Strength and Resilience

figure_breaking_through_wall_anim_150_wht_15036The dictionary definition of resilience is “something that is capable of  returning to its original shape after being stretched, bent or otherwise deformed“.

The term is applied to inanimate objects, to people and to systems.

A rubber ball is resilient … it is that physical property that gives it bounce.

A person is described as resilient if they are able to cope with stress without being psychologically deformed in the process.  Emotional resilience is regarded as an asset.

Systems are described as resilient when they are able to cope with variation without failing. And this use of the term is associated with another concept: strength.

Strong things can withstand a lot of force before they break. Strength is not the same as resilience.

Engineers use another term – strain – which means the amount of deformation that happens when a force is applied.

Stress is the force applied, strain is the deformation that results.

So someone who is strong and resilient will not buckle under high pressure and will absorb variation – like the suspension of you car.

But is strength-and-resilience always an asset?

Suppose some strong and resilient people finds themselves in a relentlessly changing context … one in which they actually need to adapt and evolve to survive in the long term.

How well does their highly valued strength-and-resilience asset serve them?

Not very well.

They will resist the change – they are resilient – and they will resist it for a long time – they are strong.

But the change is relentless and eventually the limit of their strength will be reached … and they snap!

And when that happens all the stored energy is suddenly released. So they do not just snap – they explode!

Just like the wall in the animation above.

The final straw that triggers the sudden failure may appear insignificant … and at any other time  it would be.

But when the pressure is really on and the system is at the limit then it can be just enough to trigger the catastrophic failure from which there is no return.

Social systems behave in exactly the same way.

Those that have demonstrated durability are both strong and resilient – but in a relentlessly changing context even they will fail eventually, and when they do the collapse is sudden and catastrophic.

Structural engineers know that catastrophic failure usually starts as a localised failure and spreads rapidly through the hyper-stressed structure; each part failing in sequence as it becomes exposed and exceeds the limit of its strength.  That is how the strong and resilient Twin Towers failed and fell on Sept 11th 2001. They were not knocked over. They were weakened to the point of catastrophic failure.

When systems are exposed to varying strains then these localised micro-fractures only occur at the peaks of stress and may not have time to spread very far. The damage is done though. The system is a bit weaker than it was before. And catastrophic failure is more likely in the future.

That is what caused the sudden loss of some of the first jet airliners which inexplicably just fell out of the sky on otherwise uneventful flights.  It took a long time for the root cause to be uncovered … the square windows.

Jet airliners fly at high altitude because it allows higher speeds and requires less fuel and so allows long distance flight over wide oceans, steppes, deserts and icecaps. But the air pressure is low at high altitude and passengers could not tolerate that; so the air pressure inside an airliner at high altitude is much higher than outside. It is a huge pressurised metal flying cannister.  And as it goes up and down the thin metal skin is exposed to high variations in stress which a metal tube can actually handle rather well … until we punch holes in it to fit windows to allow our passengers a nice view of the clouds outside.  We are used to square windows in our houses (because they are easier to make) so the original aircraft engineers naturally put square windows in the early airliners.  And that is where the problem arose … the corners of the windows concentrate the stress and over time, with enough take-offs and landings,  the metal skin at the corners of the windows will accumulate invisible micro-fractures. The metal actually fatigues. Then one day – pop – a single rivet at the corner of a square window fails and triggers the catastrophic failure of the whole structure. But the aircraft designers did not understand that process and it took quite a long time to diagnose the root cause.

The solution?

A more resilient design – use round-cornered windows that dissipate the strain rather than concentrate it.  It was that simple!

So what is the equivalent resilient design for social system? Adaptability.

But how it is possible for a system to be strong, resilient and adaptable?

The design trick is to install “emotional strain gauges” that indicate when and where the internal cultural stress is being concentrated and where the emotional strain shows first.

These emotometers will alert us to where the stresses and strains are being felt strongest and most often – rather like pain detectors. We use the patterns of information from our network of emotometers to help us focus our re-design attention to continuously adapt parts of our system to relieve the strain and to reduce the system wide risk of catastrophic failure.

And by installing emotometers across our system we will move towards a design that is strong, resilient and that continuously adapts to a changing environment.

It really is that simple.

Welcome to complex adaptive systems engineering (CASE).

A Sisyphean Nightmare

cardiogram_heart_signal_150_wht_5748[Beep] It was time for the weekly e-mentoring session so Bob switched on his laptop, logged in to the virtual meeting site and found that Lesley was already there.

<Bob> Hi Lesley. What shall we talk about today?

<Lesley> Hello Bob. Another old chestnut I am afraid. Queues.  I keep hitting the same barrier where people who are fed up with the perpetual queue chaos have only one mantra “If you want to avoid long waiting times then we need more capacity.

<Bob> So what is the problem? You know that is not the cause of chronic queues.

<Lesley> Yes, I know that mantra is incorrect – but I do not yet understand how to respectfully challenge it and how to demonstrate why it is incorrect and what the alternative is.

<Bob> OK. I understand. So could you outline a real example that we can work with.

<Lesley> Yes. Another old chestnut: the Emergency Department 4-hour breaches.

<Bob> Do you remember the Myth of Sisyphus?

<Leslie> No, I do not remember that being mentioned in the FISH course.

<Bob> Ho ho! No indeed,  it is much older. In Greek mythology Sisyphus was a king of Ephyra who was punished by the Gods for chronic deceitfulness by being compelled to roll an immense boulder up a hill, only to watch it roll back down, and then to repeat this action forever.


<Lesley> Ah! I see the link. Yes, that is exactly how people in the ED feel.  Everyday it feels like they are pushing a heavy boulder uphill – only to have to repeat the same labour the next day. And they do not believe it can ever be any better with the resources they have.

<Bob> A rather depressing conclusion! Perhaps a better metaphor is the story in the film  “Ground Hog Day” where Bill Murray plays the part of a rather arrogant newsreader who enters a recurring nightmare where the same day is repeated, over and over. He seems powerless to prevent it.  He does eventually escape when he learns the power of humility and learns how to behave differently.

<Lesley> So the message is that there is a way out of this daily torture – if we are humble enough to learn the ‘how’.

<Bob> Well put. So shall we start?

<Lesley> Yes please!

<Bob> OK. As you know very well it is important not to use the unqualified term ‘capacity’.  We must always state if we are referring to flow-capacity or space-capacity.

<Lesley> Because they have different units and because they are intimately related to lead time by Little’s Law.

<Bob> Yes.  Little’s Law is mathematically proven Law of flow physics – it is not negotiable.

<Lesley> OK. I know that but how does it solve problem we started with?

<Bob> Little’s Law is necessary but it is not sufficient. Little’s Law relates to averages – and is therefore just the foundation. We now need to build the next level of understanding.

<Lesley> So you mean we need to introduce variation?

<Bob> Yes. And the tool we need for this is a particular form of time-series chart called a Vitals Chart.

<Lesley> And I am assuming that will show the relationship between flow, lead time and work in progress … over time ?

<Bob> Exactly. It is the temporal patterns on the Vitals Chart that point to the root causes of the Sisyphean Chaos. The flow design flaws.

<Lesley> Which are not lack of flow-capacity or space-capacity.

<Bob> Correct. If the chaos is chronic then there must already be enough space-capacity and flow-capacity. Little’s Law shows that, because if there were not the system would have failed completely a long time ago. The usual design flaw in a chronically chaotic system is one or more misaligned policies.  It is as if the system hardware is OK but the operating software is not.

<Lesley> So to escape from the Sisyphean Recurring ED 4-Hour Breach Nightmare we just need enough humility and enough time to learn how to diagnose and redesign some of our ED system operating software? Some of our own policies? Some of our own mantras?

<Bob> Yup.  And not very much actually. Most of the software is OK. We need to focus on the flaws.

<Lesley> So where do I start?

<Bob> You need to do the ISP-1 challenge that is called Brainteaser 104.  That is where you learn how to create a Vitals Chart.

<Lesley> OK. Now I see what I need to do and the reason:  understanding how to do that will help me explain it to others. And you are not going to just give me the answer.

<Bob> Correct. I am not going to just give you the answer. You will not fully understand unless you are able to build your own Vitals Chart generator. You will not be able to explain the how to others unless you demonstrate it to yourself first.

<Lesley> And what else do I need to do that?

<Bob> A spreadsheet and your raw start and finish event data.

<Lesley> But we have tried that before and neither I nor the database experts in our Performance Department could work out how to get the real time work in progress from the events – so we assumed we would have to do a head count or a bed count every hour which is impractical.

<Bob> It is indeed possible as you are about to discover for yourself. The fact that we do not know how to do something does not prove that it is impossible … humility means accepting our inevitable ignorance and being open to learning. Those who lack humility will continue to live the Sisyphean Nightmare of ED Ground Hog Day. The choice to escape is ours.

<Lesley> I choose to learn. Please send me BT104.

<Bob> It is on its way …

Actions Speak

media_video_icon_anim_150_wht_14142In a recent blog we explored the subject of learning styles and how a balance of complementary learning styles is needed to get the wheel-of-change turning.

Experience shows that many of us show a relative weakness in the ‘Activist’ quadrant of the cycle.

That implies we are less comfortable with learning-by-doing. Experimenting.

This behaviour is driven by a learned fear.  The fear-of-failure.

So when did we learn this fear?

Typically it is learned during childhood and is reinforced throughout adulthood.

The fear comes not from the failure though  … it comes from the emotional reaction of others to our supposed failure. The emotional backlash of significant others. Parents and parent-like figures such as school teachers.

Children are naturally curious and experimental and fearless.  That is how they learn. They make lots of mistakes – but they learn from them. Walking, talking, tying a shoelace, and so on.  Small mistakes do not created fear. We learn fear from others.

Full-of-fear others.

To an adult who has learned how to do many things it becomes easy to be impatient with the trial-and-error approach of a child … and typically we react in three ways:

1) We say “Don’t do that” when we see our child attempt something in a way we believe will not work or we believe could cause an accident. We teach them our fears.

2) We say “No” when we disagree with an idea or an answer that a child has offered. We discount them by discounting their ideas.

3) We say “I’ll do it” when we see a child try and fail. We discount their ability to learn how to solve problems and we discount our ability to let them.

Our emotional reaction is negative in all three cases and that is what teaches our child the fear of failure.

So they stop trying as hard.

And bit-by-bit they lose their curiosity and their courage.

We have now put them on the path to scepticism and cynicism.  Which is how we were taught.

This fear-of-failure brainwashing continues at school.

But now it is more than just fear of disappointing our parents; now it is fear of failing tests and exams … fear of the negative emotional backlash from peers, teachers and parents.

Some give up: they flee.  Others become competitive: they fight.

Neither strategies dissolve the source of the fear though … they just exacerbate it.

So it is rather too common to see very accomplished people paralysed with fear when circumstances dictate that they need to change in some way … to learn a new skill for example … to self-improve maybe.

Their deeply ingrained fear-of-failure surfaces and takes over control – and the fright/flight/fight behaviour is manifest.

So to get to the elusive win-win-win outcomes we want we have to weaken the fear-of-failure reflex … we need to develop a new habit … learning-by-doing.

The trick to this is to focus on things that fall 100% inside our circle of control … the Niggles that rank highest on our Niggle-o-Gram®.

And when we Study the top niggle; and then Plan the change; and then Do what we planned, and then Study effect of our action … then we learn-by-doing.

But not just by doing …. by Studying, Planning, Doing and Studying again.

Actions Speak not just to us but to everyone else too.

The Jigsaw

6MDesignJigsawSystems are made of interdependent parts that link together – rather like a jigsaw.

If pieces are distorted, missing, or in the wrong place then the picture is distorted and the system does not work as well as it could.

And if pieces of one jigsaw are mixed up with those of another then it is even more difficult to see any clear picture.

A system of improvement is just the same.

There are many improvement jigsaws each of which have pieces that fit well together and form a synergistic whole. Lean, Six Sigma, and Theory of Constraints are three well known ones.

Each improvement jigsaw evolved in a different context so naturally the picture that emerges is from a particular perspective: such as manufacturing.

So when the improvement context changes then the familiar jigsaws may not work as well: such as when we shift context from products to services, and from commercial to public.

A public service such as healthcare requires a modified improvement jigsaw … so how do we go about getting that?

One way is to ‘evolve’ an old jigsaw into a new context. That is tricky because it means adding new pieces and changing old pieces and the ‘zealots’ do not like changing their familiar jigsaw so they resist.

Another way is to ‘combine’ several old jigsaws in the hope that together they will provide enough perspectives. That is even more tricky because now you have several tribes of zealots who resist having their familiar jigsaws modified.

What about starting with a blank canvas and painting a new picture from scratch? Well it is actually very difficult to create a blank canvas for learning because we cannot erase what we already know. Our current mental model is the context we need for learning new knowledge.

So what about using a combination of the above?

What about first learning a new creative approach called design? And within that framework we can then create a new improvement jigsaw that better suits our specific context using some of the pieces of the existing ones. We may need to modify the pieces a bit to allow them to fit better together, and we may need to fashion new pieces to fill the gaps that we expose. But that is part of the fun.

6MDesignJigsawThe improvement jigsaw shown here is a new hybrid.

It has been created from a combination of existing improvement knowledge and some innovative stuff.

Pareto analysis was described by Vilfredo Pareto over 100 years ago.  So that is tried and tested!

Time-series charts were invented by Walter Shewhart almost 100 years ago. So they are tried and tested too!

The combination of Pareto and Shewhart tools have been used very effectively for over 50 years. The combination is well proven.

The other two pieces are innovative. They have different parents and different pedigrees. And different purposes.

The Niggle-o-Gram® is related to 2-by-2, FMEA and EIQ and the 4N Chart®.  It is the synthesis of them that creates a powerful lens for focussing our improvement efforts on where the greatest return-on-investment will be.

The Right-2-Left Map® is a descendent of the Design family and has been crossed with Graph Theory and Causal Network exemplars to introduce their best features.  Its purpose is to expose errors of omission.

The emergent system is synergistic … much more effective than each part individually … and more even than their linear sum.

So when learning this new Science of Improvement we have to focus first on learning about the individual pieces and we do that by seeing examples of them used in practice.  That in itself is illuminating!

As we learn about more pieces a fog of confusion starts to form and we run the risk of mutating into a ‘tool-head’.  We know about the pieces in detail but we still do not see the bigger picture.

To avoid the tool-head trap we must balance our learning wheel and ensure that we invest enough time in learning-by-doing.

Then one day something apparently random will happen that triggers a ‘click’.  Familiar pieces start to fit together in a unfamiliar way and as we see the relationships, the sequences, and the synergy – then a bigger picture will start to emerge. Slowly at first and then more quickly as more pieces aggregate.

Suddenly we feel a big CLICK as the final pieces fall into place.  The fog of confusion evaporates in the bright sunlight of a paradigm shift in our thinking.

The way forward that was previously obscured becomes clearly visible.

Ah ha!

And we are off on the next stage  of our purposeful journey of improvement.