Seeing Inside the Black Box

box_opening_up_closing_150_wht_8035 Improvement Science requires the effective, efficient and coordinated use of diagnosis, design and delivery tools.

Experience has also taught us that it is not just about the tools – each must be used as it was designed.

The craftsman knows his tools and knows what instrument to use, where and when the context dictates; and how to use it with skill.

Some tools are simple and effective – easy to understand and to use. The kitchen knife is a good example. It does not require an instruction manual to use it.

Other tools are more complex. Very often because they have a specific purpose. They are not generic. And they may not be intuitively obvious how to use them.  Many labour-saving household appliances have specific purposes: the microwave oven, the dish-washer and so on – but they have complex controls and settings that we need to manipulate to direct the “domestic robot” to deliver what we actually want.  Very often these controls are not intuitively obvious – we are dealing with a black box – and our understanding of what is happening inside is vague.

Very often we do not understand how the buttons and dials that we can see and touch – the inputs – actually influence the innards of the box to determine the outputs. We do not have a mental model of what is inside the Black Box. We do not know – we are ignorant.

In this situation we may resort to just blindly following the instructions;  or blindly copying what someone else does; or blindly trying random combinations of inputs until we get close enough to what we want. No wiser at the end than we were at the start.  The common thread here is “blind”. The box is black. We cannot see inside.

And the complex black box is deliberately made so – because the supplier of the super-tool does not want their “secret recipe” to be known to all – least of all their competitors.

This is a perfect recipe for confusion and for conflict. Lose-Lose-Lose.

Improvement Science is dedicated to eliminating confusion and conflict – so Black Box Tools are NOT on the menu.

Improvement Scientists need to understand how their tools work – and the best way to achieve that level of understanding is to design and build their own.

This may sound like re-inventing the wheel but it is not about building novel tools – it is about re-creating the tried and tested tools – for the purpose of understanding how they work. And understanding their strengths, their weaknesses, their opportunities and their risks or threats.

And doing that requires guidance from a mentor who has been through this same learning journey. Starting with simple, intuitive tools, and working step-by-step to design, build and understand the more complex ones.

So where do we start?

In the FISH course the first tool we learn to use is a Gantt Chart.

It was invented by Henry Laurence Gantt about 100 years ago and requires nothing more than pencil and paper. Coloured pencils and squared paper are even better.

Gantt_ChartThis is an example of a Gantt Chart for a Day Surgery Unit.

At the top are the “tasks” – patients 1 and 2; and at the bottom are the “resources”.

Time runs left to right.

Each coloured bar appears twice: once on each chart.

The power of a Gantt Chart is that it presents a lot of information in a very compact and easy-to-interpret format. That is what Henry Gantt intended.

A Gantt Chart is like the surgeon’s scalpel. It is a simple, generic easy-to-create tool that has a wide range of uses. The skill is knowing where, when and how to use it: and just as importantly where-not, when-not and how-not.

DRAT_04The second tool that an Improvement Scientist learns to use is the Shewhart or time-series chart.

It was invented about 90 years ago.

This is a more complex tool and as such there is a BIG danger that it is used as a Black Box with no understanding of the innards.  The SPC  and Six-Sigma Zealots sell it as a Magic Box. It is not.

We could paste any old time-series data into a bit of SPC software; twiddle with the controls until we get the output we want; and copy the chart into our report. We could do that and hope that no-one will ask us to explain what we have done and how we have done it. Most do not because they do not want to appear ‘ignorant’. The elephant is in the room though.  There is a conspiracy of silence.

The elephant-in-the-room is the risk we take when use Black Box tools – the risk of GIGO. Garbage In Garbage Out.

And unfortunately we have a tendency to blindly trust what comes out of the Black Box that a plausible Zealot tells us is “magic”. This is the Emporer’s New Clothes problem.  Another conspiracy of silence follows.

The problem here is not the tool – it is the desperate person blindly wielding it. The Zealots know this and they warn the Desperados of the risk and offer their expensive Magician services. They are not interested in showing how the magic trick is done though! They prefer the Box to stay Black.

So to avoid this cat-and-mouse scenario and to understand both the simpler and the more complex tools, and to be able to use them effectively and safely, we need to be able to build one for ourselves.

And the know-how to do that is not obvious – if it were we would have already done it – so we need guidance.

And once we have  built our first one – a rough-and-ready working prototype – then we can use the existing ones that have been polished with long use. And we can appreciate the wisdom that has gone into their design. The Black Box becomes Transparent.

So learning how the build the essential tools is the first part of the Improvement Science Practitioner (ISP) training – because without that knowledge it is difficult to progress very far. And without that understanding it is impossible to teach anyone anything other than to blindly follow a Black Box recipe.

Of course Magic Black Box Solutions Inc will not warm to this idea – they may not want to reveal what is inside their magic product. They are fearful that their customers may discover that it is much simpler than they are being told.  And we can test that hypothesis by asking them to explain how it works in language that we can understand. If they cannot (or will not) then we may want to keep looking for someone who can and will.


line_figure_phone_400_wht_9858<Lesley>Hi Bob! How are you today?

<Bob>OK thanks Lesley. And you?

<Lesley>I am looking forward to our conversation. I have two questions this week.

<Bob>OK. What is the first one?

<Lesley>You have taught me that improvement-by-design starts with the “purpose” question and that makes sense to me. But when I ask that question in a session I get an “eh?” reaction and I get nowhere.

<Bob>Quod facere bonum opus et quomodo te cognovi unum?


<Bob>I asked you a purpose question.

<Lesley>Did you? What language is that? Latin? I do not understand Latin.

<Bob>So although you recognize the language you do not understand what I asked, the words have no meaning. So you are unable to answer my question and your reaction is “eh?”. I suspect the same is happening with your audience. Who are they?

<Lesley>Front-line clinicians and managers who have come to me to ask how to solve their problems. There Niggles. They want a how-to-recipe and they want it yesterday!

<Bob>OK. Remember the Temperament Treacle conversation last week. What is the commonest Myers-Briggs Type preference in your audience?

<Lesley>It is xSTJ – tough minded Guardians.  We did that exercise. It was good fun! Lots of OMG moments!

<Bob>OK – is your “purpose” question framed in a language that the xSTJ preference will understand naturally?

<Lesley>Ah! Probably not! The “purpose” question is future-focused, conceptual , strategic, value-loaded and subjective.

<Bob>Indeed – it is an iNtuitor question. xNTx or xNFx. Pose that question to a roomful of academics or executives and they will debate it ad infinitum.

<Lesley>More Latin – but that phrase I understand. You are right.  And my own preference is xNTP so I need to translate my xNTP “purpose” question into their xSTJ language?

<Bob>Yes. And what language do they use?

<Lesley>The language of facts, figures, jobs-to-do, work-schedules, targets, budgets, rational, logical, problem-solving, tough-decisions, and action-plans. Objective, pragmatic, necessary stuff that keep the operational-wheels-turning.

<Bob>OK – so what would “purpose” look like in xSTJ language?

<Lesley>Um. Good question. Let me start at the beginning. They came to me in desperation because they are now scared enough to ask for help.

<Bob>Scared of what?

<Lesley>Unintentionally failing. They do not want to fail and they do not need beating with sticks. They are tough enough on themselves and each other.

<Bob>OK that is part of their purpose. The “Avoid” part. The bit they do not want. What do they want? What is the “Achieve” part? What is their “Nice If”?

<Lesley>To do a good job.

<Bob>Yes. And that is what I asked you – but in an unfamiliar language. Translated into English I asked “What is a good job and how do you know you are doing one?”

<Lesley>Ah ha! That is it! That is the question I need to ask. And that links in the first map – The 4N Chart®. And it links in measurement, time-series charts and BaseLine© too. Wow!

<Bob>OK. So what is your second question?

<Lesley>Oh yes! I keep getting asked “How do we work out how much extra capacity we need?” and I answer “I doubt that you need any more capacity.”

<Bob>And their response is?

<Lesley>Anger and frustration! They say “That is obvious rubbish! We have a constant stream of complaints from patients about waiting too long and we are all maxed out so of course we need more capacity! We just need to know the minimum we can get away with – the what, where and when so we can work out how much it will cost for the business case.

<Bob>OK. So what do they mean by the word “capacity”. And what do you mean?

<Lesley>Capacity to do a good job?

<Bob>Very quick! Ho ho! That is a bit imprecise and subjective for a process designer though. The Laws of Physics need the terms “capacity”, “good” and “job” clearly defined – with units of measurement that are meaningful.

<Lesley>OK. Let us define “good” as “delivered on time” and “job” as “a patient with a health problem”.

<Bob>OK. So how do we define and measure capacity? What are the units of measurement?

<Lesley>Ah yes – I see what you mean. We touched on that in FISH but did not go into much depth.

<Bob>Now we dig deeper.

<Lesley>OK. FISH talks about three interdependent forms of capacity: flow-capacity, resource-capacity, and space-capacity.

<Bob>Yes. They are the space-and-time capacities. If we are too loose with our use of these and treat them as interchangeable then we will create the confusion and conflict that you have experienced. What are the units of measurement of each?

<Lesley>Um. Flow-capacity will be in the same units as flow, the same units as demand and activity – tasks per unit time.

<Bob>Yes. Good. And space-capacity?

<Lesley>That will be in the same units as work in progress or inventory – tasks.

<Bob>Good! And what about resource-capacity?

<Lesley>Um – Will that be resource-time – so time?

<Bob>Actually it is resource-time per unit time. So they have different units of measurement. It is invalid to mix them up any-old-way. It would be meaningless to add them for example.

<Lesley>OK. So I cannot see how to create a valid combination from these three! I cannot get the units of measurement to work.

<Bob>This is a critical insight. So what does that mean?

<Lesley>There is something missing?

<Bob>Yes. Excellent! Your homework this week is to work out what the missing pieces of the capacity-jigsaw are.

<Lesley>You are not going to tell me the answer?

<Bob>Nope. You are doing ISP training now. You already know enough to work it out.

<Lesley>OK. Now you have got me thinking. I like it. Until next week then.

<Bob>Have a good week.

Temperament Treacle

stick_figure_help_button_150_wht_9911If the headlines in the newspapers are a measure of social anxiety then healthcare in the UK is in a state of panic: “Hospitals Fear The Winter Crisis Is Here Early“.

The Panic Button is being pressed and the Patient Safety Alarms are sounding.

Closer examination of the statement suggests that the winter crisis is not unexpected – it is just here early.  So we are assuming it will be worse than last year – which was bad enough.

The evidence shows this fear is well founded.  Last year was the worst on the last 5 years and this year is shaping up to be worse still.

So if it is a predictable annual crisis and we have a lot of very intelligent, very committed, very passionate people working on the problem – then why is it getting worse rather than better?

One possible factor is Temperament Treacle.

This is the glacially slow pace of effective change in healthcare – often labelled as “resistance to change” and implying deliberate scuppering of the change boat by powerful forces within the healthcare system.

Resistance to the flow of change is probably a better term. We could call that cultural viscosity.  Treacle has a very high viscosity – it resists flow.  Wading through treacle is very hard work. So pushing change though cultural treacle is hard work. Many give up in exhaustion after a while.

So why the term “Temperament Treacle“?

Improvement Science has three parts – Processes, Politics and Systems.

Process Science is applied physics. It is an objective, logical, rational science. The Laws of Physics are not negotiable. They are absolute.

Political Science is applied psychology. It is a subjective, illogical, irrational science. The Laws of People are totally negotiable.  They are arbitrary.

Systems Science is a combination of Physics and Psychology. A synthesis. A synergy. A greater-than-the-sum-of-the-parts combination.

The Swiss physician Carl Gustav Jung studied psychology – and in 1920 published “Psychological Types“.  When this ground-breaking work was translated into English in 1923 it was picked up by Katherine Cook Briggs and made popular by her daughter Isabel.  Isabel Briggs married Clarence Myers and in 1942 Isabel Myers learned about the Humm-Wadsworth Scale,  a tool for matching people with jobs. So using her knowledge of psychological type differences she set out to develop her own “personality sorting tool”. The first prototype appeared in 1943; in the 1950’s she tested the third iteration and measured the personality types of 5,355 medical students and over 10,000 nurses.   The Myers-Briggs Type Indicator was published 1962 and since then the MBTI® has been widely tested and validated and is the most extensively used personality type instrument. In 1980 Isabel Myers finished writing Gifts Differing just before she died at the age of 82 after a twenty year long battle with cancer.

The essence of Jung’s model is that an individual’s temperament is largely innate and the result of a combination of three dimensions:

1. The input or perceiving  process (P). The poles are Intuitor (N) or Sensor (S).
2. The decision or judging process (J). The poles are Thinker (T) or Feeler (F).
3. The output or doing process. The poles are Extraversion (E) or Intraversion (I).

Each of Jung’s dimensions had two “opposite” poles so when combined they gave eight types.  Isabel Myers, as a result of her extensive empirical testing, added a fourth dimension – which gives the four we see in the modern MBTI®.  The fourth dimension linked the other three together – it describes if the J or the P process is the one shown to the outside world. So the MBTI® has sixteen broad personality types.  In 1998 a book called “Please Understand Me II” written by David Keirsey, the MBTI® is put into an historical context and Keirsey concluded that there are four broad Temperaments – and these have been described since Ancient times.

When Isabel Myers measured different populations using her new tool she discovered a consistent pattern: that the proportions of the sixteen MBTI® types were consistent across a wide range of societies. Personality type is, as Jung had suggested, an innate part of the “human condition”. She also saw that different types clustered in different occupations. Finding the “right job” appeared to be a process of natural selection: certain types fitted certain roles better than others and people self-selected at an early age.  If their choice was poor then the person would be unhappy and would not achieve their potential.

Isabel’s work also showed that each type had both strengths and weaknesses – and that people performed better and felt happier when their role played to their temperament strengths.  It also revealed that considerable conflict could be attributed to type-mismatch.  Polar opposite types have the least psychological “common ground” – so when they attempt to solve a common problem they do so by different routes and using different methods and language. This generates confusion and conflict.  This is why Isabel Myers gave her book the title of “Gifts Differing” and her message was that just having awareness of and respect for the innate type differences was a big step towards reducing the confusion and conflict.

So what relevance does this have to change and improvement?

Well it turns out that certain types are much more open to change than others and certain types are much more resistant.  If an organisation, by the very nature of its work, attracts the more change resistant types then that organisation will be culturally more viscous to the flow of change. It will exhibit the cultural characteristics of temperament treacle.

The key to understanding Temperament and the MBTI® is to ask a series of questions:

Q1. Does the person have the N or S preference on their perceiving function?

A1=N then Q2: Does the person have a T or F preference on their judging function?
A2=T gives the xNTx combination which is called the Rational or phlegmatic temperament.
A2=F gives the xNFx combination which is called the Idealist or choleric temperament.

A1=S then Q3: Does the person show a J or P preference to the outside world?
A3=J gives the xSxJ combination which is called the Guardian or melancholic temperament.
A3=P gives the xSxP combination which is called the Artisan or sanguine temperament.

So which is the most change resistant temperament?  The answer may not be a big surprise. It is the Guardians. The melancholics. The SJ’s.

Bureaucracies characteristically attract SJ types. The upside is that they ensure stability – the downside is that they prevent agility.  Bureaucracies block change.

The NF Idealists are the advocates and the mentors: they love initiating and facilitating transformations with the dream of making the world a better place for everyone. They light the emotional bonfire and upset the apple cart. The NT Rationals are the engineers and the architects. They love designing and building new concepts and things – so once the Idealists have cracked the bureaucratic carapace they can swing into action. The SP Sanguines are the improvisors and expeditors – they love getting the new “concept” designs to actually work in the messy real world.

Unfortunately the grand designs dreamed up by the ‘N’s often do not work in practice – and the scene is set for the we-told-you-so game, and the name-shame-blame game.

So if initiating and facilitating change is the Achilles Heel of the SJ’s then what is their strength?

Let us approach this from a different perspective:

Let us put ourselves in the shoes of patients and ask ourselves: “What do we want from a System of Healthcare and from those who deliver that care – the doctors?”

1. Safe?
2. Reliable?
3. Predictable?
4. Decisive?
5. Dependable?
6. All the above?

These are the strengths of the SJ temperament. So how do doctors measure up?

In a recent observational study, 168 doctors who attended a leadership training course completed their MBTI® self-assessments as part of developing insight into temperament from the perspective of a clinical leader.  From the collective data we can answer our question: “Are there more SJ types in the medical profession than we would expect from the general population?”

Doctor_Temperament The table shows the results – 60% of doctors were SJ compared with 35% expected for the general population.

Statistically this is highly significant difference (p<0.0001). Doctors are different.

It is of enormous practical importance well.

We are reassured that the majority of doctors have a preference for the very traits that patients want from them. That may explain why the Medical Profession always ranks highest in the league table of “trusted professionals”. We need to be able to trust them – it could literally be a matter of life or death.

The table also shows where the doctors were thin on the ground: in the mediating, improvising, developing, constructing temperaments. The very set of skills needed to initiate and facilitate effective and sustained change.

So when the healthcare system is lurching from one predictable crisis to another – the innate temperament of the very people we trust to deliver our health care are the least comfortable with changing the system of care itself.

That is a problem. A big problem.

Studies have show that when we get over-stressed, fearful and start to panic then in a desperate act of survival we tend to resort to the aspects of our temperament that are least well developed.  An SJ who is in panic-mode may resort to NP tactics: opinion-led purposeless conceptual discussion and collective decision paralysis. This is called the “headless chicken and rabbit in the headlights” mode. We have all experienced it.

A system that is no longer delivering fit-for-purpose performance because its purpose has shifted requires redesign.  The temperament treacle inhibits the flow of change so the crisis is not averted. The crisis happens, invokes panic and triggers ineffective and counter-productive behaviour. The crisis deepens and performance can drop catastrophically when the red tape is cut. It was the only thing holding the system together!

But while the bureaucracy is in disarray then innovation can start to flourish. And the next cycle starts.

It is a painful, slow, wasteful process called “reactionary evolution by natural selection“.

Improvement Science is different. It operates from a “proactive revolution through collective design” that is enjoyable, quick and efficient but it requires mastery of synergistic political science and process science. We do not have that capability – yet.

The table offers some hope.  It shows the majority of doctors are xSTJ.  They are Logical Guardians. That means that they solve problems using tried-tested-and-trustworthy logic. So they have no problem with the physics. Show them how to diagnose and design processes and they are inside their comfort zone.

Their collective weak spot is managing the politics – the critical cultural dimension of change. Often the result is manipulation rather than motivation. It does not work. The improvement stalls. Cynicism increases. The treacle gets thicker.

System-redesign requires synergistic support, development, improvisation and mediation. These strengths do exist in the medical profession – but they appear to be in short supply – so they need to be identified, and nurtured.  And change teams need to assemble and respect the different gifts.

One further point about temperament.  It is not immutable. We can all develop a broader set of MBTI® capabilities with guidance and practice – especially the ones that fill the gaps between xSTJ and xNFP.  Those whose comfort zone naturally falls nearer the middle of the four dimensions find this easier. And that is one of the goals of Improvement Science training.

Sorting_HatAnd if you are in a hurry then you might start today by identifying the xSFJ “supporters” and the xNFJ “mentors” in your organisation and linking them together to build a temporary bridge over the change culture chasm.

So to find your Temperament just click here to download the Temperament Sorter.

The Mirror

mirror_mirror[Dring Dring]

The phone announced the arrival of Leslie for the weekly ISP mentoring conversation with Bob.

<Leslie> Hi Bob.

<Bob> Hi Leslie. What would you like to talk about today?

<Leslie> A new challenge – one that I have not encountered before.

<Bob>Excellent. As ever you have pricked my curiosity. Tell me more.

<Leslie> OK. Up until very recently whenever I have demonstrated the results of our improvement work to individuals or groups the usual response has been “Yes, but“. The habitual discount as you call it. “Yes, but your service is simpler; Yes, but your budget is bigger; Yes, but your staff are less militant.” I have learned to expect it so I do not get angry any more.

<Bob> OK. The mantra of the skeptics is to be expected and you have learned to stay calm and maintain respect. So what is the new challenge?

<Leslie>There are two parts to it.  Firstly, because the habitual discounting is such an effective barrier to diffusion of learning;  our system has not changed; the performance is steadily deteriorating; the chaos is worsening and everything that is ‘obvious’ has been tried and has not worked. More red lights are flashing on the patient-harm dashboard and the Inspectors are on their way. There is an increasing  turnover of staff at all levels – including Executive.  There is an anguished call for “A return to compassion first” and “A search for new leaders” and “A cultural transformation“.

<Bob> OK. It sounds like the tipping point of awareness has been reached, enough people now appreciate that their platform is burning and radical change of strategy is required to avoid the ship sinking and them all drowning. What is the second part?

<Leslie> I am getting more emails along the line of “What would you do?

<Bob> And your reply?

<Leslie> I say that I do not know because I do not have a diagnosis of the cause of the problem. I do know a lot of possible causes but I do not know which plausible ones are the actual ones.

<Bob> That is a good answer.  What was the response?

<Leslie>The commonest one is “Yes, but you have shown us that Plan-Do-Study-Act is the way to improve – and we have tried that and it does not work for us. So we think that improvement science is just more snake oil!”

<Bob>Ah ha. And how do you feel about that?

<Leslie>I have learned the hard way to respect the opinion of skeptics. PDSA does work for me but not for them. And I do not understand why that is. I would like to conclude that they are not doing it right but that is just discounting them and I am wary of doing that.

<Bob>OK. You are wise to be wary. We have reached what I call the Mirror-on-the-Wall moment.  Let me ask what your understanding of the history of PDSA is?

<Leslie>It was called Plan-Do-Check-Act by Walter Shewhart in the 1930’s and was presented as a form of the scientific method that could be applied on the factory floor to improving the quality of manufactured products.  W Edwards Deming modified it to PDSA where the “Check” was changed to “Study”.  Since then it has been the key tool in the improvement toolbox.

<Bob>Good. That is an excellent summary.  What the Zealots do not talk about are the limitations of their wonder-tool.  Perhaps that is because they believe it has no limitations.  Your experience would seem to suggest otherwise though.

<Leslie>Spot on Bob. I have a nagging doubt that I am missing something here. And not just me.

<Bob>The reason PDSA works for you is because you are using it for the purpose it was designed for: incremental improvement of small bits of the big system; the steps; the points where the streams cross the stages.  You are using your FISH training to come up with change plans that will work because you understand the Physics of Flow better. You make wise improvement decisions.  In fact you are using PDSA in two separate modes: discovery mode and delivery mode.  In discovery mode we use the Study phase to build your competence – and we learn most when what happens is not what we expected.  In delivery mode we use the Study phase to build our confidence – and that grows most when what happens is what we predicted.

<Leslie>Yes, that makes sense. I see the two modes clearly now you have framed it that way – and I see that I am doing both at the same time, almost by second nature.

<Bob>Yes – so when you demonstrate it you describe PDSA generically – not as two complimentary but contrasting modes. And by demonstrating success you omit to show that there are some design challenges that cannot be solved with either mode.  That hidden gap attracts some of the “Yes, but” reactions.

<Leslie>Do you mean the challenges that others are trying to solve and failing?

<Bob>Yes. The commonest error is to discount the value of improvement science in general; so nothing is done and the inevitable crisis happens because the system design is increasingly unfit for the evolving needs.  The toast is not just burned it is on fire and is now too late to  use the discovery mode of PDSA because prompt and effective action is needed.  So the delivery mode of PDSA is applied to a emergent, ill-understood crisis. The Plan is created using invalid assumptions and guesswork so it is fundamentally flawed and the Do then just makes the chaos worse.  In the ensuing panic the Study and Act steps are skipped so all hope of learning is lost and and a vicious and damaging spiral of knee-jerk Plan-Do-Plan-Do follows. The chaos worsens, quality falls, safety falls, confidence falls, trust falls, expectation falls and depression and despair increase.

<Leslie>That is exactly what is happening and why I feel powerless to help. What do I do?

<Bob>The toughest bit is past. You have looked squarely in the mirror and can now see harsh reality rather than hasty rhetoric. Now you can look out of the window with different eyes.  And you are now looking for a real-world example of where complex problems are solved effectively and efficiently. Can you think of one?

<Leslie>Well medicine is one that jumps to mind.  Solving a complex, emergent clinical problems requires a clear diagnosis and prompt and effective action to stabilise the patient and then to cure the underlying cause: the disease.

<Bob>An excellent example. Can you describe what happens as a PDSA sequence?

<Leslie>That is a really interesting question.  I can say for starters that it does not start with P – we have learned are not to have a preconceived idea of what to do at the start because it badly distorts our clinical judgement.  The first thing we do is assess the patient to see how sick and unstable they are – we use the Vital Signs. So that means that we decide to Act first and our first action is to Study the patient.

<Bob>OK – what happens next?

<Leslie>Then we will do whatever is needed to stabilise the patient based on what we have observed – it is called resuscitation – and only then we can plan how we will establish the diagnosis; the root cause of the crisis.

<Bob> So what does that spell?

<Leslie> A-S-D-P.  It is the exact opposite of P-D-S-A … the mirror image!

<Bob>Yes. Now consider the treatment that addresses the root cause and that cures the patient. What happens then?

<Leslie>We use the diagnosis is used to create a treatment Plan for the specific patient; we then Do that, and we Study the effect of the treatment in that specific patient, using our various charts to compare what actually happens with what we predicted would happen. Then we decide what to do next: the final action.  We may stop because we have achieved our goal, or repeat the whole cycle to achieve further improvement. So that is our old friend P-D-S-A.

<Bob>Yes. And what links the two bits together … what is the bit in the middle?

<Leslie>Once we have a diagnosis we look up the appropriate treatment options that have been proven to work through research trials and experience; and we tailor the treatment to the specific patient. Oh I see! The missing link is design. We design a specific treatment plan using generic principles.

<Bob>Yup.  The design step is the jam in the improvement sandwich and it acts like a mirror: A-S-D-P is reflected back as P-D-S-A

<Leslie>So I need to teach this backwards: P-D-S-A and then Design and then A-S-P-D!

<Bob>Yup – and you know that by another name.

<Leslie> 6M Design®! That is what my Improvement Science Practitioner course is all about.

<Bob> Yup.

<Leslie> If you had told me that at the start it would not have made much sense – it would just have confused me.

<Bob>I know. That is the reason I did not. The Mirror needs to be discovered in order for the true value to appreciated. At the start we look in the mirror and perceive what we want to see. We have to learn to see what is actually there. Us. Now you can see clearly where P-D-S-A and Design fit together and the missing A-S-D-P component that is needed to assemble a 6M Design® engine. That is Improvement-by-Design in a nine-letter nutshell.

<Leslie> Wow! I can’t wait to share this.

<Bob> And what do you expect the response to be?

<Leslie>”Yes, but”?

<Bob> From the die hard skeptics – yes. It is the ones who do not say “Yes, but” that you want to engage with. The ones who are quiet. It is always the quiet ones that hold the key.

Three Essentials

There are three necessary parts before ANY improvement-by-design effort will gain traction. Omit any one of them and nothing happens.


1. A clear purpose and an outline strategic plan.

2. Tactical measurement of performance-over-time.

3. A generic Improvement-by-Design framework.

These are necessary minimum requirements to be able to safely delegate the day-to-day and week-to-week tactical stuff the delivers the “what is needed”.

These are necessary minimum requirements to build a self-regulating, self-sustaining, self-healing, self-learning win-win-win system.

And this is not a new idea.  It was described by Joseph Juran in the 1960’s and that description was based on 20 years of hands-on experience of actually doing it in a wide range of manufacturing and service organisations.

That is 20 years before  the terms “Lean” or “Six Sigma” or “Theory of Constraints” were coined.  And the roots of Juran’s journey were 20 years before that – when he started work at the famous Hawthorne Works in Chicago – home of the Hawthorne Effect – and where he learned of the pioneering work of  Walter Shewhart.

And the roots of Shewhart’s innovations were 20 years before that – in the first decade of the 20th Century when innovators like Henry Ford and Henry Gantt were developing the methods of how to design and build highly productive processes.

Ford gave us the one-piece-flow high-quality at low-cost production paradigm. Toyota learned it from Ford.  Gantt gave us simple yet powerful visual charts that give us an understanding-at-a-glance of the progress of the work.  And Shewhart gave us the deceptively simple time-series chart that signals when we need to take more notice.

These nuggets of pragmatic golden knowledge have been buried for decades under a deluge of academic mud.  It is nigh time to clear away the detritus and get back to the bedrock of pragmatism. The “how-to-do-it” of improvement. Just reading Juran’s 1964 “Managerial Breakthrough” illustrates just how much we now take for granted. And how ignorant we have allowed ourselves to become.

Acquired Arrogance is a creeping, silent disease – we slip from second nature to blissful ignorance without noticing when we divorce painful reality and settle down with our own comfortable collective rhetoric.

The wake-up call is all the more painful as a consequence: because it is all the more shocking for each one of us; and because it affects more of us.

The pain is temporary – so long as we treat the cause and not just the symptom.

The first step is to acknowledge the gap – and to start filling it in. It is not technically difficult, time-consuming or expensive.  Whatever our starting point we need to put in place the three foundation stones above:

1. Common purpose.
2. Measurement-over-time.
3. Method for Improvement.

Then the rubber meets the road (rather than the sky) and things start to improve – for real. Lots of little things in lots of places at the same time – facilitated by the Junior Managers. The cumulative effect is dramatic. Chaos is tamed; calm is restored; capability builds; and confidence builds. The cynics have to look elsewhere for their sport and the skeptics are able to remain healthy.

Then the Middle Managers feel the new firmness under their feet – where before there were shifting sands. They are able to exert their influence again – to where it makes a difference. They stop chasing Scotch Mist and start reporting real and tangible improvement – with hard evidence. And they rightly claim a slice of the credit.

And the upwelling of win-win-win feedback frees the Senior Managers from getting sucked into reactive fire-fighting and the Victim Vortex; and that releases the emotional and temporal space to start learning and applying System-level Design.  That is what is needed to deliver a significant and sustained improvement.

And that creates the stable platform for the Executive Team to do Strategy from. Which is their job.

It all starts with the Three Essentials:

1. A Clear and Common Constancy of Purpose.
2. Measurement-over-time of the Vital Metrics.
3. A Generic Method for Improvement-by-Design.