Seeing Is Believing or Is It?

Do we believe what we see or do we see what we believe?  It sounds like a chicken-and-egg question – so what is the answer? One, the other or both?

Before we explore further we need to be clear about what we mean by the concept “see”.  I objectively see with my real eyes but I subjectively see with my mind’s eye. So to use the word see for both is likely to result in confusion and conflict and to side-step this we will use the word perceive for seeing-with-our-minds-eye.   

When we are sure of our belief then we perceive what we believe. This may sound incorrect but psychologists know better – they have studied sensation and perception in great depth and they have proved that we are all susceptible to “perceptual bias”. What we believe we will see distorts what we actually perceive – and we do it unconsciously. Our expectation acts like a bit of ancient stained glass that obscures and distorts some things and paints in a false picture of the rest.  And that is just during the perception process: when we recall what we perceived we can add a whole extra layer of distortion and can can actually modify our original memory! If we do that often enough we can become 100% sure we saw something that never actually happened. This is why eye-witness accounts are notoriously inaccurate! 

But we do not do this all of the time.  Sometimes we are open-minded, we have no expectation of what we will see or we actually expect to be surprised by what we will see. We like the feeling of anticipation and excitement – of not knowing what will happen next.   That is the psychological basis of entertainment, of exploration, of discovery, of learning, and of improvement science.

An experienced improvement facilitator knows this – and knows how to create a context where deeply held beliefs can be explored with sensitivity and respect; how to celebrate what works and how and why it does; how to challenge what does not; and how to create novel experiences; foster creativity and release new ideas that enhance what is already known, understood and believed.

Through this exploration process our perception broadens, sharpens and becomes more attuned with reality. We achieve both greater clarity and deeper understanding – and it is these that enable us to make wiser decisions and commit to more effective action.

Sometimes we have an opportunity to see for real what we would like to believe is possible – and that can be the pivotal event that releases our passion and generates our commitment to act. It is called the Black Swan effect because seeing just one black swan dispels our belief that all swans are white.

A practical manifestation of this principle is in the rational design of effective team communication – and one of the most effective I have seen is the Communication Cell – a standardised layout of visual information that is easy-to-see and that creates an undistorted perception of reality.  I first saw it many years ago as a trainee pilot when we used it as the focus for briefings and debriefings; I saw it again a few years ago at Unipart where it is used for daily communication; and I have seen it again this week in the NHS where it is being used as part of a service improvement programme.

So if you do not believe then come and see for yourself.

March Madness

Whether we like it or not we are driven by a triumvirate of celestial clocks. Our daily cycle is the result of the rotation of the Earth; the ebb and flow of the tides is caused by the interaction of the orbiting Moon and the spinning Earth; and the annual sequence of seasons is the outcome of the tilted Earth circling the Sun.  The other planets, stars and galaxies appear not to have much physical influence – despite what astrologists would have us believe. 

Hares are said to behave oddly in the month of March – as popularised by Lewis Carroll in Alice’s Adentures in Wonderland – but there is another form of March Madness that affects people – one that is not celestial and seasonal in origin – its cause is fiscal and financial. The madness that accompanies the end of the tax year.

This fiscal cycle is man-made and is arbitrary – it could just as well be any other month and does indeed differ from country to country – and the reason it is April 6th in the UK is because it is based on the ecclesiastical year which starts on March 25th but was shifted to April 6th when 11 days were lost on the adoption of the Gregorian calendar in 1752.  The driver of the fiscal cycle is taxation and the embodiment in Law of the requirement to present standard annual financial statements for the purpose of personal taxation.

The problem is that this system was designed for a time when the bean-counting bureaucracy was people-pen-paper based and to perform this onerous task more often than annually would have been counter-productive.  That is the upside. The downside is that an annual fiscal cycle shackled to a single date creates a feast-and-famine cash flow effect. The public coffers would have a shark-fin shaped wonga-in-progress chart!  And preparing for the end of the financial year creates multi-faceted March madness: annual cash hoarding leads to delayed investment decisions and underspent budgets being disposed of carelessly; short term tax minimisation strategies distort long term investment decisions and financial targets take precident over quality and delivery goals. Success or failure hinges on the the financial equivalent of threading the eye of a long needle with a bargepole. The annual fiscal policy distorts the behaviour of system and benefits nobody. 

It would be a better design for everyone if fiscal feedback was continuous – especially as the pace of change is quickening to the point that an annual financial planning cycle is painfully long . The good news is that there are elements of fiscal load levelling aleady: companies can choose a date for their annual returns; sales tax is charged continuosuly and collected quarterly; income tax is collected monthly or weekly. But with the ubiquitous digital computer the cost of the bureaucracy is now so low that the annual fiscal fiasco is technically unnecessary and it has become more of a liability than an asset.

What would be the advantages of scrapping it? Individuals could change their tax review date and interval to one that better suits them and this would spread the bureaucratic burden on the inland revenue over the year; the country would have a smoother tax revenue flow and less ]need to  borrow to fund public expenses; and publically funded organisations could budget on a trimester or even monthly basis and become more responsive to financial fluxes and changes in the system. It could be better for everyone – but it would require radical redesign. We are not equipped to do that – we would need to understand the principles of improvement science that relate to elimination of variation.

And what about the other annual cycle that plagues the population – the Education Niggle? This is the one that requires everyone with children of school age to be forced to take family holidays at the same time: Easter, Summer and Christmas – creating another batch-and-queue feast-and-famine cycle. This fiasco originated in the early 1800’s when educational reformers believed that continuous schooling was unhealthy and institutionalised when the Forster Elementary Education Act of 1870 provided partially state funded schools – especially for the poor – to provide a sufficient supply of educated workers for the burgeoning Industrial Revolution. Once the expectation of a long summer vacation was established it has been difficult to change.  More recent evidence shows that the loss of learning momentum has a detrimental effect on children not to mention the logistical problems created if both parents are working. Children are born all year round and have wide variation in their abilities and rate of learning and to impose an arbitrary educational cycle is clearly more for the convenience of the schools and teachers than aligned to the needs of children, their families or society.  As our required skills become more generic and knowledge focussed the need for effective and efficient continuous education has never been greater. Digital communication technology is revolutionising this whole sector and individually-tailored, integrated, life-long  learning and continuous assessment is now both feasible and more affordable.

And then there is healthcare!  Where do we start?

It is time to challenge and change our out-of-date no-longer-fit-for-purpose bureaucratic establishment designs – so there will be no shortage of opportunties or work for every competent and capable Improvement Scientist!

Never Events and Nailing Niggles

Some events should NEVER happen – such as removing the wrong kidney; or injecting an anti-cancer drug designed for a vein into the spine; or sailing a cruise ship over a charted underwater reef; or driving a bus full of sleeping school children into a concrete wall.

But  these catastrophic irreversible and tragic Never Events do keep happening – rarely perhaps – but persistently. At the Never-Event investigation the Finger-of-Blame goes looking for the incompetent culprit while the innocent victims call for compensation.

And after the smoke has cleared and the pain of loss has dimmed another Never-Again-Event happens – and then another, and then another. Rarely perhaps – but not never.

Never Events are so awful and emotionally charged that we remember them and we come to believe that they are not rare and from that misperception we develop a constant nagging feeling of fear for the future. It is our fear that erodes our trust which leads to the paralysis that prevents us from acting.  In the globally tragic event of 9/11 several thousand innocents victims died while the world watched in horror.  More innocent victims than that die needlessly every day in high-tech hospitals from avoidable errors – but that statistic is never shared.

The metaphor that is often used is the Swiss Cheese – the sort on cartoons with lots of holes in it. The cheese represents a quality check – a barrier that catches and corrects mistakes before they cause irreversible damage. But the cheesy check-list is not perfect; it has holes in it.  Mistakes slip through.

So multiple layers of cheesy checks are added in the hope that the holes in the earlier slices will be covered by the cheese in the later ones – and our experience shows that this multi-check design does reduce the number of mistakes that get through. But not completely. And when, by rare chance, holes in each slice line up then the error penetrates all the way through and a Never Event becomes a Actual Catastrophe.  So, the typical recommendation from the after-the-never-event investigation is to add another layer of cheese to the stack – another check on the list on top of all the others.

But the cheese is not durable: it deteriorates over time with the incessant barrage of work and the pressure of increasing demand. The holes get bigger, the cheese gets thinner, and new holes appear. The inevitable outcome is the opening up of unpredictable, new paths through the cheese to a Never Event; more Never Events; more after-the-never-event investigation; and more slices of increasingly expensive and complex cheese added to the tottering, rotting heap.

A drawback of the Swiss Cheese metaphor is that it gives the impression that the slices are static and each cheesy check has a consistent position and persistent set of flaws in it. In reality this is not the case – the system behaves as if the slices and the holes are moving about: variation is jiggling , jostling and wobbling the whole cheesy edifice.

This wobble does not increase the risk of a Never Event  but it prevents the subsequent after-the-event investigation from discovering the specific conjunction of holes that caused it. The Finger of Blame cannot find a culprit and the cause is labelled a “system failure” or an unlucky individual is implicated and named-shamed-blamed and sacrificed to the Gods of Chance on the Alter of Hope! More often new slices of KneeJerk Cheese are added in the desperate hope of improvement – and creating an even greater burden of back-covering bureaucracy than before – and paradoxically increasing the number of holes!

Improvement Science offers a more rational, logical, effective and efficient approach to dissolving this messy, inefficient and ineffective safety design.

First it recognises that to prevent a Never Event then no errors should reach the last layer of cheese checking – the last opportunity to block the error trajectory. An error that penetrates that far is a Near Miss and these will happen more often than Never Events so they are the key to understanding and dissolving the problem.

Every Near Miss that is detected should be reported and investigated immediately – because that is the best time to identify the hole in the previous slice – before it wobbles out of sight. The goal of the investigation is understanding not accountability. Failure to report a near miss; failure to investigate it; failure to learn from it; failure to act on it; and failure to monitor the effect of the action are all errors of omission (EOOs) and they are the worst of management crimes.

The question to ask is “What error happened immediately before the Near Miss?”  This event is called a Not Again. Focussing attention on this Not Again and understanding what, where, when, who and how it happened is the path to preventing the Near Miss and the Never Event.  Why is not the question to ask – especially when trust is low and cynicism and fear are high – the question to ask is “how”.

The first action after Naming the Not Again is to design a counter-measure for it – to plug the hole – NOT to add another slice of Check-and Correct cheese! The second necessary action is to treat that Not Again as a Near-Miss and to monitor it so when it happens again the cause can be identified. These common, every day, repeating causes of Not Agains are called Niggles; the hundreds of minor irritations that we just accept as inevitable. This is where the real work happens – identifying the most common Niggle and focussing all attention on nailing it! Forever.  Niggle naming and nailing is everyone’s responsibility – it is part of business-as-usual – and if leaders do not demonstrate the behaviour and set the expectation then followers will not do it.

So what effect would we expect?

To answer that question we need a better metaphor than our static stack of Swiss cheese slices: we need something more dynamic – something like a motorway!

Suppose you were to set out walking across a busy motorway with your eyes shut and your fingers in your ears – hoping to get to the other side without being run over. What is the chance that you will make it across safely?  It depends on how busy the traffic is and how fast you walk – but say you have a 50:50 chance of getting across one lane safely (which is the same chance as tossing a fair coin and getting a head) – what is the chance that you will get across all six lanes safely? The answer is the same chance as tossing six heads in a row: a 1-in-2 chance of surviving the first lane (50%), a 1 in 4 chance of getting across two lanes (25%), a 1 in 8 chance of making it across three (12.5%) …. to a 1 in 64 chance of getting across all six (1.6%). Said another way that is a 63 out of 64 chance of being run over somewhere which is a 98.4% chance of failure – near certain death! Hardly a Never Event.

What happens to our risk of being run over if the traffic in just one lane is stopped and that lane is now 100% safe to cross? Well you might think that it depends on which lane it is but it doesn’t – the risk of failure is now 31/32 or 96.8% irrespective of which lane it is – so not much improvement apparently!  We have doubled the chance of success though!

Is there a better improvement strategy?

What if we work collectively to just reduce the flow of Niggles in all the lanes at the same time – and suppose we are all able to reduce the risk of a Niggle in our lane-of-influence from 1-in-2 to 1-in-6. How we do it is up to us. To illustrate the benefit we replace our coin with a six-sided die (no pun intended) and we only “die” if we throw a 1.  What happens to our pedestrian’s probability of survival? The chance of surviving the first lane is now 5/6 (83.3%), and both first and second 5/6 x 5/6 = 25/36 (69%.4) and so on to all six lanes which is 5/6 x 5/6 x 5/6 x 5/6 x 5/6 x 5/6 = 15625/46656 = 33.3% which is a lot better than our previous 1.6%!  And what if we keep plugging the holes in our bits of the cheese and we increase our individual lane success rate to 95% – our pedestrians probability of survival is now 73.5%. The chance of a catastrophic event becomes less and less.

The arithmetic may be a bit scary but the message is clear: to prevent the Never Events we must reduce the Near Misses and to to do that we investigate every Near Miss and expose the Not Agains and then use them to Name and Nail all the Niggles.  And we have complete control over the causes of our commonest Niggles because we create them.

This strategy will improve the safety of our system. It has another positive benefit – it will free up our Near Miss investigation team to do something else: it frees them to assist in the re-design the system so that Not Agains cannot happen at all – they become Never Events too – and the earlier in the path that safety-design happens the better – because it renders the other layers of check-and-correct cheesocracy irrelevant.

Just imagine what would happen in a real system if we did that …

And now try to justify not doing it …

And now consider what an individual, team and organisation would need to learn to do this …

It is called Improvement Science.

And learning the Foundations of Improvement Science in Healthcare (FISH) is one place to start.


The Journal of Improvement Science

Improvement Science encompasses research, improvement and audit and includes both subjective and objective dimensions.  An essential part of collective improvement is sharing our questions and learning with others.

From the perspective of the learner it is necessary to be able to trust that what is shared is valid and from the perspective of the questioner it is necessary to be able to challenge with respect.

Sharing new knowledge is not the only purpose of publication: for academic organisations it is also a measure of performance so there is a academic peer pressure to publish both quantity and quality – an academic’s career progression depends on it.

This pressure has created a whole industry of its own – the academic journal – and to ensure quality is maintained it has created the scholastic peer review process.  The  intention is to filter submitted papers and to only publish those that are deemed worthy – those that are believed by the experts to be of most value and of highest quality.

There are several criteria that editors instruct their volunteer “independent reviewers” to apply such as originality, relevance, study design, data presentation and balanced discussion.  This process was designed over a hundred years ago and it has stood the test of time – but – it was designed specifically for research and before the invention of the Internet, of social media and the emergence of Improvement Science.

So fast-forward to the present and to a world where improvement is now seen to  be complementary to research and audit; where time-series statistics is viewed as a valid and complementary data analysis method; and where we are all able to globally share information with each other and learn from each other in seconds through the medium of modern electronic communication.

Given these changes is the traditional academic peer review journal system still fit for purpose?

One way to approach this question is from the perspective of the customers of the system – the people who read the published papers and the people who write them.  What niggles do they have that might point to opportunities for improvement?

Well, as a reader:

My first niggle is to have to pay a large fee to download an electronic copy of a published paper before I can read it. All I can see is the abstract which does not tell me what I really want to know – I want to see the details of the method and the data not just the authors edited highlights and conclusions.

My second niggle is the long lead time between the work being done and the paper being published – often measured in years!  This implies that the published news is old news  useful for reference maybe but useless for stimulating conversation and innovation.

My third niggle is what is not published.  The well-designed and well-conducted studies that have negative outcomes; lessons that offer as much opportunity for learning as the positive ones.  This is not all – many studies are never done or never published because the outcome might be perceived to adversely affect a commercial or “political” interest.

My fourth niggle is the almost complete insistence on the use of empirical data and comparative statistics – data from simulation studies being treated as “low-grade” and the use of time-series statistics as “invalid”.  Sometimes simulations and uncontrolled experiments are the only feasible way to answer real-world questions and there is more to improvement than a RCT (randomised controlled trial).

From the perspective of an author of papers I have some additional niggles – the secrecy that surrounds the review process (you are not allowed to know who has reviewed the paper); the lack of constructive feedback that could help an inexperienced author to improve their studies and submissions; and the insistence on assignment of copyright to the publisher – as an author you have to give up ownership of your creative output.

That all said there are many more nuggets to the peer review process than niggles and to a very large extent what is published can be trusted – which cannot be said for the more popular media of news, newspapers, blogs, tweets, and the continuous cacophony of partially informed prejudice, opinion and gossip that goes for “information”.

So, how do we keep the peer-reviewed baby and lose the publication-process bath water? How do we keep the nuggets and dump the niggles?

What about a Journal of Improvement Science along the lines of:

1. Fully electronic, online and free to download – no printed material.
2. Community of sponsors – who publically volunteer to support and assist authors.
3. Continuously updated ranking system – where readers vote for the most useful papers.
4. Authors can revise previously published papers – using feedback from peers and readers.
5. Authors retain the copyright – they can copy and distribute their own papers as much as they like.
6. Expected use of both time-series and comparative statistics where appropriate.
7. Short publication lead times – typically days.
8. All outcomes are publishable – warts and all.
9. Published authors are eligible to be sponsors for future submissions.
10. No commercial sponsorship or advertising.

STOP PRESS: JOIS is now launched: Click here to enter.

Resetting Our Systems

 Our bodies are amazing self-monitoring and self-maintaining systems – and we take them completely for granted!

The fact that it is all automatic is good news for us because it frees us up to concentrate on other things – BUT – it has a sinister side too.  Our automatic monitor-and-maintain design does not imply what is maintained is healthy – the system is just designed to keep itself stable.

Take our blood pressure as an example. We all have two monitor-and-maintain systems that work together – one that stablises short-term changes in blood pressure (such as when you recline, stand, run, fight, and flee) and the other that stablises long-term changes. The image above is a very simplified version of the long-term regulation system!

Around one quarter of all adults are classified as having high blood pressure – which means that it is consistently higher than is healthy – and billions of £ are spent every year on drugs to reduce blood pressure in millions of people.  Why is this an issue? How does it happen? What lessons are there for the student of Improvement Science?

High blood pressure (or hypertension) is dangerous – and the higher it is the more dangerous it is. It is called the silent killer and the reason is that it is called silent is because there are no symptoms. The reason it called a killer is because over time it causes irreversible damage to vital organs – the heart, kidneys and arteries in the brain.

The vast majority of hypertensives have what is called essential hypertension – which means that there is no obvious single cause.  It is believed that this is the result of their system gradually becoming reset so that it actively maintains the high blood pressure.  This is just like gradually increasing the setting on the thermostat in our house – say by just 0.01 degree per week – not much and not even measurable – but over time the cumulative effect would have a big impact on our heating bills!

So, what resets our long-term blood pressure regulation system? It is believed that the main culprit is stress because when we feel stressed our bodies react in the short-term by pushing our blood pressure up – it is called the fright-fight-flight response. If the stress is repeated time and time again our pressure-o-stat becomes gradually reset and the high blood pressure is then maintained, even when we do not feel stressed. And we do not notice – until something catastrophic happens! And that is too late.

The same effect happens in organisations except that the pressure is emotional and is created by the stress of continually fighting to meet performance targets. The result is a gradual resetting of our expectations and behaviours and the organisation develops emotional hypertension which leads to irreversible damage to the organisations culture. This emotional creep goes largely unnoticed until a catastrophic event happens – and if severe enough the organisation will be crippled and may not survive. The Mid Staffs Hospital patient safety catastrophe is a real and recent example of cultural creep in a healthcare organisation driven by incessant target-driven behaviour. It is a stark lesson to us all. 

So what is the solution?

The first step is to realise that we cannot just rely on hope, ignore the risk and wait for the early warning  symptoms – by that time the damage may be irreversible; or the catastrophe may get us without warning. We have to actively look for the signs of the creeping cultural change – and we have to do that over a long period of time because it is gradual. So, if we have just be jolted out of denial by a too-close-for-comfort expereince then we need to adopt a different strategy and use an external absolute reference – an emotionally and culturally healthy organisation.

The second step is to adopt a method that will tell us reliably if there is a significant shift in our emotional pressure and a method that is sensitive eneough to alert  us before it goes outside a safe range – because we want to intervene as early as possible and only when necessary. Masterly inactivity and cat-like observation according to one wise medical mentor.  

The third step is to actively remove as many of the stressors as possible – and for an organisation this means replacing DRATs (Delusional Ratios and Arbitrary Targets) with well-designed specification limits; and replacing reactive fire-fighting with proactive feedback. This is the role of the leaders.

The fourth step is to actively reduce the emotional pressure but to do it gradually because the whole system needs to adjust. Dropping the emotional pressure too quickly is as dangerous as discounting its importance.

The key to all of this is the appropriate use of data and time-series analysis because the smaller long-term shifts are hidden in the large short-term variation. This is where many get stuck because they are not aware that there two different sorts of statistics. The  correct sort for monitoring systems is called time-series statistics and it not the same as the statistics that we learn at school and university. That is called comparative statistics. This is a shame really because time-series statistics is much more applicable to every day life problems such as managing our blood pressure, our weight, our finances, and the cultural health of our organisations.

Fortunately time-series statistics is easier to learn and use than school statistics so to get started on resetting your personal and organisational emot-o-stat please help yourself to the complimentary guide by clicking here.