June 2015 – HCSE Blog

27/06/201507/09/2024

What is Productivity?

It was the time for Bob and Leslie’s regular coaching session. Bob was already on line when Leslie dialed in to the teleconference.

<Leslie> Hi Bob, sorry I am a bit late.

<Bob> No problem Leslie. What aspect of improvement science shall we explore today?

<Leslie> Well, I’ve been working through the Safety-Flow-Quality-Productivity cycle in my project and everything is going really well. The team are really starting to put the bits of the jigsaw together and can see how the synergy works.

<Bob> Excellent. And I assume they can see the sources of antagonism too.

<Leslie> Yes, indeed! I am now up to the point of considering productivity and I know it was introduced at the end of the Foundation course but only very briefly.

<Bob> Yes, productivity was described as a system metric. A ratio of a steam metric and a stage metric … what we get out of the streams divided by what we put into the stages. That is a very generic definition.

<Leslie> Yes, and that I think is my problem. It is too generic and I get it confused with concepts like efficiency. Are they the same thing?

<Bob> A very good question and the short answer is “No”, but we need to explore that in more depth. Many people confuse efficiency and productivity and I believe that is because we learn the meaning of words from the context that we see them used in. If others use the words imprecisely then it generates discussion, antagonism and confusion and we are left with the impression of that it is a ‘difficult’ subject. The reality is that it is not difficult when we use the words in a valid way.

<Leslie> OK. That reassures me a bit … so what is the definition of efficiency?

<Bob> Efficiency is measure of wasted resource – it is the ratio of the minimum cost of the resources required to complete one task divided by the actual cost of the resources used to complete one task.

<Leslie> Um. OK … so how does time come into that?

<Bob> Cost is a generic concept … it can refer to time, money and lots of other things. If we stick to time and money then we know that if we have to employ ‘people’ then time will cost money because people need money to buy essential stuff that the need for survival. Water, food, clothes, shelter and so on.

<Leslie> So, we could use efficiency in terms of resource-time required to complete a task?

<Bob> Yes. That is a very useful way of looking at it.

<Leslie> So, how is productivity different? Completed tasks out divided by the cash in to pay for resource time would be a productivity metric. It looks the same.

<Bob> Does it? The definition of efficiency is possible cost divided by actual cost. It is not the same as our definition of system productivity.

<Leslie> Ah yes, I see. So do others define productivity the same way?

<Bob> Let us try looking it up on Wikipedia …

<Leslie> OK … here we go …

“Productivity is an average measure of the efficiency of production. It can be expressed as the ratio of output to inputs used in the production process, i.e. output per unit of input”.

Now that is really confusing! It looks like efficiency and productivity are the same. Let me see what the Wikipedia definition of efficiency is …

“Efficiency is the (often measurable) ability to avoid wasting materials, energy, efforts, money, and time in doing something or in producing a desired result”.

But that is closer to your definition of efficiency – the actual cost is the minimum cost plus the cost of waste.

<Bob> Yes. I think you are starting to see where the confusion arises. And this is because there is a critical piece of the jigsaw missing.

<Leslie> Oh …. and what is that?

<Bob> Worth.

<Leslie> Eh?

<Bob> Efficiency has nothing to do with whether the output of the stream has any worth. I can produce a worthless product very efficiently. And what if we have the situation where the output of my process is actually harmful. The more efficiently I use my resources the more harm I will cause from a fixed amount of resource … and in that situation it is actually safer to have an inefficient process!

<Leslie> Wow! That really hits the nail on the head … and the implications are … um … profound. Efficiency is objective and relates only to flow … and between flow and productivity we have to cross the Safety-Quality line. Productivity also includes the subjective concept of worth or value. That all makes complete sense now. A productive system is a subjectively and objectively win-win-win design.

<Bob> Yup. Get the safety, flow and quality perspectives of the design in synergy and productivity will sky-rocket. It is called a Fit-4-Purpose design that creates a Value-4-Money product or service

20/06/2015

Measure and Matter

Improvement implies learning. And to learn we need feedback from reality because without it we will continue to believe our own rhetoric.

So reality feedback requires both sensation and consideration.

There are many things we might sense, measure and study … so we need to be selective … we need to choose those things that will help us to make the wise decisions.

Wise decisions lead to effective actions which lead to intended outcomes.

Many measures generate objective data that we can plot and share as time-series charts. Pictures that tell an evolving story.

There are some measures that matter – our intended outcomes for example. Our safety, flow, quality and productivity charts.

There are some measures that do not matter – the measures of compliance for example – the back-covering blame-avoiding management-by-fear bureaucracy.

And there are some things that matter but are hard to measure … objectively at least.

We can sense them subjectively though. We can feel them. If we choose to.

And to do that we only need to go to where the people are and the action happens and just watch, listen, feel and learn. We do not need to do or say anything else.

And it is amazing what we learn in a very short period of time. If we choose to.

If we enter a place where a team is working well we will see smiles and hear laughs. It feels magical. They will be busy and focused and they will show synergism. The team will be efficient, effective and productive.

If we enter place where is team is not working well we will see grimaces and hear gripes. It feels miserable. They will be busy and focused but they will display antagonism. The team will be inefficient, ineffective and unproductive.

So what makes the difference between magical and miserable?

The difference is the assumptions, attitudes, prejudices, beliefs and behaviours of those that they report to. Their leaders and managers.

If the culture is management-by-fear (a.k.a bullying) then the outcome is unproductive and miserable.

If the culture is management-by-fearlessness (a.k.a. inspiring) then the outcome is productive and magical.

It really is that simple.

13/06/201507/09/2024

Excellent or Mediocre?

Many organisations proclaim that their vision, goal, objective and mission is to achieve excellence but then proceed to deliver mediocre performance.

Why is this?

It is certainly not from lack of purpose, passion or people.

So, the flaw must lie somewhere in the process.

The clue lies in how we measure performance … and to see the collective mindset behind the design of the performance measurement system we just need to examine the key performance indicators or KPIs.

Do they measure failure or success?

Let us look at some from the NHS …. hospital mortality, hospital acquired infections, never events, 4-hour A&E breaches, cancer wait breaches, 18 week breaches, and so on.

In every case the metric reported is a failure metric. Not a success metric.

And the focus of action is all about getting away from failure.

Damage mitigation, damage limitation and damage compensation.

So, we have the answer to our question: our performance metrics prove we know we are doing a good job when we are not failing.

But are we?

When we are not failing we are not doing a bad job … is that the same as doing a good job?

Q: Does excellent = not excrement?

A: No. There is something between the extremes of excrement and excellent.

And the succeed-or-fail dichotomy is a distorting simplification created by applying an arbitrary threshold to a continuous measure of performance.

So, how, specifically, have we designed our current system to avoid failure?

Usually by imposing an arbitrary target connected to a punitive reaction to failure. Performance management by fear.

This tactic generates an expected and predictable punishment-avoidance and back-covering behaviour which is manifest as a lot of repeated checking and correcting of the inevitable errors that we find. A lot of extra work that requires extra time and that requires extra money.

So, while an arbitrary-target-driven-check-and-correct design may avoid failing on safety, the additional cost may cause us to then fail on financial viability.

Out of the frying pan and into the fire.

No wonder Governance and Finance come into conflict!

And if we do manage to pull off an uneasy compromise … then what level of quality are we achieving?

Studies show that if take a random sample of 100 people from the pool of ‘disappointed by their experience’ and we ask if they are prepared to complain then only 5% will do so.

So, if we use complaints as our improvement feedback loop and we react to that and make changes that eliminate these complaints then what do we get? Excellence?

Nope.

We get what we designed … just good enough to avoid the 5% of complaints but not the 95% of disappointment.

We get mediocrity.

And what do we do then?

We start measuring ‘customer satisfaction’ … which is actually asking the question ‘did your experience meet your expectation?’

And if we find that satisfaction scores are disappointingly low then how do we improve them?

We have two choices: improve the experience or reduce the expectation.

But as we are very busy doing the necessary checking-and-correcting then our path of least resistance to greater satisfaction is … to lower expectations.

And we do that by donning the black hat of the pessimist and we lay out the the risks and dangers.

And by doing that we generate anxiety and fear. Which was not the intended outcome.

Our mission statement proclaims ‘trusted to achieve excellence’ rather than ‘designed to deliver mediocrity’.

But mediocrity is what the evidence says we are delivering. Just good enough to avoid a smack.

And if we are honest with ourselves then we are forced to conclude that:

A design that uses failure metrics as the primary feedback loop can achieve no better than mediocrity.

So, if we choose to achieve excellence then we need a better feedback design.

We need a design that uses success metrics as the primary feedback loop and we use failure metrics only in safety critical contexts.

And the ideal people to specify the success metrics are those who feel the benefit directly and immediately … the patients who receive care and the staff who give it.

Ask a patient what they want and they do not say “To be treated in less than 18 weeks”. In fact I have yet to meet a patient who has even heard of the 18-week target!

A patient will say ‘I want to know what is wrong, what can be done, when it can be done, who will do it, what do I need to do, and what can I expect to be the outcome’.

Do we measure any of that?

Do we measure accuracy of diagnosis? Do we measure use of best evidenced practice? Do we know the possible delivery time (not the actual)? Do we inform patients of what they can expect to happen? Do we know what they can expect to happen? Do we measure the experience and outcome for every patient? Good and not so good? Do we feed that information back continuously and learn from it?

Nope.

So …. if we choose and commit to delivering excellence then we will need to start measuring-4-success and feeding what we see back to those who deliver the care.

Warts and all.

We want to know when we are doing a good job, and we need to know where to focus further improvement effort.

And if we abdicate that commitment and choose to deliver mediocrity-by-default then we are the engineers of our own chaos and despair.

We have the choice.

We are the agents of our own destiny.

06/06/2015

Bitten by the ISP bug

There is a condition called SFQPosis which is an infection that is transmitted by a vector called an ISP.

The primary symptom of SFQPosis is sudden clarity of vision and a new understanding of how safety, flow, quality and productivity improvements can happen at the same time …

… when they are seen as partners on the same journey.

There are two sorts of ISP … Solitary and Social.

Solitary ISPs infect one person at a time … often without them knowing. And there is often a long lag time between the infection and the appearance of symptoms. Sometimes years – and often triggered by an apparently unconnected event.

In contrast the Social ISPs will tend to congregate together and spend their time foraging for improvement pollen and nectar and bringing it back to their ‘hive’ to convert into delicious ‘improvement honey’ which once tasted is never forgotten.

It appears that Jeremy Hunt, the Secretary of State for Health, has recently been bitten by an ISP and is now exhibiting the classic symptoms of SFQPosis.

Here is the video of Jeremy describing his symptoms at the recent NHS Confederation Conference. The talk starts at about 4 minutes.

His account suggests that he was bitten while visiting the Virginia Mason Hospital in the USA and on return home then discovered some Improvement hives in the UK … and some of the Solitary ISPs that live in England.

Warwick and Sheffield NHS Trusts are buzzing with ISPs … and the original ISP that infected them was one Kate Silvester.

The repeated message in Jeremy’s speech is that improved safety, quality and productivity can happen at the same time and are within our gift to change – and the essence of achieving that is to focus on flow.

The sequence is safety first (eliminate the causes of avoidable harm), then flow second (eliminate the causes of avoidable chaos), then quality (measure both expectation and experience) and then productivity will soar.

And everyone will benefit.

This is not a zero-sum win-lose game.

So listen for the buzz of the ISPs …. follow it and ask them to show you how … ask them to innoculate you with SFQPosis.

And here is a recent video of Dr Steve Allder, a consultant neurologist and another ISP that Kate infected with SFQPosis a few years ago. Steve is describing his own experience of learning how to do Improvement-by-Design.

01/06/2015

Too Big To Eat

One of the traps for the less experienced improvement scientist is to take on a project that is too ambitious, too early.

The success with a “small” project will attract the attention of those with an eye on a bigger prize and it is easy to be wooed by the Siren call to sail closer to their Rocks.

This is a significant danger and a warning flag needs to be waved.

Organisations can only take on these bigger challenges after they have developed enough improvement capability themselves … and that takes time and effort. It is not a quick fix.

And it makes no difference how much money is thrown at the problem. The requirement is for the leaders to learn how to do it first and that does not take long to do … but it does require some engagement and effort.

And this is difficult for busy people to do …but it is not impossible.

The questions that need to be asked repeatedly are:

1. Is this important enough to dedicate some time to? If not then do not start.

2. What can I do in the time I can dedicate to this? Delegation is abdication when it comes to improvement.

Those who take on too big a project too early will find it is like being chained to a massive weight … and it gets heavier over time as others add their problems to your heap in the belief that delegating a problem is the same as solving it. It isn’t.

So if your inner voice says “This feels too big for me” then listen to it and ask it what specifically is creating that feeling … work backwards from the feeling. And only after you have identified the root causes can you make a rational decision.

Then make the decision and stick to it … explaining your reasons.