December 2014 – HCSE Blog

28/12/2014

Guess-work or Grunt-work?

Improvement flows from change. Change flows from action. Action flows from decision.

And we can make a decision in one of two ways – we can use guess-work or we can use grunt-work.

Of course it does not feel as black and white as that so let us put those two options at the opposite ends of a spectrum. Pure guess-work at one and and pure grunt-work at the other.

Guess-work is the easier end. To guess we just need a random number generator of some sort – like a dice. Grunt-work is the harder end. And what exactly is “grunt-work”?

Using available knowledge to work out a decision that will get us to our intended outcome is grunt-work. It does not require creativity, imagination, assumptions, beliefs, judgements and all the usual machinery that we humans employ to make decisions. It just requires following the tried-and-tested recipe and doing the grunt-work. A computer does grunt-work. It just follows the recipe we give it.

But experience shows that we even with hard work we do not always get the outcome we intend. So what is going wrong?

When the required knowledge is available and we do not use it we are exhibiting ineptitude. So in that context then we have a clear path of improvement: We invest first in dissolving our own ineptitude. We invest in learning what is already known. And that is grunt-work. Hard work.

When the required knowledge is not available then we are exhibiting ignorance. And our ignorance is exposed in two ways: firstly when we cannot make a decision of what to do because we have no option other than to guess. And secondly when what we predicted would happen as a result of our action did not actually happen. Reality disproved our rhetoric.

When we are ignorant we have a different path of improvement – first we need to do research to improve our knowledge and understanding, and only then when we are able to apply the new knowledge to make reliable predictions. We need tested and trusted knowledge to design a path to out intended outcome.

And as Richard Feynman perceptively observed … research starts with an educated guess. We might call it an hypothesis but it is a guess nevertheless. From that we make predictions and then we do experiments using reality to test our rhetoric. All guesses that fail the reality-check are rejected. So our vast body of scientific knowledge is the accumulation of guesses that did not fail the reality-check.

The critical word in the paragraph above is “educated”. How do researchers make educated guesses?

What does the word “educated” imply?

School is all about learning what is already “known”. There is no debate. The teachers are always right, only the students can be wrong. It is assumed.

But most of our learning comes from what we experience before and after school. We are all enrolled in the University of Life – and the teacher there is reality, not rhetoric.

And when we are tested by reality we are very often found to be lacking something. Well actually we are always found to be lacking. Sometimes we flunk the test outright and have to go back to the bottom of the learning ladder. Sometimes we scrape a bare pass … we survive … but we know we came close to failing. Sometimes we secure a safe pass … and still we know we could have done better. We can always do better.

But how? Is it because we were ignorant? Or was it because we were inept?

Examinations at The University of Rhetoric are designed to measure our ineptitude.

The University of Life is not so didactic or autocratic. The challenges it presents come from anywhere in the Ignorance-Ineptitude Zone. We need educated guesswork to survive there.

So one problem we face is how do we differentiate ignorance from ineptitude?

At this point it is important to separate individual ignorance from collective ignorance; and individual ineptitude from collective ineptitude. There are two dimensions at play.

The history of science is characterised by individuals who first resolved their individual ignorance when they discover something new. Only later was it appreciated that they were the first. So long as that discovery is shared then collective ignorance has reduced too. There is no need for everyone to rediscover everything when we share our learning.

Newton’s “discovery” of the Laws of Motion is a good example of an individual discovery quickly becoming collective knowledge. And with that collective knowledge we have proved we are able to land a spaceship on a far distant comet! That is grunt-work.

Einstein’s “discovery” of Relativity did not disprove Newton’s Laws of Motion, it re-framed and re-fined them so that even more profound predictions could be made. Some of the predictions are only now being tested as our technology has evolved to be able to perform the measurements with sufficient precision and accuracy. That is grunt-work. And it is increasingly collective grunt-work.

We are all born individually ignorant and individually inept.

Through experience and education we become aware of collective knowledge and with that we develop our individual capabilities. We do not re-invent every wheel.

And with that individual capability we are able to survive. We can secure a “pass” in the University of Life Survival Challenge.

But it leaves a lot of room for improvement.

Continuing to build collective knowledge through scientific research into more and more complicated and complex challenges, such as climate change, is necessary. But it is not sufficient. We need more.

Developing our collective capability to put that knowledge to the service of every living thing on the Earth is our challenge. And that is not grunt-work because we do not have a recipe to follow. We have to discover how to do that.

And that journey of discovery is called Improvement Science.

20/12/2014

People first or Process first?

A recurring theme this week has been the interplay between the cultural and the technical dimensions of system improvement.

The hearts and the minds. The people and the process. The psychology and the physics.

Reflecting on the many conversations what became clear was that both are required but not always in the same amount and in the same sequence.

The context is critical.

In some cases we can start with some technical stuff. Some flow physics and a Gantt and Run chart or two.

In other cases we have to start with some cultural stuff. Some conversations about values, beliefs and behaviours.

And they are both tricky but in different ways.

The technical stuff is counter-intuitive. We have to engage our logical, rational thinking brains and work it through step-by-step, making every assumption explicit and every definition clear.

If we go with our gut we get it wrong (although we feel it is right) and then we fail, and then we blame others or ourselves. Either way we lose confidence. The logical thinking is hard work. It makes our heads ache. So we cut corners.

But once we have understood then it gets much easier because we can then translate our hard won understanding into a trusted heuristic. We do not need to work it out every time. We can just look up the correct recipe.

And there lurks a trap … the problem that was at first unrecognised, then impossible, then difficult, and then doable … becomes easy and even obvious … but only after we have worked out a solution. And that obvious-in-hindsight effect is a source of many dangers …

… we can become complacent, over-confident, and even dismissive of others who have not been through the ‘pain’ of learning. We may be tempted to elevate our status and to inflate our importance by hoarding our hard-won understanding. We risk losing our humility … and when we do that we stop being curious and we stop learning. And then we are part of the problem again.

So to avoid those traps we need to hold ourselves in the role of the teacher and coach. We need to actively share what we have learned and explain how we came to know it. One step at a time … the blood, the sweat and the tears … the confusion and eureka moments. Not one giant leap from where we started to where we got to. And when we have the generosity to share our knowledge … it is surprising how much we learn! We learn more from teaching than by being taught.

The cultural stuff is counter-intuitive too. We have to engage our emotional, irrational, feeling brains and step back from the objective fine-print to look at the subjective full-picture. We have to become curious. We have to look at the problem from as many perspectives as we can. We have to practice humble inquiry by asking others what they see.

If we go with our gut and rely only on our learned and habitual beliefs, our untested assumptions and our prejudices … we get it wrong. When we filter reality to match our rhetoric, we leap to invalid conclusions, and we make unwise decisions, and they lead to counter-productive actions.

Our language and behaviour gives the game away … we cannot help it … because all this is happening unconsciously and out of our awareness.

So we need to solicit unfiltered feedback from trusted others who will describe what they see. And that is tough to do.

So how do we know where to act first? Cultural or technical?

The conclusion I have come to is to use a check-list … the Safe System Improvement check-list so to speak.

Check cultural first – Is there a need to do some people stuff? If so then do it.

Check technical second – Is there a need to do some process stuff? If so then do it.

If neither are needed then we need to get out of the way and let the people redesign the processes. Only they can.

13/12/2014

Catalyst

[Bing Bong] Bob was already logged into the weekly coaching Webex when Leslie arrived: a little late.

<Bob> Hi Leslie, how has your week been?

<Leslie> Hi Bob, sorry I am a bit late. It has been a very interesting week.

<Bob> My curiosity is pricked … are you willing to share?

<Leslie> Yes indeed! First an update on the improvement project was talked about a few weeks ago.

<Bob> The call centre one?

<Leslie> Yes. The good news is that the improvement has been sustained. It was not a flash in the pan. The chaos is gone and the calm has continued.

<Bob> That is very good to hear. And how did the team react?

<Leslie> That is one of the interesting things. They went really quiet. There was no celebration, no cheering, no sounds of champagne corks popping. It was almost as if they did not believe what they were seeing and they feared that if they celebrated too early they would somehow trigger a failure … or wake up from a dream.

<Bob> That is a very common reaction. It takes a while for reality to sink in – the reality that they have changed something, that the world did not end, and that their chronic chaos has evaporated. It is like a grief reaction … they have to mourn the loss of their disbelief. That takes time. About six weeks usually.

<Leslie> Yes, that is exactly what has happened – and I know they have now got over the surprise because the message I got this week was simply “OK, that appears to have worked exactly as you predicted it would. Will you help us solve the next impossible problem?“

<Bob> Well done Leslie! You have helped them break through the “Impossibility Barrier”. So what was your answer?

<Leslie> Well I was really tempted to say “Of course, let me at it!” but I did not. Instead I asked a question “What specifically do you need my help to do?“

<Bob> OK. And how was that reply received?

<Leslie> They were surprised, and they said “But we could not have done this on our own. You know what to do right at the start and even with your help it took us months to get to the point where we were ready to make the change. So you can do this stuff much more quickly than we can.“

<Bob> Well they are factually correct.

<Leslie> Yes I know, so I pointed out that although the technical part of the design does not take very long … that was not the problem … what slowed us down was the cultural part of the change. And that is done now so does not need to be repeated. The next study-plan-do cycle will be much quicker and they only need me for the technical bits they have not seen before.

<Bob> Excellent. So how would you now describe your role?

<Leslie> More of a facilitator and coach with a bit of only-when-needed training thrown in.

<Bob> Exactly … and I have a label for this role … I call it a Catalyst.

<Leslie> That is interesting, why so?

<Bob> Because the definition of a catalyst fits rather well. Using the usual scientific definition, a catalyst increases the yield and rate of a chemical reaction. With a catalyst, reactions occur faster and with less energy and catalysts are not consumed, they are recycled, so only tiny amounts are required.

<Leslie> Ah yes, that feels about right. But I am not just catalysing the reaction that produced the desired result am I?

<Bob> No. What else are you doing?

<Leslie> I am also converting some of the substrate into potential future catalysts too.

<Bob> Yes, you are. And that is what is needed for the current paradigm to shift.

<Leslie> Wow! I see that. This is powerful stuff!

<Bob> It is indeed. And the reaction you are catalysing is the combination of wisdom with ineptitude.

<Leslie> Eh? Can you repeat that again. Wisdom and ineptitude? Those are not words that I hear very often. I hear words like dumb, stupid, ignorant, incompetent and incapable. What is the reason you use those words?

<Bob> Simply because the dictionary definitions fit. Ineptitude means not knowing what to do to get the result we want, which is not the same as just not knowing stuff or not having the necessary skills. What we need are decisions which lead to effective actions and to intended outcomes. Wise decisions. If we demonstrate ineptitude we reveal that we lack the wisdom to make those effective decisions. So we need to combine ineptitude with wisdom to get the capability to achieve our purpose.

<Leslie> But why use the word “wisdom”? Why not just “knowledge”?

<Bob> Because knowledge is not enough. Knowledge just implies that I recognise what I am seeing. “I know this. I have seen it before“. Appreciating the implication of what I recognise is something more … it is called “understanding”.

<Leslie> Ah! I know this. I have seen this before. I know what a time-series chart is and I know how to create one but it takes guidance, time and practice to understand the implications of what the chart is saying about the system. But where does wisdom fit?

<Bob>Understanding is past-focussed. We understand how we got to where we are in the present. We cannot change the past so understanding has nothing to do with wise decisions or effective actions or intended outcomes. It is retrospection.

<Leslie> So wisdom is future-focussed. It is prospective. It is the ability to predict the outcome of an action and that ability is necessary to make wise decisions. That is why wisdom is the antidote to ineptitude!

<Bob> Well put! And that is what you did long before you made the change in the call centre … you learned how to make reliable predictions … and the results have confirmed yours was a wise decision. They got their intended outcome. You are not inept.

<Leslie> Ah! Now I understand the difference. I am a catalyst for improvement because I am able to diagnose and treat ineptitude. That is what you did for me. You are a catalyst.

<Bob> Welcome to the world of the Improvement Science Practitioner. You have earned your place.

The word “ineptitude” is coined by Dr Atul Gawande in the first of the 2014 Reith Lectures entitled “Why Do Doctors Fail?“.

Click HERE to listen to his first lecture (30 minutes).

In his second lecture he describes how it is the design of the system that delivers apparently miraculous outcomes. It is the way that the parts work together and the attention to context and to detail that counts.

Click HERE to hear his second lecture “The Century of the System” (30 minutes).

And Atul has a proven track record in system improvement … he is the doctor-surgeon-instigator of the WHO Safer Surgery Check List – a simple idea borrowed from aviation that is now used worldwide and is preventing 1000’s of easily avoidable deaths during and after surgery.

Click HERE to hear his third lecture “The Problem of Hubris” (30 minutes).

Click HERE to hear his fourth lecture “The Idea of Wellbeing” (30 minutes).

06/12/2014

Righteous Indignation

This heading in the the newspaper today caught my eye.

Reading the rest of the story triggered a strong emotional response: anger.

My inner chimp was not happy. Not happy at all.

So I took my chimp for a walk and we had a long chat and this is the story that emerged.

The first trigger was the eye-watering fact that the NHS is facing something like a £26 billion litigation cost. That is about a quarter of the total NHS annual budget!

The second was the fact that the litigation bill has increased by over £3 billion in the last year alone.

The third was that the extra money will just fall into a bottomless pit – the pockets of legal experts – not to where it is intended, to support overworked and demoralised front-line NHS staff. GPs, nurses, AHPs, consultants … the ones that deliver care.

That is why my chimp was so upset. And it sounded like righteous indignation rather than irrational fear.

So what is the root cause of this massive bill? A more litigious society? Ambulance chasing lawyers trying to make a living? Dishonest people trying to make a quick buck out of a tax-funded system that cannot defend itself?

And what is the plan to reduce this cost?

Well in the article there are three parts to this:
“apologise and learn when you’re wrong, explain and vigorously defend when we’re right, view court as a last resort.”

This sounds very plausible but to achieve it requires knowing when we are wrong or right.

How do we know?

Generally we all think we are right until we are proved wrong.

It is the way our brains are wired. We are more sure about our ‘rightness’ than the evidence suggests is justified. We are naturally optimistic about our view of ourselves.

So to be proved wrong is emotionally painful and to do it we need:
1) To make a mistake.
2) For that mistake to lead to psychological or physical harm.
3) For the harm to be identified.
4) For the cause of the harm to be traced back to the mistake we made.
5) For the evidence to be used to hold us to account, (to apologise and learn).

And that is all hunky-dory when we are individually inept and we make avoidable mistakes.

But what happens when the harm is the outcome of a combination of actions that individually are harmless but which together are not? What if the contributory actions are sensible and are enforced as policies that we dutifully follow to the letter?

Who is held to account? Who needs to apologise? Who needs to learn? Someone? Anyone? Everyone? No one?

The person who wrote the policy? The person who commissioned the policy to be written? The person who administers the policy? The person who follows the policy?

How can that happen if the policies are individually harmless but collectively lethal?

The error here is one of a different sort.

It is called an ‘error of omission’. The harm is caused by what we did not do. And notice the ‘we’.

What we did not do is to check the impact on others of the policies that we write for ourselves.

Example:

The governance department of a large hospital designs safety policies that if not followed lead to disciplinary action and possible dismissal. That sounds like a reasonable way to weed out the ‘bad apples’ and the policies are adhered to.

At the same time the operations department designs flow policies (such as maximum waiting time targets and minimum resource utilisation) that if not followed lead to disciplinary action and possible dismissal. That also sounds like a reasonable way to weed out the layabouts whose idleness cause queues and delays and the policies are adhered to.

And at the same time the finance department designs fiscal policies (such as fixed budgets and cost improvement targets) that if not followed lead to disciplinary action and possible dismissal. Again, that sounds like a reasonable way to weed out money wasters and the policies are adhered to.

What is the combined effect? The multiple safety checks take more time to complete, which puts extra workload on resources and forces up utilisation. As the budget ceiling is lowered the financial and operational pressures build, the system heats up, stress increases, corners are cut, errors slip through the safety checks. More safety checks are added and the already over-worked staff are forced into an impossible position. Chaos ensues … more mistakes are made … patients are harmed and justifiably seek compensation by litigation. Everyone loses (except perhaps the lawyers).

So why was my inner chimp really so unhappy?

Because none of this is necessary. This scenario is avoidable.

Reducing the pain of complaints and the cost of litigation requires setting realistic expectations to avoid disappointment and it requires not creating harm in the first place.

That implies creating healthcare systems that are inherently safe, not made not-unsafe by inspection-and-correction.

And it implies measuring and sharing intended and actual outcomes not just compliance with policies and rates of failure to meet arbitrary and conflicting targets.

So if that is all possible and all that is required then why are we not doing it?

Simple. We never learned how. We never knew it is possible.