Books – HCSE Blog

29/12/2019

A New Decade of Hope

At the end of the decade it is the time to reflect on what has happened in the past before planning for the future. As always, the hottest topic in health care is the status of the emergency care services, and we have the data – it is public.

This shows the last 9 years of aggregate, monthly data for Scotland (red), England (blue), Wales (teal) and N.Ireland (orange). It does not take a data scientist and a supercomputer to interpret – there is a progressive system-wide progressive deterioration year-on-year. The winter dips are obvious and the worst of these affect all four countries indicating a systemic cause … the severity of the winter weather/illness cycle -i.e. the Flu Season.

What this chart also says is that all the effort and money being expended in winter planning is not working well enough – and the nagging question is “Why not?”

Many claim that it is the predicted demographic “time bomb” … but if it is predicted then how come it has not been mitigated?

Many claim that it is a growing funding gap … but most NHS funding is spent on staff and and training nurses, doctors and allied health professionals (AHPs) takes time. Again, a predicted eventuality that has not been mitigated.

This looming crisis in a lack of heath care workers is a global health challenge … and is described by Mark Britnell in “Human – Solving the global workforce crisis in healthcare“.

Mark was the CEO of University Hospitals Birmingham from 2000 and has worked for KPMG since 2009 in a global health role so is well placed to present a strategic overview.

But, health care workers deliver care to patients – one at a time. They are not responsible for designing the system of health care delivery; or ensuring all the pieces of that vast jigsaw link up and work in a synchronised way; or for the long term planning needed to mitigate the predictable effects of demographic drift and technology advances.

Who is responsible for that challenge and are they adequately trained to do it?

The evidence would appear to suggest that there is a gap that either no one has noticed or that no one is prepared to discuss. An Undiscussable?

The global gap in the healthcare workforce is predicted to be about 20% by 2030. That is a big gap to fill because with the NHS workforce of 1.3 million people – that implies training 260,000 new staff of all types in the next 10 years, in addition to replacing those that leave.

Assuming the processes and productivity stay as they are now.

So, perhaps there is a parallel approach, one that works more quickly and a lower cost.

When current health care processes are examined through a flow engineering lens they are found to be poorly designed. They are both ineffective (do not reliably deliver the intended outcome) and inefficient (waste a lot of resources in delivering any outcome). Further examination reveals that the processes have never been designed … they have evolved.

And just because something is described as current practice does not prove that it is good design.

An expected symptom of a poorly designed process is a combination of chronic queues, delays, chaos, reactive fire-fighting and burnout. And the assumed cause is often lack of resources because when extra resource is added the queues and chaos subsides, for a while.

But, if the unintentional poor design of the process is addressed then a sequence of surprising things can happen. The chaos evaporates immediately without any extra resources. A feeling of calm is restored and the disruptive fire-fighting stops. The health care workers are able to focus on what they do best and pride-in-work is restored. Patient experience improves and staff feel that feedback and become more motivated. The complaining abates, sickness and absence falls, funded-but-hard-to-recruit-to posts are refilled and there are more hands on the handle of a more efficient/effective/productive pump. The chronic queues and delays start to melt away – as if by magic.

And if that all sounds totally impossible then here are a couple of recent, real-world case studies written by different teams in different cities in different parts of the UK. One from cancer care and one from complex diabetic care.

They confirm that this chaos-to-calm transformation is possible.

So, is there a common thread that links these two examples?

Yes, there is, and once again the spotlight is shone on the Undiscussable Gap … the fact that the NHS does not appear to have the embedded capability to redesign itself.

There is a hidden workforce gap that none of the existing programmes will address – because it is not a lack of health care workers – it is a lack of appropriately trained health care manager-designers.

The Undiscussable Elephant Is In The Room … the Undiscussable Emperor Has No Clothes.

And if history teaches us anything, Necessity is the Mother of Innovation and the chart at the top of the page shows starkly that there is an Growing Urgent Necessity.

And if two embedded teams can learn this magic trick of flipping chaos into calm at no cost, then perhaps others can too?

Welcome to the New Decade of Hope and Health Care Systems Engineering.

02/09/2017

O.O.D.A.

OODA is something we all do thousands of times a day without noticing.

Observe – Orient – Decide – Act.

The term is attributed to Colonel John Boyd, a real world “Top Gun” who studied economics and engineering, then flew and designed fighter planes, then became a well-respected military strategist.

OODA is a continuous process of updating our mental model based on sensed evidence.

And it is a fast process because happens largely out of awareness.

This was Boyd’s point: In military terms, the protagonist that can make wiser and faster decisions are more likely to survive in combat.

And notice that it is not a simple linear sequence … it is a system … there are parallel paths and both feed-forward and feed-backward loops … there are multiple information flow paths.

And notice that the Implicit Guidance & Control links do not go through Decision – this means they operate out of awareness and are much faster.

And notice the Feed Forward links link the OODA steps – this is the conscious, sequential, future looking process that we know by another name:

Study-Adjust-Plan-Do.

We use the same process in medicine: first we study the patient and the problem they are presenting (history, examination, investigation), then we adjust our generic mental model of how the body works to the specific patient (diagnosis), then we plan and decide a course of action to achieve the intended outcome, and then we act, we do it (treatment).

But at any point we can jump back to an earlier step and we can jump forwards to a later one. The observe, orient, decide, act modes are running in parallel.

And the more experience we have of similar problems the faster we can complete the OODA (or SAPD) work because we learn what is the most useful information to attend to, and we learn how to interpret it.

We learn the patterns and what to look for – and that speeds up the process – a lot!

This emergent learning is then re-inforced if the impact of our action matches our intent and prediction and our conscious learning is then internalised as unconscious “rules of thumb” called heuristics.

We start by thinking our way consciously and slowly … and … we finish by feeling our way unconsciously and quickly.

Until … we encounter a novel problem that does not fit any of our learned pattern matching neural templates. When that happens, our unconscious, parallel processing, pattern-matching system alerts us with a feeling of confusion and bewilderment – and we freeze (often with fright!)

Now we have a choice: We can retreat to using familiar, learned, reactive, knee-jerk patterns of behaviour (presumably in the hope that they will work) or we can switch into a conscious learning loop and start experimenting with novel ideas.

If we start at Hypothesis then we have the Plan-Do-Study-Act cycle; where we generate novel hypotheses to explain the unexpected, and we then plan experiments to test our hypotheses; and we then study the outcome of the experiments and we then we act on our conclusions.

This mindful mode of thinking is well described in the book “Managing the Unexpected” by Weick and Sutcliffe and is the behaviour that underpins the success of HROs – High Reliability Organisations.

The image is of the latest (3rd edition) but the previous (2nd edition) is also worth reading.

So we have two interdependent problem solving modes – the parallel OODA system and the sequential SAPD process.

And we can switch between them depending on the context.

Which is an effective long-term survival strategy because the more we embrace the unexpected, the more opportunities we will have to switch into exploration mode and learn new patterns; and the more patterns we recognise the more efficient and effective our unconscious decision-making process will become.

This complex adaptive system behaviour has another name … Resilience.

10/12/2016

Hungry, Hardworking, Humble

This week I read a new book by one of my favourite authors – Patrick Lencioni.

The book is The Ideal Team Player.

Patrick’s books are written as stories which makes them very accessible and easily memorable. And each one captures a priceless pearl of wisdom.

Improving a complex adaptive system such as health care can only be done by the people in the system working together and sharing expectations, experiences, knowledge, understanding and wisdom.

So each person needs to understand what it is to be able to contribute effectively to a team – because teams are how complex systems are designed and how they are improved.

Patrick identifies three “virtues” – and he uses that term appropriately.

Hungry … which means a having a burning ambition. Something needed and wanted. An unsatisfied longing. A vision. A mission. A goal. A pull. A purpose.

Hardworking … which means a willingness to do what is needed to satisfy the hunger. Going that extra mile. Reading that extra book. Solving that extra problem. Giving that extra bit of feedback. Doing that extra job that no one else wants to do. Investing in the future.

Humble … which means that Ego is not running the show. Confidence is linked to competence. Impact and intent are aligned. The mind is open to learning. The eyes are open to seeing. The ears are open to listening. And the mouth is only open for asking questions and telling stories.

The three virtues are necessary and sufficient, they are effective and efficient.

So if any one is missing the outcome is not achievable.

Time to pick up the mirror and look deeply into it … and ask:

“Am I hungry enough?”
“Am I prepared to commit my lifetime?”
“Am I open to learning from reality and from others?”

Our tangible record of past behaviour provides us with our answers.

It is the time to dig deep and ask the question: am hungry, hardworking and humble?

23/04/2016

Undiscussables

Last week I shared a link to Dr Don Berwick’s thought provoking presentation at the Healthcare Safety Congress in Sweden.

Near the end of the talk Don recommended six books, and I was reassured that I already had read three of them. Naturally, I was curious to read the other three.

One of the unfamiliar books was “Overcoming Organizational Defenses” by the late Chris Argyris, a professor at Harvard. I confess that I have tried to read some of his books before, but found them rather difficult to understand. So I was intrigued that Don was recommending it as an ‘easy read’. Maybe I am more of a dimwit that I previously believed! So fear of failure took over my inner-chimp and I prevaricated. I flipped into denial. Who would willingly want to discover the true depth of their dimwittedness!

Later in the week, I was forwarded a copy of a recently published paper that was on a topic closely related to a key thread in Dr Don’s presentation:

understanding variation.

The paper was by researchers who had looked at the Board reports of 30 randomly selected NHS Trusts to examine how information on safety and quality was being shared and used. They were looking for evidence that the Trust Boards understood the importance of variation and the need to separate ‘signal’ from ‘noise’ before making decisions on actions to improve safety and quality performance. This was a point Don had stressed too, so there was a link.

The randomly selected Trust Board reports contained 1488 charts, of which only 88 demonstrated the contribution of chance effects (i.e. noise). Of these, 72 showed the Shewhart-style control charts that Don demonstrated. And of these, only 8 stated how the control limits were constructed (which is an essential requirement for the chart to be meaningful and useful).

That is a validity yield of 8 out of 1488, or 0.54%, which is for all practical purposes zero. Oh dear!

This chance combination of apparently independent events got me thinking.

Q1: What is the reason that NHS Trust Boards do not use these signal-and-noise separation techniques when it has been demonstrated, for at least 12 years to my knowledge, that they are very effective for facilitating improvement in healthcare? (e.g. Improving Healthcare with Control Charts by Raymond G. Carey was published in 2003).

Q2: Is there some form of “organizational defense” system in place that prevents NHS Trust Boards from learning useful ‘new’ knowledge?

So I surfed the Web to learn more about Chris Argyris and to explore in greater depth his concept of Single Loop and Double Loop learning. I was feeling like a dimwit again because to me it is not a very descriptive title! I suspect it is not to many others too.

I sensed that I needed to translate the concept into the language of healthcare and this is what emerged.

Single Loop learning is like treating the symptoms and ignoring the disease.

Double Loop learning is diagnosing the underlying disease and treating that.

So what are the symptoms?
The pain of NHS Trust failure on all dimensions – safety, delivery, quality and productivity (i.e. affordability for a not-for-profit enterprise).

And what are the signs?
The tell-tale sign is more subtle. It’s what is not present that is important. A serious omission. The missing bits are valid time-series charts in the Trust Board reports that show clearly what is signal and what is noise. This diagnosis is critical because the strategies for addressing them are quite different – as Julian Simcox eloquently describes in his latest essay. If we get this wrong and we act on our unwise decision, then we stand a very high chance of making the problem worse, and demoralizing ourselves and our whole workforce in the process! Does that sound familiar?

And what is the disease?
Undiscussables. Emotive subjects that are too taboo to table in the Board Room. And the issue of what is discussable is one of the undiscussables so we have a self-sustaining system. Anyone who attempts to discuss an undiscussable is breaking an unspoken social code. Another undiscussable is behaviour, and our social code is that we must not upset anyone so we cannot discuss ‘difficult’ issues. But by avoiding the issue (the undiscussable disease) we fail to address the root cause and end up upsetting everyone. We achieve exactly what we are striving to avoid, which is the technical definition of incompetence. And Chris Argyris labelled this as ‘skilled incompetence’.

Does an apparent lack of awareness of what is already possible fully explain why NHS Trust Boards do not use the tried-and-tested tool called a system behaviour chart to help them diagnose, design and deliver effective improvements in safety, flow, quality and productivity?

Or are there other forces at play as well?

Some deeper undiscussables perhaps?

08/03/2014

The Battle of the Chimps

Improvement implies change.
Change implies action.
Action implies decision.

So how is the decision made?
With Urgency?
With Understanding?

Bitter experience teaches us that often there is an argument about what to do and when to do it. An argument between two factions. Both are motivated by a combination of anger and fear. One side is motivated more by anger than fear. They vote for action because of the urgency of the present problem. The other side is motivated more by fear than anger. They vote for inaction because of their fear of future failure.

The outcome is unhappiness for everyone.

If the ‘action’ party wins the vote and a failure results then there is blame and recrimination. If the ‘inaction’ party wins the vote and a failure results then there is blame and recrimination. If either party achieves a success then there is both gloating and resentment. Lose Lose.

The issue is not the decision and how it is achieved.The problem is the battle.

Dr Steve Peters is a psychiatrist with 30 years of clinical experience. He knows how to help people succeed in life through understanding how the caveman wetware between their ears actually works.

In the run up to the 2012 Olympic games he was the sports psychologist for the multiple-gold-medal winning UK Cycling Team. The World Champions. And what he taught them is described in his book – “The Chimp Paradox“.

Steve brilliantly boils the current scientific understanding of the complexity of the human mind down into a simple metaphor.

One that is accessible to everyone.

The metaphor goes like this:

There are actually two ‘beings’ inside our heads. The Chimp and the Human. The Chimp is the older, stronger, more emotional and more irrational part of our psyche. The Human is the newer, weaker, logical and rational part. Also inside there is the Computer. It is just a memory where both the Chimp and the Human store information for reference later. Beliefs, values, experience. Stuff like that. Stuff they use to help them make decisions.

And when some new information arrives through our senses – sight and sound for example – the Chimp gets first dibs and uses the Computer to look up what to do. Long before the Human has had time to analyse the new information logically and rationally. By the time the Human has even started on solving the problem the Chimp has come to a decision and signaled it to the Human and associated it with a strong emotion. Anger, Fear, Excitement and so on. The Chimp operates on basic drives like survival-of-the-self and survival-of-the-species. So if the Chimp gets spooked or seduced then it takes control – and it is the stronger so it always wins the internal argument.

But the human is responsible for the actions of the Chimp. As Steve Peters says ‘If your dog bites someone you cannot blame the dog – you are responsible for the dog‘. So it is with our inner Chimps. Very often we end up apologising for the bad behaviour of our inner Chimp.

Because our inner Chimp is the stronger we cannot ‘control’ it by force. We have to learn how to manage the animal. We need to learn how to soothe it and to nurture it. And we need to learn how to remove the Gremlins that it has programmed into the Computer. Our inner Chimp is not ‘bad’ or ‘mad’ it is just a Chimp and it is an essential part of us.

Real chimpanzees are social, tribal and territorial. They live in family groups and the strongest male is the boss. And it is now well known that a troop of chimpanzees in the wild can plan and wage battles to acquire territory from neighbouring troops. With casualties on both sides. And so it is with people when their inner Chimps are in control.

Which is most of the time.

Scenario:
A hospital is failing one of its performance targets – the 18 week referral-to-treatment one – and is being threatened with fines and potential loss of its autonomy. The fear at the top drives the threat downwards. Operational managers are forced into action and do so using strategies that have not worked in the past. But they do not have time to learn how to design and test new ones. They are bullied into Plan-Do mode. The hospital is also required to provide safe care and the Plan-Do knee-jerk triggers fear-of-failure in the minds of the clinicians who then angrily oppose the diktat or quietly sabotage it.

This lose-lose scenario is being played out in 100’s if not 1000’s of hospitals across the globe as we speak. The evidence is there for everyone to see.

The inner Chimps are in charge and the outcome is a turf war with casualties on all sides.

So how does The Chimp Paradox help dissolve this seemingly impossible challenge?

First it is necessary to appreciate that both sides are being controlled by their inner Chimps who are reacting from a position of irrational fear and anger. This means that everyone’s behaviour is irrational and their actions likely to be counter-productive.

What is needed is for everyone to be managing their inner Chimps so that the Humans are back in control of the decision making. That way we get wise decisions that lead to effective actions and win-win outcomes. Without chaos and casualties.

To do this we all need to learn how to manage our own inner Chimps … and that is what “The Chimp Paradox” is all about. That is what helped the UK cyclists to become gold medalists.

In the scenario painted above we might observe that the managers are more comfortable in the Pragmatist-Activist (PA) half of the learning cycle. The Plan-Do part of PDSA – to translate into the language of improvement. The clinicians appear more comfortable in the Reflector-Theorist (RT) half. The Study-Act part of PDSA. And that difference of preference is fueling the firestorm.

Improvement Science tells us that to achieve and sustain improvement we need all four parts of the learning cycle working smoothly and in sequence.

So what at first sight looks like it must be pitched battle which will result in two losers; in reality is could be a three-legged race that will result in everyone winning. But only if synergy between the PA and the RT halves can be achieved.

And that synergy is achieved by learning to respect, understand and manage our inner Chimps.

01/12/2012

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.

[/reveal]

19/11/2011

FISH

Several years ago I read an inspirational book called Fish! which recounts the tale of a manager who is given the task of “sorting out” the worst department in her organisation – a department that everyone hated to deal with and that everyone hated to work in. The nickname was The Toxic Energy Dump.

The story retells how, by chance, she stumbled across help in the unlikeliest of places – the Pike Place fish market in Seattle. There she learned four principles that transformed her department and her worklife:

1. Work Made Fun Gets Done
2. Make Someone’s Day
3. Be Fully Present
4. Choose Your Attitude

The take home lesson from Fish! is that we make our work miserable by the way we behave towards each other. So if we are unhappy at work and we do nothing about our behaviour then our misery will continue.

This means we can choose to make work enjoyable – and it is the responsibility of leaders at all levels to create the context for this to happen. Miserable staff = poor leadership. And leadership starts with the leader.

Effective leadership is inspiring others to achieve through example.
Leadership does not work without trust.
Play is more than an activity – it is creative energy – and requires a culture of trust not a culture of fear.
To make someone’s day all you need to so is show them how much you appreciate them.
The attitude and behaviour of a leader has a powerful effect on those that they lead.
Effective leaders know what they stand for and ask others to hold them to account.

FISH has another meaning – it stands for Foundations of Improvement Science for Health – and it is the core set of skills needed to create a SELF – a Safe Environment for Learning and Fun. The necessary context for culture change. It is more than that though – FISH also includes the skills to design more productive processes – releasing valuable lifetime and energy to invest in creative fun.

Fish are immersed in their environment – and so are people. We learn by immersion in reality. Rhetoric – be it thinking, talking or writing – is a much less effective teacher.

So all we have to do is co-create a context for improvement and then immerse ourselves in it. The improvement that results is an inevitable consequence of th design. We design our system for improvement and it improves itself.

To learn more about Foundations of Improvement Science for Health (FISH) click: here

15/10/2011

The Devil and the Detail

There are two directions from which we can approach an improvement challenge. From the bottom up – starting with the real details and distilling the principle later; and from the top down – starting with the conceptual principle and doing the detail later. Neither is better than the other – both are needed.

As individuals we have an innate preference for real detail or conceptual principle – and our preference is manifest by the way we think, talk and behave – it is part of our personality. It is useful to have insight into our own personality and to recognise that when other people approach a problem in a different way then we may experience a difference of opinion, a conflict of styles, and possibly arguments.

One very well established model of personality type was proposed by Carl Gustav Jung who was a psychologist and who approached the subject from the perspective of understanding psychological “illness”. Jung’s “Psychological Types” was used as the foundation of the life-work of Isabel Briggs Myers who was not a psychologist and who was looking from the direction of understanding psychological “normality”. In her book Gifts Differing – Understanding Personality Type (ISBN 978-0891-060741) she demonstrates using empirical data that there is not one normal or ideal type that we are all deviate from – rather that there is a set of stable types that each represents a “different gift”. By this she means that different personality types are suited to different tasks and when the type resonantes with the task it results in high-performance and is seen an asset or “strength” and when it does not it results in low performance and is seen as a liability or “weakness”.

One of the multiple dimensions of the Jungian and Myers-Briggs personality type model is the Sensor – iNtuitor dimension the S-N dimension. This dimension represents where we hold our reference model that provides us with data – data that we convert to information – and informationa the we use to derive decisions and actions.

A person who is naturally inclined to the Sensor end of the S-N dimension prefers to use Reality and Actuality as their reference – and they access it via their senses – sight, sound, touch, smell and taste. They are often detail and data focussed; they trust their senses and their conscious awareness; and they are more comfortable with routine and structure.

A person who is naturally inclined to the iNtuitor end of the S-N dimension prefers to use Rhetoric and Possibility as their reference and their internal conceptual model that they access via their intuition. They are often principle and concept focussed and discount what their senses tell them in favour their intuition. Intuitors feel uncomfortable with routine and structure which they see as barriers to improvement.

So when a Sensor and an iNtuitor are working together to solve a problem they are approaching it from two different directions and even when they have a common purpose, common values and a common objective it is very likely that conflict will occur if they are unaware of their different gifts.

Gaining this awareness is a key to success because the synergy of the two approaches is greater than either working alone – the sum is greater than the parts – but only if there is awareness and mutual respect for the different gifts. If there is no awareness and low mutual respect then the sum will be less than the parts and the problem will not be dissolvable.

In her research, Isabel Briggs Myers found that about 60% of high school students have a preference for S and 40% have a preference for N – but when the “academic high flyers” were surveyed the ratio was S=17% and N=83% – and there was no difference between males and females. When she looked at the S-N distribution in different training courses she discovered that there were a higher proportion of S-types in Administrators (59%), Police (80%), and Finance (72%) and a higher proportion of N-types in Liberal Arts (59%), Engineering (65%), Science (83%), Fine Arts (91%), Occupational Therapy (66%), Art Education (87%), Counselor Education (85%), and Law (59%). Her observation suggested that individuals select subjects based on their “different gifts” and this throws an interesting light on why traditional professions may come into conflict and perhaps why large organisations tend to form departments of “like-minded individuals”. Departments with names like Finance, Operations and Governance – or FOG.

This insight also offers an explanation for the conflict between “strategists” who tend to be N-types and who naturally gravitate to the “manager” part of an organisation and the “tacticians” who tend to be S-types and who naturally gravitate to the “worker” part of the same organisation.

It has also been shown that conventional “intelligence tests” favour the N-types over the S-types and suggests why highly intelligent academics my perform very poorly when asked to apply their concepts and principles in the real world. Effective action requires pragmatists – but academics tend to congregate in academic instituitions – often disrespectfully labelled by pragmatists as “Ivory Towers”.

Unfortunately this innate tendency to seek-like-types is counter-productive because it re-inforces the differences, exacerbates the communication barriers, and leads to “tribal” and “disrespectful” and “trust eroding” behaviour, and to the “organisational silos” that are often evident.

Complex real-world problems cannot be solved this way because they require the synergy of the gifts – each part playing to its strength when the time is right.

The first step to know-how is self-awareness.

If you would like to know your Jungian/MBTI® type you can do so by getting the app: HERE

16/07/2011

Safety-By-Design

The picture is of Elisha Graves Otis demonstrating, in the mid 19th century, his safe elevator that automatically applies a brake if the lift cable breaks. It is a “simple” fail-safe mechanical design that effectively created the elevator industry and the opportunity of high-rise buildings.

“To err is human” and human factors research into how we err has revealed two parts – the Error of Intention (poor decision) and the Error of Execution (poor delivery) – often referred to as “mistakes” and “slips”.

Most of the time we act unconsciously using well practiced skills that work because most of our tasks are predictable; walking, driving a car etc.

The caveman wetware between our ears has evolved to delegate this uninteresting and predictable work to different parts of the sub-conscious brain and this design frees us to concentrate our conscious attention on other things.

So, if something happens that is unexpected we may not be aware of it and we may make a slip without noticing. This is one way that process variation can lead to low quality – and these are the often the most insidious slips because they go unnoticed.

It is these unintended errors that we need to eliminate using safe process design.

There are two ways – by designing processes to reduce the opportunity for mistakes (i.e. improve our decision making); and then to avoid slips by designing the subsequent process to be predictable and therefore suitable for delegation.

Finally, we need to add a mechanism to automatically alert us of any slips and to protect us from their consequences by failing-safe. The sign of good process design is that it becomes invisible – we are not aware of it because it works at the sub-conscious level.

As soon as we become aware of the design we have either made a slip – or the design is poor.

Suppose we walk up to a door and we are faced with a flat metal plate – this “says” to us that we need to “push” the door to open it – it is unambiguous design and we do not need to invoke consciousness to make a push-or-pull decision. The technical term for this is an “affordance”.

In contrast a door handle is an ambiguous design – it may require a push or a pull – and we either need to look for other clues or conduct a suck-it-and-see experiment. Either way we need to switch our conscious attention to the task – which means we have to switch it away from something else. It is those conscious interruptions that cause us irritation and can spawn other, possibly much bigger, slips and mistakes.

Safe systems require safe processes – and safe processes mean fewer mistakes and fewer slips. We can reduce slips through good design and relentless improvement.

A simple and effective tool for this is The 4N Chart® – specifically the “niggle” quadrant.

Whenever we are interrupted by a poorly designed process we experience a niggle – and by recording what, where and when those niggles occur we can quickly focus our consciousness on the opportunity for improvement. One requirement to do this is the expectation and the discipline to record niggles – not necessarily to fix them immediately – but just to record them and to review them later.

In his book “Chasing the Rabbit” Steven Spear describes two examples of world class safety: the US Nuclear Submarine Programme and Alcoa, an aluminium producer. Both are potentially dangerous activities and, in both examples, their world class safety record came from setting the expectation that all niggles are recorded and acted upon – using a simple, effective and efficient niggle-busting process.

In stark and worrying contrast, high-volume high-risk activities such as health care remain unsafe not because there is no incident reporting process – but because the design of the report-and-review process is both ineffective and inefficient and so is not used.

The risk of avoidable death in a modern hospital is quoted at around 1:300 – if our risk of dying in an elevator were that high we would take the stairs! This worrying statistic is to be expected though – because if we lack the organisational capability to design a safe health care delivery process then we will lack the organisational capability to design a safe improvement process too.

Our skill gap is clear – we need to learn how to improve process safety-by-design.

Download Design for Patient Safety report written by the Design Council.

Other good examples are the WHO Safer Surgery Checklist, and the story behind this is told in Dr Atul Gawande’s Checklist Manifesto.

02/07/2011

Low-Tech-Toc

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

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

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

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

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

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

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

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

19/02/2011

Do You Have A Miserable Job?

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

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

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

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

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

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

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

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

22/01/2011

Sentenced to Death-by-Meeting!

Do you ever feel a sense of dread when you are summoned to an urgent meeting; or when you get the minutes and agenda the day before your monthly team meeting; or when you see your diary full of meetings for weeks in advance – like a slow and painful punishment?

If so then you may have unwittingly sentenced yourself to Death by Meeting. What? We do it to ourselves? No way! That would be madness!

But think about it. We consciously and deliberately ingest all sorts of other toxins: chemicals like caffeine, alcohol and cigarette smoke – so what is so different about immersing ourselves in the emotional toxic waste that many meetings seem to generate?

Perhaps we have learned to believe that there is no other way and because we have never experienced focussed, fun, and effective meetings where problems are surfaced, shared and solved quickly – problems that thwart us as individuals. Meetings where the problem-solving sum is greater than the problem-accumulating parts.

A meeting is a system that is designed to solve problems. We can improve our system incrementally but it is a slow process; to achieve a breakthrough we need to radically redesign the system. There are three steps to doing this:

1. First decide what sort of problems the meeting is required to solve: strategic, operational or tactical;
2. Second design, test and practice a problem solving process for each category of problem; and
3. Third, select the appropriate tool for the task.

In his illuminating book Death by Meeting, Patrick Lencioni describes three meeting designs and illustrates with a story why meetings don’t work if the wrong tool is used for the wrong task. It is a sobering story.

There is another dimension to the design of meetings; that is how we solve problems as groups – and how, as a group, we seem to waste a lot of effort and time in unproductive discussion. In his book Six Thinking Hats Edward De Bono provides an explanation for our habitual behaviour and a design for a radically different group problem solving process – one that a group would not arrive at by evolution – but one that has been proven to work.

If we feel sentenced to death-by-meetings then we could buy and read these two small books – a zero-risk, one-off investment of effort, time and money for a guaranteed regular reward of fun, free time and success!

So if I complain to myself and others about pointless meetings and I have not bothered to do something about it myself then I now know that it is I who sentenced myself to Death-by-Meeting. Unintentionally and unconsciously perhaps – but me nevertheless.

11/12/2010

The Drama Triangle

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

But what choice do we believe we have?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

“Yes … but …”

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

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

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

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

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

13/06/2010

What We Need is a Healthy Crisis!

Some years ago I read a book by John Kotter that was about how organisations get themselves into and out of trouble. Recently I read another book by Patrick Lencioni called “Silos and Politics” which carried similar message – some successful organisations become “unfocussed” and “complacent” to the extent that internal silos and petty politics come to occupy more time than improvement – the politics and silos become a self-sustaining name-shame-blame-game. John Kotter showed that the path out of this unhealthy state is to realise that organisational survival is at risk – and this provides a compelling reason to align efforts – usually in a dramatic and desperate exercise in organisational survival. The term Kotter used was “burning platform” which is somewhat prophetic given the ecological, economic and political catastrophe that is currently unfolding in the Gulf of Mexico. Patrick Lencioni takes a different tack on the same problem – and concludes that organisational silos are the result of the attitudes that filter down from the boardroom. He advocates looking for the “symptoms” and if observed in an organisation then it is a good time to engineer a crisis to focus attention on delivering one collective, qualitative, and audacious goal – something that the whole organisation will need to collaborate to achieve and one that provides a “win” for everyone. So, before you get sucked into an unhealthy life-and-death crisis look for the early symptoms that indicate the need to create a healthy crisis: one that will require just as much passion and creativity to resolve and which will lead to a sustainable breakthrough improvement!

07/03/2010

What is the Dis-Ease?

Do you ever go into places where there is a feeling of uneasiness?

You can feel it almost immediately – there is something in the room that no one is talking about.

An invisible elephant in the room, a rotting something under the table.

This week I have been pondering the cause of this dis-ease and my eureka moment happened while re-reading a book called “The Speed of Trust” by Stephen R. Covey.

A common elephant-in-the-room appears to be distrust and this got me thinking about both the causes of distrust and the effects of distrust. My doodle captures the output of my musing. For me, a potent cause of distrust is to be discounted; and discounting comes from disrespect. This can happen both within yourself and between yourself and others. If you feel un-trust-worthy then you tend to disengage; and by disengaging the system functions less well – it becomes dysfunctional. Dysfunction erodes respect and so on around the vicious circle.

This then led me to the question: Why haven’t we all drowned in our own distrust by now? I believe what happens is that we reach an equilibrium where our level of trust is stable; so there must be a counteracting trust-building force that balances the trust-eroding force. That trust-building force seem to comes from our day-to-day social interactions with others.

The Achilles Heel of negative-cause-effect circles is that you can break into them at many points to sap their power and reduce their influence. So, one strategy might be to identify the Errors of Commission that create the Disease of Distrust.

Consider the question: “If I have developed a high level of trust then what could I do to erode it as quickly as possible?”.

Disrespectful attitude and discounting behaviour would be all that is needed to start the vicious downward spiral of distrust disease.

Who of us never disrespects or discounts others?

Are we all infected with the same disease?

Is there a cure or can we only expect to hold it in remission?

How can we strengthen our emotional immune systems and neutralise the infective agents of the Disease of Distrust?

Do we just need to identify and stop our trust eroding behaviour?

That would be a start.