The Heart of Change

In 1628 a courageous and paradigm shifting act happened. A small 72-page book was published in Frankfurt that openly challenged 1500 years of medical dogma. The book challenged the authority of Galen (129-200) the most revered medical researcher of antiquity and Hippocrates (460 BC – 370 BC) the Father of Medicine.

The writer of the book was a respected and influential English doctor called William Harvey (1578-1657) who was physician to King James I and who became personal physician to King Charles I.

William_HarveyWilliam Harvey was from yeoman stock. The salt-of-the-earth. Loyal, honest and hard-working free men often owned their land – but who were way down the social pecking order. They were the servant class.

William was the eldest son of Thomas Harvey from Folkstone who had a burning ambition to raise the station of his family from yeoman to gentry. This implied that the family was allowed to have their own coat of arms. To the modern mind this is almost meaningless – in the 17th Century it was not!

And Thomas was wealthy enough to have William formally educated and the dutiful William worked hard at his studies and was rewarded by gaining a place at Caius College in Cambridge University.  John Caius (1510-1573) was a physician who had studied in Padua, Italy – the birthplace of modern medicine. William did well and after graduating from Cambridge in 1597 he too travelled through Europe to study in Padua. There he saw Galenic dogma challenged and defused using empirical evidence. This was at the same time that Galileo Galilei (1564-1642) was challenging the geocentric dogma of the Catholic Church using empirical evidence gained by simple celestial observation with his new telescope. This was the Renaissance. The Rebirth of Learning. This was the end of the Dark Ages of Dogma.

Harvey brought this “new thinking” back to Elizabethan England and decided to focus his attention on the heart. And what Harvey discovered was that the accepted truth from the ancients about how the heart worked was wrong. Galen was wrong. Hippocrates was wrong.

But this was not the most interesting part of the story.  It was the how he proved it that was radically different. He used evidence from reality to disprove the rhetoric. He used the empirical method espoused by Francis Bacon (1561-1626): what we now call the Scientific Method. In effect what Harvey said was “If you do not believe or agree with me then all you need to do is repeat the observation yourself.  Do an autopsy“.  [aut=self and opsy=see]. William Harvey saw and conducted human dissection in Padua, and practiced both it and animal vivisection back in England – and by that means he discovered how the heart actually worked.

Harvey opened a crack in the cultural ice that had frozen medical innovation for 1500 years. The crack in the paradigm was a seed of doubt planted by a combination of curiosity and empirical experimentation:

Q1: If Galen was wrong about the heart then what else was he wrong about? The Four Humours too?
Q2: If the heart is just a simple pump then where does the Spirit reside?

Looking back with our 21st century perspective these are meaningless questions.  To a person in the 17th Century these were fundamental paradigm-challenging questions.  They rocked the whole foundation of their belief system.  The believed that illness was a natural phenomenon and was not caused by magic, curses and evil spirits; but they believed that celestial objects, the stars and planets, were influential. In 1628 astronomy and astrology were the same thing.   

And Harvey was savvy. He was both religious and a devout Royalist and he knew that he would need the support of the most powerful person in England – the monarch. And he knew that he needed to be a respectable member of a powerful institution – the Royal College of Physicians (RCP) which he gained in 1604. A remarkable achievement in itself for someone of yeoman stock. With this ticket he was able to secure a position at St Bartholomew’s Hospital in Smithfield, London and in 1615 he became the RCP Lumleian Lecturer which involved lecturing on anatomy – which he did from 1616.  By virtue of his position Harvey was able to develop a lucrative private practice in London and by that route was introduced to the Court. In 1618 he was appointed as Physician Extraordinary to King James I. [The Physician Ordinary was the top job].

And even with this level of influence, credibility and royal support his paradigm-challenging message met massive cultural and political resistance because he was challenging a 1500 year old belief.

Over the 12 years between 1616 and 1628 Harvey invested a lot of time sharing his ideas and the evidence with influential friends and he used their feedback to deepen his understanding, to guide his experiments, and to sharpen his arguments. He had learned how to debate at school and had developed his skill at Cambridge so he know how to turn argments-against into arguments-for.

Harvey was intensely curious, he knew how to challenge himself, to learn, to influence others, and to change their worldview.  He knew that easily observable phenomemon could help spread the message – such as the demonstration of venous valves in the arm illustrated in his book.  

DeMotuCordisAfter the publication of De Motu Cordis in 1628 his personal credibility and private practice suffered massively because as a self-declared challenger of the current paradigm he was treated with skepticism and distrust by his peers. Gossip is effective.

And even with all his passion, education, evidence, influence and effort it still took 20 years for his message to become widely enough accepted to survive him.  And it did so because others resonated with the message; others like a Rene Descartes (1596-1650). 

William Harvey is now remembered as one of the founders of modern medical science.  When he published De Motu Cordis he triggered a paradim shift – one that we take for granted today.  Harvey showed that the path to improvement is through respectfully challenging accepted dogma with a combination of curiosity, humility, hard-work, and empirical evidence. Reality reinforced rhetoric.

Today we are used to having the freedom of speech and we are familiar with using experimental data to test our hypotheses.  In 1628 this was new thinking and was very risky. People were burned at the stake for challenging the authority of the Catholic Church and the Holy Roman Inquisition was still active well into the 18th Century!

Harvey was also innovative in the use of arithmetic. He showed that the volume of blood pumped by the heart in a day was far more than the liver could reasonably generate.  But at that time arithmetic was the domain of merchants, accountants and money-lenders and was not seen as a tool that a self-respecting natural philosopher would use!  The use of mathematics as a scientific tool did not really take off until after Sir Isaac Newton (1642-1727) published the Principia in 1687 – 30 years after Harvey’s death. [To read more about William Harvey click here].

William Harvey was an Improvementologist.

 So what lessons can modern Improvement Scientists draw from his story?

  • The first is that all significant challanges to current thinking will meet emotional and political resistance. They will be discounted and ridiculed because they challenge the authority of experts.
  • The second is that challenges must be made respectfully. The current thinking has both purpose and value. Improvements build on the foundation of knowledge and only challenge what is not fit for purpose.
  • The third is that the challenge must be more than rhetorical – it must be backed with replicatable evidence. A difference of opinion is just that. Reality is the ultimate arbiter.
  • The fourth is that having an idea is not enough – testig, proving, explaining and demonstrating are needed too. It is hard work to change a mental paradigm and it requires an emotionally secure context to do it. People who are under pressure will find it more difficult and more traumatic. 
  • The fifth is that patience and persistence are needed. Worldview change takes time and happen in small steps. The new paradigm needs to find its place.

And Harvey did not say that Galen and Hippocrates were completely wrong – just partly wrong. And he explained that the reason that Hippocrates and Galen could not test their ideas about human anatomy was because dissection of human bodies was illegal in Greek and Roman societies. Padua in Renaissance Italy was one of the first places where dissection was permitted by Law.   

So which part of the Galenic dogma did Harvey challenge?

He challenged the dogma that blood was created continuously by the liver. He challenged the dogma that there were invisible pores between the right and left sides of the heart. He challenged the dogma that the arteries ‘sucked’ the blood from the heart. He challenged the dogma that the ‘vitalised’ arterial blood was absorbed by the tissues. And he challenged these beliefs with empirical evidence. He showed evidence that the blood circulated fom the right heart to the lungs to the left heart to the body and back to the right heart. He showed evidence that the heart was a muscular pump. And he showed evidence that it worked the same way in man and in animals.  

FourHumoursIn so doing he undermined the foundation of the whole paradigm of ancient belief that illness was the result of an imbalance between the Four Humours. Yellow Bile (associated with the liver), Black Bile (associated with the Spleen), Blood (as ociated with the heart) and Phlegm (associated with the lungs).   

We still have the remnants of this ancient belief in our language.  The Four Humours were also associated with Four Temperaments – four observable personality types. The phlegmatic type (excess phlegm), the sanguine type (excess blood), the choleric type (excess yellow bile), and the melancholic type (excess black bile).

We still talk about “the heart of the matter” and being “heartless”, “heartfelt”  and “change of heart” because the heart was believed to be where emotion and passion resided. Sanguine is the term given to people who show warmth, passion, a live-now-pay-later, optimistic and energetic disposition. And this is not an unreasonable hypothesis given that we are all very aware of changes in how our heart beats when we are emotionally aroused; and how the color of our skin changes.

So when Harvey suggested that blood flowed in a circle from the heart to the arteries and back to the heart via the veins; and that the heart was just a pump then this idea shook the current paradigm on many levels – right down to its roots.

And the ancient justification for a whole raft of medical diagnoses, prognoses and treatments was challenged. The House of Cards was challenged. And many people owed their livelihoods to these ancient beliefs – so it is no surprise that his peers were not jumping  for joy to hear what Harvey said.

But Harvey had reality on his side – and reality trumps rhetoric.

And the same is true today, 500 years later.

The current paradigm is being shaken. The belief that we can all live today and pay tomorrow. The belief that our individual actions have no global impact and no long lasting consequences. The belief that competition is the best route to contentment.

The evidence is accumulating that these beliefs are wrong.

The difference is that today the paradigm is being challenged by a collective voice – not by a lone voice.

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Shifting, Shaking and Shaping

Stop Press: For those who prefer cartoons to books please skip to the end to watch the Who Moved My Cheese video first.

ThomasKuhnIn 1962 – that is half a century ago – a controversial book was published. The title was “The Structure of Scientific Revolutions” and the author was Thomas S Kuhn (1922-1996) a physicist and historian at Harvard University.  The book ushered in the concept of a ‘paradigm shift’ and it upset a lot a people.

In particular it upset a lot of scientists because it suggested that the growth of knowledge and understanding is not smooth – it is jerky. And Kuhn showed that the scientists were causing the jerking.

Kuhn described the process of scientific progress as having three phases: pre-science, normal science and revolutionary science.  Most of the work scientists do is normal science which means exploring, consolidating, and applying the current paradigm. The current conceptual model of how things work.  Anyone who argues against the paradigm is regarded as ‘mistaken’ because the paradigm represents the ‘truth’.  Kuhn draws on the history of science for his evidence, quoting  examples of how innovators such as Galileo, Copernicus, Newton, Einstein and Hawking radically changed the way that we now view the Universe. But their different models were not accepted immediately and ethusiastically because they challenged the status quo. Galileo was under house arrest for much of his life because his ‘heretical’ writings challenged the Church.  

Each revolution in thinking was both disruptive and at the same time constructive because it opened a door to allow rapid expansion of knowledge and understanding. And that foundation of knowledge that has been built over the centuries is one that we all take for granted.  It is a fragile foundation though. It could be all lost and forgotten in one generation because none of us are born with this knowledge and understanding. It is not obvious. We all have to learn it.  Even scientists.

Kuhn’s book was controversial because it suggested that scientists spend most of their time blocking change. This is not necessarily a bad thing. Stability for a while is very useful and the output of normal science is mostly positive. For example the revolution in thinking introduced by Isaac Newton (1643-1727) led directly to the Industrial Revolution and to far-reaching advances in every sphere of human knowledge. Most of modern engineering is built on Newtonian mechanics and it is only at the scales of the very large, the very small and the very quick that it falls over. Relativistic and quantum physics are more recent and very profound shifts in thinking and they have given us the digital computer and the information revolution. This blog is a manifestation of the quantum paradigm.

Kuhn concluded that the progess of change is jerky because scientists create resistance to change to create stability while doing normal science experiments.  But these same experiments produce evidence that suggest that the current paradigm is flawed. Over time the pressure of conflicting evidence accumulates, disharmony builds, conflict is inevitable and intellectual battle lines are drawn.  The deeper and more fundamental the flaw the more bitter the battle.

In contrast, newcomers seek harmony in the cacophony and propose new theories that explain both the old and the new. New paradigms. The stage is now set for a drama and the public watch bemused as the academic heavyweights slug it out. Eventually a tipping point is reached and one of the new paradigms becomes dominant. Often the transition is triggered by one crucial experiment.

There is a sudden release of the tension and a painful and disruptive conceptual  lurch – a paradigm shift. Then the whole process starts over again. The creators of the new paradigm become the consolidators and in time the defenders and eventually the dogmatics!  And it can take decades and even generations for the transition to be completed.

It is said that Albert Einstein (1879-1955) never fully accepted quantum physics even though his work planted the seeds for it and experience showed that it explained the experimental observations better. [For more about Einstein click here].              

The message that some take from Kuhn’s book is that paradigm shifts are the only way that knowledge  can advance.  With this assumption getting change to happen requires creating a crisis – a burning platform. Unfortunatelty this is an error of logic – it is a unverified generalisation from an observed specific. The evidence is growing that this we-always-need-a-burning-platform assumption is incorrect.  It appears that the growth of  knowledge and understanding can be smoother, less damaging and more effective without creating a crisis.

So what is the evidence that this is possible?

Well, what pattern would you look for to illustrate that it is possible to improve smoothly and continually? A smooth growth curve of some sort? Yes – but it is more than that.  It is a smooth curve that is steeper than anyone else’s and one that is growing steeper over time.  Evidence that someone is learning to improve faster than their peers – and learning painlessly and continuously without crises; not painfully and intermittently using crises.

Two examples are Toyota and Apple.

ToyotaLogoToyota is a Japanese car manufacturer that has out-performed other car manufacturers consistently for 40 years – despite the global economic boom-bust cycles. What is their secret formula for their success?

WorldOilPriceChartWe need a bit of history. In the 1980’s a crisis-of-confidence hit the US economy. It was suddenly threatened by higher-quality and lower-cost imported Japanese products – for example cars.

The switch to buying Japanese cars had been triggered by the Oil Crisis of 1973 when the cost of crude oil quadrupled almost overnight – triggering a rush for smaller, less fuel hungry vehicles.  This is exactly what Toyota was offering.

This crisis was also a rude awakening for the US to the existence of a significant economic threat from their former adversary.  It was even more shocking to learn that W Edwards Deming, an American statistician, had sown the seed of Japan’s success thirty years earlier and that Toyota had taken much of its inspiration from Henry Ford.  The knee-jerk reaction of the automotive industry academics was to copy how Toyota was doing it, the Toyota Production System (TPS) and from that the school of Lean Tinkering was born.

This knowledge transplant has been both slow and painful and although learning to use the Lean Toolbox has improved Western manufacturing productivity and given us all more reliable, cheaper-to-run cars – no other company has been able to match the continued success of Japan.  And the reason is that the automotive industry academics did not copy the paradigm – the intangible, subjective, unspoken mental model that created the context for success.  They just copied the tangible manifestation of that paradigm.  The tools. That is just cynically copying information and knowledge to gain a competitive advantage – it is not respecfully growing understanding and wisdom to reach a collaborative vision.

AppleLogoApple is now one of the largest companies in the world and it has become so because Steve Jobs (1955-2011), its Californian, technophilic, Zen Bhuddist, entrepreneurial co-founder, had a very clear vision: To design products for people.  And to do that they continually challenged their own and their customers paradigms. Design is a logical-rational exercise. It is the deliberate use of explicit knowledge to create something that delivers what is needed but in a different way. Higher quality and lower cost. It is normal science.

Continually challenging our current paradigm is not normal science. It is revolutionary science. It is deliberately disruptive innovation. But continually challenging the current paradigm is uncomfortable for many and, by all accounts, Steve Jobs was not an easy person to work for because he was future-looking and demanded perfection in the present. But the success of this paradigm is a matter of fact: 

“In its fiscal year ending in September 2011, Apple Inc. hit new heights financially with $108 billion in revenues (increased significantly from $65 billion in 2010) and nearly $82 billion in cash reserves. Apple achieved these results while losing market share in certain product categories. On August 20, 2012 Apple closed at a record share price of $665.15 with 936,596,000 outstanding shares it had a market capitalization of $622.98 billion. This is the highest nominal market capitalization ever reached by a publicly traded company and surpasses a record set by Microsoft in 1999.”

And remember – Apple almost went bust. Steve Jobs had been ousted from the company he co-founded in a boardroom coup in 1985.  After he left Apple floundered and Steve Jobs proved it was his paradigm that was the essential ingredient by setting up NeXT computers and then Pixar. Apple’s fortunes only recovered after 1998 when Steve Jobs was invited back. The rest is history so click to see and hear Steve Jobs describing the Apple paradigm.

So the evidence states that Toyota and Apple are doing something very different from the rest of the pack and it is not just very good product design. They are continually updating their knowledge and understanding – and they are doing this using a very different paradigm.  They are continually challenging themselves to learn. To illustrate how they do it – here is a list of the five principles that underpin Toyota’s approach:

  • Challenge
  • Improvement
  • Go and see
  • Teamwork
  • Respect

This is Win-Win-Win thinking. This is the Science of Improvement. This is Improvementology®.

So what is the reason that this proven paradigm seems so difficult to replicate? It sounds easy enough in theory! Why is it not so simple to put into practice?

The requirements are clearly listed: Respect for people (challenge). Respect for learning (improvement). Respect for reality (go and see). Respect for systems (teamwork).

In a word – Respect.

Respect is a big challenge for the individualist mindset which is fundamentally disrespectful of others. The individualist mindset underpins the I-Win-You-Lose Paradigm; the Zero-Sum -Game Paradigm; the Either-Or Paradigm; the Linear-Thinking Paradigm; the Whole-Is-The-Sum-Of-The-Parts Paradigm; the Optimise-The-Parts-To-Optimise-The-Whole Paradigm.

Unfortunately these are the current management paradigms in much of the private and public worlds and the evidence is accumulating that this paradigm is failing. It may have been adequate when times were better, but it is inadequate for our current needs and inappropriate for our future needs. 

So how can we avoid having to set fire to the current failing management paradigm to force a leap into the cold and uninviting reality of impending global economic failure?  How can we harness our burning desire for survival, security and stability? How can we evolve our paradigm pro-actively and safely rather than re-actively and dangerously?

all_in_the_same_boat_150_wht_9404We need something tangible to hold on to that will keep us from drowning while the old I-am-OK-You-are-Not-OK Paradigm is dissolved and re-designed. Like the body of the caterpillar that is dissolved and re-assembled inside the pupa as the body of a completely different thing – a butterfly.

We need a robust  and resilient structure that will keep us safe in the transition from old to new and we also need something stable that we can steer to a secure haven on a distant shore.

We need a conceptual lifeboat. Not just some driftwood,  a bag of second-hand tools and no instructions! And we need that lifeboat now.

But why the urgency?

UK_PopulationThe answer is basic economics.

The UK population is growing and the proportion of people over 65 years old is growing faster.  Advances in healthcare means that more of us survive age-related illnesses such as cancer and heart disease. We live longer and with better quality of life – which is great.

But this silver-lining hides a darker cloud.

The proportion of elderly and very elderly will increase over the next 20 years as the post WWII baby-boom reaches retirement age. The number of people who are living on pensions is increasing and the demands on health and social services is increasing.  Pensions and public services are not paid out of past savings  they are paid out of current earnings.  So the country will need to earn more to pay the bills. The UK economy will need to grow.

UK_GDP_GrowthBut the UK economy is not growing.  Our Gross Domestic Product (GDP) is currently about £380 billion and flat as a pancake. This sounds like a lot of dosh – but when shared out across the population of 56 million it gives a more modest figure of just over £100 per person per week.  And the time-series chart for the last 20 years shows that the past growth of about 1% per quarter took a big dive in 2008 and went negative! That means serious recession. It recovered briefly but is now sagging towards zero.

So we are heading for a big economic crunch and hiding our heads in the sand and hoping for the best is not a rational strategy. The only way to survive is to cut public services or for tax-funded services to become more productive. And more productive means increasing the volume of goods and services for the same cost. These are the services that we will need to support the growing population of  dependents but without increasing the cost to the country – which means the taxpayer.

The success of Toyota and Apple stemmed from learning how to do just that: how to design and deliver what is needed; and how to eliminate what is not; and how to wisely re-invest the released cash. The difference can translate into higher profit, or into growth, or into more productivity. It just depends on the context.  Toyota and Apple went for profit and growth. Tax-funded public services will need to opt for productivity. 

And the learning-productivity-improvement-by-design paradigm will be a critical-to-survival factor in tax-payer funded public services such as the NHS and Social Care.  We do not have a choice if we want to maintain what we take for granted now.  We have to proactively evolve our out-of-date public sector management paradigm. We have to evolve it into one that can support dramatic growth in productivity without sacrificing quality and safety.

We cannot use the burning platform approach. And we have to act with urgency.

We need a lifeboat!

Our current public sector management paradigm is sinking fast and is being defended and propped up by the old school managers who were brought up in it.  Unfortunately the evidence of 500 years of change says that the old school cannot unlearn. Their mental models go too deep.  The captains and their crews will go down with their ships.  [Remember the Titanic the unsinkable ship that sank in 1912 on the maiden voyage. That was a victory of reality over rhetoric.]

Those of us who want to survive are the ‘rats’. We know when it is time to leave the sinking ship.  We know we need lifeboats because it could be a long swim! We do not want to freeze and drown during the transition to the new paradigm.

So where are the lifeboats?

One possibility is an unfamiliar looking boat called “6M Design”. This boat looks odd when viewed through the lens of the conventional management paradigm because it combines three apparently contradictiry things: the rational-logical elements of system design;  the respect-for-people and learning-through-challenge principles embodied by Toyota and Apple; and the counter-intuitive technique of systems thinking.

Another reason it feel odd is because “6M Design” is not a solution; it is a meta-solution. 6M Design is a way of creating a good-enough-for-now solution by changing the current paradigm a bit at a time. It is a-how-to-design framework; it is not the-what-to-do solution. 6M Design is a paradigm shaper – not a paradigm shaker or a paradigm shifter.

And there is yet another reason why 6M Design does not float the current management boat.  It does not need to be controlled by self-appointed experts.  Business schools and management consultants, who have a vested interest in defending the current management paradigm, cannot make a quick buck from it because they are irrelevant. 6M Design is intended to be used by anyone and everyone as a common language for collectively engaging in respectful challenge and lifelong learning. Anyone can learn to use it. Anyone.

We do not need a crisis to change. But without changing we will get the crisis we do not want. If we choose to change then we can choose a safer and smoother path of change.

The choice seems clear.  Do you want to go down with the ship or stay afloat aboard an innovation boat?

And we will need something to help us navigate our boat.

If you are a reflective, conceptual learner then you might ike to read a synopsis of Thomas Kuhn’s book.  You can download a copy here. [There is also a 50 year anniversary edition of the original that was published this year].

And if you prefer learning from stories then there is an excellent one called “Who Moved My Cheese” that describes the same challenge of change. And with the power of the digital paradigm you can watch the video here.

Defusing Trust Eroders – Part III

<Bing Bong>

laptop_mail_PA_150_wht_2109Leslie’s computer heralded the arrival of yet another email!  They were coming in faster and faster – now that the word had got out on the grapevine about Improvementology

Leslie glanced at the sender. It was from Bob. That was a surprise. Bob had never emailed out-of-the-blue before.  Leslie was too impatient to wait until later to read the email.

<Dear Leslie, could I trouble you to ask your advice on something. It is not urgent.  A ten minute chat on the phone would be all I need. If that is OK please let me know a good time is and I will ring you. Bob>

Leslie was consumed with curiosity. What could Bob possibly want advice on? It was Leslie who sought advice from Bob – not the other way around.

Leslie could not wait and emailed back immediately that it was OK to talk now.

<Ring Ring>

Hello Bob, what a pleasant surprise! I am very curious to know what you need my advice about.

? Thank you Leslie.  What I would like your counsel on is how to engage in learning the science of improvement.

Wow!  That is a surprising question. I am really confused now. You helped me to learn this new thinking and now you are asking me to teach you?

? Yes. On the surface it seems counter-intuitive. It is a genuine request though. I need to learn and understand what works for you and what does not.

OK. I think I am getting an idea of what you are asking.  But I am only just getting grips with the basics. I do not know how to engage others yet and I certainly would not be able to teach anyone!

? I must apologise. I was not clear in my request. I need to understand how you engaged yourself in learning. I only provided the germ of the idea – it was you who added what was needed for it to develop into something tangible and valuable for you.  I need to understand how that happened.

Ahhhh! I see what you mean. Yes. Let me think. Would it help if I describe my current mental metaphor?

? That sounds like an excellent plan.

OK. Well your phrase ‘germ of an idea’ was a trigger. I see the science of improvement as a seed of information that grows into a sturdy tree of understanding.  Just like the ‘tiny acorn into the mighty oak’ concept.  Using that seed-to-tree metaphor helped me to appreciate that the seed is necessary but it is not sufficient. There are other things that are needed too. Soil, water, air, sunlight, and protection from hazards and predators.

I then realised that the seed-to-tree metaphor goes deeper.  One insight that I had was when I realised that the first few leaves are critical to success – because they provide the ongoing energy and food to support the growth of more leaves, and the twigs, branches, trunk, and roots that support the leaves and supply them with water and nutrients.  I see the tree as synergistic system that has a common purpose: to become big enough and stable enough to be able to survive the inevitable ups-and-downs of reality. To weather the winter storms and survive the summer droughts.

plant_metaphor_240x135It seemed to me that the first leaf needed to be labelled ‘safety’ because in our industry if we damage our customers or our staff we do not get a second chance!  The next leaf to grow is labelled ‘quality’ and that means quality-by-design.  Doing the right thing and doing it right first time without needing inspection-and-correction. The safety and quality leaves provide the resources needed to grow the next leaf which I labelled ‘delivery’.  Getting the work done in time, on time, every time.  Together these three leaves support the growth of the fourth – ‘economy’ which means using only what is necessaryand also having just enough reserve to ride over the inevitable rocks and ruts in the road of reality.

I then reflected on what the water and the sunshine would represent when applying improvement science in the real world.

It occurred to me that the water in the tree is like money in a real system.  It is required for both growth and health; it must flow to where it is needed, when it is needed and as much as needed. Too little will prevent growth, and too much water at the wrong time and wrong place is just as unhealthy.  I did some reading about the biology of trees and I learned that the water is pulled up the tree! The ‘suck’ is created by the water evaporating from the leaves. The plant does not have a committee that decides where the available water should go! It is a simple self-adjusting system.  

The sunshine for the tree is like feedback for people. In a plant the suns energy provides the motive force for the whole system.  In our organisations we call it motivation and the feedback loop is critical to success. Keeping people in the dark about what is required and how they are doing is demotivating.  Healthy organisations are feedback-fuelled!

? Yes. I see the picture in my mind clearly. That is a powerful metaphor. How did it help overcome the natural resistance to change?

Well using the 6M Design method and taking the ‘sturdy tree of understanding’ as the objective of the seed-to-tree process I then considered what the possible ways it could fail – the failure modes and effects analysis method that you taught me.

? OK. Yes I see how that approach would help – approaching the problem from the far side of the invisible barrier. What insights did that lead to?

poison_faucet_150_wht_9860Well it highlighted that just having enough water and enough sunshine was not sufficient – it had to be clean water and the right sort of sunshine.  The quality is as critical as the quantity. A toxic environment will kill tender new shoots of improvement long before they can get established.  Cynicism is like cyanide! Non-specific cost cutting is like blindly wielding a pair of sharp secateurs. Ignoring the competition from wasteful weeds and political predators is a guaranteed recipe-for-failure too.       

This metaphor really helped because it allowed me to draw up a checklist of necessary conditions for successful growth of knowledge and understanding.  Rather like the shopping list that a gardener might have. Viable seeds, fertile soil, clean water, enough sunlight, and protection from threats and hazards, especially in the early stages. And patience. Growing from seed takes time. Not all seeds will germinate. Not all seeds can thrive in the context our gardener is able to create.  And the harsher the elements the fewer the types of seed that have any chance of survival. The conditions select the successful seeds. Deserts select plants that hoard water so the desert remains a desert. If money is too tight the miserly will thrive at the expense of the charitable – and money remains hoarded and fought over as the organisation withers. And the timing is crucial – the seeds need to be planted at the right time in the cycle of change.  Too early and they cannot germinateg, too late and they do not have time to become strong enough to survive in the real world.    

? Yes. I see. The deeper you dig into your seeds-to-trees metaphor the more insightful it becomes.

Bob, you just said something really profound then that has unlocked something for me.

? Did I? What was it?

RainForestYou said ‘seeds-to-trees’.  Up until you said that I was unconsciously limiting myself to one-seed-to-one-tree. Of course! If it works for the individual it can work for the collective.  Woods and forests are collectives. The best example I can think of is a tropical rainforest.  With ample water and sunshine the plant-collective creates a synergistic system that has endured millions of years of global climate change. And one of the striking features of the tropical rain forest is the diversity of species. It is as if that diversity is an important part of the design. Competition is ever present though – all the trees compete for sunlight – but it is healthy competition. Trees do not succeed individually by hunting each other down. And the diversity seems to be an important component of healthy competition too. It is as if they are in a shared race to the sun and their differences are an asset rather than a liability. If all the trees were the same the forest would be at greater risk of all making the same biological blunder and suddenly becoming extinct if their environment changes unpredictably.  Uniformity only seems to work in harsh conditions.

? That is a profound observation Leslie. I had not consciously made that distinction.

So have I answered your question? Have I helped you? It has certainly helped me by being asked to putting my thoughts into words. I see it clearer too now.

? Yes. You are a good teacher. I believe others will resonate with your seeds-to-trees metaphor just as I have.

Thank you Bob. I believe I am beginning to understand something you said in a previous conversation – “the teacher is the person who learns the most”.  I am going to test our seeds-to-trees metaphor on the real world! And I will feedback what I learn – because in doing that I will amplify and clarify my own learning.

? Thank you Leslie. I look forward to learning with you.

Defusing Trust Eroders – Part I

Defusing Trust Eroders – Part II

Defusing Trust Eroders – Part II

line_figure_phone_400_wht_9858<Ring Ring><Ring Ring>

? Hello Leslie. How are you today?

Hi Bob – I am OK. Thank you for your time today. Is 15 minutes going to be enough?

? Yes. There is evidence that the ideal chunk of time for effective learning is around 15 minutes.

OK. I said I would read the material you sent me and reflect on it.

? Yes. Can you retell your Nerve Curve as a storyboard and highlight your ‘ah ha’ moments?

OK. And that was the first ‘ah ha’. I found the storyboard format a really effective way to capture my sequence of emotional states.

campfire_burning_150_wht_174?Yes.  There are very close links between stories, communication, learning and improvement. Before we learned to write we used campfire stories to pass collective knowledge from generation to generation.  It is an ancient, in-built skill we all have and we all enjoy a good story.

Yes. My first reaction was to the way you described the Victim role.  It really resonated with how I was feeling and how I was part of the dynamic. You were spot on with the feelings that dominated my thinking – anxiety and fear. The big ‘ah ha’ for me was to understand the discount that I was making. Not of others – of myself.

? OK. What was the image that you sketched on your storyboard?

I am embarrased to say – you will think I am silly.

? I will not think you are silly.

employee_diciplined_400_wht_5635Ouch! I know. And I knew that as soon as I said it. I think I was actually saying it to myself – or part of myself. Like I was trying to appease part of myself. Anyway, the picture I sketched was me as a small child at school standing with my head down, hands by my sides, and being told off in front of the whole class for getting a sum wrong. I was crying. I was not very good at maths and even now my mind sort of freezes and I get tears in my eyes and feel scared whenever someone tries to explain something using equations! I can feel the terror starting to well up just talking about it.

? OK. Do not panic. The story you have told is very common. Many of our fears of failure originate from early memories of experiencing ‘education by humiliation’. It is a blunt motivational tool that causes untold and long lasting damage. It is a symptom of a low quality education system design. Education is an exercise in improvement of knowledge and understanding. The unintended outcome of this clumsy educational tactic is a belief that we cannot solve problems ourselves and it is that invalid belief that creates the self-fulfilling prophecy of repeated failure.

Yes! And I know I can solve maths problems – I do it all the time – and I help my children with their maths homework. So it is not the maths that is triggering my fear. What is it?

? The answer to your question will become clear. What is the next picture on your storyboard?

emotion_head_mad_400_wht_7632The next picture was of the teacher who was telling me off. Or rather the face of the teacher. It was a face of frustration and anger. I drew a thought bubble and wrote in it “This small, irritating child cannot solve even a simple maths problem and is slowing down the whole lesson by bursting into tears everytime they get stuck. I blame the parents who are clearly too soft. They all need to learn some discipline – the hard way.

? Does this shed any light on your question?

Wow! Yes! It is not the maths that I am reacting to – it is the behaviour of the teacher. I am scared of the behaviour. I feel powerless. They are the teacher, I am just a small, incompetent, stupid, blubbing child. They do not care that I do not understand the question, and that I am in distress, and that I am scared that I will be embarassed in front of the whole class, and that I am scared that my parents will see a bad mark on my school report. And I feel trapped. I need to rationalise this. To make sense of it. Maybe I am stupid? That would explain why I cannot solve the mths problem. Maybe I should just give in and accept that I am a failure and to stupid to do maths?

There was a pause. Then Leslie continued in a different tone. A more determined tone.

But I am not a failure. This is just my knee jerk habitual reaction to an authority figure displaying anger towards me.  I can decide how I react. I have complete control over that.  I can disconnect the behaviour I experience and my reaction to it. I can choose.  Wow!         

? OK. How are you feeling right now? Can you describe it using a visual metaphor?

ready_to_launch_PA_150_wht_5052Um – weird. Mixed feelings. I am picturing myself sitting on a giant catapault. The ends of the huge elastic bands are anchored in the present and I am sitting in the loop but it is stretched way back into the past. There is something formless in the past that has been holding me back and the tension has been slowly building over time. And it feels that I have just cut that tie to the past, and I am free, and I am now being accelerated into the future. I did that. I am in control of my own destiny and it suddenly feels fun and exciting.

? OK. How do you feel right now about the memory of the authority figure from the past?

OK actually. That is really weird. I thought that I would feel angry but I do not. I just feel free. It was not them that was the problem. Their behaviour was not my fault – and it was my reaction to their behaviour that was the issue. My habitual behaviour. No, wait a second. Our habitual behaviour. It is a dynamic. It takes both people to play the game.

There was a pause.  Leslie sensed that Bob knew that some time was needed to let the emotions settle a bit.

? Are you OK to continue with your storyboard?

emotion_head_sad_frown_400_wht_7644Yes. The next picture is of the faces of my parents. They are looking at my school report. They look sad and are saying “We always dreamed that Leslie would be a doctor or something like that. I suppose we will have to settle for something less ambitious. Do not worry Leslie, it is not your fault, it will be OK, we will help you.” I felt like I had let them down and I had shattered their dream. I felt so ashamed. They had given me everything I had ever asked for. I also felt angry with myself and with them. And that is when I started beating myself up. I no longer needed anyone else to do that! I could persecute myself. I could play both parts of the game in my own head. That is what I did just now when it felt like I was talking to myself.  

? OK. You have now outlined the three roles that together create the dynamic for a stable system of learned behaviour. A system that is very resistant to change.  It is like a triangular role-playing-game. We pass the role-hats as we swap places in the triangle and we do it in collusion with others and ourselves and we do it unconsciously.  The purpose of the game is to create opportunities for social interaction – which we need and crave – the process has a clear purpose. The unintended outcome of this design is that it generates bad feelings, it erodes trust and it blocks personal and organisational development and improvement. We get stuck in it – rather like a small boat in a whirlpool. And we cannot see that we are stuck in it. We just feel bad as we spin around in an emotional maelstrom. And we feel cheated out of something better but we do not know what it is and how to get it.

There was a long pause. Leslie’s mind was racing. The world had just changed. The pieces had been blown apart and were now re-assembling in a different configuration. A simpler, clearer and more elegant design. 

So, tell me if I have this right. Each of the three roles involves a different discount?


And each discount requires a different – um – tactic to defuse?


So the way to break out of this trust eroding behavioural hamster-wheel is to learn to recognise which role we are in and to consciously deploy the discount defusing tactic.

? Yes.

And by doing that enough times we learn how to spot the traps that other people are creating and avoid getting sucked into them.

? Yes. And we also avoid starting them ourselves.

Of course! And by doing that we develop growing respect for ourselves and for each other and a growing level of trust in ourselves and in others? We have started to defuse the trust eroding behaviour and that lowers the barrier to personal and organisational development and improvement.

? Yes.

So what are the three discount defusing tactics?

There was a pause. Leslie knew what was coming next. It would be a question.

? What role are you in now?

Oh! Yes. I see. I am still feeling like that small school child at school but now I am asking for the answer and I am discounting myself by assuming that I cannot solve this problem myself. I am assuming that I need you to rescue me by telling me the answer. I am still in the trust eroding game, I do not trust myself and I am inviting you to play too, and to reinforce my belief that I cannot solve the problem.  

? And do you need me to tell you the answer?

No. I can probably work this out myself.  And if I do get stuck then I can ask for hints or nudges – not for the answer. I need to do the learning work.

? OK. I will commit to hinting and nudging if asked and if I do not know the answer I will say so.

Phew! That was definitely a rollercoaster ride on the Nerve Curve. Looking back it all makes complete sense and I now know what to do – but at the start it felt like I was heading into the Dark Unknown. You are right. It is liberating and exhilarating!

? That feeling of clarity of hindsight and exhilaration from learning is what we always strive for. Both as educators and educatees.

You mean it is the same for you? You are still riding the Nerve Curve? Still feeling surprised, confused, scared, resolved, enlightened then delighted?

? Yes. Every day. It is fun. I believe that there is No Limit to Learning so there is an inexhaustible Font of Fun.

Wow! I am off to have more Fun from Learning. Thank you so much yet again.

two_stickmen_shaking_hands_puzzle_150_wht_5229? Thank you Leslie.

Defusing Trust Eroders – Part I

Defusing Trust Eroders – Part III

Defusing Trust Eroders – Part I


Bob heard the beep and looked at his phone. There was a text message from Leslie, one of his Improvementology mentees.

It said:

Hi Bob, Do you have time to help me with a behaviour barrier that I keep hitting and cannot see a way around?

Bob thumbed his reply:

?Yes. I am free at the moment – please feel free to call.


?Hello Leslie. How can I help?

Hi Bob.  I really hope  you can help me with this recurring Niggle. I have looked through my Foundation notes and I cannot see where it is described and it does not seem to be a Nerve Curve problem.

?I will do my best. Can you outline the context or give me an example?

It is easier to give you an example.  This week I was working with a team in my organisation who approached me to help them with recurring niggles in their process. I went to see for myself and I mapped their process and identified where their niggles were and what was driving them.  That was the easy bit.  But when I started to make suggestions of what they could do to resolve their problems they started to give me a hard time and kept saying ‘Yes, but …”.  It was as if they were asking for help but did not really want it.  They kept emphasising that all their problems were caused by other people outside their department and kept asking me what I could do about it. I felt as if they were pushing the problem onto me and I was also feeling guilty for not being able to sort it out for them.

There was a pause. Then Bob said.

?You are correct Leslie. This is not a Nerve Curve issue.  It is a different people-related system issue. It is ubiquitous and it is a potentially deadly organisational disease. We call it Trust Eroding Behaviour.

That sounds exactly how it felt for me. I went to help in good faith and quickly started to feel distrustful of their motives. It was not a good feeling and I do not know if I want to go back. One part of me says ‘ It is your duty – you have made a commitment’ and another part of me says ‘Stop – you are being suckered.’  What is happening?

?Do you remember that the Improvement Science framework has three parts – Processes, People and Systems?


?OK. This is part of the People component and it is similar to but different from the Nerve Curve.  The Nerve Curve is a hard-wired emotional response to any change. The Fright, Fight, Flight response. It is just the way we are and it is not ‘correctable’. This is different. This is a learned behaviour.  Which means it can be unlearned.

Unlearned? That is not a concept that I am familiar with. Can you explain? Is it the same as forgetting?

?Forgetting means that you cannot bring something to conscious awareness.  Unlearning is different – it operates at a deeper psychological and emotional level.  Have you ever tried to change a bad habit?

Yes I have. I used to smoke which is definitely a bad habit and I managed to give up but it was really tough.

?What you did was to unlearn the smoking habit.  You did not forget about smoking.  You could not because you are repeatedly reminded by other people who still indulge in the habit.

Ah ha! I see what you mean. Yes – after I kicked the habit I became a bit of a Stop-Smoking evangelist. I even had a tee shirt. It did not seem to make much impact on the still-smokers though.  If anything it seemed to make them more determined to keep doing it – just to spite me!

?Yes. What you describe is what many people report. It is part if the same learned behaviour patterns. The habit that is causing the issue is rather like smoking because it causes short-term pleasure and long-term pain. It is both attractive and destructive.  The behaviour feels good briefly but it is toxic to trust which is why we call it the Trust Eroding Behaviour.

What is the habit? I do not recognise the behaviour that you are referring to.

?The habit is called discounting.  The reason we are not aware of it is we do it unconsciously. 

What is it that we do?

?It is easier to give you some examples.  How do you feel when all the feedback you get is silence? How do you feel when someone complains that their mistake was not their fault? How do you feel when you try to help but you hit invisible barriers that block your progess?

sad_faceOuch! Those are uncomfortable questions. When I get no feedback I feel anxious and even fearful that I have made a mistake,  and no one is telling me, and a nasty surprise is on its way. When someone keeps complaining that even though they made the mistake they are not to blame I feel angry. When I try to help others and fail I feel sad because my reputation, credibility and self-confidence is damaged.

?OK. Do not panic. These negative emotional reactions are the normal reaction to discounting behaviour.  Another word for discounting is disrespect. The three primary emotions we feel are fear, anger and sadness. Fear is the sense of impending loss; anger is the sense of present loss; and sadness is the sense of past loss.  They are the same emotions that we feel on the Nerve Curve.  What is different is the cause. Discounting is a learned disrepectful behaviour.

Oooo! That really resonates with me. Just reflecting on one day at work I can think of lots of examples of all of those negative feelings. So when do we learn this discounting habit?

?It is believed that we learn this behaviour when we are very young – before the age of seven.  And because we learn it so young we internalise it and we become unaware of it.  It then becomes a habit that is reinforced with years of practice.

Wow! That rings true for me – and it may explain why I actively avoided some people at school – they were just toxic.  But they had friends, went to college, got jobs, married andstarted families – just like me. Does that mean we grow out of it? 

?Most people unlearn some of these behavioural habits because life-experience teaches them that they are counter-productive. We all carry some of them though and they tend to emerge when we are tired and under pressure. Some people get sort of stuck and carry these behaviours into their adult life. Their behaviour can be toxic to organisations.

I definitely resonate with that statement! Is there a way to unlearn this discounting habit?

?Yes – just becoming aware of its existence is the first step. There are some strategies that we can learn, practice and use to defuse the discounting behaviour and over time our bad habit can be kicked.”

Wow! That sounds really useful.  And not just at work – I can see benefits in other areas of my life too.

?Yes. Improvement science is powerful medicine.

So what do I need to do?

?You have learned the 6M Design framework for resolving process niggles. There is an equivalent one for dissolving people niggles.  I will send you some material to read and then we can talk again.

Will it help me resolve the problem that I have with the department that asked for my help who are behaving like Victims?


OK – please send me the material. I promise to read it, reflect on it and I will arrange another conversation. I cannot wait to learn how to nail this niggle! I can see a huge win-win-win opportunity here.

?OK. The material is on its way. I look forward to our next conversation.

Defusing Trust Eroders – Part I

Defusing Trust Eroders – Part II

Defusing Trust Eroders – Part III

The Six Dice Game

<Ring Ring><Ring Ring>

?Hello, you are through to the Improvement Science Helpline. How can we help?

This is Leslie, one of your FISH apprentices.  Could I speak to Bob – my ISP coach?

?Yes, Bob is free. I will connect you now.

<Ring Ring><Ring Ring>

?Hello Leslie, Bob here. How can I help?

Hi Bob, I have a problem that I do not feel my Foundation training has equipped me to solve. Can I talk it through with you?

?Of course. Can you outline the context for me?

Yes. The context is a department that is delivering an acceptable quality-of-service and is delivering on-time but is failing financially. As you know we are all being forced to adopt austerity measures and I am concerned that if their budget is cut then they will fail on delivery and may start cutting corners and then fail on quality too.  We need a win-win-win outcome and I do not know where to start with this one.

?OK – are you using the 6M Design method?

Yes – of course!

?OK – have you done The 4N Chart for the customer of their service?

Yes – it was their customers who asked me if I could help and that is what I used to get the context.

?OK – have you done The 4N Chart for the department?

Yes. And that is where my major concerns come from. They feel under extreme pressure; they feel they are working flat out just to maintain the current level of quality and on-time delivery; they feel undervalued and frustrated that their requests for more resources are refused; they feel demoralized; demotivated and scared that their service may be ‘outsourced’. On the positive side they feel that they work well as a team and are willing to learn. I do not know what to do next.

?OK. Do not panic. This sounds like a very common and treatable system illness.  It is a stream design problem which may be the reason your Foundation training feels insufficient. Would you like to see how a Practitioner would approach this?

Yes please!

?OK. Have you mapped their internal process?

Yes. It is a six-step process for each job. Each step has different requirements and are done by different people with different skills. In the past they had a problem with poor service quality so extra safety and quality checks were imposed by the Governance department.  Now the quality of each step is measured on a 1-6 scale and the quality of the whole process is the sum of the individual steps so is measured on a scale of 6 to 36. They now have been given a minimum quality target of 21 to achieve for every job. How they achieve that is not specified – it was left up to them.

?OK – do they record their quality measurement data?

Yes – I have their report.

?OK – how is the information presented?

As an average for the previous month which is reported up to the Quality Performance Committee.

?OK – what was the average for last month?

Their results were 24 – so they do not have an issue delivering the required quality. The problem is the costs they are incurring and they are being labelled by others as ‘inefficient’. Especially the departments who are in budget and are annoyed that this department keeps getting ‘bailed out’.

?OK. One issue here is the quality reporting process is not alerting you to the real issue. It sounds from what you say that you have fallen into the Flaw of Averages trap.

I don’t understand. What is the Flaw of Averages trap?

?The answer to your question will become clear. The finance issue is a symptom – an effect – it is unlikely to be the cause. When did this finance issue appear?

Just after the Safety and Quality Review. They needed to employ more agency staff to do the extra work created by having to meet the new Minimum Quality target.

?OK. I need to ask you a personal question. Do you believe that improving quality always costs more?

I have to say that I am coming to that conclusion. Our Governance and Finance departments are always arguing about it. Governance state ‘a minimum standard of safety and quality is not optional’ and finance say ‘but we are going out of business’. They are at loggerheads. The departments get caught in the cross-fire.

?OK. We will need to use reality to demonstrate that this belief is incorrect. Rhetoric alone does not work. If it did then we would not be having this conversation. Do you have the raw data from which the averages are calculated?

Yes. We have the data. The quality inspectors are very thorough!

?OK – can you plot the quality scores for the last fifty jobs as a BaseLine chart?

Yes – give me a second. The average is 24 as I said.

?OK – is the process stable?

Yes – there is only one flag for the fifty. I know from my FISH training that is not a cause for alarm.

?OK – what is the process capability?

I am sorry – I don’t know what you mean by that?

?My apologies. I forgot that you have not completed the Practitioner training yet. The capability is the range between the red lines on the chart.

Um – the lower line is at 17 and the upper line is at 31.

?OK – how many points lie below the target of 21.

None of course. They are meeting their Minimum Quality target. The issue is not quality – it is money.

There was a pause.  Leslie knew from experience that when Bob paused there was a surprise coming.

?Can you email me your chart?

A cold-shiver went down Leslie’s back. What was the problem here? Bob had never asked to see the data before.

Sure. I will send it now.  The recent fifty is on the right, the data on the left is from after the quality inspectors went in and before the the Minimum Quality target was imposed. This is the chart that Governance has been using as evidence to justify their existence because they are claiming the credit for improving the quality.

?OK – thanks. I have got it – let me see.  Oh dear.

Leslie was shocked. She had never heard Bob use language like ‘Oh dear’.

There was another pause.

?Leslie, what is the context for this data? What does the X-axis represent?

Leslie looked at the chart again – more closely this time. Then she saw what Bob was getting at. There were fifty points in the first group, and about the same number in the second group. That was not the interesting part. In the first group the X-axis went up to 50 in regular steps of five; in the second group it went from 50 to just over 149 and was no longer regularly spaced. Eventually she replied.

Bob, that is a really good question. My guess it is that this is the quality of the completed work.

?It is unwise to guess. It is better to go and see reality.

You are right. I knew that. It is drummed into us during the Foundation training! I will go and ask. Can I call you back?

?Of course. I will email you my direct number.

[reveal heading=”Click here to read the rest of the story“]

<Ring Ring><Ring Ring>

?Hello, Bob here.

Bob – it is Leslie. I am  so excited! I have discovered something amazing.

?Hello Leslie. That is good to hear. Can you tell me what you have discovered?

I have discovered that better quality does not always cost more.

?That is a good discovery. Can you prove it with data?

Yes I can!  I am emailing you the chart now.

?OK – I am looking at your chart. Can you explain to me what you have discovered?

Yes. When I went to see for myself I saw that when a job failed the Minimum Quality check at the end then the whole job had to be re-done because there was no time to investigate and correct the causes of the failure.  The people doing the work said that they were helpless victims of errors that were made upstream of them – and they could not predict from one job to the next what the error would be. They said it felt like quality was a lottery and that they were just firefighting all the time. They knew that just repeating the work was not solving the problem but they had no other choice because they were under enormous pressure to deliver on-time as well. The only solution they could see is was to get more resources but their requests were being refused by Finance on the grounds that there is no more money. They felt completely trapped.

?OK. Can you describe what you did?

Yes. I saw immediately that there were so many sources of errors that it would be impossible for me to tackle them all. So I used the tool that I had learned in the Foundation training: the Niggle-o-Gram. That focussed us and led to a surprisingly simple, quick, zero-cost process design change. We deliberately did not remove the Inspection-and-Correction policy because we needed to know what the impact of the change would be. Oh, and we did one other thing that challenged the current methods. We plotted both the successes and the failures on the BaseLine chart so we could see both the the quality and the work done on one chart.  And we updated the chart every day and posted it chart on the notice board so everyone in the department could see the effect of the change that they had designed. It worked like magic! They have already slashed their agency staff costs, the whole department feels calmer and they are still delivering on-time. And best of all they now feel that they have the energy and time to start looking at the next niggle. Thank you so much! Now I see how the tools and techniques I learned in FISH school are so powerful and now I understand better the reason we learned them first.

?Well done Leslie. You have taken an important step to becoming a fully fledged Improvement Science Practitioner. There are many more but you have learned some critical lessons in this challenge.

This scenario is fictional but realistic.

And it has been designed so that it can be replicated easily using a simple game that requires only pencil, paper and some dice.

If you do not have some dice handy then you can use this little program that simulates rolling six dice.

The Six Digital Dice program (for PC only).

1. Prepare a piece of A4 squared paper with the Y-axis marked from zero to 40 and the X-axis from 1 to 80.
2. Roll six dice and record the score on each (or one die six times) – then calculate the total.
3. Plot the total on your graph. Left-to-right in time order. Link the dots with lines.
4. After 25 dots look at the chart. It should resemble the leftmost data in the charts above.
5. Now draw a horizontal line at 21. This is the Minimum Quality Target.
6. Keep rolling the dice – six per cycle, adding the totals to the right of your previous data.

But this time if the total is less than 21 then repeat the cycle of six dice rolls until the score is 21 or more. Record on your chart the output of all the cycles – not just the acceptable ones.

7. Keep going until you have 25 acceptable outcomes. As long as it takes.

Now count how many cycles you needed to complete in order to get 25 acceptable outcomes.  You should find that it is about twice as many as before you “imposed” the Inspect-and-Correct QI policy.

This illustrates the problem of an Inspection-and-Correction design for quality improvement.  It does improve the quality of the output – but at a higher cost.  We are treating the symptoms and ignoring the disease.

The internal design of the process is unchanged – and it is still generating mistakes.

How much quality improvement you get and how much it costs you is determined by the design of the underlying process – which has not changed. There is a Law of Diminishing returns here – and a risk.

The risk is that if quality improves as the result of applying a quality target then it encourages the Governance thumbscrews to be tightened further and forces the people further into cross-fire between Governance and Finance.

The other negative consequence of the Inspection-and-Correction approach is that it increases both the average and the variation in lead time which also fuels the calls for more targets, more sticks, calls for  more resources and pushes costs up even further.

The lesson from this simple reality check seems clear.

The better strategy for improving quality is to design the root causes of errors out of the processes  because then we will get improved quality and improved delivery and improved productivity and we will discover that we have improved safety as well.

The Six Dice Game is a simpler version of the famous Red Bead Game that W Edwards Deming used to explain why the arbitrary-target-driven-stick-and-carrot style of management creates more problems than it solves.

The illusion of short-term gain but the reality of long-term pain.

And if you would like to see and hear Deming talking about the science of improvement there is a video of him speaking in 1984. He is at the bottom of the page.  Click here.


The F Word

There is an F-word that organisations do not like to use – except maybe in conspiratorial corridor conversations.

What word might that be? What are good candidates for it?

Finance perhaps?

Certainly a word that many people do not want to utter – especially when the financial picture is not looking very rosy. And when the word finance is mentioned in meetings there is usually a groan of anguish. So yes, finance is a good candidate – but it is not the F-word.

Failure maybe?

Yes – definitely a word that is rarely uttered openly. The concept of failure is just not acceptable. Organisations must succeed, sustain and grow. Talk of failure is for losers not for winners. To talk about failure is tempting fate. So yes, another excellent candidate – but it is not the F-word.

OK – what about Fear?

That is definitely something no one likes to admit to.  Especially leaders. They are expected to be fearless. Fear is a sign of weakness! Once you start letting the fear take over then panic starts to set in – then rash decisions follow then you are really on the slippery slope. Your organisation fragments into warring factions and your fate is sealed. That must be the F-word!

Nope.  It is another very worthy candidate but it is not the F-word.

[reveal heading=”Click here to reveal the F-word“]

The dreaded F-word is Feedback.

We do not like feedback.  We do not like asking for it. We do not like giving it. We do not like talking about it. Our systems seem to be specifically designed to exclude it. Potentially useful feedback information is kept secret, confidential, for-our-eyes only.  And if it is shared it is emasculated and anonymized.

And the brave souls who are prepared to grasp the nettle – the 360 Feedback Zealots – are forced to cloak feedback with secrecy and confidentiality. We are expected to ask  for feedback, to take it on the chin, but not to know who or where it came from. So to ease the pain of anonymous feedback we are allowed to choose our accusers. So we choose those who we think will not point out our blindspot. Which renders the whole exercise worthless.

And when we actually want feedback we extract it mercilessly – like extracting blood from a reluctant stone. And if you do not believe me then consider this question: Have you ever been to a training course where your ‘certificate of attendance’ was with-held until you had completed the feedback form? The trainers do this for good reason. We just hate giving feedback. Any feedback. Positive or negative. So if they do not extract it from us before we leave they do not get any.

Unfortunately by extracting feedback from us under coercion is like acquiring a confession under torture – it distorts the message and renders it worthless.

What is the problem here?  What are we scared of?

We all know the answer to the question.  We just do not want to point at the elephant in the room.

We are all terrified of discovering that we have the organisational equivalent of body-odour. Something deeply unpleasant about our behaviour that we are blissfully unaware of but that everyone else can see as plain as day. Our behaviour blindspot. The thing we would cringe with embarrassment about if we knew. We are social animals – not solitary ones. We need on feedback yet we fear it too.

We lack the courage and humility to face our fear so we resort to denial. We avoid feedback like the plague. Feedback becomes the F-word.

But where did we learn this feedback phobia?

Maybe we remember the playground taunts from the Bullies and their Sychophants? From the poisonous Queen-Bees and their Wannabees?  Maybe we tried to protect ourselves with incantations that our well-meaning parents taught us. Spells like “Sticks and stones may break my bones but names will never hurt me“.  But being called names does hurt. Deeply. And it hurts because we are terrified that there might be some truth in the taunt.

Maybe we learned to turn a blind-eye and a deaf-ear; to cross the street at the first sign of trouble; to turn the other cheek? Maybe we just learned to adopt the Victim role? Maybe we were taught to fight back? To win at any cost? Maybe we were not taught how to defuse the school yard psycho-games right at the start?  Maybe our parents and teachers did not know how to teach us? Maybe they did not know themselves?  Maybe the ‘innocent’ schoolyard games are actually much more sinister?  Maybe we carry them with us as habitual behaviours into adult life and into our organisations? And maybe the bullies and Queen-Bees learned something too? Maybe they learned that they could get away with it? Maybe they got to like the Persecutor role and its seductive musk of power? If so then then maybe the very last thing the Bullies and Queen-Bees will want to do is to encourage open, honest feedback – especially about their behaviour. Maybe that is the root cause of the conspiracy of silence? Maybe?

But what is the big deal here?

The ‘big deal’ is that this cultural conspiracy of silence is toxic.  It is toxic to trust. It is toxic to teams. It is toxic to morale.  It is toxic to motivation. It is toxic to innovation. It is toxic to improvement. It is so toxic that it kills organisations – from the inside. Slowly.

Ouch! That feels uncomfortably realistic. So what is the problem again – exactly?

The problem is a deliberate error of omission – the active avoidance of feedback.

So ….. if it were that – how would we prove that is the root cause? Eh?

By correcting the error of omission and then observing what happens.

And this is where it gets dangerous for leaders. They are skating on politically thin ice and they know it.

Subjective feedback is very emotive.  If we ask ten people for their feedback on us we will get ten different replies – because no two people perceive the world (and therefore us) the same way.  So which is ‘right’? Which opinions do we take heed of and which ones do we discount? It is a psycho-socio-political minefield. So no wonder we avoid stepping onto the cultural barbed-wire!

There is an alternative.  Stick to reality and avoid rhetoric. Stick to facts and avoid feelings. Feed back the facts of how the organisational system is behaving to everyone in the organisation.

And the easiest way to do that is with three time-series charts that are updated and shared at regular and frequent intervals.

First – the count of safety and quality failure near-misses for each interval – for at least 50 intervals.

Second – the delivery time of our product or service for each customer over the same time period.

Third – the revenue generated and the cost incurred for each interval for the same 50 intervals.

No ratios, no targets, no balanced scorecard.

Just the three charts that paint the big picture of reality. And it might not be a very pretty picture.

But why at least 50 intervals?

So we can see the long term and short term variation over time. We need both … because …

Our Safety Chart shows that near misses keep happening despite all the burden of inspection and correction.

Our Delivery Chart shows that our performance is distorted by targets and the Horned Gaussian stalks us.

Our Viability Chart shows that our costs are increasing as we pay dearly for past mistakes and our revenue is decreasing as our customers protect their purses and their persons by staying away.

That is the not-so-good news.

The good news is that as soon as we have a multi-dimensional-frequent-feedback loop installed we will start to see improvement. It happens like magic. And the feedback accelerates the improvement.

And the news gets better.

To make best use of this frequent feedback we just need to include in our Constant Purpose – to improve safety, delivery and viability. And then the final step is to link the role of every person in the organisation to that single win-win-win goal. So that everyone can see how they contribute and how their job is worthwhile.

Shared Goals, Clear Roles and Frequent Feedback.

And if you resonate with this message then you will resonate with “The Three Signs of  Miserable Job” by Patrick Lencioni.

And if you want to improve your feedback-ability then a really simple and effective feedback tool is The 4N Chart

And please share your feedback.