March 2015 – HCSE Blog

29/03/2015

Over-Egged Expectation

Resistance-to-change is an oft quoted excuse for improvement torpor. The implied sub-message is more like “We would love to change but They are resisting“.

Notice the Us-and-Them language. This is the observable evidence of an “We‘re OK and They’re Not OK” belief. And in reality it is this unstated belief and the resulting self-justifying behaviour that is an effective barrier to systemic improvement.

This Us-and-Them language generates cultural friction, erodes trust and erects silos that are effective barriers to the flow of information, of innovation and of learning. And the inevitable reactive solutions to this Us-versus-Them friction create self-amplifying positive feedback loops that ensure the counter-productive behaviour is sustained.

One tangible manifestation are DRATs: Delusional Ratios and Arbitrary Targets.

So when a plausible, rational and well-evidenced candidate for an alternative approach is discovered then it is a reasonable reaction to grab it and to desperately spray the ‘magic pixie dust’ at everything.

This a recipe for disappointment: because there is no such thing as ‘improvement magic pixie dust’.

The more uncomfortable reality is that the ‘magic’ is the result of a long period of investment in learning and the associated hard work in practising and polishing the techniques and tools.

It may look like magic but is isn’t. That is an illusion.

And some self-styled ‘magicians’ choose to keep their hard-won skills secret … because by sharing them know that they will lose their ‘magic powers’ in a flash of ‘blindingly obvious in hindsight’.

And so the chronic cycle of despair-hope-anger-and-disappointment continues.

System-wide improvement in safety, flow, quality and productivity requires that the benefits of synergism overcome the benefits of antagonism. This requires two changes to the current hope-and-despair paradigm. Both are necessary and neither are sufficient alone.

1) The ‘wizards’ (i.e. magic folk) share their secrets.
2) The ‘muggles’ (i.e. non-magic folk) invest the time and effort in learning ‘how-to-do-it’.

The transition to this awareness is uncomfortable so it needs to be managed pro-actively … by being open about the risk … and how to mitigate it.

That is what experienced Practitioners of Improvement Science (and ISP) will do. Be open about the challenged ahead.

And those who desperately want the significant and sustained SFQP improvements; and an end to the chronic chaos; and an end to the gaming; and an end to the hope-and-despair cycle …. just need to choose. Choose to invest and learn the ‘how to’ and be part of the future … or choose to be part of the past.

Improvement science is simple … but it is not intuitively obvious … and so it is not easy to learn.

If it were we would be all doing it.

And it is the behaviour of a wise leader of change to set realistic and mature expectations of the challenges that come with a transition to system-wide improvement.

That is demonstrating the OK-OK behaviour needed for synergy to grow.

21/03/2015

Walk Confidently before Running

Improvement is not a continuous process. It has starts and stops, and ups and downs. Improvement implies change, and that is intentionally disruptive. So the context will determine the progress as much as the change.

A commonly observed behaviour is probably at the root of why the majority of improvements initiatives fail to achieve a significant and sustained improvement. Trying to run before mastering the skill of walking.

An experienced improvement coach will not throw learners into the deep end and watch them sink or swim. That is not coaching; it is cruelty.

So the first improvement projects must be doable and done with lots of hands-off support, encouragement and praise for progress.

This has the benefit of developing confidence and capability.

It has a danger of leading to over-confidence though. Confidence that exceeds capability.

There is a risk that the growing learner will take on a future improvement project that is outside their capability zone.

The danger of doing this is that they fall at the second hurdle and their new confidence can be damaged and even smashed. This can leave the learner feeling less motivated and more fearful than before.

There are a number of ways that an improvement coach can mitigate this risk:

1. Make the learners aware up front that this is a risk.
2. Scope each project to stretch but not scare.
3. Be prepared to stop and reduce scope if necessary.
4. Set the expectation to consolidate the basics by teaching others.

These are not mutually exclusive options. Seeing, doing and teaching can happen in parallel and that is actually the most productive way to learn.

As children we learned to walk with confidence before we learned to run … because falling flat on our face hurts both physically and emotionally!

This is just the same.

14/03/2015

Co-Labor-Ation

Bob and Leslie were already into the dialogue of their regular ISP coaching session when Bob saw an incoming text from one of his other ISPees. It was simply marked: “Very Urgent”.

<Bob> Leslie, I have just received an urgent SMS that I think I need to investigate immediately. Could we put this conversation on ice for 10 minutes and I will call you back?

<Leslie> Of course. I have lots to do. Please do not rush back if it requires more time.

<Bob> Thank you.

Ten minutes later Leslie saw that Bob was phoning and picked up.

<Leslie> Hi Bob. I hope you were able to sort out the urgent problem. The fact that you are back suggests you did.

<Bob> Hi Leslie. Thank you for your understanding and patience. The issue was urgent and the root cause is not yet solved, but lessons are being learned. And this is one you are going to come up against too so it may be an opportune time to explore it.

<Leslie> H’mm. Now you have pricked my curiosity. But you can’t discuss someone else’s problem with me surely!

<Bob> No indeed. Strict confidentiality is essential. We can talk about the generic issue though, without disclosing any details. Do you remember that project you were doing last year where you achieved an initial success and then it all seemed to go wobbly?

<Leslie> Yes. At the time you said that I needed to put that one on the shelf and to press on with other projects. I think the phrase you used was “it needs to stew for a while“.

<Bob> And what happened?

<Leslie> The hard won improvement in performance slipped back and I felt like a failure and started to lose confidence. You said not to blame myself but to learn and move on. The lesson was I did not appreciate the difference between circles of control and circles of influence. I was trying to influence others before I had mastered self-control.

<Bob> Yes. There was another factor too but I did not feel it was the time to explore it. Now feels like a better time.

<Leslie> OK … now my curiosity is really fired up.

<Bob> Do you remember last week’s blog about the Improvement Gearbox?

<Leslie> Yes. I really liked the mechanical metaphor. It resonated with so many things. I have used it several times this week in conversations.

<Bob> Well, there is a close relationship between the level of challenge and the gearbox. As complexity increases we need to be able to use more of the gears, and to change up and down with ease and according to need.

<Leslie> Change down? I sort of assumed that once you got to fourth gear you stay there.

<Bob> That is true if the terrain is level and everyone is on board the bus with the same destination in mind. In reality the terrain goes up and down and as we learn we need to stop and let some people get off and take others on board.

<Leslie> So we need to change down gears on the uphill bits, change up gears on the downhill, and go through the whole gear sequence when we deliberately slow to a halt, and then get on our way again.

<Bob> Yes. Well put. The world is changing all the time and the team on board is in dynamic flux. Some arrive, some leave and others stay on the bus but change seats as we move along. Not all seats suit all people. What is comfortable for one may be painful for another.

<Leslie> So how come the urgent call?

<Bob> A fight had broken out on their bus, the tribes were arguing because the improvements they have made have blown away some of the fog and exposed some deeper cultural cracks. Cracks that had been there all the time but were concealed by the fog of the daily chaos and the smoke of the burning martyrs. They had taken their eye off the road and were heading for a blind bend unaware of what was around the corner.

<Leslie> So your intervention was to shout “Pay attention to the road and make a decision … steer or stop!“

<Bob> Yes, that about sums it up. A co-labor-ation call.

<Leslie> Eh? Dis you just say collaboration in a weird way?

<Bob> Yes. I chopped it up into concepts … “co” means together, “labor” means work and “ation” means action or process. If they do not learn to co-labor-ate then they will come off the road, crash, and burn. And join the graveyard of improvement train wrecks that litter the verges of the rocky road of change.

<Leslie> Fourth gear stuff?

<Bob> Whole gearbox stuff. All gears between first and fourth because they are all necessary at different times. Each gear builds on those which go before. There are no good or bad gears just fit-for-current-purpose or not. Bad driving is ineptitude. Not using the vehicle’s gearbox effectively and efficiently and risking the safety and comfort of the passengers and other road users. Poor leadership is analogous to poor driving. Dangerous.

<Leslie> So an effective leader of change needs to be able to use all the gears competently and to know when to use which and when to change. And in doing so demonstrate what a safe pair of leadership hands looks like and what it can achieve … through collaborative effort.

<Bob> Perfect! It is time for you to tear up your L plates.

07/03/2015

The Improvement Gearbox

One of the most rewarding experiences for an improvement science coach is to sense when an individual or team shift up a gear and start to accelerate up their learning curve.

It is like there is a mental gearbox hidden inside them somewhere. Before they were thrashing themselves by trying to go too fast in a low gear. Noisy, ineffective, inefficient and at high risk of blowing a gasket!

Then, they discover that there is a higher gear … and that to get to it they have to take a risk … depress the emotional clutch, ease back on the gas, slip into neutral, and trust themselves to find the new groove and … click … into the higher gear, and then ease up the power while letting out the clutch. And then accelerate up the learning curve. More effective, more efficient. More productive. More fun.

Organisations appear to behave in much the same way.

Some scream along in the slow-lane … thrashing their employee engine. The majority chug complacently in the middle-lane of mediocrity. A few accelerate past in the fast-lane to excellence.

And they are all driving exactly the same model of car.

So it is not the car that is making the difference … it is the driving.

Those who have studied organisations have observed five cultural “gears”; and which gear an organisation is in most of the time can be diagnosed by listening to the sound of the engine – the conversations of the employees.

If they are muttering “work sucks” then they are in first gear. The sense of hopelessness, futility, despair and anger consumes all their emotional fuel. Fortunately this is uncommon.

If we mainly hear “my work sucks” then they are in second gear. The feeling is of helplessness and apathy and the behaviour is Victim-like. They believe that they cannot solve their own problems … someone else must do it for them or tell them what to do. They grumble a lot.

If the dominant voice is “I’m great but you lot suck” then we are hearing third gear attitudes. The selfishly competitive behaviour of the individualist achiever. The “keep your cards close to your chest” style of dyadic leadership. The advocate of “it is OK to screw others to get ahead”. They grumble a lot too – about the apathetic bunch.

And those who have studied organisations suggest that about 80% of healthcare organisations are stuck in first, second or third cultural gear. And we can tell who they are … the lower 80% of the league tables. The ones clamouring for more … of everything.

So how come so many organisations are so stuck? Unable to find fourth gear?

One cause is the design of their feedback loops. Their learning loops.

If an organisation only uses failure as a feedback loop then it is destined to get no more than mediocrity. Third gear at best, and usually only second.

Example.
We all feel disappointment when our experience does not live up to our expectation. But only the most angry of us will actually do something and complain. Especially when we have no other choice of provider!

Suppose we are commissioners of healthcare services and we are seeing a rising tide of patient and staff complaints. We want to improve the safety and quality of the services that we are paying for; so we draw up a league table using complaints as feedback fodder and we focus on the worst performing providers … threatening them with dire consequences for being in the bottom 20%. What happens? Fear of failure motivates them to ‘pull up their socks’ and the number of complaints falls.

Job done?

Unfortunately not.

All we have done is to bully those stuck in first or second gear into thrashing their over-burdened employee engine even harder. We have not helped anyone find their higher gear. We have hit the target, missed the point, and increased the risk of system failure!

So what about those organisations stuck in third gear?

Well they are ticking their performance boxes, meeting our targets, keeping their noses clean. Some are just below, and some just above the collective mean of barely acceptable mediocrity.

But expectation is changing.

The 20% who have discovered fourth gear are accelerating ahead and are demonstrating what is possible. And they are raising expectation, increasing the variation of service quality … for the better.

And the other 80% are falling further and further behind; thrashing their tired and demoralised staff harder and harder to keep up. Complaining increasingly that life is unfair and that they need more, time, money and staff engagement. Eventually their executive head gaskets go “pop” and they fall by the wayside.

Finding cultural fourth gear is possible but it is not easy. There are no short cuts. We have to work our way up the gears and we have to learn when and how to make smooth transitions from first to second, second to third and then third to fourth.

And when we do that the loudest voice we hear is “We are OK“.

We need to learn how to do a smooth cultural hill start on the steep slope from apathy to excellence.

And we need to constantly listen to the sound of our improvement engine; to learn to understand what it is saying; and learn how and when to change to the next cultural gear.