December 2010 – HCSE Blog

25/12/2010

Happy Xmas

Have you ever had a Christmas day that felt like you were trying to cram too much into one day – and ended up feeling stressed and irritable – and not enjoying yourself as much as you wanted – then doing it all the same next year just because you felt it was what was expected?

This is a feeling we all get all the time with many things – we keep doing them the same way and get into a rut.

So what would happen if you changed the plan on year?
Would the world come to an end? Probably not.

What have you got to lose by pacing yourself?
It is possible to get further by going slower?

We all know that it is – we all know that if we all rush for the same goal as a disorganised rabble we can trip each other up and everyone goes slower – just observe our behaviour sometimes. And the more stressed and panicky we get the more likely we are going to switch to look-out-for-number-one behaviour and starting pushing in and pushing others out. Someone will get through first but they do not get through as quickly as they could have. Smooth flow is more efficient than turbulent – so with consideration and collaboration everyone gets further, faster and easier. Everyone.

16/12/2010

Inborn Errors of Management

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

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

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

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

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

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

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

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.

05/12/2010

Lies, Damned Lies and Statistics!

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

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

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

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

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

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

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

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

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

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