Catch-22

There is a Catch-22 in health care improvement and it goes a bit like this:

Most people are too busy fire-fighting the chronic chaos to have time to learn how to prevent the chaos, so they are stuck.

There is a deeper Catch-22 as well though:

The first step in preventing chaos is to diagnose the root cause and doing that requires experience, and we don’t have that experience available, and we are too busy fire-fighting to develop it.


Health care is improvement science in action – improving the physical and psychological health of those who seek our help. Patients.

And we have a tried-and-tested process for doing it.

First we study the problem to arrive at a diagnosis; then we design alternative plans to achieve our intended outcome and we decide which plan to go with; and then we deliver the plan.

Study ==> Plan ==> Do.

Diagnose  ==> Design & Decide ==> Deliver.

But here is the catch. The most difficult step is the first one, diagnosis, because there are many different illnesses and they often present with very similar patterns of symptoms and signs. It is not easy.

And if we make a poor diagnosis then all the action plans that follow will be flawed and may lead to disappointment and even harm.

Complaints and litigation follow in the wake of poor diagnostic ability.

So what do we do?

We defer reassuring our patients, we play safe, we request more tests and we refer for second opinions from specialists. Just to be on the safe side.

These understandable tactics take time, cost money and are not 100% reliable.  Diagnostic tests are usually precisely focused to answer specific questions but can have false positive and false negative results.

To request a broad batch of tests in the hope that the answer will appear like a rabbit out of a magician’s hat is … mediocre medicine.


This diagnostic dilemma arises everywhere: in primary care and in secondary care, and in non-urgent and urgent pathways.

And it generates extra demand, more work, bigger queues, longer delays, growing chaos, and mounting frustration, disappointment, anxiety and cost.

The solution is obvious but seemingly impossible: to ensure the most experienced diagnostician is available to be consulted at the start of the process.

But that must be impossible because if the consultants were seeing the patients first, what would everyone else do?  How would they learn to become more expert diagnosticians? And would we have enough consultants?


When I was a junior surgeon I had the great privilege to have the opportunity to learn from wise and experienced senior surgeons, who had seen it, and done it and could teach it.

Mike Thompson is one of these.  He is a general surgeon with a special interest in the diagnosis and treatment of bowel cancer.  And he has a particular passion for improving the speed and accuracy of the diagnosis step; because it can be a life-saver.

Mike is also a disruptive innovator and an early pioneer of the use of endoscopy in the outpatient clinic.  It is called point-of-care testing nowadays, but in the 1980’s it was a radically innovative thing to do.

He also pioneered collecting the symptoms and signs from every patient he saw, in a standard way using a multi-part printed proforma. And he invested many hours entering the raw data into a computer database.

He also did something that even now most clinicians do not do; when he knew the outcome for each patient he entered that into his database too – so that he could link first presentation with final diagnosis.


Mike knew that I had an interest in computer-aided diagnosis, which was a hot topic in the early 1980’s, and also that I did not warm to the Bayesian statistical models that underpinned it.  To me they made too many simplifying assumptions.

The human body is a complex adaptive system. It defies simplification.

Mike and I took a different approach.  We  just counted how many of each diagnostic group were associated with each pattern of presenting symptoms and signs.

The problem was that even his database of 8000+ patients was not big enough! This is why others had resorted to using statistical simplifications.

So we used the approach that an experienced diagnostician uses.  We used the information we had already gleaned from a patient to decide which question to ask next, and then the next one and so on.


And we always have three pieces of information at the start – the patient’s age, gender and presenting symptom.

What surprised and delighted us was how easy it was to use the database to help us do this for the new patients presenting to his clinic; the ones who were worried that they might have bowel cancer.

And what surprised us even more was how few questions we needed to ask arrive at a statistically robust decision to reassure-or-refer for further tests.

So one weekend, I wrote a little computer program that used the data from Mike’s database and our simple bean-counting algorithm to automate this process.  And the results were amazing.  Suddenly we had a simple and reliable way of using past experience to support our present decisions – without any statistical smoke-and-mirror simplifications getting in the way.

The computer program did not make the diagnosis, we were still responsible for that; all it did was provide us with reliable access to a clear and comprehensive digital memory of past experience.


What it then enabled us to do was to learn more quickly by exploring the complex patterns of symptoms, signs and outcomes and to develop our own diagnostic “rules of thumb”.

We learned in hours what it would take decades of experience to uncover. This was hot stuff, and when I presented our findings at the Royal Society of Medicine the audience was also surprised and delighted (and it was awarded the John of Arderne Medal).

So, we called it the Hot Learning System, and years later I updated it with Mike’s much bigger database (29,000+ records) and created a basic web-based version of the first step – age, gender and presenting symptom.  You can have a play if you like … just click HERE.


So what are the lessons here?

  1. We need to have the most experienced diagnosticians at the start of the improvement process.
  2. The first diagnostic assessment can be very quick so long as we have developed evidence-based heuristics.
  3. We can accelerate the training in diagnostic skills using simple information technology and basic analysis techniques.

And exactly the same is true in the health care system improvement.

We need to have an experienced health care improvement practitioner involved at the start, because if we skip this critical study step and move to plan without a correct diagnosis, then we will make errors, poor decisions, and counter-productive actions.  And then generate more work, more queues, more delays, more chaos, more distress and increased costs.

Exactly the opposite of what we want.

Q1: So, how do we develop experienced improvement practitioners more quickly?

Q2: Is there a hot learning system for improvement science?

A: Yes, there is. It can be found here.

The Marmite Effect

Have you heard the phrase “you either love it or you hate it“?  It is called the Marmite Effect.

Improvement science has Marmite-like effect on some people, or more specifically, the theory part does.

Both evidence and experience show that most people prefer to learn-by-doing first; and then consolidate their learning with the minimum, necessary amount of supporting theory.

But that is not how we usually share what we know with others.  We usually attempt to teach the theory first, perhaps in the belief that it will speed up the process of learning.

Sadly, it usually has the opposite effect. Too much theory too soon often creates a barrier to engagement. It actually slows learning down! Which was not the impact we were intending.


The implications of this is that teachers of the science of improvement need to provide a range of different ways to engage with the subject.  Complementary ways.  And leave the choice of which suits whom … to the learner.

And the way to tell if it is working is … the sound of laughter.

Why is that?


Laughing is a complex behaviour that leaves us feeling happier. Which is good.

Comedians make a living from being able to trigger this behaviour in their audiences, and we will gladly part with hard cash when we know something will make us feel better.

And laughing is one of the healthiest ways to feel better!

So why do we laugh when we are learning?

It is believed that one trigger for the laughter reaction is the sudden shift from one perspective to another.  More specifically, a mental shift that relieves a growing emotional tension.  The punch line of a really good joke for example.

And later-in-life learning is often more a process of unlearning.

When we challenge a learned assumption with evidence and if we disprove it … we are unlearning.  And doing that generates emotional tension. We are often very attached to our unconscious assumptions and will usually resist them being challenged.

The way to unlearn effectively is to use the evidence of our own eyes to raise doubts about our unconscious assumptions.  We need to actively generate a bit of confusion.

Then, we resolve the apparent paradox by creatively shifting perspective, often with a real example, a practical explanation or a hands-on demonstration.

And when we experience the “Ah ha! Now I see!” reaction, and we emerge from the fog of confusion, we will relieve the emotional tension and our involuntary reaction is to laugh.

But if our teacher unintentionally triggers a Marmite effect; a “Yeuk, I am NOT enjoying this!” feeling, then we need to respect that, and step back, and adopt a different tack.


Over the last few months I have been experimenting with different approaches to introducing the principles of improvement-by-design.

And the results are clear.

A minority prefer to start with the abstract theory, and then apply it in practice.

The majority have various degrees of Marmite reaction to the theory, and some are so put off that they actively disengage.  But when they have an opportunity to see the same principles demonstrated in a concrete, practical way; they learn and laugh.

Unlearning-by-doing seems to work better for the majority.

So, if you want to have fun and learn how to deliver significant and sustained improvements … then the evidence points to this as the starting point …

… the Flow Design Practical Skills One Day Workshop.

And if you also want to dip into a bit of the tried-and-tested theory that underpins improvement-by-design then you can do that as well, either before or later (when it becomes necessary), or both.


So, to have lots of fun and learn some valuable improvement-by-design practical skills at the same time …  click here.

The Storyboard

This week about thirty managers and clinicians in South Wales conducted two experiments to test the design of the Flow Design Practical Skills One Day Workshop.

Their collective challenge was to diagnose and treat a “chronically sick” clinic and the majority had no prior exposure to health care systems engineering (HCSE) theory, techniques, tools or training.

Two of the group, Chris and Jat, had been delegates at a previous ODWS, and had then completed their Level-1 HCSE training and real-world projects.

They had seen it and done it, so this experiment was to test if they could now teach it.

Could they replicate the “OMG effect” that they had experienced and that fired up their passion for learning and using the science of improvement?

Continue reading “The Storyboard”

The Chicken Coop

Chickens make interesting pets. They have personalities – no two are the same – and they produce something useful and valuable. Eggs. Yum yum!

But chickens are yummy too … especially to foxes. So we have a problem. We need to keep our ‘chucks’ safe and that means a fox-proof coop.

Here’s a picture of a chicken coop … looks great doesn’t it? You can just hear the happy clucks and taste the fresh eggs.

Have you any idea how complicated, difficult and expensive this would be to build from scratch?

Better not even try … just reach for the laptop and credit card and order a prefabricated one.  Just assembling the courier-delivered-flat-packed-made-in-China-from-renewable-forest-softwood coop will be enough of a DIY challenge!


We have had chickens for years and we have learned that they are very funny-feathered-characters-who-lay-eggs.

And we started with an old Wendy house, some softwood battening, some rolls of weld-mesh, a bag of screws and staples and a big dollop of suck-it-and-see.

The first attempt was Heath-Robinson but it worked OK.  The old Wendy house was transformed into a cosy coop and a safe-from-foxes chuck run.

And the eggs were delicious and nutritious.


But the arrow of time is relentless, and as with all organic things, the “rot had set in”.

The time had come for an update. Doing nothing was not an option.

Q: Start from scratch with a blank piece of paper and design and build a new coop and run (i.e. scrap the old one)? Or re-purpose what we have (i.e. cut out the rot, keep the good stuff and re-fashion something that is fit-for-purpose for years to come?

Oh, and we also need to keep-the-ship-afloat in the process – i.e. the keep the chucks safe-from-foxes and happily laying eggs.  That meant doing the project in one day.


What was interesting about this mini-transformation project was that I could apply exactly the same improvement framework as I would to a health care systems engineering one.

I had a clear problem (unsafe, semi-rotten chicken coop) and a clear purpose (fit-for-purpose and affordable coop and run).

Next I needed a diagnosis.  What was rotten and what was not?  And that required a bit of poking with a probe … and what I found was that most of the rot was hidden!

First I needed to study the problem (symptoms) and the purpose (required outcome) and the problem again (disease).

This was going to require some radical surgery!

With a clear destination and diagnosis it was now time to plan. For this I needed a robust design framework for exploring “radical” options – particularly those that open new opportunities that the old design prevented!  This is called “future-proofing”.

And the capital cost is always a factor – building a shiny, high-tech version of an old design that is no longer fit-for-purpose is a waste of capital investment and locks us into the past.


And remember, the innovative, fit-for-purpose, elegant, affordable design is just a dream when it is still only a plan.  Someone has to do the building work.  And it has to be feasible with the time, tools and skills available.  And all that needs to be considered at the design stage too!

With the benefit of hindsight, I have come to appreciate that the most valuable long-term investment is the new theory, new techniques, new tools and the new skills to use them. This is called “innovation”.


So with a diagnosis, a design, a sunny day, a sharpened-pencil-behind-the-ear, a just-in-time delivery of the bulkier building materials, a freshly charged power drill, and a hot cuppa … the work started.

It was going to be like performing a major operation.

The chucks were more than happy to be let out to scratch around in the garden; and groundwork always generates the opportunity for a creepy-crawly feast!  But safety comes first – foxes mainly hunt at night so in one daylight period I had to surgically excise the rot and then transform what was left into a safe space for the chucks to sleep.

When the study and plan work has been done diligently – the do phase is enjoyable.

If we skip the study phase and leap straight to plan with all the old assumptions (some rotten some not) still in place … the do phase is usually miserable! (No wonder many people have developed a high level of aversion to change!).


And the outcome?

Happy chucks, safely tucked up in their transformed, rot-free, safe-from-harm, coop and run.

The work is not quite finished – a new roof is awaiting installation but that is a quality issue not a safety one.

Safety always comes first.

And just look at how much rot had to be chopped out.

Any surgeon will tell you … “for the fastest recovery you have to cut out all the rot first“.

And that requires careful planning, courage, skill, a sharp blade, focus and … team work!