April 2014 – HCSE Blog

26/04/2014

Synchronicity

[Beep, Beep, Beep, Beep, Beeeeep] The reminder roused Bob from deep reflection and he clicked the Webex link on his desktop to start the meeting. Leslie was already online.

<Bob> Hi Leslie. How are you? And what would you like to share and explore today?

<Leslie> Hi Bob, I am well thank you and I would like to talk about chaos again.

<Bob> OK. That is always a rich mine of new insights! Is there a specific reason?

<Leslie>Yes. The story I want to share is of the chaos that I have been experiencing just trying to get a new piece of software available for my team to use. You would not believe the amount of time, emails, frustration and angst it has taken to negotiate this through the ‘proper channels’.

<Bob> Let me guess … about six months?

<Leslie> Spot on! How did you know?

<Bob> Just prior experience of similar stories. So what is your diagnosis of the cause of the chaos?

<Leslie> My intuition shouts at me that people are just being deliberately difficult and that makes me feel angry and want to shout at them … but I have learned that behaviour is counter-productive.

<Bob> So what did you do?

<Leslie> I escalated the ‘problem’ to my line manager.

<Bob> And what did they do?

<Leslie> I am not sure, I was not copied in, but it seemed to clear the ‘obstruction’.

<Bob> And were the ‘people’ you mentioned suddenly happy and willing to help?

<Leslie> Not really … they did what we needed but they did not seem very happy about it.

<Bob> OK. You are describing a Drama Triangle, a game, and your behaviour was from the Persecutor role.

<Leslie>What! But I deliberately did not send any ANGRY emails or get into a childish argument. I escalated the issue I could not solve because that is what we are expected to do.

<Bob> Yes I know. If you had engaged in a direct angry conversation, by whatever means, that would have been an actively aggressive act. By escalating the issue and someone Bigger having the angry conversation you have engaged in a passive aggressive act. It is still playing the game from the Persecutor role and in fact is the more common mode of Persecution.

<Leslie> But it got the barrier cleared and the problem sorted?

<Bob> And did it leave everyone feeling happier than before?

<Leslie> I guess not. I certainly felt like a bit of a ‘tale teller’ and the IT technician probably hates me and fears for his job, and the departmental heads probably distrust each other even more than before.

<Bob> So this approach may appear to work in the short term but it creates a much bigger long term problem – and it is that long term problem of ‘distrust’ that creates the chaos. So it is a self-sustaining design.

<Leslie> Oh dear! Is there a way to avoid this and to defuse the chronic distrust?

<Bob> Yes. You have demonstrated a process that you would like to improve – you want the same short term outcome, your software installed and working, and you want it quicker and with less angst and leaving everyone feeling good about how they have played a part in achieving that objective.

<Leslie>Yes. That would be my ideal.

<Bob>So what is different between what you did and your ‘ideal’ scenario? What did you do that you should not have and what did you not do that you could have?

<Leslie> Well I triggered off a drama triangle which I should not have. I also assumed that the IT people would know what to do because I do not understand the technical nuances of getting new software procured and installed. What I could have done is make it much clearer for them what I needed, why I needed it and how and when I needed it. I could have done a lot more homework before asking them for assistance. I could also have given my inner Chimp a banana and gone to talk to them face-to-face and ask their opinion early on so I could see the problem from their perspective as well as mine.

<Bob> Yes – that all sounds reasonable and respectful. What you are doing is ‘synchronising‘. You are engaging in understanding the process well enough so that you can align all the actions that need to be done, in the correct order and then sharing that. It is rather like being the composer of a piece of music – you share the score so that the individual players know what to do and when. There is one other task you need to do.

<Leslie>I need to be the conductor!

<Bob> Yes. You are the metronome. You set the pace and guide the orchestra. They are the specialists with their instruments – that is not your role.

<Leslie> And when I do that then the music is harmonious and pleasing-to-the-ear; not a chaotic cacophony!

<Bob> Indeed … and the music is the voice of the system – and is the feedback that everyone hears – and not only do the musicians derive pleasure from contributing then the wider audience will hear what can be achieved and see how it is achieved.

<Leslie> Wow! That musical metaphor works really well for me. Thanks Bob, I need to go and work on my communicating, composing and conducting capabilities.

19/04/2014

SuDoKu

An Improvement-by-Design challenge is very like a Sudoku puzzle. The rules are deceptively simple but the solving the puzzle is not so simple.

For those who have never tried a Sudoku puzzle the objective is to fill in all the empty boxes with a number between 1 and 9. The constraint is that each row, column and 3×3 box (outlined in bold) must include all the numbers between 1 and 9 i.e. no duplicates.

What you will find when you try is that, at each point in the puzzle solving process there are more than one choice for most empty cells.

The trick is to find the empty cells that have only one option and fill those in. That changes the puzzle and makes it ‘easier’.

And when you keep following this strategy, and so long as you do not make any mistakes, then you will solve the puzzle. It just takes concentration, attention to detail, and discipline.

In the example above, the top-right cell in the left-box on the middle-row can only hold a 6; and the top-middle cell in the middle-box on the bottom-row must be a 3.

So we can see already there are three ways ‘into’ the solution – put the 6 in and see where that takes us; put the 3 in and see where that takes us; or put both in and see where that takes us.

The final solution will be the same – so there are multiple paths from where we are to our objective. Some may involve more mental work than others but all will involve completing the same number of empty cells.

What is also clear is that the sequence order that we complete the empty cells is not arbitrary. Usually the boxes and rows with the fewest empty cells get competed earlier and those with the most empty cells at the start get completed later.

And even if the final configuration is the same, if we start with a different set of missing cells the solution path will be different. It may be very easy, very hard or even impossible without some ‘guessing’ and hoping for the best.

Exactly the same is true of improvement-by-design challenges.

The rules of flow science are rather simple; but when we have a system of parallel streams (the rows) interacting with parallel stages (the columns); and when we have safety, delivery, and economy constraints to comply with at every part of the system … then finding and ‘improvement plan’ that will deliver our objective is a tough challenge.

But it is possible with concentration, attention-to-detail and discipline; and that requires some flow science training and some improvement science practice.

OK – I am off for lunch and then maybe indulge in a Sudoku puzzle or two – just for fun – and then maybe design an improvement plan to two – just for fun!

13/04/2014

Alignment of Purpose

<Lesley> Hi Bob, how are you today?

<Bob> I’m OK thanks Lesley. Having a bit of a break from the daily grind.

<Lesley> Oh! I am sorry, I had no idea you were on holiday. I will call when you are back at work.

<Bob> No need Lesley. Our chats are always a welcome opportunity to reflect and learn.

<Lesley> OK, if you are sure. The top niggle on my list at the moment is that I do not feel my organisation values what I do.

<Bob> OK. Have you done the diagnostic Right-2-Left Map® backwards from that top niggle?

<Lesley>Yes. The final straw was that I was asked to justify my improvement role.

<Bob> OK, and before that?

<Lesley> There have been some changes in the senior management team.

<Bob> OK. This sounds like the ‘New Brush Sweeps Clean’ effect.

<Lesley> I have heard that phrase before. What does it mean in this context?

<Bob> Senior management changes are very disruptive events. The more senior the change the more disruptive it is. Let us call it a form of ‘Disruptive Innovation’. The trigger for the change is important. One trigger might be a well-respected and effective leader retiring or moving to an even more senior role. This leaves a leadership gap which is an opportunity for someone to grow and develop. Another trigger might be a less-respected and ineffective leader moving on and leaving a trail of rather-too-visible failures. It is the latter tends to be associated with the New Broom effect.

<Lesley> How is that?

<Bob>Well, put yourself in the shoes of the New Leader who has inherited a Trail of Disappointment – you need to establish your authority and expectation quickly and decisively. Ambiguity and lack of clarity will only contribute to further disappointment. So you have to ask everyone to justify what they do. And if they cannot then you need to know that. And if they can then you need to decide if what they do is aligned with your purpose. This is the New Brush.

<Lesley> So what if I can justify what I do and that does not fit with the ‘New Leader’s Plan’?

<Bob> If what you do is aligned to your Life Purpose but not with the New Brush then you have to choose. And experience shows that the road to long term personal happiness is the one the aligns with your individual purpose. And often it is just a matter of timing. The New Brush is indiscriminate and impatient – anything that does not fit neatly into the New Plan has to go.

<Lesley> OK my purpose is to improve the safety, flow, quality and productivity of healthcare processes – for the benefit of all. That is not negotiable. It is what fires my passion and fuels my day. So does it matter really where or how I do that?

<Bob> Not really. You do need be mindful of the pragmatic constraints though … your life circumstances. There are many paths to your Purpose, so it is wise to choose one that is low enough risk to both you and those you love.

<Lesley> Ah! Now I see why you say that timing is important. You need to prepare to be able to make the decision. You do not what to be caught by surprise and off balance.

<Bob>Yes. That is why as an ISP you always start with your own Purpose and your own Right-2-Left Map®. Then you will know what to prepare and in what order so that you have the maximum number of options when you have to make a choice. Sometimes the Universe will create the trigger and sometimes you have to initiate it yourself.

<Lesley> So this is just another facet of Improvement Science?

<Bob> Yes.

05/04/2014

Firewall

Fires are destructive, indifferent, and they can grow and spread very fast.

The picture is of the Buncefield explosion and conflagration that occurred on 11th December 2005 near Hemel Hempstead in the UK. The root cause was a faulty switch that failed to prevent tank number 912 from being overfilled. This resulted in an initial 300 gallon petrol spill which created the perfect conditions for an air-fuel explosion. The explosion was triggered by a spark and devastated the facility. Over 2000 local residents needed to be evacuated and the massive fuel fire took days to bring under control. The financial cost of the accident has been estimated to run into tens of millions of pounds.

The Great Fire of London in September 1666 led directly to the adoption of new building standards – notably brick and stone instead of wood because they are more effective barriers to fire.

A common design to limit the spread of a fire is called a firewall.

And we use the same principle in computer systems to limit the spread of damage when a computer system goes out of control.

Money is the fuel that keeps the wheels of healthcare systems turning. And healthcare is an expensive business so every drop of cash-fuel is precious. Healthcare is also a risky business – from both a professional and a financial perspective. Mistakes can quickly lead to loss of livelihood, expensive recovery plans and huge compensation claims. The social and financial equivalent of a conflagration.

Financial fires spread just like real ones – quickly. So it makes good sense not to have all the cash-fuel in one big pot. It makes sense to distribute it to smaller pots – in each department – and to distribute the cash-fuel intermittently. These cash-fuel silos are separated by robust financial firewalls and they are called Budgets.

The social sparks that ignite financial fires are called ‘Niggles‘. They are very numerous but we have effective mechanisms for containing them. The problem happens when a multiple sparks happen at the same time and place and together create a small chain reaction. Then we get a complaint. A ‘Not Again‘. And we are required to spend some of our precious cash-fuel investigating and apologizing. We do not deal with the root cause, we just scrape the burned toast.

And then one day the chain reaction goes a bit further and we get a ‘Near Miss‘. That has a different reporting mechanism so it stimulates a bigger investigation and it usually culminates in some recommendations that involve more expensive checking, documenting and auditing of the checking and documentation. The root cause, the Niggles, go untreated – because there are too many of them.

But this check-and-correct reaction is also expensive and we need even more cash-fuel to keep the organizational engine running – but we do not have any more. Our budgets are capped. So we start cutting corners. A bit here and a bit there. And that increases the risk of more Niggles, Not Agains, and Near Misses.

Then the ‘Never Event‘ happens … a Safety and Quality catastrophe that triggers the financial conflagration and toasts the whole organization.

So although our financial firewalls, the Budgets, are partially effective they also have downsides:

1. Paradoxically they can create the perfect condition for a financial conflagration when too small a budget leads to corner-cutting on safety.

2. They lead to ‘off-loading’ which means that too-expensive-to-solve problems are chucked over the financial firewalls into the next department. The cost is felt downstream of the source – in a different department – and is often much larger. The sparks are blown downwind.

For example: a waiting list management department is under financial pressure and is running short staffed as a recruitment freeze has been imposed. The overburdening of the remaining staff leads to errors in booking patients for operations. The knock on effect that is patients being cancelled on the day and the allocated operating theatre time is wasted. The additional cost of wasted theatre time is orders of magnitude greater than the cost-saving achieved in the upstream stage. The result is a lower quality service, a greater cost to the whole system, and the risk that safety corners will be cut leading to a Near Miss or a Never Event.

The nature of real systems is that small perturbations can be rapidly amplified by a ‘tight’ financial design to create a very large and expensive perturbation called a ‘catastrophe’. A silo-based financial budget design with a cost-improvement thumbscrew feature increases the likelihood of this universally unwanted outcome.

So if we cannot use one big fuel tank or multiple, smaller, independent fuel tanks then what is the solution?

We want to ensure smooth responsiveness of our healthcare engine, we want healthcare cash-fuel-efficiency and we want low levels of toxic emissions (i.e. complaints) at the same time. How can we do that?

Fuel-injection.

Electronic Fuel Injection (EFI) designs have now replaced the old-fashioned, inefficient, high-emission carburettor-based engines of the 1970’s and 1980’s.

The safer, more effective and more efficient cash-flow design is to inject the cash-fuel where and when it is needed and in just the right amount.

And to do that we need to have a robust, reliable and rapid feedback system that controls the cash-injectors.

But we do not have such a feedback system in healthcare so that is where we need to start our design work.

Designing an automated cash-injection system requires understanding how the Seven Flows of any system work together and the two critical flows are Data Flow and Cash Flow.

And that is possible.