nerve Curve problem.

?I will do my best. Can you outline the context or give me an example?

It is easier to give you an example.  This week I was working with a team in my organisation who approached me to help them with recurring niggles in their process. I went to see for myself and I mapped their process and identified where their niggles were and what was driving them.  That was the easy bit.  But when I started to make suggestions of what they could do to resolve their problems they started to give me a hard time and kept saying ‘Yes, but …”.  It was as if they were asking for help but did not really want it.  They kept emphasising that all their problems were caused by other people outside their department and kept asking me what I could do about it. I felt as if they were pushing the problem onto me and I was also feeling guilty for not being able to sort it out for them.

There was a pause. Then Bob said.

?You are correct Leslie. This is not a Nerve Curve issue.  It is a different people-related system issue. It is ubiquitous and it is a potentially deadly organisational disease. We call it Trust Eroding Behaviour.

That sounds exactly how it felt for me. I went to help in good faith and quickly started to feel distrustful of their motives. It was not a good feeling and I do not know if I want to go back. One part of me says ‘ It is your duty – you have made a commitment’ and another part of me says ‘Stop – you are being suckered.’  What is happening?

?Do you remember that the Improvement Science framework has three parts – Processes, People and Systems?


?OK. This is part of the People component and it is similar to but different from the Nerve Curve.  The Nerve Curve is a hard-wired emotional response to any change. The Fright, Fight, Flight response. It is just the way we are and it is not ‘correctable’. This is different. This is a learned behaviour.  Which means it can be unlearned.

Unlearned? That is not a concept that I am familiar with. Can you explain? Is it the same as forgetting?

?Forgetting means that you cannot bring something to conscious awareness.  Unlearning is different – it operates at a deeper psychological and emotional level.  Have you ever tried to change a bad habit?

Yes I have. I used to smoke which is definitely a bad habit and I managed to give up but it was really tough.

?What you did was to unlearn the smoking habit.  You did not forget about smoking.  You could not because you are repeatedly reminded by other people who still indulge in the habit.

Ah ha! I see what you mean. Yes – after I kicked the habit I became a bit of a Stop-Smoking evangelist. I even had a tee shirt. It did not seem to make much impact on the still-smokers though.  If anything it seemed to make them more determined to keep doing it – just to spite me!

?Yes. What you describe is what many people report. It is part if the same learned behaviour patterns. The habit that is causing the issue is rather like smoking because it causes short-term pleasure and long-term pain. It is both attractive and destructive.  The behaviour feels good briefly but it is toxic to trust which is why we call it the Trust Eroding Behaviour.

What is the habit? I do not recognise the behaviour that you are referring to.

?The habit is called discounting.  The reason we are not aware of it is we do it unconsciously. 

What is it that we do?

?It is easier to give you some examples.  How do you feel when all the feedback you get is silence? How do you feel when someone complains that their mistake was not their fault? How do you feel when you try to help but you hit invisible barriers that block your progess?

sad_faceOuch! Those are uncomfortable questions. When I get no feedback I feel anxious and even fearful that I have made a mistake,  and no one is telling me, and a nasty surprise is on its way. When someone keeps complaining that even though they made the mistake they are not to blame I feel angry. When I try to help others and fail I feel sad because my reputation, credibility and self-confidence is damaged.

?OK. Do not panic. These negative emotional reactions are the normal reaction to discounting behaviour.  Another word for discounting is disrespect. The three primary emotions we feel are fear, anger and sadness. Fear is the sense of impending loss; anger is the sense of present loss; and sadness is the sense of past loss.  They are the same emotions that we feel on the Nerve Curve.  What is different is the cause. Discounting is a learned disrepectful behaviour.

Oooo! That really resonates with me. Just reflecting on one day at work I can think of lots of examples of all of those negative feelings. So when do we learn this discounting habit?

?It is believed that we learn this behaviour when we are very young – before the age of seven.  And because we learn it so young we internalise it and we become unaware of it.  It then becomes a habit that is reinforced with years of practice.

Wow! That rings true for me – and it may explain why I actively avoided some people at school – they were just toxic.  But they had friends, went to college, got jobs, married andstarted families – just like me. Does that mean we grow out of it? 

?Most people unlearn some of these behavioural habits because life-experience teaches them that they are counter-productive. We all carry some of them though and they tend to emerge when we are tired and under pressure. Some people get sort of stuck and carry these behaviours into their adult life. Their behaviour can be toxic to organisations.

I definitely resonate with that statement! Is there a way to unlearn this discounting habit?

?Yes – just becoming aware of its existence is the first step. There are some strategies that we can learn, practice and use to defuse the discounting behaviour and over time our bad habit can be kicked.”

Wow! That sounds really useful.  And not just at work – I can see benefits in other areas of my life too.

?Yes. Improvement science is powerful medicine.

So what do I need to do?

?You have learned the 6M Design framework for resolving process niggles. There is an equivalent one for dissolving people niggles.  I will send you some material to read and then we can talk again.

Will it help me resolve the problem that I have with the department that asked for my help who are behaving like Victims?


OK – please send me the material. I promise to read it, reflect on it and I will arrange another conversation. I cannot wait to learn how to nail this niggle! I can see a huge win-win-win opportunity here.

?OK. The material is on its way. I look forward to our next conversation.

Defusing Trust Eroders – Part I

Defusing Trust Eroders – Part II

Defusing Trust Eroders – Part III

The Six Dice Game

<Ring Ring><Ring Ring>

?Hello, you are through to the Improvement Science Helpline. How can we help?

This is Leslie, one of your FISH apprentices.  Could I speak to Bob – my ISP coach?

?Yes, Bob is free. I will connect you now.

<Ring Ring><Ring Ring>

?Hello Leslie, Bob here. How can I help?

Hi Bob, I have a problem that I do not feel my Foundation training has equipped me to solve. Can I talk it through with you?

?Of course. Can you outline the context for me?

Yes. The context is a department that is delivering an acceptable quality-of-service and is delivering on-time but is failing financially. As you know we are all being forced to adopt austerity measures and I am concerned that if their budget is cut then they will fail on delivery and may start cutting corners and then fail on quality too.  We need a win-win-win outcome and I do not know where to start with this one.

?OK – are you using the 6M Design method?

Yes – of course!

?OK – have you done The 4N Chart for the customer of their service?

Yes – it was their customers who asked me if I could help and that is what I used to get the context.

?OK – have you done The 4N Chart for the department?

Yes. And that is where my major concerns come from. They feel under extreme pressure; they feel they are working flat out just to maintain the current level of quality and on-time delivery; they feel undervalued and frustrated that their requests for more resources are refused; they feel demoralized; demotivated and scared that their service may be ‘outsourced’. On the positive side they feel that they work well as a team and are willing to learn. I do not know what to do next.

?OK. Do not panic. This sounds like a very common and treatable system illness.  It is a stream design problem which may be the reason your Foundation training feels insufficient. Would you like to see how a Practitioner would approach this?

Yes please!

?OK. Have you mapped their internal process?

Yes. It is a six-step process for each job. Each step has different requirements and are done by different people with different skills. In the past they had a problem with poor service quality so extra safety and quality checks were imposed by the Governance department.  Now the quality of each step is measured on a 1-6 scale and the quality of the whole process is the sum of the individual steps so is measured on a scale of 6 to 36. They now have been given a minimum quality target of 21 to achieve for every job. How they achieve that is not specified – it was left up to them.

?OK – do they record their quality measurement data?

Yes – I have their report.

?OK – how is the information presented?

As an average for the previous month which is reported up to the Quality Performance Committee.

?OK – what was the average for last month?

Their results were 24 – so they do not have an issue delivering the required quality. The problem is the costs they are incurring and they are being labelled by others as ‘inefficient’. Especially the departments who are in budget and are annoyed that this department keeps getting ‘bailed out’.

?OK. One issue here is the quality reporting process is not alerting you to the real issue. It sounds from what you say that you have fallen into the Flaw of Averages trap.

I don’t understand. What is the Flaw of Averages trap?

?The answer to your question will become clear. The finance issue is a symptom – an effect – it is unlikely to be the cause. When did this finance issue appear?

Just after the Safety and Quality Review. They needed to employ more agency staff to do the extra work created by having to meet the new Minimum Quality target.

?OK. I need to ask you a personal question. Do you believe that improving quality always costs more?

I have to say that I am coming to that conclusion. Our Governance and Finance departments are always arguing about it. Governance state ‘a minimum standard of safety and quality is not optional’ and finance say ‘but we are going out of business’. They are at loggerheads. The departments get caught in the cross-fire.

?OK. We will need to use reality to demonstrate that this belief is incorrect. Rhetoric alone does not work. If it did then we would not be having this conversation. Do you have the raw data from which the averages are calculated?

Yes. We have the data. The quality inspectors are very thorough!

?OK – can you plot the quality scores for the last fifty jobs as a BaseLine chart?

Yes – give me a second. The average is 24 as I said.

?OK – is the process stable?

Yes – there is only one flag for the fifty. I know from my FISH training that is not a cause for alarm.

?OK – what is the process capability?

I am sorry – I don’t know what you mean by that?

?My apologies. I forgot that you have not completed the Practitioner training yet. The capability is the range between the red lines on the chart.

Um – the lower line is at 17 and the upper line is at 31.

?OK – how many points lie below the target of 21.

None of course. They are meeting their Minimum Quality target. The issue is not quality – it is money.

There was a pause.  Leslie knew from experience that when Bob paused there was a surprise coming.

?Can you email me your chart?

A cold-shiver went down Leslie’s back. What was the problem here? Bob had never asked to see the data before.

Sure. I will send it now.  The recent fifty is on the right, the data on the left is from after the quality inspectors went in and before the the Minimum Quality target was imposed. This is the chart that Governance has been using as evidence to justify their existence because they are claiming the credit for improving the quality.

?OK – thanks. I have got it – let me see.  Oh dear.

Leslie was shocked. She had never heard Bob use language like ‘Oh dear’.

There was another pause.

?Leslie, what is the context for this data? What does the X-axis represent?

Leslie looked at the chart again – more closely this time. Then she saw what Bob was getting at. There were fifty points in the first group, and about the same number in the second group. That was not the interesting part. In the first group the X-axis went up to 50 in regular steps of five; in the second group it went from 50 to just over 149 and was no longer regularly spaced. Eventually she replied.

Bob, that is a really good question. My guess it is that this is the quality of the completed work.

?It is unwise to guess. It is better to go and see reality.

You are right. I knew that. It is drummed into us during the Foundation training! I will go and ask. Can I call you back?

?Of course. I will email you my direct number.

[reveal heading=”Click here to read the rest of the story“]

<Ring Ring><Ring Ring>

?Hello, Bob here.

Bob – it is Leslie. I am  so excited! I have discovered something amazing.

?Hello Leslie. That is good to hear. Can you tell me what you have discovered?

I have discovered that better quality does not always cost more.

?That is a good discovery. Can you prove it with data?

Yes I can!  I am emailing you the chart now.

?OK – I am looking at your chart. Can you explain to me what you have discovered?

Yes. When I went to see for myself I saw that when a job failed the Minimum Quality check at the end then the whole job had to be re-done because there was no time to investigate and correct the causes of the failure.  The people doing the work said that they were helpless victims of errors that were made upstream of them – and they could not predict from one job to the next what the error would be. They said it felt like quality was a lottery and that they were just firefighting all the time. They knew that just repeating the work was not solving the problem but they had no other choice because they were under enormous pressure to deliver on-time as well. The only solution they could see is was to get more resources but their requests were being refused by Finance on the grounds that there is no more money. They felt completely trapped.

?OK. Can you describe what you did?

Yes. I saw immediately that there were so many sources of errors that it would be impossible for me to tackle them all. So I used the tool that I had learned in the Foundation training: the Niggle-o-Gram. That focussed us and led to a surprisingly simple, quick, zero-cost process design change. We deliberately did not remove the Inspection-and-Correction policy because we needed to know what the impact of the change would be. Oh, and we did one other thing that challenged the current methods. We plotted both the successes and the failures on the BaseLine chart so we could see both the the quality and the work done on one chart.  And we updated the chart every day and posted it chart on the notice board so everyone in the department could see the effect of the change that they had designed. It worked like magic! They have already slashed their agency staff costs, the whole department feels calmer and they are still delivering on-time. And best of all they now feel that they have the energy and time to start looking at the next niggle. Thank you so much! Now I see how the tools and techniques I learned in FISH school are so powerful and now I understand better the reason we learned them first.

?Well done Leslie. You have taken an important step to becoming a fully fledged Improvement Science Practitioner. There are many more but you have learned some critical lessons in this challenge.

This scenario is fictional but realistic.

And it has been designed so that it can be replicated easily using a simple game that requires only pencil, paper and some dice.

If you do not have some dice handy then you can use this little program that simulates rolling six dice.

The Six Digital Dice program (for PC only).

1. Prepare a piece of A4 squared paper with the Y-axis marked from zero to 40 and the X-axis from 1 to 80.
2. Roll six dice and record the score on each (or one die six times) – then calculate the total.
3. Plot the total on your graph. Left-to-right in time order. Link the dots with lines.
4. After 25 dots look at the chart. It should resemble the leftmost data in the charts above.
5. Now draw a horizontal line at 21. This is the Minimum Quality Target.
6. Keep rolling the dice – six per cycle, adding the totals to the right of your previous data.

But this time if the total is less than 21 then repeat the cycle of six dice rolls until the score is 21 or more. Record on your chart the output of all the cycles – not just the acceptable ones.

7. Keep going until you have 25 acceptable outcomes. As long as it takes.

Now count how many cycles you needed to complete in order to get 25 acceptable outcomes.  You should find that it is about twice as many as before you “imposed” the Inspect-and-Correct QI policy.

This illustrates the problem of an Inspection-and-Correction design for quality improvement.  It does improve the quality of the output – but at a higher cost.  We are treating the symptoms and ignoring the disease.

The internal design of the process is unchanged – and it is still generating mistakes.

How much quality improvement you get and how much it costs you is determined by the design of the underlying process – which has not changed. There is a Law of Diminishing returns here – and a risk.

The risk is that if quality improves as the result of applying a quality target then it encourages the Governance thumbscrews to be tightened further and forces the people further into cross-fire between Governance and Finance.

The other negative consequence of the Inspection-and-Correction approach is that it increases both the average and the variation in lead time which also fuels the calls for more targets, more sticks, calls for  more resources and pushes costs up even further.

The lesson from this simple reality check seems clear.

The better strategy for improving quality is to design the root causes of errors out of the processes  because then we will get improved quality and improved delivery and improved productivity and we will discover that we have improved safety as well.

The Six Dice Game is a simpler version of the famous Red Bead Game that W Edwards Deming used to explain why the arbitrary-target-driven-stick-and-carrot style of management creates more problems than it solves.

The illusion of short-term gain but the reality of long-term pain.

And if you would like to see and hear Deming talking about the science of improvement there is a video of him speaking in 1984. He is at the bottom of the page.  Click here.


The F Word

There is an F-word that organisations do not like to use – except maybe in conspiratorial corridor conversations.

What word might that be? What are good candidates for it?

Finance perhaps?

Certainly a word that many people do not want to utter – especially when the financial picture is not looking very rosy. And when the word finance is mentioned in meetings there is usually a groan of anguish. So yes, finance is a good candidate – but it is not the F-word.

Failure maybe?

Yes – definitely a word that is rarely uttered openly. The concept of failure is just not acceptable. Organisations must succeed, sustain and grow. Talk of failure is for losers not for winners. To talk about failure is tempting fate. So yes, another excellent candidate – but it is not the F-word.

OK – what about Fear?

That is definitely something no one likes to admit to.  Especially leaders. They are expected to be fearless. Fear is a sign of weakness! Once you start letting the fear take over then panic starts to set in – then rash decisions follow then you are really on the slippery slope. Your organisation fragments into warring factions and your fate is sealed. That must be the F-word!

Nope.  It is another very worthy candidate but it is not the F-word.

[reveal heading=”Click here to reveal the F-word“]

The dreaded F-word is Feedback.

We do not like feedback.  We do not like asking for it. We do not like giving it. We do not like talking about it. Our systems seem to be specifically designed to exclude it. Potentially useful feedback information is kept secret, confidential, for-our-eyes only.  And if it is shared it is emasculated and anonymized.

And the brave souls who are prepared to grasp the nettle – the 360 Feedback Zealots – are forced to cloak feedback with secrecy and confidentiality. We are expected to ask  for feedback, to take it on the chin, but not to know who or where it came from. So to ease the pain of anonymous feedback we are allowed to choose our accusers. So we choose those who we think will not point out our blindspot. Which renders the whole exercise worthless.

And when we actually want feedback we extract it mercilessly – like extracting blood from a reluctant stone. And if you do not believe me then consider this question: Have you ever been to a training course where your ‘certificate of attendance’ was with-held until you had completed the feedback form? The trainers do this for good reason. We just hate giving feedback. Any feedback. Positive or negative. So if they do not extract it from us before we leave they do not get any.

Unfortunately by extracting feedback from us under coercion is like acquiring a confession under torture – it distorts the message and renders it worthless.

What is the problem here?  What are we scared of?

We all know the answer to the question.  We just do not want to point at the elephant in the room.

We are all terrified of discovering that we have the organisational equivalent of body-odour. Something deeply unpleasant about our behaviour that we are blissfully unaware of but that everyone else can see as plain as day. Our behaviour blindspot. The thing we would cringe with embarrassment about if we knew. We are social animals – not solitary ones. We need on feedback yet we fear it too.

We lack the courage and humility to face our fear so we resort to denial. We avoid feedback like the plague. Feedback becomes the F-word.

But where did we learn this feedback phobia?

Maybe we remember the playground taunts from the Bullies and their Sychophants? From the poisonous Queen-Bees and their Wannabees?  Maybe we tried to protect ourselves with incantations that our well-meaning parents taught us. Spells like “Sticks and stones may break my bones but names will never hurt me“.  But being called names does hurt. Deeply. And it hurts because we are terrified that there might be some truth in the taunt.

Maybe we learned to turn a blind-eye and a deaf-ear; to cross the street at the first sign of trouble; to turn the other cheek? Maybe we just learned to adopt the Victim role? Maybe we were taught to fight back? To win at any cost? Maybe we were not taught how to defuse the school yard psycho-games right at the start?  Maybe our parents and teachers did not know how to teach us? Maybe they did not know themselves?  Maybe the ‘innocent’ schoolyard games are actually much more sinister?  Maybe we carry them with us as habitual behaviours into adult life and into our organisations? And maybe the bullies and Queen-Bees learned something too? Maybe they learned that they could get away with it? Maybe they got to like the Persecutor role and its seductive musk of power? If so then then maybe the very last thing the Bullies and Queen-Bees will want to do is to encourage open, honest feedback – especially about their behaviour. Maybe that is the root cause of the conspiracy of silence? Maybe?

But what is the big deal here?

The ‘big deal’ is that this cultural conspiracy of silence is toxic.  It is toxic to trust. It is toxic to teams. It is toxic to morale.  It is toxic to motivation. It is toxic to innovation. It is toxic to improvement. It is so toxic that it kills organisations – from the inside. Slowly.

Ouch! That feels uncomfortably realistic. So what is the problem again – exactly?

The problem is a deliberate error of omission – the active avoidance of feedback.

So ….. if it were that – how would we prove that is the root cause? Eh?

By correcting the error of omission and then observing what happens.

And this is where it gets dangerous for leaders. They are skating on politically thin ice and they know it.

Subjective feedback is very emotive.  If we ask ten people for their feedback on us we will get ten different replies – because no two people perceive the world (and therefore us) the same way.  So which is ‘right’? Which opinions do we take heed of and which ones do we discount? It is a psycho-socio-political minefield. So no wonder we avoid stepping onto the cultural barbed-wire!

There is an alternative.  Stick to reality and avoid rhetoric. Stick to facts and avoid feelings. Feed back the facts of how the organisational system is behaving to everyone in the organisation.

And the easiest way to do that is with three time-series charts that are updated and shared at regular and frequent intervals.

First – the count of safety and quality failure near-misses for each interval – for at least 50 intervals.

Second – the delivery time of our product or service for each customer over the same time period.

Third – the revenue generated and the cost incurred for each interval for the same 50 intervals.

No ratios, no targets, no balanced scorecard.

Just the three charts that paint the big picture of reality. And it might not be a very pretty picture.

But why at least 50 intervals?

So we can see the long term and short term variation over time. We need both … because …

Our Safety Chart shows that near misses keep happening despite all the burden of inspection and correction.

Our Delivery Chart shows that our performance is distorted by targets and the Horned Gaussian stalks us.

Our Viability Chart shows that our costs are increasing as we pay dearly for past mistakes and our revenue is decreasing as our customers protect their purses and their persons by staying away.

That is the not-so-good news.

The good news is that as soon as we have a multi-dimensional-frequent-feedback loop installed we will start to see improvement. It happens like magic. And the feedback accelerates the improvement.

And the news gets better.

To make best use of this frequent feedback we just need to include in our Constant Purpose – to improve safety, delivery and viability. And then the final step is to link the role of every person in the organisation to that single win-win-win goal. So that everyone can see how they contribute and how their job is worthwhile.

Shared Goals, Clear Roles and Frequent Feedback.

And if you resonate with this message then you will resonate with “The Three Signs of  Miserable Job” by Patrick Lencioni.

And if you want to improve your feedback-ability then a really simple and effective feedback tool is The 4N Chart

And please share your feedback.


Resistance to Change

Many people who are passionate about improvement become frustrated when they encounter resistance-to-change.

It does not matter what sort of improvement is desired – safety, delivery, quality, costs, revenue, productivity or all of them.

The natural and intuitive reaction to meeting resistance is to push harder – and our experience of the physical world has taught us that if we apply enough pressure at the right place then resistance will be overcome and we will move forward.

Unfortunately we sometimes discover that we are pushing against an immovable object and even our maximum effort is futile – so we give up and label it as “impossible”.

Much of Improvement Science appears counter-intuitive at first sight and the challenge of resistance is no different.  The counter-intuitive response to feeling resistance is to pull back, and that is exactly what works better. But why does it work better? Isn’t that just giving up and giving in? How can that be better?

To explain the rationale it is necessary to examine the nature of resistance more closely.

Resistance to change is an emotional reaction to an unconsciously perceived threat that is translated into a conscious decision, action and justification: the response. The range of verbal responses is large, as illustrated in the caption, and the range of non-verbal responses is just as large.  Attempting to deflect or defuse all of them is impractical, ineffective and leads to a feeling of frustration and futility.

This negative emotional reaction we call resistance is non-specific because that is how our emotions work – and it is triggered as much by the way the change is presented as by what the change is.

Many change “experts” recommend  the better method of “driving” change is selling-versus-telling and recommend learning psycho-manipulation techniques to achieve it – close-the-deal sales training for example. Unfortunately this strategy can create a psychological “arms race” which can escalate just as quickly and lead to the same outcome: an  emotional battle and psychological casualties. This outcome is often given the generic label of “stress”.

An alternative approach is to regard resistance behaviour as multi-factorial and one model separates the non-specific resistance response into separate categories: Why DoDon’t Do – Can’t Do – Won’t Do.

The Why Do response is valuable feedback because is says “we do not understand the purpose of the proposed change” and it is not unusual for proposals to be purposeless. This is sometimes called “meddling”.  This is fear of the unknown.

The Don’t Do  is valuable feedback that is saying “there is a risk with this proposed change – an unintended negative consequence that may be greater than the intended positive outcome“.  Often it is very hard to explain this NoNo reaction because it is the output of an unconscious thought process that operates out of awareness. It just doesn’t feel good. And some people are better at spotting the risks – they prefer to wear the Black Hat – they are called skeptics.  This is fear of failure.

The Can’t Do is also valuable feedback that is saying “we get the purpose and we can see the problem and the benefit of a change – we just cannot see the path that links the two because it is blocked by something.” This reaction is often triggered by an unconscious recognition that some form of collaborative working will be required but the cultural context is low on respect and trust. It can also just be a manifestation of a knowledge, skill or experience gap – the “I don’t know how to do” gap. Some people habitually adopt the Victim role – most are genuine and do not know how.

The Won’t Do response is also valuable feedback that is saying “we can see the purpose, the problem, the benefit, and the path but we won’t do it because we don’t trust you“. This reaction is common in a low-trust culture where manipulation, bullying and game playing is the observed and expected behaviour. The role being adopted here is the Persecutor role – and the psychological discount is caring for others. Persecutors lack empathy.

The common theme here is that all resistance-to-change responses represent valuable feedback and explains why the better reaction to resistance is to stop talking and start listening because to make progress will require using the feedback to diagnose what components or resistance are present. This is necessary because each category requires a different approach.

For example Why Do requires making the both problem and the purpose explicit; Don’t Do requires exploring the fear and bringing to awareness what is fuelling it; Can’t Do requires searching for the skill gaps and filling them; and Won’t Do requires identifying the trust-eroding beliefs, attitudes and behaviours and making it safe to talk about them.

Resistance-to-change is generalised as a threat when in reality it represents an opportunity to learn and to improve – which is what Improvement Science is all about.

Never Events and Nailing Niggles

Some events should NEVER happen – such as removing the wrong kidney; or injecting an anti-cancer drug designed for a vein into the spine; or sailing a cruise ship over a charted underwater reef; or driving a bus full of sleeping school children into a concrete wall.

But  these catastrophic irreversible and tragic Never Events do keep happening – rarely perhaps – but persistently. At the Never-Event investigation the Finger-of-Blame goes looking for the incompetent culprit while the innocent victims call for compensation.

And after the smoke has cleared and the pain of loss has dimmed another Never-Again-Event happens – and then another, and then another. Rarely perhaps – but not never.

Never Events are so awful and emotionally charged that we remember them and we come to believe that they are not rare and from that misperception we develop a constant nagging feeling of fear for the future. It is our fear that erodes our trust which leads to the paralysis that prevents us from acting.  In the globally tragic event of 9/11 several thousand innocents victims died while the world watched in horror.  More innocent victims than that die needlessly every day in high-tech hospitals from avoidable errors – but that statistic is never shared.

The metaphor that is often used is the Swiss Cheese – the sort on cartoons with lots of holes in it. The cheese represents a quality check – a barrier that catches and corrects mistakes before they cause irreversible damage. But the cheesy check-list is not perfect; it has holes in it.  Mistakes slip through.

So multiple layers of cheesy checks are added in the hope that the holes in the earlier slices will be covered by the cheese in the later ones – and our experience shows that this multi-check design does reduce the number of mistakes that get through. But not completely. And when, by rare chance, holes in each slice line up then the error penetrates all the way through and a Never Event becomes a Actual Catastrophe.  So, the typical recommendation from the after-the-never-event investigation is to add another layer of cheese to the stack – another check on the list on top of all the others.

But the cheese is not durable: it deteriorates over time with the incessant barrage of work and the pressure of increasing demand. The holes get bigger, the cheese gets thinner, and new holes appear. The inevitable outcome is the opening up of unpredictable, new paths through the cheese to a Never Event; more Never Events; more after-the-never-event investigation; and more slices of increasingly expensive and complex cheese added to the tottering, rotting heap.

A drawback of the Swiss Cheese metaphor is that it gives the impression that the slices are static and each cheesy check has a consistent position and persistent set of flaws in it. In reality this is not the case – the system behaves as if the slices and the holes are moving about: variation is jiggling , jostling and wobbling the whole cheesy edifice.

This wobble does not increase the risk of a Never Event  but it prevents the subsequent after-the-event investigation from discovering the specific conjunction of holes that caused it. The Finger of Blame cannot find a culprit and the cause is labelled a “system failure” or an unlucky individual is implicated and named-shamed-blamed and sacrificed to the Gods of Chance on the Alter of Hope! More often new slices of KneeJerk Cheese are added in the desperate hope of improvement – and creating an even greater burden of back-covering bureaucracy than before – and paradoxically increasing the number of holes!

Improvement Science offers a more rational, logical, effective and efficient approach to dissolving this messy, inefficient and ineffective safety design.

First it recognises that to prevent a Never Event then no errors should reach the last layer of cheese checking – the last opportunity to block the error trajectory. An error that penetrates that far is a Near Miss and these will happen more often than Never Events so they are the key to understanding and dissolving the problem.

Every Near Miss that is detected should be reported and investigated immediately – because that is the best time to identify the hole in the previous slice – before it wobbles out of sight. The goal of the investigation is understanding not accountability. Failure to report a near miss; failure to investigate it; failure to learn from it; failure to act on it; and failure to monitor the effect of the action are all errors of omission (EOOs) and they are the worst of management crimes.

The question to ask is “What error happened immediately before the Near Miss?”  This event is called a Not Again. Focussing attention on this Not Again and understanding what, where, when, who and how it happened is the path to preventing the Near Miss and the Never Event.  Why is not the question to ask – especially when trust is low and cynicism and fear are high – the question to ask is “how”.

The first action after Naming the Not Again is to design a counter-measure for it – to plug the hole – NOT to add another slice of Check-and Correct cheese! The second necessary action is to treat that Not Again as a Near-Miss and to monitor it so when it happens again the cause can be identified. These common, every day, repeating causes of Not Agains are called Niggles; the hundreds of minor irritations that we just accept as inevitable. This is where the real work happens – identifying the most common Niggle and focussing all attention on nailing it! Forever.  Niggle naming and nailing is everyone’s responsibility – it is part of business-as-usual – and if leaders do not demonstrate the behaviour and set the expectation then followers will not do it.

So what effect would we expect?

To answer that question we need a better metaphor than our static stack of Swiss cheese slices: we need something more dynamic – something like a motorway!

Suppose you were to set out walking across a busy motorway with your eyes shut and your fingers in your ears – hoping to get to the other side without being run over. What is the chance that you will make it across safely?  It depends on how busy the traffic is and how fast you walk – but say you have a 50:50 chance of getting across one lane safely (which is the same chance as tossing a fair coin and getting a head) – what is the chance that you will get across all six lanes safely? The answer is the same chance as tossing six heads in a row: a 1-in-2 chance of surviving the first lane (50%), a 1 in 4 chance of getting across two lanes (25%), a 1 in 8 chance of making it across three (12.5%) …. to a 1 in 64 chance of getting across all six (1.6%). Said another way that is a 63 out of 64 chance of being run over somewhere which is a 98.4% chance of failure – near certain death! Hardly a Never Event.

What happens to our risk of being run over if the traffic in just one lane is stopped and that lane is now 100% safe to cross? Well you might think that it depends on which lane it is but it doesn’t – the risk of failure is now 31/32 or 96.8% irrespective of which lane it is – so not much improvement apparently!  We have doubled the chance of success though!

Is there a better improvement strategy?

What if we work collectively to just reduce the flow of Niggles in all the lanes at the same time – and suppose we are all able to reduce the risk of a Niggle in our lane-of-influence from 1-in-2 to 1-in-6. How we do it is up to us. To illustrate the benefit we replace our coin with a six-sided die (no pun intended) and we only “die” if we throw a 1.  What happens to our pedestrian’s probability of survival? The chance of surviving the first lane is now 5/6 (83.3%), and both first and second 5/6 x 5/6 = 25/36 (69%.4) and so on to all six lanes which is 5/6 x 5/6 x 5/6 x 5/6 x 5/6 x 5/6 = 15625/46656 = 33.3% which is a lot better than our previous 1.6%!  And what if we keep plugging the holes in our bits of the cheese and we increase our individual lane success rate to 95% – our pedestrians probability of survival is now 73.5%. The chance of a catastrophic event becomes less and less.

The arithmetic may be a bit scary but the message is clear: to prevent the Never Events we must reduce the Near Misses and to to do that we investigate every Near Miss and expose the Not Agains and then use them to Name and Nail all the Niggles.  And we have complete control over the causes of our commonest Niggles because we create them.

This strategy will improve the safety of our system. It has another positive benefit – it will free up our Near Miss investigation team to do something else: it frees them to assist in the re-design the system so that Not Agains cannot happen at all – they become Never Events too – and the earlier in the path that safety-design happens the better – because it renders the other layers of check-and-correct cheesocracy irrelevant.

Just imagine what would happen in a real system if we did that …

And now try to justify not doing it …

And now consider what an individual, team and organisation would need to learn to do this …

It is called Improvement Science.

And learning the Foundations of Improvement Science in Healthcare (FISH) is one place to start.


Harried to the Rescue!

We are social animals and we need social interaction with others of our kind – it is the way our caveman wetware works.

And we need it as much as we need air, water, food and sleep. Solitary confinement is an effective punishment – you don’t need to physically beat someone to psychologically hurt them – just actively excluding them or omitting to notice them is effective and has the advantage that it leaves no visible marks – and no trail of incriminating evidence.

This is the Dark Art of the Game Player and the act of social omission is called discounting – so once we know what to look for the signature of the Game Player is obvious – and we can choose to play along or not.

Some people have learned how to protect themselves from gamey behaviour – they have learned to maintain a healthy balance of confidence and humility. They ask for feedback, they know their strengths and their weaknesses, and they and strive to maintain and develop their capability through teaching and learning. Sticks and stones may break their bones but names can never hurt them.

Other people have not learned how to spot the signs and to avoid being sucked into games – they react to the discounting by trying harder, working harder, taking on more and more – all to gain morsels of recognition. Their strategy works but it has an unfortunate consequence – it becomes an unconscious habit and they become players of the game called “Harried”.  The start is signalled by a big sigh as they are hooked into their preferred Rescuer role – always there to pick up the pieces – always offering to talke on extra work – always on the look out for an opportunity to take on more burden. “Good Ol’ Harried” they hear “S/he works every hour God sends like a Trojan”. The unspoken ulterior motive of the instigator of the game is less admirable “Delegate the job to Harried – or better still – just mess it up a bit do nothing – just wait – Harried will parachute in and save the day – and save me having to do it myself.” The conspirators in the game are adopting different roles – Victim and Persecutor – and it is in their interest to have Rescuers around who will willingly join the game. The Persecutors are not easy to see because their behaviour is passive – discounting is passive aggressive behaviour – they discount others need for a work-life balance. The Victims are easier to spot – they claim not be able to solve their own problems by acting helpless and letting Harried take over. And the whole social construct is designed with one purpose – to create a rich opportunity for social interaction – because even though they are painful, games are better than solitary anonymity.

According to Eric Berne, founder of the school of Transactional Analysis, games are learned behaviour – and they spring from an injunction that we are all taught as children: that each of us is reliant on others for recognition – and those others are our parents. Sure, recognition from influential others is important BUT it is not our only source. We can give ourselves recognition. Each of us can learn to celebrate a job well done; a lesson learned; a challenge overcome – and through that route we can learn to recognise others genuinely, openly and without expectation of a return compliment. But to learn this we have to grasp the nettle and to unlearn our habit of playing the Persecutor-Rescuer-Victim games; and to do that we must first shine a light onto our blindspots.

Gamey behaviour is a potent yet invisible barrier to improvement. So if it is endemic in an organisation that wants to improve then it needs to be diagnosed and managed as an integral part of the improvement process. It is a critical human factor and in Improvement Science the human factors and the  process factors progress hand in hand.

Here is an paragraph from Games Nurses Play by Pamela Levin:

“Harried” is a game played when situations are complicated. The aim is to make the situation even more complicated so that a person feels justified in giving up. “Harried Midwife” is so named because I (P.L.) first observed the game on an obstetric floor, but it has its counterpart in other clinical settings. The game is aided by institutional needs, since it is a rare hospital unit that has the staff adequate in numbers these days. In the situation I observed, the harried nurse sent her only nurse’s aide to lunch when three deliveries were pending. Instead of using a methodical approach, she went running about checking a pulse here, a chart there, a dilatation here, and an I.V. there, so she never was caught up with the work. She lost her pen and couldn’t “chart” until she found it. She answered the telephone and lost the message. She was so busy setting up the delivery room, she forgot to notify the doctor of the impending delivery. The baby, which arrived in the labor room, was considered contaminated, and could not be discharged to the newborn nursery. After the chaos had died down, the nurse felt justified in doing almost no work for the rest of the day.

Click for the complete Games Nurses Play article here

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!


There is a common, and often fatal, organisational disease called “egomatosis”.

It starts as a swelling of the Egocentre in the Executive Organ that is triggered by a deficiency in the Humility Feedback Loop (HFL), which in turn is linked to underdevelopment or dysfunction of the phonic sensory input system – selective deafness.

Unfortunately, the Egocentre is located next to other perception centres – specifically insight – so as the egoma develops the visual perception also becomes progressively distorted until a secondary cultural blind-spot develops.

In effect, the Executive organ becomes progressively cut off from objective reality – and this lack of accurate information impairs the Humility Feedback Loop further – accelerating the further enlargement of the egoma.

A dangerous positive feedback loop is now created that leads to a self-amplifying spiral of distorted perception and a progressive decline of judgement and effective decision making.

The external manifestation of this state is a characteristic behaviour called “dystrustosis” – or difficulty in extending trust to others combined with a progressive loss of self-trust.

The unwitting sufferer becomes progressively deaf, blind, fearful, delusional, paranoid and insecure – often distancing themselves emotionally and physically and communicating only via intermediaries using One-Way-Directives.

Those who attempt to communicate with the sufferer of this insidious condition often resort to SHOUTING and using BIG LETTERS which, unfortunately, only mirrors the same behaviour.  As the sufferer’s perception of reality becomes more distorted their lack of insight and humility blocks them from considering themselves as a contributor to the problem.

The ensuing conflict only serves to accelerate their decline and the sufferer progresses to the stage of “fulminant egomatosis”.

“Fulminant egomatosis” is a condition that is easy to identify and to diagnose.  Just listen for the shouting, observe the dystrustosis and feel the fear.

Unfortunately, it is a difficult condition to manage because of the lack of awareness and insight that are the cardinal signs.

Many affected leaders and their organisations now enter a state of Denial – unconsciously hoping that the problem will resolve itself – which is indeed what happens eventually – though not in the way they desperately hope for.

In the interim, the health of the organisation deteriorates and many executives succumb, unaware of, or unwilling to acknowledge the illness that claimed them; meekly accepting the “inevitable fate” and submitting to the terminal option – usually delivered by the Chair of the Board – Retire or Resign!

The circling corporate vultures squabble over the fiscal remains – leaving no tangible sign to mark the passing of the sufferer and their hapless organisation.  There are no graveyards for the victims of fulminant egomatosis and the memory of their passing soon fades from the collective memory.  Failure is a taboo subject – an undiscussable.

Some organisations become aware of their affliction while they are still alive, but only after they have reached the terminal stage and are too sick to save.  The death throes are destructive and unpleasant to watch – and unfortunately fuel the self-justifying delusion of other infected organisations who erroneously conclude that “it could never happen to them” and then unwittingly follow the same path.

Unfortunately, egomatosis is an infectious cultural disease.  The spores, or “memes” as they are called, can spread to other organisations.  Just as Dr Ignaz Semmelweis discovered in 1847, the agents-of-destruction are often carried on the hands of those who perform organisational postmortems.  These meme vectors are often the very people brought into assist the ailing organisation, and so become chronically infected themselves and gravitate to others who share their delusions.  They are excluded by healthy organisations, but their siren-calls sound plausible and they gain entry to weaker organisations who are unaware that they carry the dangerous memes!  Actively employing the services of management consultants in preference to encouraging organisational innovation incurs a high risk of silent infection!  Appearance of the symptoms and signs is often delayed and by then it may be too late. 

The organisations that are naturally immune to egomatosis were “built to last” because they were born with a well-developed sense of purpose, vision, humility, confidence and humour.  They habitually and unconsciously look for, detect, and defuse the early signs of egomatosis.  They do not fear failure, and they have learned to leverage the gap between intent and impact.  These organisations have a strong cultural immune system and are able to both prevent infection and disarm the toxic-memes they inevitably encounter.  They are safe,  fun, challenging, exciting, innovative and motivating, places to work – characteristics that serve to strengthen their immunity, boost their resilience, and secure their future.

Some infected organisations are fortunate enough to become aware of their infection before it is too late, and they are able to escape the vicious cycle of decline.  These “good to great” organisations have enough natural humility to learn by observing the fate of others and are able to detect the early symptoms and to seek help from someone who understands their illness and can guide their diagnosis and treatment.  Such healers facilitate and demonstrate rather than direct and delegate.

All organisations are susceptible to egomatosis, so prevention is preferable to cure.

To prevent the disease, organisations must consciously and actively develop their internal and external feedback loops – using all their senses – including their olfactory organ.  Cultural and political bull**** has a characteristic odour!

They also regularly exercise their Humility Feedback Loop to keep it healthy – and they have discovered that the easiest way to do that is to challenge themselves – to actively look for their own gaps and gaffes – to look for their own positive deviants – to search out opportunities to improve – and to practice the very things that they know they are not good at.

They are prepared to be proved lacking and have learned to stop, look, laugh at themselves – then listen, learn, act, improve and share.

There is no known cure for egomatosis – it is a consequence of the 1.3 kg of ChimpWare between our ears that we have inherited from our ancestors – so vigilance must be maintained throughout the life of the organisation. 

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

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 …