September 2011 – HCSE Blog

25/09/2011

Cutting The Cost Cake

We are in now in cost cake cutting times! We are being forced by financial reality to tighten the fiscal belt until our eyeballs water – and then more so.

The cost cake is a mixture of three ingredients – the worthwhile, the necessary, and the rest – the stuff that is worthless and not wanted – the worthless stuff, the unhealthy stuff, the waste. But it costs just as much per morsel as the rest. And there is a problem – all three ingredients are mixed up together and our weighing scales can not say how much of each is in there – it just tells us the total weight and cost.

If we are forced to cut the cost of the cake we have to cut all three. Our cake gets smaller – not better – which means that we all go a bit hungrier. Or as is more likely – the hand that weilds the knife will cut themselves a full slice and someone else will starve.

Would it not be better if we could separate out the ingredients and see them for what the are – worthy (green), necessary (yellow) and the worthless waste (red) – and then use the knife to slice off the waste? Then we could mix up what is left and share out a smaller but healthier meal. We might even re-invest our savings in buying more of the better ingredients and bake ourselves a healthier cake. We would have a choice.

If we translate this culinary metaphor into the real world then we will see the need for a way of separating and counting the cost of time spent on worthy, necessary and worthless work. If we can do that then we can remove just the worthless stuff and either reduce the cost or reinvest the resource in something more worthwhile.

The problem we find when we try to do this is that our financial accounting systems do not work this way.

The closed door to a healthier future is staring us in the face – it is barn-door obvious – we just need to design our accounting methods so that they can do what we need them to do.

What are we waiting for? Let us work together to find a way to open that closed door. It is in all of our interests!

17/09/2011

The Cost of Distrust

Previously we have explored “costs” associated with processes and systems – costs that could be avoided through the effective application of Improvement Science. The Cost of Errors. The Cost of Queues. The Cost of Variation.

These costs are large, additive and cumulative and yet they pale into insignificance when compared with the most potent source of cost. The Cost of Distrust.

The picture is of Sue Sheridan and the link below is to a video of Sue telling her story of betrayed trust: in a health care system. She describes the tragic consequences of trust-eroding health care system behaviour. Sue is not bitter though – she remains hopeful that her story will bring everyone to the table of Safety Improvement

View the Video

The symptoms of distrust are easy to find. They are written on the faces of the people; broadcast in the way they behave with each other; heard in what they say; and felt in how they say it. The clues are also in what they do not do and what they do not say. What is missing is as important as what is present.

There are also tangible signs of distrust too – checklists, application-for-permission forms, authorisation protocols, exception logs, risk registers, investigation reports, guidelines, policies, directives, contracts and all the other machinery of the Bureaucracy of Distrust.

The intangible symptoms of distrust and the tangible signs of distrust both have an impact on the flow of work. The untrustworthy behaviour creates dissatisfaction, demotivation and conflict; the bureaucracy creates handoffs, delays and queues. All are potent sources of more errors, delays and waste.

The Cost of Distrust is is counted on all three dimensions – emotional, temporal and financial.

It may appear impossible to assign a finanical cost of distrust because of the complex interactions between the three dimensions in a real system; so one way to approach it is to estimate the cost of a high-trust system. A system in which the trustworthy behaviour is explicit and trust eroding behaviour is promptly and respectfully challenged.

Picture such a system and consider these questions:

How would it feel to work in a high-trust system where you know that trust-eroding-behaviour will be challenged with respect?
How would it feel to be the customer of a high-trust system?
What would be the cost of a system that did not need the Bureaucracy of Distrust to deliver safety and quality?

Trust eroding behaviours are not reduced by decree, threat, exhortation, name-shame-blame, or pleading because all these behaviours are based on the assumption of distrust and say “I do not trust you to do this without my external motivation”. These attitudes behaviours give away the “I am OK but You are Not OK” belief.

Trust eroding behaviours are most effectively reduced by a collective charter which is when a group of people state what behaviours they do not expect and individually commit to avoiding and challenging. The charter is the tangible sign of the peer support that empowers everyone to challenge with respect because they have collective authority to do so. Authority that is made explicit through the collective charter: “We the undersigned commit to respectfully challenge the following trust eroding behaviours …”.

It requires confidence and competence to open a conversation about distrust with someone else and that confidence comes from insight, instruction and practice. The easiest person to practice with is ourselves – it takes courage to do and it is worth the investment – which is asking and answering two questions:

Q1: What behaviours would erode my trust in someone else?

Make a list and rank on order with the most trust-eroding at the top.

Q2: Do I ever exhibit any of the behaviours I have just listed?

Choose just one from your list that you feel you can commit to – and make a promose to yourself – every time you demonstrate the behaviour make a mental note of:

When it happened?
Where it happened?
Who was present?
What just happened?
How did you feel?

You do not need to actively challange your motives, or to actively change your behaviour – you just need to connect up your own emotional feedback loop. The change will happen as if by magic!

10/09/2011

Doing Our Way to New Thinking.

Most of our thinking happens out of awareness – it is unconscious. Most of the data that pours in through our senses never reaches awareness either – but that does not mean it does not have an impact on what we remember, how we feel and what we decide and do in the future. It does.

Improvement Science is the knowledge of how to achieve sustained change for the better; and doing that requires an ability to unlearn unconscious knowledge that blocks our path to improvement – and to unlearn selectively.

So how can we do that if it is unconscious? Well, there are at least two ways:

1. Bring the unconscious knowledge to the surface so it can be examined, sorted, kept or discarded. This is done through the social process of debate and discussion. It does work though it can be a slow and difficult process.

2. Do the unlearning at the unconscious level – and we can do that by using reality rather than rhetoric. The easiest way to connect ourselves to reality is to go out there and try doing things.

When we deliberately do things we are learning unconsciously because most of our sensory data never reaches awareness. When we are just thinking the unconscious is relatively unaffected: talking and thinking are the same conscious process. Discussion and dialog operate at the conscious level but differ in style – discussion is more competitive; dialog is more collaborative.

The door to the unconscious is controlled by emotions – and it appears that learning happens more effectively and more efficiently in certain emotional states. Some emotional states can impair learning; such as depression, frustration and anxiety. Strong emotional states associated with dramatic experiences can result in profound but unselective learning – the emotionally vivid memories that are often associated with unpleasant events. Sometimes the conscious memory is so emotionally charged and unpleasant that it is suppressed – but the unconscious memory is not so easily erased – so it continues to influence but out of awareness. The same is true for pleasant emotional experiences – they can create profound learning experiences – and the conscious memory may be called an inspirational or “eureka” moment – a sudden emotional shift for the better. And it too is unselective and difficult to erase.

An emotionally safe environment for doing new things and having fun at the same time comes close to the ideal context for learning. In such an enviroment we learn without effort. It does not feel like work – yet we know we have done work because we feel tired afterwards. And if we were to record the way that we behave and talk before the doing; and again afterwards then we will measure a change even though we may not notice the change ourselves. Other people may notice before we do – particularly if the change is significant – or if they only interact with us occasionally.

It is for this reason that keeping a personal journal is an effective way to capture the change in ourselves over time.

The Jungian model of personality types states that there are three dimensions to personality (Isabel Briggs Myers added a fourth later to create the MBTI®).

One dimension describes where we prefer to go for input data – sensors (S) use external reality as their reference – intuitors (N) use their internal rhetoric.

Another dimension is how we make decisions – thinkers (T) prefer a conscious, logical, rational, sequential decision process while feelers (F) favour an unconscious, emotional, “irrational”, parallel approach.

The third dimension is where we direct the output of our decisions – extraverts (E) direct it outwards into the public outside world while intraverts (I) direct it inwards to their private inner world.

Irrespective of our individual preferences, experience suggests that an effective learning sequence starts with our experience of reality (S) and depending how emotionally loaded it is (F) we may then internalise the message as a general intuitive concept (N) or a specific logical construct (T).

The implication of this is that to learn effectively and efficiently we need to be able to access all four modes of thinking and to do that we might design our teaching methods to resonate with this natural learning sequence, focussing on creating surprisingly positive reality based emotional experiences first. And we must be mindful that if we skip steps or create too many emotionally negative experiences we we may unintentionally impair the effectiveness of the learning process.

A carefully designed practical exercise that takes just a few minutes to complete can be a much more effective and efficient way to teach a profound principle than to read libraries of books or to listen to hours of rhetoric. Indeed some of the most dramatic shifts in our understanding of the Universe have been facilitated by easily repeatable experiments.

Intuition and emotions can trick us – so Doing Our Way to New Thinking may be a better improvement strategy.

03/09/2011

Three Blind Men and an Elephant

The Blind Men and the Elephant Story – adapted from the poem by John Godfrey Saxe.

“Three blind men were discussing exactly what they believed an elephant to be, since each had heard how strange the creature was, yet none had ever seen one before. So the blind men agreed to find an elephant and discover what the animal was really like. It did not take the blind men long to find an elephant at a nearby market. The first blind man approached the animal and felt the elephant’s firm flat side. “It seems to me that an elephant is just like a wall,” he said to his friends. The second blind man reached out and touched one of the elephant’s tusks. “No, this is round and smooth and sharp – an elephant is like a spear.” Intrigued, the third blind man stepped up to the elephant and touched its trunk. “Well, I can’t agree with either of you; I feel a squirming writhing thing – surely an elephant is just like a snake.” All three blind men continued to argue, based on their own individual experiences, as to what they thought an elephant was like. It was an argument that they were never able to resolve. Each of them was concerned only with their own experience. None of them could see the full picture, and none could appreciate any of the other points of view. Each man saw the elephant as something quite different, and while each blind man was correct they could not agree.”

The Elephant in this parable is the NHS and the three blind men are Governance, Operations and Finance. Each is blind because he does not see reality clearly – his perception is limited to assumptions and crippled by distorted data. The three blind men cannot agree because they do not share a common understanding of the system; its parts and its relationships. Each is looking at a multi-dimensional entity from one dimension only and for each there is no obvious way forward. So while they appear to be in conflict about the “how” they are paradoxically in agreement about the “why”. The outcome is a fruitless and wasteful series of acrimonious arguments, meaningless meetings and directionless discussions. It is not until they declare their common purpose that their differences of opinion are seen in a realistic perspective and as an opportunity to share and to learn and to create an collective understanding that is greater than the sum of the parts.