August 2013 – HCSE Blog

31/08/2013

Race for the Line

It is surprising how competitive most people are. We are constantly comparing ourselves with others and using what we find to decide what to do next. Groan or Gloat. Chase or Cruise.

This is because we are social animals. Comparing with other is hard-wired into us. We have little choice.

But our natural competitive behaviour can become counter-productive when we learn that we can look better-by-comparison if we block or trip-up our competitors. In a vainglorious attempt to make ourselves look better-by-comparison we spike the wheels of our competitors’ chariots. We fight dirty.

It is not usually openly aggressive fighting. Most of our spiking is done passively. Often by deliberately not doing something. A deliberate act of omission. And if we are challenged we often justify our act of omission by claiming we were too busy.

This habitual passive-aggressive learned behaviour is not only toxic to improvement, it creates a toxic culture too. It is toxic to everything.

And it ensures that we stay stuck in The Miserable Job Swamp. It is a bad design.

So we need a better one.

One idea is to eliminate competition. This sounds plausible but it does not work. We are hard-wired to compete because it has proven to be a very effective long term survival strategy. The non-competitive have not survived. To be deliberately non-competitive will guarantee mediocrity and future failure.

A better design is to leverage our competitive nature and this is surprisingly easy to do.

We flip the “battle” into a “race”.

To do that we need:

1) A clear destination – a shared common purpose – that can be measured. We need to be able to plot our progress using objective evidence.

2) A proven, safe, effective and efficient route plan to get us to our destination.

3) A required arrival time that is realistic. Open-ended time-scales do not work.

4) Regular feedback to measure our individual progress and to compare ourselves with others. Selective feedback is ineffective. Secrecy or anonymous feedback is counter-productive at best and toxic at worst.

5) The ability to re-invest our savings on all three win-win-win dimensions: emotional, temporal and financial. This fuels the engine of improvement. Us.

The rest just happens – but not by magic – it happens because this is a better Improvement-by-Design.

25/08/2013

Find and Fill

Many barriers to improvement are invisible.

This is because they are caused by what is not present rather than what is. They are gaps or omissions.

Some gaps are blindingly obvious. This is because we expect to see something there so we notice when it is missing. We would notice the gap if a rope bridge across chasm is obviously missing because only end posts are visible.

Many gaps are not obvious. This is because we have no experience or expectation. The gap is invisible. We are blind to the omission.

These are the gaps that we accidentally stumble into. Such as a gap in our knowledge and understanding that we cannot see. These are the gaps that create the fear of failure. And the fear is especially real because the gap is invisible and we only know when it is too late.

It is like walking across an emotional minefield. At any moment we could step on an ignorance mine and our confidence would be blasted into fragments.

So our natural and reasonable reaction is to stay outside the emotional minefield and inside our comfort zones – where we feel safe. We give up trying to learn and trying to improve. Every-one hopes that Some-one or Any-one will do it for us. No-one does.

The path to Improvement is always across an emotional minefield because improvement implies unlearning. So we need a better design than blundering about hoping not to fall into an invisible gap. We need a safer design.

There are a number of options:

Option 1. Ask someone who knows the way across the minefield and can demonstrate it. Someone who knows where the mines are and knows how to avoid them. Someone to tell us where to step and where not to.

Option 2. Clear a new path and mark it clearly so others can trust that it is safe. Remove the ignorance mines. Find and Fill the knowledge map.

Option 1 is quicker but it leaves the ignorance mines in place. So sooner or later someone will step on one. Boom!

We need to be able to do Option 2.

The obvious strategy for Option 2 is to clear the ignorance mines. We could do this by deliberately blundering about setting off the mines. We could adopt the burn-and-scrape or learn-from-mistakes approach.

Or we could detect, defuse and remove them.

The former requires people willing to take emotional risks; the latter does not require such a sacrifice.

And “learn-by-mistakes” only works if people are able to make mistakes visibly so everyone can learn. In an adversarial, competitive, distrustful context this can not happen: and the result is usually for the unwilling troops to be forced into the minefield with the threat of a firing-squad if they do not!

And where a mistake implies irreversible harm it is not acceptable to learn that way. Mistakes are covered up. The ignorance mines are re-set for the next hapless victim to step on. The emotional carnage continues. Any change 0f sustained, system-wide improvement is blocked.

So in a low-trust cultural context the detect-defuse-and-remove strategy is the safer option.

And this requires a proactive approach to finding the gaps in understanding; a proactive approach to filling the knowledge holes; and a proactive approach to sharing what was learned.

Or we could ask someone who knows where the ignorance mines are and work our way through finding and filling our knowledge gaps. By that means any of us can build a safe, effective and efficient path to sustainable improvement.

And the person to ask is someone who can demonstrate a portfolio of improvement in practice – an experienced Improvement Science Practitioner.

And we can all learn to become an ISP and then guide others across their own emotional minefields.

All we need to do is take the first step on a well-trodden path to sustained improvement.

17/08/2013

Fudge? We Love Fudge!

It is almost autumn again. The new school year brings anticipation and excitement. The evenings are drawing in and there is a refreshing chill in the early morning air.

This is the time of year for fudge.

Alas not the yummy sweet sort that Grandma cooked up and gave out as treats.

In healthcare we are already preparing the Winter Fudge – the annual guessing game of attempting to survive the Winter Pressures. By fudging the issues.

This year with three landmark Safety and Quality reports under our belts we have more at stake than ever … yet we seem as ill prepared as usual. Mr Francis, Prof Keogh and Dr Berwick have collectively exhorted us to pull up our socks.

So let us explore how and why we resort to fudging the issues.

Watch the animation of a highly simplified emergency department and follow the thoughts of the manager. You can pause, rewind, and replay as much as you like. Follow the apparently flawless logic – it is very compelling. The exercise is deliberately simplified to eliminate wriggle room. But it is valid because the behaviour is defined by the Laws of Physics – and they are not negotiable.

The problem was combination of several planning flaws – two in particular.

First is the “Flaw of Averages” which is where the past performance-over-time is boiled down to one number. An average. And that is then used to predict precise future behaviour. This is a very big mistake.

The second is the “Flaw of Fudge Factors” which is a attempt to mitigate the effects of first error by fudging the answer – by adding an arbitrary “safety margin”.

This pseudo-scientific sleight-of-hand may polish the planning rhetoric and render it more plausible to an unsuspecting Board – but it does not fool Reality.

In reality the flawed design failed – as the animation dramatically demonstrated. The simulated patients came to harm. Unintended harm to be sure – but harm nevertheless.

So what is the alternative?

The alternative is to learn how to avoid Sir Flaw of Averages and his slippery friend Mr Fudge Factor.

And learning how to do that is possible … it is called Improvement Science.

And you can start right now … click HERE.

10/08/2013

Taming the Wicked Bull and the OH Effect

“Take the bull by the horns” is a phrase that is often heard in Improvement circles.

The metaphor implies that the system – the bull – is an unpredictable, aggressive, wicked, wild animal with dangerous sharp horns.

“Unpredictable” and “Dangerous” is certainly what the newspapers tell us the NHS system is – and this generates fear. Fear-for-our-safety and fear drives us to avoid the bad tempered beast.

It creates fear in the hearts of the very people the NHS is there to serve – the public. It is not the intended outcome.

“Bullish” is a phrase we use for “aggressive behaviour” and it is disappointing to see those accountable behave in a bullish manner – aggressive, unpredictable and dangerous.

We are taught that bulls are to be avoided and we are told to not to wave red flags at them! For our own safety.

But that is exactly what must happen for Improvement to flourish. We all need regular glimpses of the Red Flag of Reality. It is called constructive feedback – but it still feels uncomfortable. Our natural tendency to being shocked out of our complacency is to get angry and to swat the red flag waver. And the more powerful we are, the sharper our horns are, the more swatting we can do and the more fear we can generate. Often intentionally.

So inexperienced improvement zealots are prodded into “taking the executive bull by the horns” – but it is poor advice.

Improvement Scientists are not bull-fighters. They are not fearless champions who put themselves at personal risk for personal glory and the entertainment of others. That is what Rescuers do. The fire-fighters; the quick-fixers; the burned-toast-scrapers; the progress-chasers; and the self-appointed-experts. And they all get gored by an angry bull sooner or later. Which is what the crowd came to see – Bull Fighter Blood and Guts!

So attempting to slay the wicked bullish system is not a realistic option.

What about taming it?

This is the game of Bucking Bronco. You attach yourself to the bronco like glue and wear it down as it tries to throw you off and trample you under hoof. You need strength, agility, resilience and persistence. All admirable qualities. Eventually the exhausted beast gives in and does what it is told. It is now tamed. You have broken its spirit. The stallion is no longer a passionate leader; it is just a passive follower. It has become a Victim.

Improvement requires spirit – lots of it.

Improvement requires the spirit-of-courage to challenge dogma and complacency.
Improvement requires the spirit-of-curiosity to seek out the unknown unknowns.
Improvement requires the spirit-of-bravery to take calculated risks.
Improvement requires the spirit-of-action to make the changes needed to deliver the improvements.
Improvement requires the spirit-of-generosity to share new knowledge, understanding and wisdom.

So taming the wicked bull is not going to deliver sustained improvement. It will only achieve stable mediocrity.

So what next?

What about asking someone who has actually done it – actually improved something?

Good idea! Who?

What about someone like Don Berwick – founder of the Institute of Healthcare Improvement in the USA?

Excellent idea! We will ask him to come and diagnose the disease in our system – the one that lead to the Mid-Staffordshire septic safety carbuncle, and the nasty quality rash in 14 Trusts that Professor Sir Bruce Keogh KBE uncovered when he lifted the bed sheet.

[Click HERE to see Dr Bruce’s investigation].

We need a second opinion because the disease goes much deeper – and we need it from a credible, affable, independent, experienced expert. Like Dr Don B.

So Dr Don has popped over the pond, examined the patient, formulated his diagnosis and delivered his prescription.

[Click HERE to read Dr Don’s prescription].

Of course if you ask two experts the same question you get two slightly different answers. If you ask ten you get ten. This is because if there was only one answer that everyone agreed on then there would be no problem, no confusion, and need for experts. The experts know this of course. It is not in their interest to agree completely.

One bit of good news is that the reports are getting shorter. Mr Robert’s report on the failing of one hospital is huge and has 209 recommendations. A bit of a bucketful. Dr Bruce’s report is specific to the Naughty Fourteen who have strayed outside the statistical white lines of acceptable mediocrity.

Dr Don’s is even shorter and it has just 10 recommendations. One for each finger – so easy to remember.

1. The NHS should continually and forever reduce patient harm by embracing wholeheartedly an ethic of learning.

2. All leaders concerned with NHS healthcare – political, regulatory, governance, executive, clinical and advocacy – should place quality of care in general, and patient safety in particular, at the top of their priorities for investment, inquiry, improvement, regular reporting, encouragement and support.

3. Patients and their carers should be present, powerful and involved at all levels of healthcare organisations from wards to the boards of Trusts.

4. Government, Health Education England and NHS England should assure that sufficient staff are available to meet the NHS’s needs now and in the future. Healthcare organisations should ensure that staff are present in appropriate numbers to provide safe care at all times and are well-supported.

5. Mastery of quality and patient safety sciences and practices should be part of initial preparation and lifelong education of all health care professionals, including managers and executives.

6. The NHS should become a learning organisation. Its leaders should create and support the capability for learning, and therefore change, at scale, within the NHS.

7. Transparency should be complete, timely and unequivocal. All data on quality and safety, whether assembled by government, organisations, or professional societies, should be shared in a timely fashion with all parties who want it, including, in accessible form, with the public.

8. All organisations should seek out the patient and carer voice as an essential asset in monitoring the safety and quality of care.

9. Supervisory and regulatory systems should be simple and clear. They should avoid diffusion of responsibility. They should be respectful of the goodwill and sound intention of the vast majority of staff. All incentives should point in the same direction.

10. We support responsive regulation of organisations, with a hierarchy of responses. Recourse to criminal sanctions should be extremely rare, and should function primarily as a deterrent to wilful or reckless neglect or mistreatment.

The meat in the sandwich are recommendations 5 and 6 that together say “Learn Improvement Science“.

And what happens when we commit and engage in that learning journey?

Steve Peak has described what happens in this this very blog. It is called the OH effect.

OH stands for “Obvious-in-Hindsight”.

Obvious means “understandable” which implies visible, sensible, rational, doable and teachable.

Hindsight means “reflection” which implies having done something and learning from reality.

So if you would like to have a sip of Dr Don’s medicine and want to get started on the path to helping to create a healthier healthcare system you can do so right now by learning how to FISH – the first step to becoming an Improvement Science Practitioner.

The good news is that this medicine is neither dangerous nor nasty tasting – it is actually fun!

And that means it is OK for everyone – clinicians, managers, patients, carers and politicians. All of us.

03/08/2013

The Five-and-Two Improvement Plan

One of the reasons that many people find improvement difficult is because they are told that they will undergo a “transformational” change and they will have a “Road-To-Damascus Moment” when the “penny drops” and the “light bulb goes on”.

This is rubbish advice.

The unstated implication is that “and if you do not then there is something wrong with you“.

There is no Improvementologist I know who ever had a massive “ah ha” moment – the insight was gained gradually, bit-by-bit, over a long period of time.

And that is for a good reason.

We are all very weak-willed.

We all very easily slip back into Victim role, and I’m Not OK or They’re not OK thinking. Especially when bad news is so plentiful and so cheap.

The “Eureka Mantra” does not work with trying to improve physical health by losing weight so why should it work for anything else? Diets do not work – if they did we would all be a healthy weight.

A few months ago I ran an experiment – to see if I could lose a significant amount of weight without much effort – certainly without doing any extra exercise. How? By “not burning the toast” on the first place. By ingesting fewer carbs.

That experiment has shown it is possible – I have the evidence – hard facts not just fuzzy feelings.

The most surprising lesson was that all I had to do was to reduce carb intake for two days a week. I just skipped the sugar, biscuits, bread, potatoes, crisps etc for two days a week. It was not difficult. In fact it was so easy I am not surprised that the Five-and-Two weight reduction plan is going viral.

So I wonder what would happen if we try the same experiment for other areas of improvement – psychological. What if we just change the “diet” from “carbs” to “cants”. What if for two days a week we just restrict our “cant” intake. What if we turn down the volume of our inner voice that tells us what we cant do? What if we just ignore the people whose response to every improvement suggestion is “yes …but”? What if we just do this and measure what happens?

For only two days a week though.

I’m not interested in being suddenly transformed – a gradual metamorphosis is OK by me. My intuition is that it will be important to maintain a normal diet of whining and denying for the other five days – because I need variation and I do seem to get pleasure from wallowing in my own toxic emotional swamp.

That sounds doable.

I could probably maintain a “negative thought filter” for two days a week – and then return to my curmudgeonly comfort zone for the other five.

I’ll need to choose which days wisely though … and I had better wear a special hat, tie or badge that indicates which mode I am in – a pessimistic Black Hat five days a week and an optimistic Yellow Hat for the other two perhaps.

I wonder if anyone will notice?

And the idea of choosing your attitude for a day reminds me of a little book called FISH!