The Tyranny of Choice

Bob’s new all-singing-and-dancing touchscreen phone pronounced the arrival of an email from an Improvement Science apprentice. This was always an opportunity for learning so he swiped the flashing icon and read the email. It was from Leslie.

<Leslie>Hi Bob, I have come across a new challenge that I never thought I would see – the team that I am working with are generating so many improvement-by-design ideas that we cannot decide what to try. Can you help?

Bob thumbed a reply immediately:
<Bob>Ah ha! The Tyranny of Choice challenge. Yes, I believe I can help. I am free to talk now if you are.

[“You have a call from Leslie”]
Bob’s new all-singing-and-dancing touchscreen phone said that it was Leslie on the line – (it actually said it in the synthetic robot voice that Bob had set as the default).

<Bob>Hello Leslie.

<Leslie>Hi Bob, thank you for replying so quickly. I gather that you have encountered this challenge before?

<Bob>Yes. It usually appears when a team are nearing the end of a bumpy ride on the Nerve Curve and are starting to see new possibilities that previously were there but hidden.

<Leslie>That is just where we are. The problem is we have flipped from no options to so many we cannot decide what to do.

<Bob>It is often assumed that choice is a good thing, but you can have too much of a good thing. Many studies have shown that when the number of innovative choices are limited then people are more likely to make a decision and actually do something. As the number of choices increase it gets much harder to choose so we default to the more comfortable and familiar status quo. We avoid making a decision and we do nothing. That is the Tyranny of Choice.

<Leslie>Yes, that is just how it feels. Paralyzed by indecision. So how do we get past this barrier?

<Bob>The same way we get past all barriers. We step back,  broaden our situational awareness and list all the obvious things and then consider doing exactly the opposite of what out intuition tells us. We just follow the tried-and-tested 6M Design script.

<Leslie>Arrgh! Yes, of course. We start with a 4N Chart.

<Bob>Yes, and specifically we start with the Nuggets.  We look for what is working despite the odds. The positive deviants. Who do you know is decisive when faced with a host of confusing and conflicting options? Not tyrannized by choice.

<Leslie>Other than you?

<Bob>It does not matter who. How do they do it?

<Leslie>Well – “they” use a special sort of map that I confess I have not mastered yet – the Right-2-Left Map.

<Bob>Yes, an effective way to avoid getting lost in the Labyrinth of Options. What else?

<Leslie>“They” know what the critical steps are and “they” give clear step-by-step guidance of what to do to complete them.

<Bob>This is called “story-boarding”.  It is rather like sketching each scene of a play – then practicing each scene script individually until they are second nature and ready when needed.

<Leslie>That is just like what the emergency medical teams do. They have scripts that they use for emergent situations where it is dangerous to try to plan what to do in the moment.  They call them “care bundles”. It avoids a lot of time-wasting, debate, prevarication and the evidence shows that it delivers better outcomes and saves lives.

<Bob>In an emergency situation the natural feeling of fear creates the emotional drive to act; but without a well-designed and fully-tested script the same fear can paralyze the decision process. It is the rabbit-in-the-headlights effect.  When the feeling of urgency is less a different approach is needed to engage the emotional-power-train.

<Leslie>Do you mean build engagement?

<Bob>Yes, and how do we do that?

<Leslie>We use a combination of subjective stories and objective evidence – heart stuff and head stuff. It is a very effective combination to break through the Carapace of Complacency as you call it. I have seen that work really well in practice.

<Bob>And the 4N Chart comes in handy here again because it helps us see the emotional-terrain in perspective and to align us in moving away from the Niggles towards the NiceIfs while avoiding the NoNos and leveraging the Nuggets.

<Leslie>Yes! I have seen that too. But what do we do when we are in new territory; when we are faced with a swarm of novel options; when we have no pre-designed scripts to help us?

<Bob>We use a meta-script?

<Leslie>A what?

<Bob>A meta-script is one that we use to design a novel action script when we need it.

<Leslie>You mean a single method for creating a plan that we are confident will work?


<Leslie>That is what the Right-2-Left Map is!


<Leslie>So the Tyranny of Choice is the result of our habitual Left-2-Right thinking.


<Leslie>And when the future choices we see are also shrouded in ambiguity it is even harder to make a decision!

<Bob>Yes. We cannot see past the barrier of uncertainty – so we stop and debate because it feels safer.

<Leslie>Which is why so many really clever people seem get stuck in the paralysis of analysis and valueless discussion.


<Leslie>So all we need to do is switch to the counter-intuitive Right-2-Left thinking and the path becomes clear?

<Bob>Not quite.  The choices become a lot easier so the Tyranny of Choice disappears. We still have choices. There are still many possible paths. But it does not matter which we choose because they all lead to the common goal.

<Leslie>Thank you Bob. I am going to have to mull this one over for a while – red wine may help.

<Bob>Yes – mulled wine is a favorite of mine too. Ching-ching!

Do Not Give Up Too Soon

clock_hands_spinning_import_150_wht_3149Tangible improvement takes time. Sometimes it takes a long time.

The more fundamental the improvement the more people are affected. The more people involved the greater the psychological inertia. The greater the resistance the longer it takes to show tangible effects.

The advantage of deep-level improvement is that the cumulative benefit is greater – the risk is that the impatient Improvementologist may give up too early – sometimes just before the benefit becomes obvious to all.

The seeds of change need time to germinate and to grow – and not all good ideas will germinate. The green shoots of innovation do not emerge immediately – there is often a long lag and little tangible evidence for a long time.

This inevitable  delay is a source of frustration, and the impatient innovator can unwittingly undo their good work.  By pushing too hard they can drag a failure from the jaws of success.

Q: So how do we avoid this trap?

The trick is to understand the effect of the change on the system.  This means knowing where it falls on our Influence Map that is marked with the Circles of Control, Influence and Concern.

Our Circle of Concern includes all those things that we are aware of that present a threat to our future survival – such as a chunk of high-velocity space rock smashing into the Earth and wiping us all out in a matter of milliseconds. Gulp! Very unlikely but not impossible.

Some concerns are less dramatic – such as global warming – and collectively we may have more influence over changing that. But not individually.

Our Circle of Influence lies between the limit of our individual control and the limit of our collective control. This a broad scope because “collective” can mean two, twenty, two hundred, two thousand, two million, two billion and so on.

Making significant improvements is usually a Circle of Influence challenge and only collectively can we make a difference.  But to deliver improvement at this level we have to influence others to change their knowledge, understanding, attitudes, beliefs and behaviour. That is not easy and that is not quick. It is possible though – with passion, plausibility, persistence, patience – and an effective process.

It is here that we can become impatient and frustrated and are at risk of giving up too soon – and our temperaments influence the risk. Idealists are impatient for fundamental change. Rationals, Guardians and Artisans do not feel the same pain – and it is a rich source of conflict.

So if we need to see tangible results quickly then we have to focus closer to home. We have to work inside our Circle of Individual Influence and inside our Circle of Control.  The scope of individual influence varies from person-to-person but our Circle of Control is the same for all of us: the outer limit is our skin.  We all choose our behaviour and it is that which influences others: for better or for worse.  It is not what we think it is what we do. We cannot read or control each others minds. We can all choose our attitudes and our actions.

So if we want to see tangible improvement quickly then we must limit the scope of our action to our Circle of Individual Influence and get started.  We do what we can and as soon as we can.

Choosing what to do and what not do requires wisdom. That takes time to develop too.

Making an impact outside the limit of our Circle of Individual Influence is more difficult because it requires influencing many other people.

So it is especially rewarding for to see examples of how individual passion, persistence and patience have led to profound collective improvement.  It proves that it is still possible. It provides inspiration and encouragement for others.

One example is the recently published Health Foundation Quality, Cost and Flow Report.

This was a three-year experiment to test if the theory, techniques and tools of Improvement Science work in healthcare: specifically in two large UK acute hospitals – Sheffield and Warwick.

The results showed that Improvement Science does indeed work in healthcare and it worked for tough problems that were believed to be very difficult if not impossible to solve. That is very good news for everyone – patients and practitioners.

But the results have taken some time to appear in published form – so it is really good news to report that the green shoots of improvement are now there for all to see.

The case studies provide hard evidence that win-win-win outcomes are possible and achievable in the NHS.

The Impossibility Hypothesis has been disproved. The cynics can step off the bus. The skeptics have their evidence and can now become adopters.

And the report offers a lot of detail on how to do it including two references that are available here:

  1. A Recipe for Improvement PIE
  2. A Study of Productivity Improvement Tactics using a Two-Stream Production System Model

These references both describe the fundamentals of how to align financial improvement with quality and delivery improvement to achieve the elusive win-win-win outcome.

A previously invisible door has opened to reveal a new Land of Opportunity. A land inhabited by Improvementologists who mark the path to learning and applying this new knowledge and understanding.

There are many who do not know what to do to solve the current crisis in healthcare – they now have a new vista to explore.

Do not give up too soon –  there is a light at the end of the dark tunnel.

And to get there safely and quickly we just need to learn and apply the Foundations of Improvement Science in Healthcare – and we first learn to FISH in our own ponds first.


Burn Your Bridges and Boats

burn_your_boatsThere are many stories from history on the theme of famous leaders symbolically burning bridges and boats.

They do this because they know that when they have no way back to the past then they are forced to face the future.

When we have no run-away option we have to overcome the challenges that face us – and we surprise and delight ourselves when we learn what we were always capable of achieving!

Our fear of change coupled with a too-easy escape route leads to giving up when the going gets a bit too tough.  We choose to fail.

Then we erode our confidence a bit more and are even less likely to try next time.

It is not our ability to succeed or the possibility of success that is the issue.  The issue is that we continually create self-fulfilling-failure-prophesies.  Or some of us do.

Fortunately there are a some tenacious, courageous and optimistic innovators who keep getting back on the horse. They are a bit angry – mainly at themselves.

And there is a Chinese proverb that says:

Those who say it cannot be done should not interrupt the person doing it.

those_who_say_it_cannot_be_doneBurning the bridges and the boats can be the bravest and wisest decision that an effective leader can make.  It broadcasts a powerful message. It says: “We are all in this together and I believe we can succeed“.

The NHS has just burned its bridges and boats.

The old wooden PCTs and SHAs have gone up in smoke – and the cash is now held by an innovative new design called Clinical Commissioning Groups.

This change was made final on 1st April 2013 (April Fool’s Day sneer the cynics) – and it is now essentially irreversible. We are all in it together.

What is most interesting to observe is how quiet it seems to have gone. We now have to sink or swim with the new system. And what seems to be happening is that people are getting on with it – and surprising themselves with what they can achieve.

Wasting time complaining reduces our chance of survival and the whiners have become a liability.

Which is good because we will see what is possible when our leaders torch our bridges and boats and we are forced to listen to our inner innovative voices! The ones that we have been drowning out with whining, wailing and complaining for years.

And there is another cultural dimension to this symbolic pyre metaphor. It is important to say “goodbye” to the past and to do so with respect. It is important to mourn the loss of what was good and to acknowledge the passing of what was bad.  It was not all good and it was not all bad. Both sadness and relief are natural parts of change and improvement. They are part of the emotional transition process. The Nerve Curve.

And I know just how this sort of transition feels because this week I went through a major one. I upgraded my old push-button mobile phone to a phablet. Wow! What a transition! I’m going to call it a “fablet”.

I have to say that I have been looking forward to it with a mixture of anticipation and anxiety. I felt a sad to finally say goodbye to my trusted Blackberry and I felt relieved to say goodbye to its Niggles.  The deed is done.  The phone number and contacts have been transferred.  There is no going back.  The boat and bridge are burned. And it was done seamlessly, quickly and with minimal pain. The trigger was the sand running out on my old phone contract. Thank you Car Phone Warehouse – you provided a fabulous service!

And the new fablet feels like an old friend already.

So, onwards and forwards … and so many new and exciting opportunities to explore!  And two days after getting the fablet I am writing Android apps in Java (that is geek-speak just to be extra-super-nerdy) – I would never have done that with the old phone!

Life or Death Decisions

The Improvement Science blog this week is kindly provided by Julian Simcox and Terry Weight.

What can surgeons learn from other professions about making life or death decisions?

Dr Kevin Fong is on a mission to find out what can be done to reduce the number of mistakes being made by surgeons in the operating theatre.

He starts out with an example of a mistake in an operation that involved a problematic tracheotomy and subsequently, despite there being plenty of extra expert advice on hand, sadly the patient died. Crucially, a nurse had been ignored who if listened to might have provided the solution that could have saved the patient’s life.

Whilst looking at other walks of life – this example is used to explore how under similar pressures such mistakes can be avoided. For example, in aviation and in fire-fighting more robust and resilient cultures and systems have evolved – but how?

The Horizon editors highlight the importance of six things and we make some comments:

1. The aviation industry continually designs out hazards and risk.

Aviation was once a very hazardous pursuit. Nowadays the trip to the airport is much riskier than the flight itself, because over the decades aviators have learned how to learn-from-mistakes and to reduce future incidents. They have learned that blaming individuals for systemic failure gets in the way of accumulating the system-wide knowledge that makes the most difference.

Peter Jordan reminds us that in the official report into the 1989 Kegworth air disaster: 31 recommendations for improved safety were made – mainly to do with patient safety during crashes – an even then the report could not resist pointing the finger at the two pilots who, when confronted with a blow-out in one of their two engines, had wrongly interpreted a variety of signals and talked themselves into switching off the wrong engine. On publication of the report they were summarily dismissed, but much later successfully claimed damages for unfair dismissal.

2. Checklists can make a difference if the Team is engaged

The programme then refers to recent research by the World Health Organisation on the use of checklists that when implemented showed a large (35%) reduction in surgical complications across a range of countries and hospitals.

In University College Hospital London we see checklists being used by the clinical team to powerful effect. The specific example given concerns the process of patient hand-over after an operation from the surgical team to the intensive care unit. Previously this process had been ill-defined and done differently by lots of people – and had not been properly overseen by anyone.

No reference is made however to the visual display of data that helps teams see the effect of their actions on their system over time, and there is no mention of whether the checklists have been designed by outsiders or by the team themselves.

In our experience these things make a critical difference to ongoing levels of engagement – and to outcomes – especially in the NHS where checklists have historically been used more as a way of ensuring compliance with standards and targets imposed from the top. Too often checklists are felt to be instruments of persecution and are therefore fiercely (and justifiably) resisted.

We see plenty of scope in the NHS for clarifying and tightening process definitions, but checklists are only one way of prompting this. Our concern is that checklists could easily become a flavour-of-the-month thing – seen as one more edict from above. And all-too-quickly becoming yet another layer of the tick-box bureaucracy, of the kind that most people say they want to get away from.

We also see many potentially powerful ideas flowing form the top of the NHS, raining down on a system that has become moribund – wearied by one disempowering change initiative after another.

3. Focussing on the team and the process – instead of the hierarchy – enhances cooperation and reduces deferential behaviour.

Learning from the Formula One Pit Stop Team processes, UCH we are told have flattened their hierarchy ensuring that at each stage of the process there is clear leadership, and well understood roles to perform. After studying their process they have realised that most of the focus had previously been on only the technically demanding work rather than on the sequence of steps and the need for ensuring clear communication between each one of those steps. We are told that flattening the hierarchy in order to prioritise team working has also helped – deference to seniority (e.g. nurses to doctors) is now seen as obstructing safer practice.

Achieving role clarity goes hand-in-hand with simplification of the system – which all starts with careful process definition undertaken collaboratively by the team as a whole. In the featured operation every individual appears to know their role and the importance of keeping things simple and consistent. In our experience this is all the more powerful when the team agree to standardise procedures as soon as any new way has been shown to be more effective.

4. Situational Awareness is an inherent human frailty.

We see how fire officers are specifically trained to deal with situations that require both a narrow focus and an ability to stand back and connect to the whole – a skill which for most people does not come naturally. Under pressure we each too often fail to appreciate either the context or the bigger picture, losing situational awareness and constraining our span of attention.

In the aviation industry we see how pilot training is nowadays considered critically important to outcomes and to the reductions of pilot error in emergencies. Flight simulators and scenario simulation now play a vital role, and this is becoming more commonplace in senior doctor training.

It seems common sense that people being trained should experience the real system whilst being able to making mistakes. Learning comes from experimentation (P-D-C-A). In potentially life-and-death situations simulation allows the learning and the building of needed experience to be done safely off-line. Nowadays, new systems containing multiple processes and lots of people can be designed using computer simulations, but these skills are as yet in short supply in the NHS.

5. Understand the psychology of how people respond to their mistakes.

Using some demonstrations using playing cards, we see how people who have a non-reactive attitude to mistakes respond better to making them and are then less likely to make the same mistake again. Conversely some individuals seem to be less resilient – we would say becoming unstable – taking longer to correct their mistakes and subsequently making more of them. Recruitment of doctors is now starting to include the use of simulators to test for this psychological ability.

6. Innovation more easily flows from systems that are stable.

Due to a bird strike a few minutes after take-off, stopping both engines, an aircraft in 2008 was forced to crash land. The landing – in to New York’s Hudson River – was an innovative novel manoeuvre, and incredibly led to the survival of all the passengers and crew. An innovation that was safely executed by the pilot who in the moment kept his cool by sticking to the procedures and checklists he had been trained in.

This capability we are told had been acquired over more than three decades by the pilot Captain “Sully” Sullenberger, who sees himself as part of an industry that over time institutionalises emerging knowledge. He tells us that he had faith in the robustness and resilience of this knowledge that had accumulated by using the lessons from the past to build a safer future. He suggests it would be immoral not to learn from historical experience. To him it was “this robustness that made it possible to innovate when the unknown occurred”.

Standardisation often spawns innovation – something which for many people remains a counter-intuitive notion.

Sullenberger was subsequently lauded as a hero, but he himself tells us that he merely stuck to the checklist procedures and that this helped him to keep his cool whilst realising he needed to think outside the box.

The programme signs off with the message that human error is always going to be with us, and that it is how we deal with human error that really matters. In aviation there is a continual search for progress, rather than someone to blame. By accepting our psychological fallibility we give ourselves – in the moment – the best possible chance.

The programme attempts to balance the actions of the individual with collective action over time to design and build a better system – one in which all individuals can play their part well. Some viewers may have ended up remembering most the importance of the “heroic” individual. In our view more emphasis could have placed on the design of the system as a whole – such that it more easily maintains its stability without needing to rely either on the heroic acts of any one individual or on finding the one scapegoat.

If heroes need to exist they are the individuals who understand their role and submit themselves to the needs of team and to achieving the outcomes that are needed by the wider system. We like that the programme ends with the following words:

Search for progress, not someone to blame!