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If you put an ear to someones chest you can hear their heart “lub-dub lub-dub lub-dub”. The sound is caused by the valves in the heart closing, like softly slamming doors, as part of the wonderfully orchestrated process of pumping blood around the lungs and body. The heart is an impressive example of bioengineering but it was not designed – it evolved over time – its elegance and efficiency emerged over a long journey of emergent evolution.  The lub-dub is a comforting sound – it signals regularity, predictability, and stabilty; and was probably the first and most familiar sound each of heard in the womb. Our hearts are sensitive to our emotional state – and it is no accident that the beat of music mirrors the beat of the heart: slow means relaxed and fast means aroused.

Systems and processes have a heart beat too – but it is not usually audible. It can been seen though if the measures of a process are plotted as time series charts. Only artificial systems show constant and unwavering behaviour – rigidity –  natural systems have cycles.  The charts from natural systems show the “vital signs” of the system.  One chart tells us something of value – several charts considered together tell us much more.

We can measure and display the electrical activity of the heart over time – it is called an electrocardiogram (ECG) -literally “electric-heart-picture”; we can measure and display the movement of muscles, valves and blood by beaming ultrasound at the heart – an echocardiogram; we can visualise the pressure of the blood over time – a plethysmocardiogram; and we can visualise the sound the heart makes – a phonocardiogram. When we display the various cardiograms on the same time scale one above the other we get a much better understanding of how the heart is behaving  as a system. And if we have learned what to expect to see with in a normal heart we can look for deviations from healthy behaviour and use those to help us diagnose the cause.  With experience the task of diagnosis becomes a simple, effective and efficient pattern matching exercise.

The same is true of systems and processes – plotting the system metrics as time-series charts and searching for the tell-tale patterns of process disease can be a simple, quick and accurate technique: when you have learned what a “healthy” process looks like and which patterns are caused by which process “diseases”.  This skill is gained through Operations Management training and lots of practice with the guidance of an experienced practitioner. Without this investment in developing knowlewdge and understanding there is a high risk of making a wrong diagnosis and instituting an ineffective or even dangerous treatment.  Confidence is good – competence is even better.

The objective of process diagnostics is to identify where and when the LUBs and HUBs appear are in the system: a LUB is a “low utilisation bottleneck” and a HUB is a “high utilisation bottleneck”.  Both restrict flow but they do it in different ways and therefore require different management. If we confuse a LUB for a HUB and choose the wrong treatent we can unintentionally make the process sicker – or even kill the system completely. The intention is OK but if we are not competent the implementation will not be OK.

Improvement Science rests on two foundations stones – Operations Management and Human Factors – and managers of any process or system need an understanding of both and to be able to apply their knowledge in practice with competence and confidence.  Just as a doctor needs to understand how the heart works and how to apply this knowledge in clinical practice. Both technical and emotional capability is needed – the Head and the Heart need each other.                          


Many of us use the terms “effective” and “efficient” and we assume that if we achieve both at the same time then we can call it “success”. They are certainly both necessary but are they sufficient? If they were then every process that was both effective (zero mistakes) and efficient (zero waste) would be hailed a success. This is our hypothesis and to disprove it we only need one example where it fails. Let us see if we can find one in our collective experience.

Threats focus our attention more than opportunities. When our safety is at risk it is a sensible strategy to give the threat our full attention – and our caveman wetware has a built-in personal threat management system: it is called the Fright, Flight, Fight response. The FFF is coordinated by the oldest, most unconscious bits of our wetware and we know it as the fast heart, dry mouth, cold sweat reaction – or adrenalin rush. When we perceive a threat we are hard-wired to generate the emotion called fear, and this tells us we need to make a decision between two actions: to stand our ground or to run away. The decision needs to be made quickly because the outcome of it may determine our survival – so we need a quick, effective and efficient way to do it. If we choose to “fight” then another emotion takes over – anger – and it hijacks our rationality: arguments, fights, battles and wars are all tangible manifestations of our collective reaction – and when the conditions are just right even a single word or action may be perceived as a threat and trigger an argument, then a fight, then a battle, then a war – a classic example of a positive feedback loop that can literally explode into an unstoppable orgy of death and destruction.

Can we measure the “success” of our hard-wired FFF system: let us consider the outcome of a war – a winner and a loser; and let us also count the cost of a war – lots of valuable resources consumed and lots of dead people on both sides. Wars inflict high costs on both sides and the “loser” is the one who loses most – the winner loses too – just less. But is it all negative? If it were then no one would ever do it – so there must be some tangible benefit. When the sides are unequally matched the victor can survive the losses and can grow from “absorbing” what remains of the loser. This is the dog-eat-dog world of survival of the strongest and represents another positive feedback loop – he who has most takes more.

Threats focus our attention and if we are not at immediate risk then they can also stimulate our creativity – and what is learned in the process of managing a threat can be of lasting value after the threat has passed.  Many of the benefits we enjoy today were “stimulated” by the threats in WWII – for example: digital computers were invented to assist making ballistics calculations and for breaking enemy secret codes. Much of the theory, techniques and tools of Improvement Science were developed during WWII to increase the productivity of weapons-of-war creation – and they have been applied more constructively in peacetime.  Wars are created by people and the “great” warriors create the most effective and efficient lose-lose processes. Using threats to drive creativity is a low-productivity design – ee can do much better than that – surely?

So, our experience suggests that effectiveness and efficiency are not enough – there seems to be a piece missing – and this piece is “intention”. Our Purpose.  This insight explains why asking the “What is our purpose?” question is so revealing:  if you do not get a reply it is likely that your audience is seeing challenge as a battle – and the First Rule of War is never to reveal your intention to your enemy – so their battle metaphor prevents them from answering honestly. If you do get an answer it is very often a “to do” answer rather than a “to get” one – unconsciously masking purpose with process and side-stepping the issue.  Their language gives it away though – processes are flagged by verbs, purposes are flagged by nouns – so if you listen to what they say then you can tell.  The other likely answer is a question: not a question for clarification, a question for deflection and the objective is more threat-assessment data and more thinking and preparation time.

If the answer to the Purpose Question is immediate, an outcome, and positive then the respondent is not using a war meta-program; they do not view the challenge as a threat and they do see a creative opportunity for improvement – they see it as a Race. Their intention is improvement for all on all dimensions: quality, delivery and money – and they recognise that healthy competition can be good for both. Do not be fooled – they are neither weak not stupid – if they perceive a safety threat they will deploy all their creative resources to eliminate it.

One of the commonest errors of commission is to eliminate healthy competition; which is what happens when we have not learned how to challenge with respect: we have let things slip to the point that we are forced to fight or flee. We have not held ourselves to account and we have not learned to ask the ourselves “What is my purpose?” People need to have a purpose to channel their effectivess and efficiency – and processes also need a purpose because socio-economic systems are the combination of people and processes.

The purpose for any socioeconomic system is the generic phrase “right-thing, right-place, right-price, on-time, first-time, every-time” and is called the system goal.  The purpose of a specific process or person within that system will be aligned to the goal and there are two parts to this: the “right-” parts which are a matter of subjectivity and the “-time” parts which are a matter of objectivity. The process must be designed to deliver the objectives – and before we know what to do we must understand how to decide what to do; and before we know how to decide we must have the wisdom and courage to ask the question and to state our purpose. Intention – Decision – Action.


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.


The wetware between our ears is both amazing and frustrating.

One of the amazing features is how we can condense a whole paradigm into a few words; and one of the frustrating features is how we condense a whole paradigm into a few words.  Take the three words – Passion, Process and Purpose – just three seven letter words beginning with P.  Together they capture the paradigm of Improvement Science – these are the three interdependent parts.

Passion provides the energy to change and the desire to do something. Purpose is the goal that is sought; the outcome that is desired. Process is the recipe, the plan, the map of the journey.  All three are necessary and only together they are sufficient.

The easier bit is Passion – we are all emotional beings – we are not rocks or clocks – we have some irrational components included in our design. Despite what we may think, most of our thinking is outside awareness, unconscious, and we are steered by feelings and signal with feelings. We are not aware of how we use emotions to filter data and to facilitate decisions and we are not aware how we broadcast our unconscious thinking in our body language.

The trickier bit is Process and Purpose – not because they are difficult concepts, but because we confuse the two.  There are two different questions that we use to use to try to separate them: the How and the Why questions.  “How?” is the question that asks about the Process; “Why?” is the question that asks about the Purpose – and we very often give a How answer to a Why question. We seem to habitually dodge the Purpose question – and that is what makes it tricky.  Asking the question “What is my purpose for …” is one that we find difficult to answer. It is difficult because our purpose is unconscious – it is a combination of many things combining in parallel – and such multi-part-interdependent-mental objects are systems; and systems are difficult to capture with a single concept and therefore difficult to bring to consciousness. We feel we have a purpose and we know when others share that purpose but we find it difficult to say what it is – so we say how it works instead.  And if we lose our feeling of purpose we become unhappy – we need Purpose.   

This trickiness of  Process and Purpose is critical to the Science of Improvement because the design method starts with a Purpose – and then works backwards to define a Process; while improvement starts with a Passion and moves forward into deciding a Process. Our normal, intuitive mode of working is to use our irrationality to trigger a sequence of actions – we are instinctively reactive.

The contra-normal, counter-intuitive mode of working is to start with our purpose and use our rationality to assemble a sequence of actions.  We pause, consider, think and then act – with purpose.  This is why vision and mission are so important to collective improvement – the vision and mission provide a quick reminder of our collective purpose.  And that is why investing time in deeply exploring the Purpose question is such an important step – when you get to your purpose and you ask the right question there is a sort of mental “click” as the thinking and the feeling align – the two parts of our wetware working as one system.


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.