In the famous “Star Wars” films when Luke Skywalker is learning to master the Force – his trainer, Jedi Master Yoda, says the famous line:
“You must unlearn what you have learned“.
These seven words capture a fundamental principle of Improvement Science – that very often we have to unlearn before we can improve.
Unlearning is not the same as forgetting – because much of what we have learned is unconscious – so to unlearn we first have to make our assumptions conscious.
Unlearning is not just erasing a memory, it is preparing the mental ground to replace the learning with something else.
And we do not want to unlearn everything – we want to keep the nexus of knowledge nuggets that form the solid foundation of new learning. We only want to unlearn what is preventing us adding new understanding, concepts and skills – the invisible layer of psychological grease that smears our vision and leaves our minds slippery and unable to grasp new concepts.
We need to apply some cognitive detergent and ad some heated debate to strip off the psycho-slime. The best detergent is I have found is called Reality and the good news is that Reality is widely available, completely free and supplies will never run out.
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Times are hard. Severe austerity measures are being imposed to plug the hole in the national finances. Cuts are being made. But will these cuts cure the problem or kill the patient? How would we know before it is too late? Is there an alternative to sticking the fiscal knife in and hoping we don’t damage a vital part of the system? Is a single bold slash or a series of planned incisions a better strategy? How deep, how far and how fast is it safe to cut? The answer to these questions is “we don’t know” – or rather that we find it very hard to predict with confidence what will happen. The reason for this is that we are dealing with a complex system of interdependent parts that connect to each other through causal links; some links are accelerators, some are brakes, some work faster and some slower. Our caveman brains were not designed to solve this sort of predicting-the-future-behaviour-of-a-complex-system problem: our brains evolved to spot potential danger quickly and to manage a network of social relationships. So to our caveman way of thinking complex systems behave in counter-intuitive ways. However, all physical systems are constrained by the Laws of Nature – so if we don’t understand how they behave then the limitation is with the caveman wetware between our ears.
We do have an amazing skill though – we have the ability to develop tools that extend our limited biological capabilites. We have mastered technology – in particular the technology of data and information. We have learned how to recode and record our expereince and our understanding so that each generation can build on the knowledge of the previous ones. The tricky problems we are facing are ones that we have never encountered before so we have to learn as we go.
So our current problem of understanding the dynamics of our economic and social system is this: we cannot do this unconsciously and intuitively in our heads. Instead we have developed tools that can extend our predictive capability. Our challenge is to learn how to use these tools – how to wield the fiscal scalpel so that it is quick, safe and effective. We need to excise the cancer of waste while preserving our vital social and economic structures and processes. We need the best tools available – diagnostic tools, decision tools, treatment planning tools, and progress monitoring tools. These tools exist – we just need to learn to use them.
A perfect example of this is the reining in of public spending and the impact of cutting social service budgets. One thing that these budgets provide are services that some people need to maintain independent living in the community. Very often elderly people are only just coping and even a minor illness can be enough to tip them over the edge and into hospital – where they can get stuck because to discharge them safely requires extra social support – support that if provided earlier might have prevented a hospital admission. So boldly slashing the social care budget will not magically excise the waste – it means that there will be less social support capacity and patients will get stuck in the hospital part of the health and social care system. This is not good for them – or anyone else. Hospitals are not hotels and getting stuck in one is not a holiday! Hospitals are for people who are very ill – and if the hospital is full of not-so-ill people who are stuck then we have an even bigger problem – because the very ill people get even more ill – and then they need even more resources to get them well again. Some do not make it. A bold slash in just one part of the health and social care system can, unintentionally, bring the whole health and social care system crashing down.
Fortunately there is a way to avoid this – and it is counter-intuitive – otherwise we would have done it already. And because it is counter-intuitive I cannot just explain it – the only way to understand it is to discover and demonstrate it to ourselves. And in the process of learning to master the tools we need we will make a lot of errors. Clearly, we do not want to impose those errors on the real system – so we need something to practice with that is not the real system yet behaves realistically enough to allow us to develop our skills. That something is a system simulation. To experience an example of a healthcare system simulation and to play the game please follow the link: click here to play the game
When we are in “heated agreement” with each other it feels like we are talking different languages and this is a sign that we need to explore further and deeper. With patience and persistence we realise they are just dialects of the same language. Our challenge now is to learn to speak clearly in one language at a time and in the same language as the person(s) we are communicating with. Improvement Science has three primary languages – the language of quality (100% qualitative) , the language of money (100% quantitative) and the language of time (100% qualitative or quantitative depending on our perspective). Learning to speak all three languages fluently – dreams are painted in the language of quality, processes are described in the language of time, and survival is a story told in the language of money which is the universal currency that we exchange for our physical needs (water, food, warmth, shelter, security, etc).
The engagement is emotional – through the subjective language of quality – and once engaged we have to master the flow of time in order to influence the flow of money. Our higher purpose is necessary but it is not sufficient – it is our actions that converts our passion into reality – and uncoordinated or badly designed action just dissipates passion and leads to exhaustion, disappointment and cynicism.
Improvement Science is about solving problems – so looking at how we solve problems is a useful exercise – and there is a continuous spectrum from 100% reactive to 100% proactive.
The reactive paradigm implies waiting until the problem is real and urgent and then acting quickly and decisively – hence the picture of the fire-fighter. Observe the equipment that the fire-fighter needs: a hat and suit to keep him safe and a big axe! It is basically a destructive and unsafe job based on the “our purpose is to stop the problem getting worse”.
The proactive paradigm implies looking for the earliest signs of the problem and planning the minimum action required to prevent the problem – hence the picture of the clinician. Observe the equipment that the clinician needs: a clean white coat to keep her patients safe and a stethoscope – a tool designed to increase her sensitivity so that subtle diagnostic sounds can be detected.
If we never do the proactive we will only ever do the reactive – and that is destructive and unsafe. If we never do the reactive we run the risk of losing everything – and that is destructive and unsafe too.
To practice safe and effective Improvement Science we must be able to do both in any combination and know which and when: we need to be impatient, decisive and reactive when a system is unstable, and we need to be patient, reflective and proactive when the system is stable. To choose our paradigm we must listen to the voice of the process. It will speak to us if we are prepared to listen and if we are prepared to learn it’s language.
Improvement Science is about learning from when what actually happens is different to that which we expected to happen. Is this surprise a failure or is this a success? It depends on our perspective. If we always get what we expect then we could conclude that we have succeeded – yet we have neither learned anything nor improved. So have we failed to learn? In contrast, if we never get what we expected then we could conclude that we always fail – yet we do not report what we have learned and improved. Our expectation might be too high! So comparing outcome with expectation seems a poor way to measure our progress with learning and improvement.
When we try something new we should expect to be surprised – otherwise it would not be new. It is what we learn from that expected surprise that is of most value. Sometime life turns out better than we expected – what can we learn from those experiences and how can we ensure that outcome happens again – predictably? Sometimes life turns out worse than we expected – what can we learn from those experiences and how can we ensure that outcome does not happen again, predictably? So, yes it is OK for us to fail and to not get what we expected – first time. What is not OK is for us to fail to learn from the lesson and to make an avoidable mistake more than once or miss an opportunity for improvement more than once.