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Mono, Micro, Meso and Macro

missing_custom_puzzle_completionSystems are made up of inter-dependent parts. And each part is a smaller system made up of inter-dependent parts. And so on.

But there is a limit … eventually we reach a size where we only have a small number of independent parts … and that is called a micro-system.

It is part of a meso-system which in turn is part of a macro-system.

And it appears that in human systems the manageable size of a micro-system is about seven people – enough to sit around a table and work together on a problem.

So the engine of organisational improvement is many micro-systems of about seven people who are able to solve the problems that fall within their collective circles of control.

And that means the vast majority of problems are solvable at the micro-system level.

In fact, without this foundation level of competent and collaborative micro-teams, the meso-systems and the macro-systems cannot get a grip on the slippery problem of systemic change for the better.

The macro-system is also critical to success because it has the strategic view and it sets the vision and values to which every other part of the system aligns.  A dysfunctional macro-system sends cracks down through the whole organisation … fragmenting it into antagonistic, competiting silos.

The meso-system level is equally critical to success because it translates the strategy into tactics and creates the context for the multitude of micro-systems to engage.

The meso-system is the nervous system of the organisation … the informal communication network that feeds data and decisions around.

And if the meso-system is dysfunctional then the organisation can see, feel and move … but it is uncoordinated, chaotic, inefficient, ineffective and largely unproductive.

So the three levels are different, essential and inter-dependent.

The long term viability of a complex adaptive system is the emergent effect of a system design that is effective and efficient. Productive. Collaborative. Synergistic.

And achieving that is not easy … but it is possible.

And for each of us it starts with just us … Mono. 

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The Slippery Slope From Calm To Chaos

figure_slipping_on_water_custom_sign_14210System behaviour is often rather variable over the short term.  We have ‘good’ days and ‘bad’ days and we weather the storm because we know the sun will shine again soon.

We are resilient and adaptable. And our memories are poor.

So when the short-term variation sits on top of a long-term trend then we do not feel the trend …

… because we are habituating. We do not notice that we are on a slippery slope.

And slippery slopes are more difficult to climb up than to slide down.

In organisational terms the slippery slope is from Calm to Chaos.  Success to Failure.  Competent to Incompetent. Complacent to  Contrite.  Top of the pops to top of the flops!

The primary reason for this is we are all part of a perpetual dynamic between context and content.  We are affected by the context we find ourselves in. We sense it and that influences our understanding, our decisions and our actions. These actions then change our context … nothing is ever the same.

So our hard-won success sows the seeds of its own failure … and unless we realise that then we are doomed to a boom-bust cycle.  To sustain success we must learn to constantly redefine our future and redesign our present.

If we do not then we are consigned to the Slippery Slope … and when we eventually accept that chaos has engulfed us then we may also discover that it may be late.  To leap from chaos to calm is VERY difficult without a deep understanding of how systems work … and if we had that wisdom then we would have avoided the slippery slope in the first place.

The good news is that there is hope … we can learn to climb out of the Swamp of Chaos … and we can develop our capability to scale the slippery slope from  Chaos through Complex, and then to Complicated, and finally back to Calm.  Organised complexity.

It requires effort and it takes time … but it is possible.

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The “I am Great (and You are Not)” Trap

business_race__PA_150_wht_3222When we start the process of learning to apply the Science of Improvement in practice we need to start within our circle of influence.

It is just easier, quicker and safer to begin there – and to build our capability, experience and confidence in steps.

And when we get the inevitable ‘amazing’ result it is natural and reasonable for us to want to share the good news with others.  We crossed the finish line first and we want to celebrate.   And that is exactly what we need to do.

We just need to be careful how we do it.

We need to be careful not to unintentionally broadcast an “I am Great (and You are Not)” message – because if we do that we will make further change even more difficult.

Competition can be healthy or unhealthy  … just as scepticism can be.

We want to foster healthy competition … and to do that we have to do something that can feel counter-intuitive … we have to listen to our competitors; and we have to learn from them; and we have to share our discoveries with them.

Eh?

Just picture these two scenarios in your mind’s eye:

Scenario One: The competition is a war. There can only be one winner … the strongest, most daring, most cunning, most ruthless, most feared competitor. So secrecy and ingenuity are needed. Information must be hoarded. Untruths and confusion must be spread.

Scenario Two: The competition is a race. There can only be one winner … the strongest, most resilient, hardest working, fastest learning, most innovative, most admired competitor.  So openness and humility are needed. Information must be shared. Truths and clarity must be spread.

Compare the likely outcomes of the two scenarios.

Which one sounds the more productive, more rewarding and more enjoyable?

So the challenge for the champions of improvement is to appreciate and to practice a different version of the “I’m Great … ” mantra …

I’m Great (And So Are You).

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Excellence By Design

top_surgeon_400_wht_7589All healthcare organisations strive for excellence, which is good, and most achieve mediocrity, which is not so good.

Why is that?

One cause is the design of their model for improvement … the one that is driven by targets, complaints, near misses, serious untoward incidents (SUIs) and never events (which are not never).

A model for improvement that is driven by failure feedback loops can only ever achieve mediocrity, not excellence.

“Whaaaaaat?!* That’s rubbish”  I hear you cry … so let us see.

Try this simple test …. just ask any employee in your organisation this question (and start with yourself):

“How do you know you are doing a good job?“

If the first answer heard is “When no one is complaining” then you have a Mediocrity Design.

When customers have a disappointing experience most do not pen a letter or write an email to complain.  Most just sigh and lower their expectations to avoid future disappointment; many will grumble to family and friends; and only a few (about 5%) will actually complain. They are the really angry extreme.  So they can easily be fobbed off with platitudes … just being earnestly listened to and unreservedly apologised to is usually enough to take the wind out of their sails.  It will escort them back to the silent but disappointed majority whose expectation is being gradually eroded by relentless disappointment. Nothing fundamental needs to change because eventually the complaints dry up, apathy is re-established and chronic mediocrity is assured.

To achieve excellence we need a better answer to the “How do you know you are doing a good job?” question.

We need to be able to say “I know I am doing a good job because this is what a good outcome looks like; this is my essential contribution to achieving that outcome; and here are the measures of the intended outcomes that we are achieving.“

In short we need a clear purpose, a defined part in the process that delivers that purpose, and we need an objective feedback loop that tells us that the purpose has been achieved and that our work is worthwhile.

And if  any of those components are missing then we know we have some improvement work to do.

The first step is usually answering the question “What is our purpose?“

The second step is using the purpose to design and install the how-are-we-doing feedback loop.

And the  third step is to learn to use the success feedback loop to ensure that we are always working to have a necessary-and-sufficient process that delivers the intended outcome and that we are playing a part in that.

And when we are reliably achieving our purpose, we set ourselves an even better outcome – an even safer, calmer, higher quality and more productive one … and doing that will generate more improvement work to do.  We will not be idle.

That is the essence of Excellence-by-Design.

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Celebrate and Share

There comes a point in every improvement journey when it is time to celebrate and share. This is the most rewarding part of the Improvement Science Practitioner (ISP) coaching role so I am going to share a real celebration that happened this week.

The picture shows Chris Jones holding his well-earned ISP-1 Certificate of Competence.  The “Maintaining the Momentum of Medicines”  redesign project is shown on the poster on the left and it is the tangible Proof of Competence. The hard evidence that the science of improvement delivers.

Chris_Jones_Poster_and_Certificate

Behind us are the A3s for one of the Welsh Health Boards;  ABMU in fact.

An A3 is a way of summarising an improvement project very succinctly – the name comes from the size of paper used.  A3 is the biggest size that will go through an A4 fax machine (i.e. folded over) and the A3 discipline is to be concise and clear at the same time.

The three core questions that the A3 answers are:
Q1: What is the issue?
Q2: What would improvement need to look like?
Q3: How would we know that a change is an improvement?

This display board is one of many in the room, each sharing a succinct story of a different improvement journey and collectively a veritable treasure trove of creativity and discovery.

The A3s were of variable quality … and that is OK and is expected … because like all skills it takes practice. Lots of practice. Perfection is not the goal because it is unachievable. Best is not the goal because only one can be best. Progress is the goal because everyone can progress … and so progress is what we share and what we celebrate.

The event was the Fifth Sharing Event in the Welsh Flow Programme that has been running for just over a year and Chris is the first to earn an ISP-1 Certificate … so we all celebrated with him and shared the story.  It is a team achievement – everyone in the room played a part in some way – as did many more who were not in the room on the day.

stick_figure_look_point_on_cliff_anim_8156Improvement is like mountain walking.

After a tough uphill section we reach a level spot where we can rest; catch our breath; take in the view; reflect on our progress and the slips, trips and breakthroughs along the way; perhaps celebrate with drink and nibble of our chocolate ration; and then get up, look up, and square up for the next uphill bit.

New territory for us.  New challenges and new opportunities to learn and to progress and to celebrate and share our improvement stories.

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The Improvement Pyramid

IS_PyramidDeveloping productive improvement capability in an organisation is like building a pyramid in the desert.

It is not easy and it takes time before there is any visible evidence of success.

The height of the pyramid is a measure of the level of improvement complexity that we can take on.

An improvement of a single step in a system would only require a small pyramid.

Improving the whole system will require a much taller one.

But if we rush and attempt to build a sky-scraper on top of the sand then we will not be surprised when it topples over before we have made very much progress.  The Egyptians knew this!

First, we need to dig down and to lay some foundations.  Stable enough and strong enough to support the whole structure.  We will never see the foundations so it is easy to forget them in our rush but they need to be there and they need to be there first.

It is the same when developing improvement science capability  … the foundations are laid first and when enough of that foundation knowledge is in place we can start to build the next layer of the pyramid: the practitioner layer.

It is the the Improvement Science Practitioners (ISPs) who start to generate tangible evidence of progress.  The first success stories help to spur us all on to continue to invest effort, time and money in widening our foundations to be able to build even higher – more layers of capability -until we can realistically take on a system wide improvement challenge.

So sharing the first hard evidence of improvement is an important milestone … it is proof of fitness for purpose … and that news should be shared with those toiling in the hot desert sun and with those watching from the safety of the shade.

So here is a real story of a real improvement pyramid achieving this magical and motivating milestone.

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V.U.T.

figure_pointing_out_chart_data_150_wht_8005It was the appointed time for the ISP coaching session and both Bob and Leslie were logged on and chatting about their Easter breaks.

<Bob> OK Leslie, I suppose we had better do some actual work, which seems a shame on such a wonderful spring day.

<Leslie> Yes, I suppose so. There is actually something I would like to ask you about because I came across it by accident and it looked very pertinent to flow design … but you have never mentioned it.

<Bob> That sounds interesting. What is it?

<Leslie> V.U.T.

<Bob> Ah ha!  You have stumbled across the Queue Theorists and the Factory Physicists.  So, what was your take on it?

<Leslie> Well it all sounded very impressive. The context is I was having a chat with a colleague who is also getting into the improvement stuff and who had been to a course called “Factory Physics for Managers” – and he came away buzzing about the VUT equation … and claimed that it explained everything!

<Bob> OK. So what did you do next?

<Leslie> I looked it up of course and I have to say the more I read the more confused I got. Maybe I am just a bid dim and not up to understanding this stuff.

<Bob> Well you are certainly not dim so your confusion must be caused by something else. Did your colleague describe how the VUT equation is applied in practice?

<Leslie> Um. No, I do not remember him describing an example – just that it explained why we cannot expect to run resources at 100% utilisation.

<Bob> Well he is correct on that point … though there is a bit more to it than that.  A more accurate statement is “We cannot expect our system to be stable if there is variation and we run flow-resources at 100% utilisation”.

<Leslie> Well that sounds just like the sort of thing we have been talking about, what you call “resilient design”, so what is the problem with the VUT equation?

<Bob> The problem is that it gives an estimate of the average waiting time in a very simple system called a G/G/1 system.

<Leslie> Eh? What is a G/G/1 system?

<Bob> Arrgh … this is the can of queue theory worms that I was hoping to avoid … but as you brought it up let us grasp the nettle.  This is called Kendall’s Notation and it is a short cut notation for describing the system design. The first letter refers to the arrivals or demand and G means a general distribution of arrival times; the second G refers to the size of the jobs or the cycle time and again the distribution is general; and the last number refers to the number of parallel resources pulling from the queue.

<Leslie> OK, so that is a single queue feeding into a single resource … the simplest possible flow system.

<Bob> Yes. But that isn’t the problem.  The problem is that the VUT equation gives an approximation to the average waiting time. It tells us nothing about the variation in the waiting time.

<Leslie> Ah I see. So it tells us nothing about the variation in the size of the queue either … so does not help us plan the required space-capacity to hold the varying queue.

<Bob> Precisely.  There is another problem too.  The ‘U’ term in the VUT equation refers to utilisation of the resource … denoted by the symbol ? or rho.  The actual term is ? / (1-?) … so what happens when rho approaches one … or in practical terms the average utilisation of the resource approaches 100%?

<Leslie> Um … 1 divided by (1-1) is 1 divided by zero which is … infinity!  The average waiting time becomes infinitely long!

<Bob> Yes, but only if we wait forever – in reality we cannot and anyway – reality is always changing … we live in a dynamic, ever-changing, unstable system called Reality. The VUT equation may be academically appealing but in practice it is almost useless.

<Leslie> Ah ha! Now I see why you never mentioned it. So how do we design for resilience in practice? How do we get a handle on the behaviour of even the G/G/1 system over time?

<Bob> We use an Excel spreadsheet to simulate our G/G/1 system and we find a fit-for-purpose design using an empirical, experimental approach. It is actually quite straightforward and does not require any Queue Theory or VUT equations … just a bit of basic Excel know-how.

<Leslie> Phew!  That sounds more up my street. I would like to see an example.

<Bob> Welcome to the first exercise in ISP-2 (Flow).

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Over-Egged Expectation

FISH_ISP_eggs_jumpingResistance-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.

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Walk Confidently before Running

running_walking_150_wht_8351Improvement 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.

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Co-Labor-Ation

Dr_Bob_ThumbnailBob 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.

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The Improvement Gearbox

GearboxOne 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.

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Circles

SFQP_enter_circle_middle_15576For a system to be both effective and efficient the parts need to work in synergy. This requires both alignment and collaboration.

Systems that involve people and processes can exhibit complex behaviour. The rules of engagement also change as individuals learn and evolve their beliefs and their behaviours.

The values and the vision should be more fixed. If the goalposts are obscure or oscillate then confusion and chaos is inevitable.

So why is collaborative alignment so difficult to achieve?

One factor has been mentioned. Lack of a common vision and a constant purpose.

Another factor is distrust of others. Our fear of exploitation, bullying, blame, and ridicule.

Distrust is a learned behaviour. Our natural inclination is trust. We have to learn distrust. We do this by copying trust-eroding behaviours that are displayed by our role models. So when leaders display these behaviours then we assume it is OK to behave that way too.  And we dutifully emulate.

The most common trust eroding behaviour is called discounting.  It is a passive-aggressive habit characterised by repeated acts of omission:  Such as not replying to emails, not sharing information, not offering constructive feedback, not asking for other perspectives, and not challenging disrespectful behaviour.

There are many causal factors that lead to distrust … so there is no one-size-fits-all solution to dissolving it.

One factor is ineptitude.

This is the unwillingness to learn and to use available knowledge for improvement.

It is one of the many manifestations of incompetence.  And it is an error of omission.

Whenever we are unable to solve a problem then we must always consider the possibility that we are inept.  We do not tend to do that.  Instead we prefer to jump to the conclusion that there is no solution or that the solution requires someone else doing something different. Not us.

The impossibility hypothesis is easy to disprove.  If anyone has solved the problem, or a very similar one, and if they can provide evidence of what and how then the problem cannot be impossible to solve.

The someone-else’s-fault hypothesis is trickier because proving it requires us to influence others effectively.  And that is not easy.  So we tend to resort to easier but less effective methods … manipulation, blame, bullying and so on.

A useful way to view this dynamic is as a set of four concentric circles – with us at the centre.

The outermost circle is called the ‘Circle of Ignorance‘. The collection of all the things that we do not know we do not know.

Just inside that is the ‘Circle of Concern‘.  These are things we know about but feel completely powerless to change. Such as the fact that the world turns and the sun rises and falls with predictable regularity.

Inside that is the ‘Circle of Influence‘ and it is a broad and continuous band – the further away the less influence we have; the nearer in the more we can do. This is the zone where most of the conflict and chaos arises.

The innermost is the ‘Circle of Control‘.  This is where we can make changes if we so choose to. And this is where change starts and from where it spreads.

SFQP_enter_circle_middle_15576So if we want system-level improvements in safety, flow, quality and productivity (or cost) then we need to align these four circles. Or rather the gaps in them.

We start with the gaps in our circle of control. The things that we believe we cannot do … but when we try … we discover that we can (and always could).

With this new foundation of conscious competence we can start to build new relationships, develop trust and to better influence others in a win-win-win conversation.

And then we can collaborate to address our common concerns – the ones that require coherent effort. We can agree and achieve our common purpose, vision and goals.

And from there we will be able to explore the unknown opportunities that lie beyond. The ones we cannot see yet.

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Cumulative Sum

Dr_Bob_Thumbnail[Bing] Bob logged in for the weekly Webex coaching session. Leslie was not yet on line, but joined a few minutes later.

<Leslie> Hi Bob, sorry I am a bit late, I have been grappling with a data analysis problem and did not notice the time.

<Bob> Hi Leslie. Sounds interesting. Would you like to talk about that?

<Leslie> Yes please! It has been driving me nuts!

<Bob> OK. Some context first please.

<Leslie> Right, yes. The context is an improvement-by-design assignment with a primary care team who are looking at ways to reduce the unplanned admissions for elderly patients by 10%.

<Bob> OK. Why 10%?

<Leslie> Because they said that would be an operationally very significant reduction.  Most of their unplanned admissions, and therefore costs for admissions, are in that age group.  They feel that some admissions are avoidable with better primary care support and a 10% reduction would make their investment of time and effort worthwhile.

<Bob> OK. That makes complete sense. Setting a new design specification is OK.  I assume they have some baseline flow data.

<Leslie> Yes. We have historical weekly unplanned admissions data for two years. It looks stable, though rather variable on a week-by-week basis.

<Bob> So has the design change been made?

<Leslie> Yes, over three months ago – so I expected to be able to see something by now but there are no red flags on the XmR chart of weekly admissions. No change.  They are adamant that they are making a difference, particularly in reducing re-admissions.  I do not want to disappoint them by saying that all their hard work has made no difference!

<Bob> OK Leslie. Let us approach this rationally.  What are the possible causes that the weekly admissions chart is not signalling a change?

<Leslie> If there has not been a change in admissions. This could be because they have indeed reduced readmissions but new admissions have gone up and is masking the effect.

<Bob> Yes. That is possible. Any other ideas?

<Leslie> That their intervention has made no difference to re-admissions and their data is erroneous … or worse still … fabricated!

<Bob> Yes. That is possible too. Any other ideas?

<Leslie> Um. No. I cannot think of any.

<Bob> What about the idea that the XmR chart is not showing a change that is actually there?

<Leslie> You mean a false negative? That the sensitivity of the XmR chart is limited? How can that be? I thought these charts will always signal a significant shift.

<Bob> It depends on the degree of shift and the amount of variation. The more variation there is the harder it is to detect a small shift.  In a conventional statistical test we would just use bigger samples, but that does not work with an XmR chart because the run tests are all fixed length. Pre-defined sample sizes.

<Leslie> So that means we can miss small but significant changes and come to the wrong conclusion that our change has had no effect! Isn’t that called a Type 2 error?

<Bob> Yes, it is. And we need to be aware of the limitations of the analysis tool we are using. So, now you know that how might you get around the problem?

<Leslie> One way would be to aggregate the data over a longer time period before plotting on the chart … we know that will reduce the sample variation.

<Bob> Yes. That would work … but what is the downside?

<Leslie> That we have to wait a lot longer to show a change, or not. We do not want that.

<Bob> I agree. So what we do is we use a chart that is much more sensitive to small shifts of the mean.  And that is called a cusum chart. These were not invented until 30 years after Shewhart first described his time-series chart.  To give you an example, do you recall that the work-in-progress chart is much more sensitive to changes in flow than either demand or activity charts?

<Leslie> Yes, and the WIP chart also reacts immediately if either demand or activity change. It is the one I always look at first.

<Bob> That is because a WIP chart is actually a cusum chart. It is the cumulative sum of the difference between demand and activity.

<Leslie> OK! That makes sense. So how do I create and use a cusum chart?

<Bob> I have just emailed you some instructions and a few examples. You can try with your unplanned admissions data. It should only take a few minutes. I will get a cup of tea and a chocolate Hobnob while I wait.

[Five minutes later]

<Leslie> Wow! That is just brilliant!  I can see clearly on the cusum chart when the shifts happened and when I split the XmR chart at those points the underlying changes become clear and measurable. The team did indeed achieve a 10% reduction in admissions just as they claimed they had.  And I checked with a statistical test which confirmed that it is statistically significant.

<Bob> Good work.  Cusum charts take a bit of getting used to and we have be careful about the metric we are plotting and a few other things but it is a useful trick to have up our sleeves for situations like this.

<Leslie> Thanks Bob. I will bear that in mind.  Now I just need to work out how to explain cusum charts to others! I do not want to be accused of using statistical smoke-and-mirrors! I think a golf metaphor may work with the GPs.

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Persistence and Patience

magnify_text_anim_16253(1)There is no doubt about it …

… change is not easy.

If it were we would all be doing it …

… all of the time.

So one skill that an effective agent of change demonstrates is persistence.

And also patience. And also reflective learning.

A recent change project demonstrated objective, measurable outcomes which showed that the original design goal was achieved. In budget. It took two years from first contact to final report.

Why two years? Could it have been done quicker?

In principle – ‘Emphatically, yes’.  In practice – ‘Evidently, no’.

With the benefit of hindsight it is always clearer what might have caused the delay.  Maybe the experience-based advice of those guiding the process was discounted.  Maybe the repeated recommendation that an initial investment in learning the basic science of improvement would deliver a quicker return was ignored.  Maybe.

So the reflective learning from the first wave was re-invested in the second wave.

And the second wave delivered a significant and objectively measurable improvement in one year.

And the reflective learning from the second wave was re-invested in the third wave.

And the third wave delivered a significant and objectively measurable improvement in six months.

And the three improvement projects were of comparable complexity.

So what is happening here?

The process of improvement is itself being improved.  Experience and learning are being re-invested.

And two repeating themes emerge ….

Patience is needed to await outcomes and to learn from them.

Persistence is needed to re-examine old paradigms with this new knowledge and new understanding.

Patience and Persistence. And these principles apply as much to the teacher as to the taught.

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A School for Rebels

Troublemaker_vs_RebelSystem-wide, significant, and sustained improvement implies system-wide change.

And system-wide change implies more than 20% of the people commit to action. This is the cultural tipping point.

These critical 20% have a badge … they call themselves rebels … and they are perceived as troublemakers by those who profit most from the status quo.

But troublemakers and rebels are radically different … as shown in the summary by Lois Kelly.

Rebels share a common, future-focussed purpose.  A mission.  They are passionate, optimistic and creative.  They understand synergy and how to release and align the stored emotional energy of both themselves and others.  And most importantly they are value-led and that makes them attractive.  Values such as honesty, integrity and industry are what make leaders together-effective.

SHCR_logoAnd as we speak there is school for rebels in healthcare gaining momentum …  and their programme is current, open to all and free to access. And the change agent development materials are excellent!

Click here to download their study guide.

Converting possibilities into realities is the essence of design … so our merry band of rebels will also need to learn how to convert their positive rhetoric into practical reality. And that is more physics than psychology.

Streams flow because of physics not because of passion.SFQP_Compass

And this is why the science of improvement is important because it is the synthesis of the people dimension and the process dimension – into a system that delivers significant and sustained improvement.

On all dimensions. Safety, Flow, Quality and Productivity.

The lighthouse is our purpose; the whale represents the magnitude of our challenge; the blue sky is the creative thinking we need … to avoid trying to boil the ocean.

And the noisy, greedy, s****y seagulls are the troublemakers who always will plague us.

[Image by Malaika Art].

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The Nanny McPhee Coaching Contract

Nanny_McPheeThere comes a point in every improvement-by-design journey when it is time for the improvement guide to leave.

An experienced improvement coach knows when that time has arrived and the expected departure is in the contract.

The Nanny McPhee Coaching Contract:

“When you need me but do not want me then I have to stay. And when you want me but do not need me then I have to leave.”

The science of improvement can appear like ‘magic’ at first because seemingly impossible simultaneous win-win-win benefits are seen to happen with minimal effort.

It is not magic.  It requires years of training and practice to become a ‘magician’.  So those who have invested in learning the know-how are just catalysts.  When their catalysts-of-change work is done then they must leave to do it elsewhere.

The key to managing this transition is to set this expectation clearly and right at the start; so it does not come as a surprise. And to offer reminders along the way.

And it is important to follow through … when the time is right.

It is not always easy though.

There are three commonly encountered situations that will test the temptation of the guide.

1) When things are going very badly because the coaching contract is being breached; usually by old, habitual, trust-eroding, error-of-omission behaviours such as: not communicating, not sharing learning, and not delivering on commitments. The coach, fearing loss of reputation and face, is tempted to stay longer and to try harder. Often getting angry and frustrated in the process.  This is an error of judgement. If the coaching contract is being persistently breached then the Exit Clause should be activated clearly and cleanly.

2) When things are going OK, it is easy to become complacent and the temptation then is to depart too soon, only to hear later that the solo-flyers “crashed and burned”, because they were not quite ready and could not (or would not) see it.  This is the “need but do not want” part of the Nanny McPhee Coaching Contract.  One role of the coach is to respectfully challenge the assertion that ‘We can do it ourselves‘ … by saying ‘OK, please demonstrate‘.

3) When things are going very well it is tempting to blow the Trumpet of Success too early, attracting the attention of others who will want to take short cuts, to bypass the effort of learning for themselves, and to jump onto someone else’s improvement bus.  The danger here is that they bring their counter-productive, behavioural baggage with them. This can cause the improvement bus to veer off course on the twists and turns of the Nerve Curve; or grind to a halt on the steeper parts of the learning curve.

An experienced improvement coach will respectfully challenge the individuals and the teams to help them develop their experience, competence and confidence. And just as they start to become too comfortable with having someone to defer to for all decisions, the coach will announce their departure and depart as announced.

This is the “want but do not need” part of the Nanny McPhee Coaching Contract.

And experience teaches us that this mutually respectful behaviour works better.

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Politicial Purpose

count_this_vote_400_wht_9473The question that is foremost in the mind of a designer is “What is the purpose?”   It is a future-focussed question.  It is a question of intent and outcome. It raises the issues of worth and value.

Without a purpose it impossible to answer the question “Is what we have fit-for-purpose?“

And without a clear purpose it is impossible for a fit-for-purpose design to be created and tested.

In the absence of a future-purpose all that remains are the present-problems.

Without a future-purpose we cannot be proactive; we can only be reactive.

And when we react to problems we generate divergence.  We observe heated discussions. We hear differences of opinion as to the causes and the solutions.  We smell the sadness, anger and fear. We taste the bitterness of cynicism. And we are touched to our core … but we are paralysed.  We cannot act because we cannot decide which is the safest direction to run to get away from the pain of the problems we have.

And when the inevitable catastrophe happens we look for somewhere and someone to place and attribute blame … and high on our target-list are politicians.

So the prickly question of politics comes up and we need to grasp that nettle and examine it with the forensic lens of the system designer and we ask “What is the purpose of a politician?”  What is the output of the political process? What is their intent? What is their worth? How productive are they? Do we get value for money?

They will often answer “Our purpose is to serve the public“.  But serve is a verb so it is a process and not a purpose … “To serve the public for what purpose?” we ask. “What outcome can we expect to get?” we ask. “And when can we expect to get it?”

We want a service (a noun) and as voters and tax-payers we have customer rights to one!

On deeper reflection we see a political spectrum come into focus … with Public at one end and Private at the other.  A country generates wealth through commerce … transforming natural and human resources into goods and services. That is the Private part and it has a clear and countable measure of success: profit.  The Public part is the redistribution of some of that wealth for the benefit of all – the tax-paying public. Us.

Unfortunately the Public part does not have quite the same objective test of success: so we substitute a different countable metric: votes. So the objectively measurable outcome of a successful political process is the most votes.

But we are still talking about process … not purpose.  All we have learned so far is that the politicians who attract the most votes will earn for themselves a temporary mandate to strive to achieve their political purpose. Whatever that is.

So what do the public, the voters, the tax-payers (and remember whenever we buy something we pay tax) … the customers of this political process … actually get for their votes and cash?  Are they delighted, satisfied or disappointed? Are they getting value-for-money? Is the political process fit-for-purpose? And what is the purpose? Are we all clear about that?

And if we look at the current “crisis” in health and social care in England then I doubt that “delight” will feature high on the score-sheet for those who work in healthcare or for those that they serve. The patients. The long-suffering tax-paying public.

Are politicians effective? Are they delivering on their pledge to serve the public? What does the evidence show?  What does their portfolio of public service improvement projects reveal?  Welfare, healthcare, education, police, and so on.The_Whitehall_Effect

Well the actual evidence is rather disappointing … a long trail of very expensive taxpayer-funded public service improvement failures.

And for an up-to-date list of some of the “eye-wateringly”expensive public sector improvement train-wrecks just read The Whitehall Effect.

But lurid stories of public service improvement failures do not attract precious votes … so they are not aired and shared … and when they are exposed our tax-funded politicians show their true skills and real potential.

Rather than answering the questions they filter, distort and amplify the questions and fire them at each other.  And then fall over each other avoiding the finger-of-blame and at the same time create the next deceptively-plausible election manifesto.  Their food source is votes so they have to tickle the voters to cough them up. And they are consummate masters of that art.

Politicians sell dreams and serve disappointment.

So when the-most-plausible with the most votes earn the right to wield the ignition keys for the engine of our national economy they deflect future blame by seeking the guidance of experts. And the only place they can realistically look is into the private sector who, in manufacturing anyway, have done a much better job of understanding what their customers need and designing their processes to deliver it. On-time, first-time and every-time.

Politicians have learned to be wary of the advice of academics – they need something more pragmatic and proven.  And just look at the remarkable rise of the manufacturing phoenix of Jaguar-Land-Rover (JLR) from the politically embarrassing ashes of the British car industry. And just look at Amazon to see what information technology can deliver!

So the way forward is blindingly obvious … combine manufacturing methods with information technology and build a dumb-robot manned production-line for delivering low-cost public services via a cloud-based website and an outsourced mega-call-centre manned by standard-script-following low-paid operatives.

But here we hit a bit of a snag.

Designing a process to deliver a manufactured product for a profit is not the same as designing a system to deliver a service to the public.  Not by a long chalk.  Public services are an example of what is now known as a complex adaptive system (CAS).

And if we attempt to apply the mechanistic profit-focussed management mantras of “economy of scale” and “division of labour” and “standardisation of work” to the messy real-world of public service then we actually achieve precisely the opposite of what we intended. And the growing evidence is embarrassingly clear.

We all want safer, smoother, better, and more affordable public services … but that is not what we are experiencing.

Our voted-in politicians have unwittingly commissioned complicated non-adaptive systems that ensure we collectively fail.

And we collectively voted the politicians into power and we are collectively failing to hold them to account.

So the ball is squarely in our court.

Below is a short video that illustrates what happens when politicians and civil servants attempt complex system design. It is called the “Save the NHS Game” and it was created by a surgeon who also happens to be a system designer.  The design purpose of the game is to raise awareness. The fundamental design flaw in this example is “financial fragmentation” which is the the use of specific budgets for each part of the system together with a generic, enforced, incremental cost-reduction policy (the shrinking budget).  See for yourself what happens …

In health care we are in the improvement business and to do that we start with a diagnosis … not a dream or a decision.

We study before we plan, and we plan before we do.

And we have one eye on the problem and one eye on the intended outcome … a healthier patient.  And we often frame improvement in the negative as a ‘we do not want a not sicker patient’ … physically or psychologically. Primum non nocere.  First do no harm.

And 99.9% of the time we do our best given the constraints of the system context that the voted-in politicians have created for us; and that their loyal civil servants have imposed on us.

Politicians are not designers … that is not their role.  Their part is to create and sell realistic dreams in return for votes.

Civil servants are not designers … that is not their role.  Their part is to enact the policy that the vote-seeking politicians cook up.

Doctors are not designers … that is not their role.  Their part is to make the best possible clinical decisions that will direct actions that lead, as quickly as possible, to healthier and happier patients.

So who is doing the complex adaptive system design?  Whose role is that?

And here we expose a gap.  No one.  For the simple reason that no one is trained to … so no one is tasked to.

But there is a group of people who are perfectly placed to create the context for developing this system design capability … the commissioners, the executive boards and the senior managers of our public services.

So that is where we might reasonably start … by inviting our leaders to learn about the science of complex adaptive system improvement-by-design.

And there are now quite a few people who can now teach this science … they are the ones who have done it and can demonstrate and describe their portfolios of successful and sustained public service improvement projects.

Would you vote for that?

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Learning Loops

campfire_burning_150_wht_174[Beep Beep] Bob’s phone reminded him that it was time for the remote coaching session with Leslie, one of the CHIPs (community of healthcare improvement science practitioners). He flipped open his laptop and logged in. Leslie was already there.

<Leslie> Hi Bob.  I hope you had a good Xmas.

<Bob> Thank you Leslie. Yes, I did. I was about to ask the same question.

<Leslie> Not so good here I am afraid to say. The whole urgent care system is in meltdown. The hospital is gridlocked, the 4-hour target performance has crashed like the Stock Market on Black Wednesday, emergency admissions have spilled over into the Day Surgery Unit, hundreds of operations have been cancelled, waiting lists are spiralling upwards and the fragile 18-week performance ceiling has been smashed. It is chaos. Dangerous chaos.

<Bob> Oh dear. It sounds as if the butterfly has flapped its wings. Do you remember seeing this pattern of behaviour before?

<Leslie> Sadly yes. When I saw you demonstrate the Save the NHS Game.  This is exactly the chaos I created when I attempted to solve the 4-hour target problem, and the chaos I have seen every doctor, manager and executive create when they do too. We seem to be the root cause!

<Bob> Please do not be too hard on yourself Leslie. I am no different. I had to realise that I was contributing to the chaos I was complaining about, by complaining about it. Paradoxically not complaining about it made no difference. My error was one of omission. I was not learning. I was stuck in a self-justifying delusional blame-bubble of my own making. My humility and curiosity disabled by my disappointment, frustration and anxiety. My inner chimp was running the show!

<Leslie> Wow! That is just how everyone is feeling and behaving. Including me. So how did you escape from the blame-bubble?

<Bob> Well first of all I haven’t completely escaped. I just spend less time there. It is always possible to get sucked back in. The way out started to appear when I installed a “learning loop”.

<Leslie> A what? Is that  like a hearing loop for the partially deaf?

<Bob> Ha! Yes! A very apt metaphor.  Yes, just like that. Very good. I will borrow that if I may.

<Leslie> So what did your learning loop consist of?

<Bob> A journal.  I started a journal. I invested a few minutes each day reflecting and writing it down. The first entries were short and rather “ranty”. I cannot possibly share them in public. It is too embarrassing. But it was therapeutic and over time the anger subsided and a quieter, calmer inner voice could be heard. The voice of curiosity. It was asking one question over and over again. “How?” … not “Why?”.

<Leslie> Like “How did I get myself into this state?“

<Bob> Exactly so.  And also “How come I cannot get myself out of this mess?“

<Leslie> And what happened next?

<Bob> I started to take more notice of things that I had discounted before. Apparently insignificant things that I discovered had profound implications. Like the “butterflies wing” effect … I discovered that small changes can have big effects.  I also learned to tune in to specific feelings because they were my warning signals.

<Leslie> Niggles you mean?

<Bob> Yes. Niggles are flashes of negative emotion that signal a design flaw. They are usually followed by an untested assumption, an invalid conclusion, an unwise decision and a counter-productive action. It all happens unconsciously and very fast so we are only aware of the final action – the MR ANGRY reply to the email that we stupidly broadcast via the Reply All button!

<Leslie> So you learned to tune into the niggle to avoid the chain reaction that led to hitting the Red Button.

<Bob> Sort of. What actually happened is that the passion unleashed by the niggle got redirected into a more constructive channel – via my Curiosity Centre to power up the Improvement Engine. It was a bit rusty! It had not been used for a long while.

<Leslie> And once the “engine” was running it sucked in niggles that were now a source of fuel! You started harvesting them using the 4N Chart! So what was the output?

<Bob> Purposeful, focused, constructive, rational actions. Not random, destructive, emotional explosions.

<Leslie> Constructive actions such as?

<Bob> Well designing and building the FISH course is one, and this ISP programme is another.

<Leslie> More learning loops!

<Bob> Yup.

<Leslie> OK. So I can see that a private journal can help an individual to build their own learning loop. How does that work with groups? We do not all need to design and build a FISH-equivalent surely!

<Bob> No indeed. What we do is we share stories. We gather together in small groups around camp fires and we share what we are learning … as we are learning it. We contribute our perspective to the collective awareness … and we all gain from everyone’s learning. We learn and teach together.

<Leslie> So the stories are about what we are learning, not what we achieved with that learning.

<Bob> Well put! The “how” we achieved it is more valuable knowledge than “what” we achieved. The “how” is the process, the “what” is just the product. And the “how” we failed to achieve is even more valuable.

<Leslie> Wow! So are you saying that the chaos we are experiencing is the expected effect of not installing enough learning loops! A system-wide error of omission.

<Bob> I would say that is a reasonable diagnosis.

<Leslie> So a rational and reasonable course of treatment becomes clear.  I am on the case!

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SFQP

SFQPThe flavour of the week has been “chaos”.  Again!

Chaos dissipates energy faster than calm so chaotic behaviour is a symptom of an inefficient design.

And we would like to improve our design to restore a state of ‘calm efficiency’.

Chaos is a flow phenomenon … but that is not where the improvement by design process starts.  There is a step before that … Safety.

Safety First
If a design is unsafe it generates harm.  So we do not want to improve the smooth efficiency of the harm generator … that will only produce more harm!  First we must consider if our system is safe enough.

Despite what many claim, our healthcare systems are actually very safe.  For sure there are embarrassing exceptions and we can always improve safety further, but we actually have quite a safe design.

It is not a very efficient design though.  There is a lot of checking and correcting which uses up time and resources … but it helps to ensure safety is good enough for now.

Having done the safety sanity check we can move on to Flow.

Flow Second
Flow comes before quality because it is impossible to deliver a high quality experience in a chaotic system.  First we need to calm any chaos.  Or rather we need to diagnose the root causes of the chaotic behaviour and do some flow re-design to restore the calm.

Chaos is funny stuff.  It does not behave intuitively.  Time is always a factor.  The butterflies wing effect is ever present.  Small causes can have big effects, both good and bad.  Big causes can have no effect.  Causes can be synergistic and they can be antagonistic.  The whole is not the sum of the parts.  This confusing and counter-intuitive behaviour is called “non linear” and we are all rubbish at getting a mental handle on it.  Our brains did not evolve that way.

The good news is that when chaos reigns it is usually possible to calm it with a small number of carefully placed, carefully timed, carefully designed, synergistic, design “tweaks”.

The problem is that when we do what intuitively feels “right” we can too easily make poor improvement decisions that lead to ineffective actions.  The chaos either does not go away or it gets worse.  So, we have learned from our ineptitude to just put up with the chaos and to accept the inefficiency, the high cost-of-chaos.

To calm the chaos we have to learn how to use the tools designed to do that.  And they do exist.

Quality
Safety and Flow represent the “absolute” half of the SFQP cycle.  Harm is an absolute metric. We can devise absolute definitions and count harmful events.  Mortality.  Mistakes.  Hospital  acquired infections.  That sort of stuff.

Flow is absolute too in the sense that the Laws of Physics determine what happens, and they are absolute too. And non-negotiable.

Quality is relative.  It is the ratio of experience and expectation and both of these are subjective but that is not the point.  The point is that it is a ratio and that makes it a relative metric.  My expectation influences my perception of quality, as does what I experience.  And this has important implications.  For example we can reduce disappointment by lowering expectation; or we can reduce disappointment by improving experience.  Lowering expectation is the easier option because to do that we only have to don the “black hat” and paint a grisly picture of a worst case scenario.  Some call it “informed consent”; I call it “abdication of empathy” and “fear-mongering”.

Variable quality can  come from variable experience, variable expectation or both.  So, to reduce quality variation we can focus on either input to the ratio; and the easiest is expectation.  Setting a realistic expectation just requires measuring experience retrospectively and sharing it prospectively.  Not satisfaction mind you – Experience. Satisfaction surveys are largely meaningless as an improvement tool because just setting a lower expectation will improve satisfaction!

And this is why quality follows flow … because if flow is chaotic then expectation becomes a lottery, and quality does too.  The chaotic behaviour of the St.Elsewhere’s® A&E Department that we saw last week implies that we cannot set any other expectation than “It might be OK or it might be Not OK … we cannot predict. So fingers crossed.”  It is a quality lottery!

But with calm and efficient flow we experience less variation and with that we can set a reasonable expectation.  Quality becomes predictable-within-limits.

Productivity
Productivity is also a relative concept.  It is the ratio of what we get out of the system divided by what we put in.  Revenue divided by expense for example.

And it does not actually emerge last.  As soon as safety, flow or quality improve then they will have an immediate impact on productivity.  Work gets easier.  The cost of harm, chaos and disappointment will fall (and they are surprisingly large costs!).

The reason that productivity-by-design comes last is because we are talking about focussed productivity improvement-by-design.  Better value for money.  And that requires a specific design focus.  And it comes last because we need some head-space and some life-time to learn and do good system design.

And SFQP is a cycle so after doing the Productivity improvement we go back to Safety and ask “How can we make our design even safer and even simpler?” And so on, round and round the SFQP loop.

Do no harm, restore the calm, delight for all, and costs will fall.

And if you would like a full-size copy of the SFQP cycle diagram to use and share just click here.

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Magnum Chaos

Magnum_ChaosThe title of this alter piece by Lorenzo Lotto is Magnum Chaos. It was painted in the first half of the 16th Century.

Chaos was the Greek name for the primeval state of existence from which everything that has order was created. Similar concepts exist in all ancient mythologies.

The sudden appearance of order from chaos is the subject of much debate and current astronomical science refers to it as the Big Bang … which is the sense that this 500 year old image captures.  Except that it appears to have happened bout 13.5 thousand million years ago.

So it is surprising to learn that the Science of Chaos did not really get going until about 50 years ago – shortly after the digital computer was developed.

The timing is no co-incidence.  The theoretical roots of chaos had been known for much longer – since Isaac Newton formulated the concept of gravity. About 200 years ago it became the “Three-Body Problem”. The motion of the Earth, Moon and Sun is a three-body gravitational problem.

And in 1887, mathematicians Ernst Bruns and Henri Poincaré showed that there is no general analytical solution for the three-body problem given by algebraic expressions and integrals. The motion of three bodies is generally non-repeating, except in special cases. No simple equation describes it.

The implication of this is that the only way to solve this sort of problem is by grunt-work, empirically, with thousands of millions of small calculations.  And in 1887 the technology was not available to do this.

So when the high-speed transistorised digital computer appeared in the 1960’s it became possible to revisit this old niggle … and the nature of chaos became much better understood.  The modern legacy of this pioneering work is the surprising accuracy that we can now predict the weather – at least over the short term – using powerful digital computers running chaotic system simulation models. Weather is a chaotic flow system.

So given the knowledge that exists about the nature of flow in naturally chaotic systems … it is surprising that not much of this understanding has diffused into the design of man-made systems; such as healthcare.

It has probably not escaped most people’s attention that the NHS is suffering yet another “winter crisis” … despite the fact that the NHS budget has doubled over the last 15 years.

If we can predict the weather, but not control it, then why cannot we avoid the annual NHS crisis – which is a much simpler system that we can influence?

StElsewhere_Fail
The chart above shows the actual behaviour of a healthcare system – a medium sized hospital that we shall call St.Elsewhere’s®.  It could be called St.Anywhere’s.  The performance metric that is being plotted over time is the % of patients who arrive each day in the A&E department and who are there for more than 4 hours. The infamous 4-hour A&E target.  The time-span on the horizontal axis is just over 5 years – and the data has been segmented by financial year.

The behaviour of this system over time is not random.  It is chaotic.

There are repeating but non-identical cyclical patterns in the data … for example the first half of the year (April to September) is “better” than the second half. And this cyclical pattern appears to be changing as time passes.

The thin blue line is the arbitrary ‘target’.  And it does require a statistical expert to conclude that this system has never come close to achieving the ‘target’.  The system design is not capable of achieving it … so beating the system with a stick is not going to help. It amounts to the Basil Fawlty tactic of beating the broken-down car with a tree branch!

The system needs to be re-designed in order to achieve the requirement of consistently less than a 5% failure rate on the 4-hour A&E target. Exhortation is ineffective.

And this is not a local problem … it is a systemic one … BBC News

To re-design a system to achieve improved performance we first need to understand why the current design is not demonstrating the behaviour we want. Guessing is not design. It is guess-work. Generating a hypothesis is not design. It is guess-work too.

Design requires understanding.

A common misunderstanding is that the primary cause of deteriorating A&E performance is increasing demand. Reality does not support this rhetoric.

StElsewhere_DemandThis system behaviour chart (SBC) shows the A&E daily demand for the same period segmented by financial year. Over time there has indeed been an increase in the average demand, but that association does not prove causality.  If increasing demand caused performance failure we would expect to see matching cyclical patterns on both charts. But it is rather obvious that there is little relation between the two charts – the periods of highest demand do not correlate with the periods of highest failure. If anything there is a negative correlation – there is actually less demand in the second half of the financial year compared with the first.

So there must be more to it than just the average A&E demand.  Could there be a chicken-and-egg problem here? Higher breach rates leading to lower demand? Word gets round about a poor quality service!  What about the weather?  What about the effect of day-length? What about holidays? What about annual budgets?

What is uncomfortably obvious is that the chaotic behaviour has been going on for a long time. That is because it is an inherent part of the design.  We created it because we designed the NHS.

One surprising lesson that Chaos Theory teaches us is that chaos is predictable.  A system can be designed to behave chaotically … and rather easily too. It does not required a complicated design – a mechanically simple system can behave chaotically – a hinged pendulum for example.

So if we can deliberately design a system to behave chaotically then surely we can understand what design features are critical to delivering chaos and what are not. And with that insight might we then examine the design of man-made systems that we do not want to behave chaotically … such as our healthcare system?

And when we do that we discover something rather uncomfortable – that our healthcare system has been nearly perfectly designed to generate chaotic behaviour.  That may not have been the intention but it is the outcome.

So how did we get ourselves into this mess … and how do we get ourselves out of it?

To understand chaotic flow behaviour we need to consider two effects: the first is called a destabilising effect, the other is a stabilising effect.

The golden rule of chaos is that if the destabilising effect dominates then we get bumpy behaviour, if the stabilizing effect dominates then we get smooth flow.

So to eliminate the chaos all we need to do is to adjust the balance of these two effects … increase the stabilisers and reduce the destabilisers.

And because of the counter-intuitive nature of non-linear flow systems, only a small change in this balance can have a big effect: it can flip us from stable to chaotic, and it can also flip us back.

The trick is knowing how to tweak the design to create the flip.  Tweak at the wrong place or wrong time and nothing improves … as our chart above illustrates.

We need chaotic-flow-diagnostic and anti-chaotic-flow-design capability … and that is clearly lacking … because if it were present we would not be having this conversation.

And that capability exists … it is called Improvement Science. We just need to learn it.

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Guess-work or Grunt-work?

back_and_forth_questions_150_wht_8159Improvement 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.

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People first or Process first?

stick_figure_balance_mind_heart_150_wht_9344A 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.

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Catalyst

everyone_has_an_idea_300_wht_12709[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.

Atul_GawandeThe 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).

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Righteous Indignation

NHS_Legal_CostsThis 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.

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Counter-Productivity

coffee_table_talk_PA_150_wht_6082The Webex icon bounced up and down on Bob’s task bar signalling that Leslie had just joined the weekly ISP coaching session.

<Leslie> Hi Bob. I have been so busy this week that I have not had time to consider a topic to explore.

<Bob> No problem Leslie, I have shelf full of topics we have not touched yet.  So shall we talk about counter-productivity?

<Leslie> Don’t you mean productivity … the fourth dimension of system improvement.

<Bob>They are related of course but we will approach the issue of productivity from a different angle. Rather like we did with safety. To improve safety we considered at the causes of un-safety and focussed our efforts there.

<Leslie> Ah yes, I see.  So to improve productivity we look at the causes of un-productivity … in other words counter-productive beliefs and behaviours that are manifest as system design flaws.

<Bob> Exactly. So remind me what the definition of a productivity metric is from your FISH course.

<Leslie> Productivity is the ratio of a stream metric and a stage metric.  Value-for-Money for example.

<Bob> Good.  So counter-productivity is also a ratio of a stream and a stage metric.

<Leslie> Um, I’m not sure I quite get that. Can you explain a bit more.

<Bob> OK. To explore deeper we need to be clear about how each metric relates to our intended outcome.  Remember in safety-by-design we count the number and severity of risks and harm because  as harm is going up then safety is going down.  So harm is an un-safety stream metric.

<Leslie> Ah! Yes I see.  So if we look at cycle-time, which is a stage metric; as cycle-time increases, the activity falls and productivity falls. So cycle-time is actually a counter-productivity metric.

<Bob>Excellent. You are getting the hang of the concept of counter-productivity.

<Leslie> And we need to be careful because productivity is a ratio so the numerator and denominator metrics work in opposite ways: increasing the magnitude of the numerator is equivalent to decreasing the magnitude of the denominator – the ratio increases.

<Bob> Indeed, there are many hazards with ratios as we have explored before. So let is consider a real and rather useful example.  Let us look at Little’s Law from the perspective of counter-productivity. Remind me of the definition of Little’s Law for a single step system.

<Leslie> Little’s Law is a mathematically proven law of flow physics which states that the average lead-time is the product of the average work-in-progress and the average cycle-time.

LT = WIP * CT

<Bob> Good and I am pleased to see that you have used cycle-time. We are considering a single stream, single stage, single step system.

<Leslie> Yes, I avoided using the unqualified term ‘activity’. I have learned that lesson the hard way too!

<Bob> So how do the terms in Little’s Law relate to streams, stages and systems?

<Leslie> Lead-time is a stream metric, cycle-time is a stage metric and work-in-progress is a …. h’mm. What it is? A stream metric or a stage metric?

<Bob>Or?

<Leslie>A system metric?  WIP is a system metric!

<Bob> Good. So now re-arrange Little’s Law as a productivity formula.

<Leslie> Work-in-Progress equals lead-time divided by cycle-time

WIP = LT / CT

<Bob> So is WIP a productivity or a counter-productivity metric?

<Leslie> H’mmm …. I will need to work this through logically and step-by-step. I do not trust my intuition on this flow stuff.

Increasing cycle-time is counter-productive because it implies activity is falling while costs are not.

But cycle-time is on the bottom of the ratio so it’s effect reverses.

So if lead-time stays the same and cycle-time increases then because it is on the bottom of the ratio that implies a more productive design. And at the same time work in progress must be falling. Urrgh! This is hurting my head.

<Bob> Good, keep going … you are nearly there.

<Leslie> So a falling WIP is a sign of increasing productivity.

<Bob> Good … and that implies?

<Leslie> WIP is a counter-productivity system metric!

<Bob> Well done. Your logic is flawless.

<Leslie> So that  is why we focus on WIP so much!  Whatever causes WIP to increase is counter-productive!

Ahhhh …. that makes complete sense.

Lo-WIP  designs are more productive than Hi-WIP designs.

<Bob> Bravo!  And translating this into financial metrics … it is because a big queue of waiting work incurs costs. Storage cost, maintenance cost, processing cost and so on. So WIP is a liability. It is not an asset!

<Leslie> But doesn’t that imply treating work-in-progress as an asset on the financial balance sheet is counter-productive?

<Bob> It does indeed.

<Leslie> Oh dear! That revelation is going to upset a lot of people in the accounting department!

<Bob> The painful reality is that  the Laws of Flow Physics are completely indifferent to what any of us believe or do not believe.

<Leslie> Wow!  I like this concept of counter-productivity … it really helps to expose some of our invalid assumptions that invisibly block improvement!

<Bob> So here is a question to ponder.  Is zero WIP desirable or even possible?

<Leslie> H’mmm.  I will have to think about that.  I know you would not have asked the question for no reason.

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Metamorphosis

butterfly_flying_around_465Some animals undergo a remarkable transformation on their journey to becoming an adult.

This metamorphosis is most obvious with a butterfly: the caterpillar enters the stage and a butterfly emerges.

The capabilities and behaviours of these development stages are very different.  A baby caterpillar crawls and feeds on leaves;  an adult butterfly flies and feeds on nectar.

There are many similarities to the transformation of an organisation from chaotic to calm; from depressed to enthused; and from struggling to flying.

It is the metamorphosis of individuals within organisations that drives the system change – the transformation from inept sceptics to capable advocates.

metamorphosis_1The journey starts with the tiny, hungry, baby caterpillar emerging from the egg.

This like a curious new sceptic emerging from denial and tentatively engaging the the process of learning. Usually triggered by seeing or hearing of a significant and sustained success that disproves their ‘impossibility hypothesis’.

metamorphosis_2A caterpillar is an eating machine. As it grows it sheds its skin and becomes larger. It also changes its appearance and eventually its behaviour.

Our curious improvement sceptic is devouring new information and is visibly growing in knowledge, understanding and confidence. 

metamorphosis_3When the caterpillar sheds the last skin a new form emerges. A pupa. It has a different appearance and behaviour. It is now stationary and it does not move or eat.

This is the contemplative sceptic who appears to have become dormant but is not … they are planning to change. This stage is very variable: it may be minutes or years.

metamorphosis_5Inside the pupa the solid body of the caterpillar is converted to ‘cellular soup’ and the cells are reassembled into a completely new structure called an adult butterfly.

Our healthy sceptic is dissolving their self-limiting beliefs and restructuring their mental model. It is stage of apparent confusion and success is not guaranteed.

metamorphosis_7And suddenly the adult butterfly emerges: fully formed but not yet able to fly. Its wings are not yet ready – they need to be inflated, to dry and be flexed.

So it is with our newly hatched improvement practitioner. They need to pause, prepare, and practice before they feel safe to fly solo.  They start small but are thinking big.

metamorphosis_8After a short rest the new wings are fully expanded and able to lift the butterfly aloft to explore the new opportunities that await. A whole new and exciting world full of flowers and nectar.

Our improvement practitioner can also feel when they are ready to explore. And then they fly – right first time.

An active improvement practitioner will inspire others to emerge, and many of those will hatch into improvement caterpillars who will busily munch on the new knowledge and grow in understanding and confidence. Then it goes quiet and, as if by magic, a new generation of improvement butterflies appear. And they continue to spread the word and the knowledge.

That is how Improvement Science grows and spreads – by metamorphosis.

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Seeing and Believing

Flow_Science_Works[Beep] It was time again for the weekly Webex coaching session. Bob dialled into the teleconference to find Leslie already there … and very excited.

<Leslie> Hi Bob, I am so excited. I cannot wait to tell you about what has happened this week.

<Bob> Hi Leslie. You really do sound excited. I cannot wait to hear.

<Leslie> Well, let us go back a bit in the story.  You remember that I was really struggling to convince the teams I am working with to actually make changes.  I kept getting the ‘Yes … but‘ reaction from the sceptics.  It was as if they were more comfortable with complaining.

<Bob> That is the normal situation. We are all very able to delude ourselves that what we have is all we can expect.

<Leslie> Well, I listened to what you said and I asked them to work through what they predicted could happen if they did nothing.  Their healthy scepticism then worked to build their conviction that doing nothing was a very dangerous choice.

<Bob> OK. And I am guessing that insight was not enough.

<Leslie> Correct.  So then I shared some examples of what others had achieved and how they had done it, and I started to see some curiosity building, but no engagement still.  So I kept going, sharing stories of ‘what’, and ‘how’.  And eventually I got an email saying “We have thought about what you said about a one day experiment and we are prepared to give that a try“.

<Bob> Excellent. How long ago was that?

<Leslie> Three months. And I confess that I was part of the delay.  I was so surprised that they said ‘OK‘ that I was not ready to follow on.

<Bob> OK. It sounds like you did not really believe it was possible either. So what did you do next?

<Leslie> Well I knew for sure that we would only get one chance.  If the experiment failed then it would be Game Over. So I needed to know before the change what the effect would be.  I needed to be able to predict it accurately. I also needed to feel reassured enough to take the leap of faith.

<Bob> Very good, so did you use some of your ISP-2 skills?

<Leslie> Yes! And it was a bit of a struggle because doing it in theory is one thing; doing it in reality is a lot messier.

<Bob> So what did you focus on?

<Leslie> The top niggle of course!  At St Elsewhere® we have a call-centre that provides out-of-office-hours telephone advice and guidance – and it is especially busy at weekends.  We are required to answer all calls quickly, which we do, and then we categorise them into ‘urgent’  and ‘non-urgent’ and pass them on to the specialists.  They call the clients back and provide expert advice and guidance for their specific problem.

<Bob>So you do not use standard scripts?

<Leslie> No, that does not work. The variety of the problems we have to solve is too wide. And the specialist has to come to a decision quite quickly … solve the problem over the phone, arrange a visit to an out of hours clinic, or to dispatch a mobile specialist to the client immediately.

<Bob> OK. So what was the top niggle?

<Leslie> We have contractual performance specifications we have to meet for the maximum waiting time for our specialists to call clients back; and we were not meeting them.  That implied that we were at risk of losing the contract and that meant loss of revenue and jobs.

<Bob> So doing nothing was not an option.

<Leslie> Correct. And asking for more resources was not either … the contract was a fixed price one. We got it because we offered the lowest price. If we employed more staff we would go out of business.  It was a rock-and-a-hard-place problem.

<Bob> OK.  So if this was ranked as your top niggle then you must have had a solution in mind.

<Leslie> I had a diagnosis.  The Vitals Chart© showed that we already had enough resources to do the work. The performance failure was caused by a scheduling policy – one that we created – our intuitively-obvious policy.

<Bob> Ah ha! So you suggested doing something that felt counter-intuitive.

<Leslie> Yes. And that generated all the ‘Yes .. but‘  discussion.

<Bob> OK. Do you have the Vitals Chart© to hand? Can you send me the Wait-Time run chart?

<Leslie> Yes, I expected you would ask for that … here it is.

StE_CallCentre_Before<Bob> OK. So I am looking at the run chart of waiting time for the call backs for one Saturday, and it is in call arrival order, and the blue line is the maximum allowed waiting time is that correct?

<Leslie>Yup. Can you see the diagnosis?

<Bob> Yes. This chart shows the classic pattern of ‘prioritycarveoutosis’.  The upper border is the ‘non-urgents’ and the lower group are the ‘urgents’ … the queue jumpers.

<Leslie> Spot on.  It is the rising tide of non-urgent calls that spill over the specification limit.  And when I shared this chart the immediate reaction was ‘Well that proves we need more capacity!‘

<Bob> And the WIP chart did not support that assertion.

<Leslie> Correct. It showed we had enough total flow-capacity already.

<Bob> So you suggested a change in the scheduling policy would solve the problem without costing any money.

<Leslie> Yes. And the reaction to that was ‘That is impossible. We are already working flat out. We need more capacity because to work quicker will mean cutting corners and it is unsafe to cut-corners‘.

<Bob> So how did you get around that invalid but widely held belief?

<Leslie> I used one of the FISH techniques. I got a few of them to play a table top game where we simulated a much simpler process and demonstrated the same waiting time pattern on a hand-drawn run chart.

<Bob> Excellent.  Did that get you to the ‘OK, we will give it a go for one day‘ decision.

<Leslie>Yes. But then I had to come up with a new design and I had test it so I know it would work.

<Bob> Because that was a step too far for them. And It sounds like you achieved that.

<Leslie> Yes.  It was tough though because I knew I had to prove to myself I could do it. If I had asked you I know what you would have said – ‘I know you can do this‘.  And last Saturday we ran the ‘experiment’. I was pacing up and down like an expectant parent!

<Bob> I expect rather like the ESA team who have just landed Rosetta’s little probe-child on an asteroid travelling at 38,000 miles per hour, billions of miles from Earth after a 10 year journey through deep space!  Totally inspiring stuff!

<Leslie> Yes. And that is why I am so excited because OUR DESIGN WORKED!  Exactly as predicted.

<Bob> Three cheers for you!  You have experienced that wonderful feeling when you see the effect of improvement-by-design with your own eyes. When that happens then you really believe what opportunities become possible.

<Leslie> So I want to show you the ‘after’ chart …

StE_CallCentre_After

<Bob> Wow!  That is a spectacular result! The activity looks very similar, and other than a ‘blip’ between 15:00 and 19:00 the prioritycarveoutosis has gone. The spikes have assignable causes I assume?

<Leslie> Spot on again!  The activity was actually well above average for a Saturday.  The subjective feedback was that the new design felt calm and under-control. The chaos had evaporated.  The performance was easily achieved and everyone was very positive about the whole experience.  The sceptics were generous enough to say it had gone better than they expected.  And yes, I am now working through the ‘spikes’ and excluding them … but only once I have a root cause that explains them.

<Bob> Well done Leslie! I sense that you now believe what is possible whereas before you just hoped it would be.

<Leslie> Yes! And the most important thing to me is that we did it ourselves. Which means improvement-by-design can be learned. It is not obvious, it feels counter-intuitive, so it is not easy … but it works.

<Bob> Yes. That is the most important message. And you have now earned your ISP Certificate of Competency.

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World Class Improvement

figure_weight_lift_success_150_wht_12334Improvement Science is exactly like a sport: it requires training and practice to do well.

Elite athletes do not just turn up and try hard … they have invested thousands of hours of blood, sweat and tears to even be eligible to turn up.

And their preparation is not random or haphazard … it is structured and scientific.  Sport is a science.

So it is well worth using this sporting metaphor to outline some critical-to-success factors … because the statistics on improvement projects is not good.

It is said that over 70% of improvement projects fail to achieve their goals.

figure_weight_lift_fail_anim_150_wht_12338That is a shocking statistic. It is like saying 70% of runners who start a race do not finish!

And in sport if you try something that you are not ready for then you can seriously damage your health. So just turning up and trying hard is not enough. In can actually be counter-productive!

Common sense tells us that those fail to complete the course were not well enough prepared to undertake the challenge.  We know that only one person can win a race … but everyone else could finish it.  And to start and finish a tough race is a major achievement for each participant.

It is actually their primary goal.

Being good enough to when we need to is the actual objective;  being the best-on-the-day is a bonus. Not winning is not a failure. Not finishing is.

So how does an Improvement Scientist prepare for the improvement challenge?

First, we need enough intrinsic motivation to get out of bed and to invest the required time and effort.  We must have enough passion to get started and to keep going.  We must be disappointed enough with past failures to commit to preventing future ones.  We must be angry enough with the present problems to take action … not on the people … but on the problem. We must be fearful enough of the future consequences of inaction to force us to act. And we need to be excited enough by the prospect of success to reach out for it.

Second, we need some technical training.  How to improve the behaviour and performance of  a complex adaptive system is not obvious. If it were we would all know how to do it. Many of the most effective designs appear counter-intuitive at first sight.  Many of our present assumptions and beliefs are actually a barrier to change.  So we need help and guidance in identifying what assumptions we need to unlearn.

stick_woman_toe_touch_150_wht_12023Third, We need to practice what we have learned until it becomes second-nature, and almost effortless. Deceptively easy to the untrained eye.  And we develop our capability incrementally by taking on challenges of graded difficulty. Each new challenge is a bit of a stretch, and we build on what we have achieved already.  There are no short cuts or quick fixes if we want to be capable and confident at taking on BIG improvement challenges.

And we need a coach as well as a trainer.

The role of a trainer is to teach us technical skills and to develop our physical strength, stamina and resilience.

The role of the coach is to help us develop our emotional stamina and resilience.  We need to learn to manage our minds as much as our muscles. We all harbour self-defeating attitudes, beliefs and behaviours. Bad habits that trip us up and cause us to slip, fall and bruise our egos and confidence.

The psychological development is actually more important than the physical … because if is our self-defeating “can’t do” and “yes but” inner voices that sap our intrinsic motivation and prevent us crawling out of bed and getting started.

bicycle_racer_150_wht_5606The UK Cycling Team that won multiple goal medals in the 2012 Olympics did not just train hard and have the latest and best equipment. They also had the support of a very special type of coach. Dr Steve Peters … who showed them how to manage their inner Chimp … and how to develop their mental strength in synergy with their technical ability. The result was a multi-gold medal winning engine.

And we can all benefit from this wisdom just by reading The Chimp Paradox by Dr Steve Peters.

So when we take on a difficult improvement challenge, one that many have tried and failed to overcome, and if we want world class performance as the outcome … then we need to learn the hard-won lessons of the extreme athletes … and we need to model their behaviour.

Because that is what it takes to become an Improvement Science Practitioner.

Our goal is to finish each improvement race that we start … to deliver a significant and sustained improvement.  We do not need to be perfect or the best … we just need to start and finish the race.

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Spring the Trap

trapped_in_question_PA_300_wht_3174[Beeeeeep] It was time for the weekly coaching chat.  Bob, a seasoned practitioner of flow science, dialled into the teleconference with Lesley.

<Bob> Good afternoon Lesley, can I suggest a topic today?

<Lesley> Hi Bob. That would be great, and I am sure you have a good reason for suggesting it.

<Bob> I would like to explore the concept of time-traps again because it something that many find confusing. Which is a shame because it is often the key to delivering surprisingly dramatic and rapid improvements; at no cost.

<Lesley> Well doing exactly that is what everyone seems to be clamouring for so it sounds like a good topic to me.  I confess that I am still not confident to teach others about time-traps.

<Bob> OK. Let us start there. Can you describe what happens when you try to teach it?

<Lesley> Well, it seems to be when I say that the essence of a time-trap is that the lead time and the flow are independent.  For example, the lead time stays the same even though the flow is changing.  That really seems to confuse people; and me too if I am brutally honest.

<Bob> OK.  Can you share the example that you use?

<Lesley> Well it depends on who I am talking to.  I prefer to use an example that they are familiar with.  If it is a doctor I might use the example of the ward round.  If it is a manager I might use the example of emails or meetings.

<Bob> Assume I am a doctor then – an urgent care physician.

<Lesley> OK.  Let us take it that I have done the 4N Chart and the  top niggle is ‘Frustration because the post-take ward round takes so long that it delays the discharge of patients who then often have to stay an extra night which then fills up the unit with waiting patients and we get blamed for blocking flow from A&E and causing A&E breaches‘.

<Bob> That sounds like a good example. What is the time-trap in that design?

<Lesley> The  post-take ward round.

<Bob> And what justification is usually offered for using that design?

<Lesley> That it is a more efficient use of the expensive doctor’s time if the whole team congregate once a day and work through all the patients admitted over the previous 24 hours.  They review the presentation, results of tests, diagnosis, management plans, response to treatment, decide the next steps and do the paperwork.

<Bob> And why is that a time-trap design?

<Lesley> Because  it does not matter if one patient is admitted or ten, the average lead time from the perspective of the patient is the same – about one day.

<Bob> Correct. So why is the doctor complaining that there are always lots of patients to see?

<Lesley> Because there are. The emergency short stay ward is usually full by the time the post take ward round happens.

<Bob> And how do you present the data that shows the lead time is independent of the flow?

<Lesley> I use a Gantt chart, but the problem I find is that there is so much variation and queue jumping it is not blindingly obvious from the Gantt chart that there is a time-trap. There is so much else clouding the picture.

<Bob>Is that where the ‘but I do not understand‘ conversation starts?

<Lesley> Yes. And that is where I get stuck too.

<Bob> OK.  The issue here is that a Gantt chart is not the ideal visualisation tool when there are lots of crossed-streams, frequently changing priorities, and many other sources of variation.  The Gantt chart gets ‘messy’.   The trick here is to use a Vitals Chart – and you can derive that from the same data you used for the Gantt chart.

<Lesley> You are right about the Gantt chart getting messy. I have seen massive wall-sized Gantt charts that are veritable works-of-art and that have taken hours to create; and everyone standing looking at it and saying ‘Wow! That is an impressive piece of work.  So what does it tell us? How does it help?‘

<Bob> Yes, I have experienced that too. I think what happens is that those who do the foundation training and discover the Gantt chart then try to use it to solve every flow problem – and in their enthusiasm they discount any warning advice.  Desperation drives over-inflated expectation which is often the pre-cursor to disappointment, and then disillusionment.  The Nerve Curve again.

<Lesley> But a Vitals Chart is an HCSE level technique and you said that we do not need to put everyone through HCSE training.

<Bob>That is correct. I am advocating an HCSE-in-training using a Vitals Chart to explain the concept of a time-trap so that everyone understands it well enough to see the flaw in the design.

<Lesley> Ah ha!  Yes, I see.  So what is my next step?

<Bob> I will let you answer that.

<Lesley> Um, let me think.

The outcome I want is everyone understands the concept of a time-trap well enough to feel comfortable with trying a time-trap-free design because they can see the benefits for them.

And to get that depth of understanding I need to design a table top exercise that starts with a time-trap design and generates raw data that we can use to build both a Gantt chart and the Vitals Chart; so I can point out and explain the characteristic finger-print of a time trap.

And then we can ‘test’ an alternative time-trap-free design and generate the prognostic Gantt and Vitals Chart and compare with the baseline diagnostic charts to reveal the improvement.

<Bob> That sounds like a good plan to me.  And if you do that, and your team apply it to a real improvement exercise, and you see the improvement and you share the story, then that will earn you a coveted HCSE Certificate of Competency.

<Lesley>Ah ha! Now I understand the reason you suggested this topic!  I am on the case!

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Fit-4-Purpose

F4P_PillsWe all want a healthcare system that is fit for purpose.

One which can deliver diagnosis, treatment and prognosis where it is needed, when it is needed, with empathy and at an affordable cost.

One that achieves intended outcomes without unintended harm – either physical or psychological.

We want safety, delivery, quality and affordability … all at the same time.

And we know that there are always constraints we need to work within.

There are constraints set by the Laws of the Universe – physical constraints.

These are absolute,  eternal and are not negotiable.

Dr Who’s fantastical tardis is fictional. We cannot distort space, or travel in time, or go faster than light – well not with our current knowledge.

There are also constraints set by the Laws of the Land – legal constraints.

Legal constraints are rigid but they are also adjustable.  Laws evolve over time, and they are arbitrary. We design them. We choose them. And we change them when they are no longer fit for purpose.

The third limit is often seen as the financial constraint. We are required to live within our means. There is no eternal font of  limitless funds to draw from.  We all share a planet that has finite natural resources  – and ‘grow’ in one part implies ‘shrink’ in another.  The Laws of the Universe are not negotiable. Mass, momentum and energy are conserved.

The fourth constraint is perceived to be the most difficult yet, paradoxically, is the one that we have most influence over.

It is the cultural constraint.

The collective, continuously evolving, unwritten rules of socially acceptable behaviour.

Improvement requires challenging our unconscious assumptions, our beliefs and our habits – and selectively updating those that are no longer fit-4-purpose.

To learn we first need to expose the gaps in our knowledge and then to fill them.

We need to test our hot rhetoric against cold reality – and when the fog of disillusionment forms we must rip up and rewrite what we have exposed to be old rubbish.

We need to examine our habits with forensic detachment and we need to ‘unlearn’ the ones that are limiting our effectiveness, and replace them with new habits that better leverage our capabilities.

And all of that is tough to do. Life is tough. Living is tough. Learning is tough. Leading is tough. But it energising too.

Having a model-of-effective-leadership to aspire to and a peer-group for mutual respect and support is a critical piece of the jigsaw.

It is not possible to improve a system alone. No matter how smart we are, how committed we are, or how hard we work.  A system can only be improved by the system itself. It is a collective and a collaborative challenge.

So with all that in mind let us sketch a blueprint for a leader of systemic cultural improvement.

What values, beliefs, attitudes, knowledge, skills and behaviours would be on our ‘must have’ list?

What hard evidence of effectiveness would we ask for? What facts, figures and feedback?

And with our check-list in hand would we feel confident to spot an ‘effective leader of systemic cultural improvement’ if we came across one?

This is a tough design assignment because it requires the benefit of  hindsight to identify the critical-to-success factors: our ‘must have and must do’ and ‘must not have and must not do’ lists.

H’mmmm ….

So let us take a more pragmatic and empirical approach. Let us ask …

“Are there any real examples of significant and sustained healthcare system improvement that are relevant to our specific context?”

And if we can find even just one Black Swan then we can ask …

Q1. What specifically was the significant and sustained improvement?
Q2. How specifically was the improvement achieved?
Q3. When exactly did the process start?
Q4. Who specifically led the system improvement?

And if we do this exercise for the NHS we discover some interesting things.

First let us look for exemplars … and let us start using some official material – the Monitor website (http://www.monitor.gov.uk) for example … and let us pick out ‘Foundation Trusts’ because they are the ones who are entrusted to run their systems with a greater degree of capability and autonomy.

And what we discover is a league table where those FTs that are OK are called ‘green’ and those that are Not OK are coloured ‘red’.  And there are some that are ‘under review’ so we will call them ‘amber’.

The criteria for deciding this RAG rating are embedded in a large balanced scorecard of objective performance metrics linked to a robust legal contract that provides the framework for enforcement.  Safety metrics like standardised mortality ratios, flow metrics like 18-week and 4-hour target yields, quality metrics like the friends-and-family test, and productivity metrics like financial viability.

A quick tally revealed 106 FTs in the green, 10 in the amber and 27 in the red.

But this is not much help with our quest for exemplars because it is not designed to point us to who has improved the most, it only points to who is failing the most!  The league table is a name-and-shame motivation-destroying cultural-missile fuelled by DRATs (delusional ratios and arbitrary targets) and armed with legal teeth.  A projection of the current top-down, Theory-X, burn-the-toast-then-scrape-it management-of-mediocrity paradigm. Oh dear!

However,  despite these drawbacks we could make better use of this data.  We could look at the ‘reds’ and specifically at their styles of cultural leadership and compare with a random sample of all the ‘greens’ and their models for success. We could draw out the differences and correlate with outcomes: red, amber or green.

That could offer us some insight and could give us the head start with our blueprint and check-list.

It would be a time-consuming and expensive piece of work and we do not want to wait that long. So what other avenues are there we can explore now and at no cost?

Well there are unofficial sources of information … the ‘grapevine’ … the stuff that people actually talk about.

What examples of effective improvement leadership in the NHS are people talking about?

Well a little blue bird tweeted one in my ear this week …

And specifically they are talking about a leader who has learned to walk-the-improvement-walk and is now talking-the-improvement-walk: and that is Sir David Dalton, the CEO of Salford Royal.

Here is a copy of the slides from Sir David’s recent lecture at the Kings Fund … and it is interesting to compare and contrast it with the style of NHS Leadership that led up to the Mid Staffordshire Failure, and to the Francis Report, and to the Keogh Report and to the Berwick Report.

Chalk and cheese!

So if you are an NHS employee would you rather work as part of an NHS Trust where the leaders walk-DD’s-walk and talk-DD’s-talk?

And if you are an NHS customer would you prefer that the leaders of your local NHS Trust walked Sir David’s walk too?

We are the system … we get the leaders that we deserve … we make the  choice … so we need to choose wisely … and we need to make our collective voice heard.

Actions speak louder than words.  Walk works better than talk.  We must be the change we want to see.

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A Little Law and Order

teamwork_puzzle_build_PA_150_wht_2341[Bing bong]. The sound heralded Lesley logging on to the weekly Webex coaching session with Bob, an experienced Improvement Science Practitioner.

<Bob> Good afternoon Lesley.  How has your week been and what topic shall we explore today?

<Lesley> Hi Bob. Well in a nutshell, the bit of the system that I have control over feels like a fragile oasis of calm in a perpetual desert of chaos.  It is hard work keeping the oasis clear of the toxic sand that blows in!

<Bob> A compelling metaphor. I can just picture it.  Maintaining order amidst chaos requires energy. So what would you like to talk about?

<Lesley> Well, I have a small shoal of FISHees who I am guiding  through the foundation shallows and they are getting stuck on Little’s Law.  I confess I am not very good at explaining it and that suggests to me that I do not really understand it well enough either.

<Bob> OK. So shall we link those two theme – chaos and Little’s Law?

<Lesley> That sounds like an excellent plan!

<Bob> OK. So let us refresh the foundation knowledge. What is Little’s Law?

<Lesley>It is a fundamental Law of process physics that relates flow, with lead time and work in progress.

<Bob> Good. And specifically?

<Lesley> Average lead time is equal to the average flow multiplied by the average work in progress.

<Bob>Yes. And what are the units of flow in your equation?

<Lesley> Ah yes! That is  a trap for the unwary. We need to be clear how we express flow. The usual way is to state it as number of tasks in a defined period of time, such as patients admitted per day.  In Little’s Law the convention is to use the inverse of that which is the average interval between consecutive flow events. This is an unfamiliar way to present flow to most people.

<Bob> Good. And what is the reason that we use the ‘interval between events’ form?

<Leslie> Because it is easier to compare it with two critically important  flow metrics … the takt time and the cycle time.

<Bob> And what is the takt time?

<Leslie> It is the average interval between new tasks arriving … the average demand interval.

<Bob> And the cycle time?

<Leslie> It is the shortest average interval between tasks departing …. and is determined by the design of the flow constraint step.

<Bob> Excellent. And what is the essence of a stable flow design?

<Lesley> That the cycle time is less than the takt time.

<Bob>Why less than? Why not equal to?

<Leslie> Because all realistic systems need some flow resilience to exhibit stable and predictable-within-limits behaviour.

<Bob> Excellent. Now describe the design requirements for creating chronically chaotic system behaviour?

<Leslie> This is a bit trickier to explain. The essence is that for chronically chaotic behaviour to happen then there must be two feedback loops – a destabilising loop and a stabilising loop.  The destabilising loop creates the chaos, the stabilising loop ensures it is chronic.

<Bob> Good … so can you give me an example of a destabilising feedback loop?

<Leslie> A common one that I see is when there is a long delay between detecting a safety risk and the diagnosis, decision and corrective action.  The risks are often transitory so if the corrective action arrives long after the root cause has gone away then it can actually destabilise the process and paradoxically increase the risk of harm.

<Bob> Can you give me an example?

<Leslie>Yes. Suppose a safety risk is exposed by a near miss.  A delay in communicating the niggle and a root cause analysis means that the specific combination of factors that led to the near miss has gone. The holes in the Swiss cheese are not static … they move about in the chaos.  So the action that follows the accumulation of many undiagnosed near misses is usually the non-specific mantra of adding yet another safety-check to the already burgeoning check-list. The longer check-list takes more time to do, and is often repeated many times, so the whole flow slows down, queues grow bigger, waiting times get longer and as pressure comes from the delivery targets corners start being cut, and new near misses start to occur; on top of the other ones. So more checks are added and so on.

<Bob> An excellent example! And what is the outcome?

<Leslie> Chronic chaos which is more dangerous, more disordered and more expensive. Lose lose lose.

<Bob> And how do the people feel who work in the system?

<Leslie> Chronically naffed off! Angry. Demotivated. Cynical.

<Bob>And those feelings are the key symptoms.  Niggles are not only symptoms of poor process design, they are also symptoms of a much deeper problem: a violation of values.

<Leslie> I get the first bit about poor design; but what is that second bit about values?

<Bob>  We all have a set of values that we learned when we were very young and that have bee shaped by life experience.  They are our source of emotional energy, and our guiding lights in an uncertain world. Our internal unconscious check-list.  So when one of our values is violated we know because we feel angry. How that anger is directed varies from person to person … some internalise it and some externalise it.

<Leslie> OK. That explains the commonest emotion that people report when they feel a niggle … frustration which is the same as anger.

<Bob>Yes.  And we reveal our values by uncovering the specific root causes of our niggles.  For example if I value ‘Hard Work’ then I will be niggled by laziness. If you value ‘Experimentation’ then you may be niggled by ‘Rigid Rules’.  If someone else values ‘Safety’ then they may value ‘Rigid Rules’ and be niggled by ‘Innovation’ which they interpret as risky.

<Leslie> Ahhhh! Yes, I see.  This explains why there is so much impassioned discussion when we do a 4N Chart! But if this behaviour is so innate then it must be impossible to resolve!

<Bob> Understanding  how our values motivate us actually helps a lot because we are naturally attracted to others who share the same values – because we have learned that it reduces conflict and stress and improves our chance of survival. We are tribal and tribes share the same values.

<Leslie> Is that why different  departments appear to have different cultures and behaviours and why they fight each other?

<Bob> It is one factor in the Silo Wars that are a characteristic of some large organisations.  But Silo Wars are not inevitable.

<Leslie> So how are they avoided?

<Bob> By everyone knowing what common purpose of the organisation is and by being clear about what values are aligned with that purpose.

<Leslie> So in the healthcare context one purpose is avoidance of harm … primum non nocere … so ‘safety’ is a core value.  Which implies anything that is felt to be unsafe generates niggles and well-intended but potentially self-destructive negative behaviour.

<Bob> Indeed so, as you described very well.

<Leslie> So how does all this link to Little’s Law?

<Bob>Let us go back to the foundation knowledge. What are the four interdependent dimensions of system improvement?

<Leslie> Safety, Flow, Quality and Productivity.

<Bob> And one measure of  productivity is profit.  So organisations that have only short term profit as their primary goal are at risk of making poor long term safety, flow and quality decisions.

<Leslie> And flow is the key dimension – because profit is just  the difference between two cash flows: income and expenses.

<Bob> Exactly. One way or another it all comes down to flow … and Little’s Law is a fundamental Law of flow physics. So if you want all the other outcomes … without the emotionally painful disorder and chaos … then you cannot avoid learning to use Little’s Law.

<Leslie> Wow!  That is a profound insight.  I will need to lie down in a darkened room and meditate on that!

<Bob> An oasis of calm is the perfect place to pause, rest and reflect.

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Feel the Fear

monster_in_closet_150_wht_14500We spend a lot of time in a state of anxiety and fear. It is part and parcel of life because there are many real threats that we need to detect and avoid.

For our own safety and survival.

Unfortunately there are also many imagined threats that feel just as real and just as terrifying.

In these cases it is our fear that does the damage because it paralyses our decision making and triggers our ‘fright’ then ‘fight’ or ‘flight’ reaction.

Fear is not bad … the emotional energy it releases can be channelled into change and improvement. Just as anger can.

So we need to be able to distinguish the real fears from the imaginary ones. And we need effective strategies to defuse the imaginary ones.  Because until we do that we will find it very difficult to listen, learn, experiment, change and improve.

So let us grasp the nettle and talk about a dozen universal fears …

Fear of dying before one’s time.
Fear of having one’s basic identity questioned.
Fear of poverty or loss of one’s livelihood.
Fear of being denied one’s fundamental rights and liberties.

Fear of being unjustly accused of wrongdoing.
Fear of public humiliation.
Fear of being unjustly seen as lacking character.
Fear of being discovered as inauthentic – a fraud.

Fear of radical change.
Fear of feedback.
Fear of failure.
Fear of the unknown.

Notice that some of these fears are much ‘deeper’ than others … this list is approximately in depth order. Some relate to ‘self’; some relate to ‘others’ and all are inter-related to some degree. Fear of failure links to fear of humiliation and to fear of loss-of-livelihood.

Of these the four that are closest to the surface are the easiest to tackle … fear of radical change, fear of feedback, fear of failure, and fear of the unknown.  These are the Four Fears that block personal improvement.

Fear of the unknown is the easiest to defuse. We just open the door and look … from an emotionally safe distance so that we can run away if our worst fears are realised … which does not happen when the fear is imagined.

This is an effective strategy for defusing the emotionally and socially damaging effects of self-generated phobias.

And we find overcoming fear-of-the-unknown exhilarating … that is how theme parks and roller-coaster rides work.

First we open our eyes, we look, we see, we observe, we reflect, we learn and we convert the unknown to the unfamiliar and then to the familiar. We may not conquer our fear completely … there may be some reasonable residual anxiety … but we have learned to contain it and to control it. We have made friends with our inner Chimp. We climb aboard the roller coaster that is called ‘life’.

Fear of failure is next.  We defuse this by learning how to fail safely so that we can learn-by-doing and by that means we reduce the risk of future failures. We make frequent small safe failures in order to learn how to avoid the rare big unsafe ones!

Many people approach improvement from an academic angle. They sit on the fence. They are the reflector-theorists. And this may because they are too fearful-of-failing to learn the how-by-doing. So they are unable to demonstrate the how and their fear becomes the fear-of-fraud and the fear-of-humiliation. They are blocked from developing their pragmatist/activist capability by their self-generated fear-of-failure.

So we start small, we stay focussed, we stay inside our circle of control, and we create a safe zone where we can learn how to fail safely – first in private and later in public.

One of the most inspiring behaviours of an effective leader is the courage to learn in public and to make small failures that demonstrate their humility and humanity.

Those who insist on ‘perfect’ leaders are guaranteed to be disappointed.

And one thing that we all fail repeatedly is to ask for, to give and to receive effective feedback. This links to the deeper fear-of-humiliation.

And it is relatively easy to defuse this fear-of-feedback too … we just need a framework to support us until we find our feet and our confidence.

The key to effective feedback is to make it non-judgemental.

And that can only be done by developing our ability to step back and out of the Drama Triangle and to cultivate an I’m OK- You’re OK  mindset.

The mindset of mutual respect. Self-respect and Other-respect.

And remember that Other-respect does not imply trust, alignment, agreement, or even liking.

Sworn enemies can respect each other while at the same time not trusting, liking or agreeing with each other.

Judgement-free feedback (JFF) is a very effective technique … both for defusing fear and for developing mutual respect.

And from that foundation radical change becomes possible, even inevitable.

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Wacky Language

wacky_languageAll innovative ideas are inevitably associated with new language.

Familiar words used in an unfamiliar context so that the language sounds ‘wacky’ to those in the current paradigm.

Improvement science is no different.

A problem arises when familiar words are used in a new context and therefore with a different meaning. Confusion.

So we try to avoid this cognitive confusion by inventing new words, or by using foreign words that are ‘correct’ but unfamiliar.

This use of novel and foreign language exposes us to another danger: the evolution of a clique of self-appointed experts who speak the new and ‘wacky’ language.

This self-appointed expert clique can actually hinder change because it can result yet another us-and-them division.  Another tribe. More discussion. More confusion. Less improvement.

So it is important for an effective facilitator-of-improvement to define any new language using the language of the current paradigm.  This can be achieved by sharing examples of new concepts and their language in familiar contexts and with familiar words, because we learn what words mean from their use-in-context.

For example:

The word ‘capacity’ is familiar and we all know what we think it means.  So when we link it to another familiar word, ‘demand’, then we feel comfortable that we understand what the phrase ‘demand-and-capacity’ means.

But do we?

The act of recognising a word is a use of memory or knowledge. Understanding what a word means requires more … it requires knowing the context in which the word is used.  It means understanding the concept that the word is a label for.

To a practitioner of flow science the word ‘capacity’ is confusing – because it is too fuzzy.  There are many different forms of capacity: flow-capacity, space-capacity, time-capacity, and so on.  Each has a different unit and they are not interchangeable. So the unqualified term ‘capacity’ will trigger the question:

What sort of capacity are you referring to?

[And if that is not the reaction then you may be talking to someone who has little understanding of flow science].

Then there are the foreign words that are used as new labels for old concepts.

Lean zealots seem particularly fond of peppering their monologues with Japanese words that are meaningless to anyone else but other Lean zealots.  Words like muda and muri and mura which are labels for important and useful flow science concepts … but the foreign name gives no clue as to what that essential concept is!

[And for a bit of harmless sport ask a Lean zealot to explain what these three words actually mean but only using  language that you understand. If they cannot to your satisfaction then you have exposed the niggle. And if they can then it is worth asking ‘What is the added value of the foreign language?’]

And for those who are curious to know the essential concepts that these four-letter M words refer to:

muda means ‘waste’ and refers to the effects of poor process design in terms of the extra time (and cost) required for the process to achieve its intended purpose.  A linked concept is a ‘niggle’ which is the negative emotional effect of a poor process design.

muri means ‘overburdening’ and can be illustrated  with an example.  Suppose you work in a system where there is always a big backlog of work waiting to be done … a large queue of patients in the waiting room … a big heap of notes on the trolley. That ‘burden’ generates stress and leads to other risky behaviours such as rushing, corner-cutting, deflection and overspill. It is also an outcome of poor process design, so  is avoidable.

mura means variation or uncertainty. Again an example helps. Suppose we are running an emergency service then, by definition, a we have no idea what medical problem the next patient that comes through the door will present us with. It could be trivial or life-threatening. That is unplanned and expected variation and is part of the what we need our service to be designed to handle.  Suppose when we arrive for our shift that we have no idea how many staff will be available to do the work because people phone in sick at the last minute and there is no resilience on the staffing capacity.  Our day could be calm-and-capable (and rewarding) or chaotic-and-incapable (and unrewarding).  It is the stress of not knowing that creates the emotional and cultural damage, and is the expected outcome of incompetent process design. And is avoidable.

And finally we come to words that are not foreign but are not very familiar either.

Words like praxis.

This sounds like ‘practice’ but is not spelt the same. So is the the same?

And it sounds like a medical condition called dyspraxia which means:  poor coordination of movement.

And when we look up praxis in an English dictionary we discover that one definition is:

the practice and practical side of a profession or field of study, as opposed to theory.

Ah ah! So praxis is a label for the the concept of ‘how to’ … and someone who has this ‘know how’ is called a practitioner.  That makes sense.

On deeper reflection we might then describe our poor collective process design capability as dyspraxic or uncoordinated. That feels about right too.

An improvement science practitioner (ISP) is someone who knows the science of improvement; and can demonstrate their know-how in practice; and can explain the principles that underpin their praxis using the language of the learner. Without any wacky language.

So if we want to diagnose and treat our organisational dyspraxia;

… and if we want smooth and efficient services (i.e. elimination of chaos and reduction of cost);

… and if we want to learn this know-how,  practice or praxis;

… then we could study the Foundations of Improvement Science in Healthcare (FISH);

… and we could seek the wisdom of  the growing Community of Healthcare Improvement Practitioners (CHIPs).

FISH & CHIPs … a new use for a familiar phrase?

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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).

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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.

Sisyphus_Cartoon

<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 …

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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.

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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.

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See-and-Share

stick_figure_liking_it_150_wht_9170Common-sense tells us that to achieve system-wide improvement we need to grasp the “culture nettle”.

Most of us believe that culture drives attitudes; and attitudes drive behaviour; and behaviour drives improvement.

Therefore to get improvement we must start with culture.

And that requires effective leadership.

So our unspoken assumptions about how leaders motivate our behaviour seem rather important to understand.

In 1960 a book was published with the  title “The Human Side of Enterprise” which went right to the heart of this issue.   The author was Doug McGregor who was a social scientist and his explanation of why improvement appears to be so difficult in large organisations was a paradigm shift in thinking.  His book inspired many leaders to try a different approach – and they discovered that it worked and that enterprise-wide transformation followed.  The organisations that these early-adopters led evolved into commercial successes and more enjoyable places to work.

The new leaders learned to create the context for change – not to dictate the content.

Since then social scientists have disproved many other ‘common sense’ beliefs by applying a rigorous scientific approach and using robust evidence.

They have busted the culture-drives-change myth …. the evidence shows that it is the other way around … change drives culture.

And what changes first is behaviour.

We are social  animals …. most of us are much more likely to change our behaviour if we see other people doing the same.  We do not like being too different.

As we speak there is a new behaviour spreading – having a bucket of cold water tipped over your head as part of a challenge to raise money for charity.

This craze has a positive purpose … feeling good about helping others through donating money to a worthwhile cause … but most of us need a nudge to get us to do it.

Seeing well-known public figures having iced-water dumped on them on a picture or video shared through multiple, parallel, social media channels is a powerful cultural signal that says “This new behaviour is OK”.

Exhortation and threats are largely ineffective – fear will move people – it will scatter them, not align them. Shaming-and-blaming into behaving differently is largely ineffective too – it generates short-term anger and long-term resentment.

This is what Doug McGregor highlighted over half a century ago … and his message is timeless.

“.. the research evidence indicates quite clearly that skillful and sensitive membership behaviour is the real clue to effective group operation“.

Appreciating this critical piece of evidence opens a new door to system-wide improvement … one that we can all walk through:  Sharing improvement stories.

Sharing stories of actions that others have done and the benefits they achieved as a result; and also sharing stories of things that we ourselves have done and achieved.

Stories of small changes that delivered big benefits for others and for ourselves.  Win-win-wins. Stories of things that took little time and little effort to do because they fell inside our circles of control.

See-and-Share is an example of skillful and sensitive membership behaviour.

Effective leaders are necessary … yes … they are needed to create the context for change. It is we members who create and share the content.

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Learning in Style

PARTImprovement implies learning – new experiences, new insights, new models and new ways of doing things.

So understanding the process of learning is core to the science of improvement.

What many people do not fully appreciate is that we differ in the way we prefer to learn.  These are habitual behaviours that we have acquired.

The diagram shows one model – the Honey and Mumford model that evolved from an earlier model described by Kolb.

One interesting feature of this diagram is the two dimensions – Perception and Processing which are essentially the same as the two core dimensions in the Myers-Briggs Type Index.

What the diagram above does not show so well is that the process of learning is a cycle – the clockwise direction in this diagram – Pragmatist then Activist then Reflector then Theorist and back to Pragmatist.

This is the PART sequence.  And it can start at any point … ARTP, RTPA, TPAR.

We all use all of these learning styles – but we have a preference for some more than others – our preferred learning styles are our learning comfort zones.

The large observational studies conducted in the 1980’s using the PART model revealed that most people have moderate to strong preferences for only one or two of these styles. Less than 20% have a preference for three and very few feel equally comfortable with all four.

The commonest patterns are illustrated by the left and right sides of the diagram: the Pragmatist-Activist combination and the Reflector-Theorist combination.

It is not that one is better than the other … all four are synergistic and an effective and efficient learning process requires being comfortable with using all four in a continuous sequence.

Imagine this as a wheel – an imbalance between the four parts represents a distorted wheel. So when this learning wheel ‘turns’  it delivers an emotionally bumpy ‘ride’.  Past experience of being pushed through this pain-and-gain process will tend to inhibit or even block learning completely.

So to get a more comfortable learning journey we first need to balance our PART wheel – and that implies knowing what our preferred styles are and then developing the learning styles that we use least to build our competence and confidence with them.  And that is possible because these are learned habits. With guidance, focus and practice we can all strengthen our less favoured learning ‘muscles’.

Those with a preference for planning-and-doing would focus on developing their reflection and then their abstraction skills. For example by monitoring the effects of their actions in reality and using that evidence to challenge their underlying assumptions and to generate new ‘theories’ for pragmatic experimentation. Actively seeking balanced feedback and reflecting on it is one way to do that.

Those with a preference for studying-and-abstracting would focus on developing their design and then their delivery skills and become more comfortable with experimenting to test their rhetoric against reality. Actively seeking opportunities to learn-by-doing is one way.

And by creating the context for individuals to become more productive self-learners we can see how learning organisations will follow naturally. And that is what we need to deliver system-wide improvement at scale and pace.

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The 85% Optimum Occupancy Myth

egg_face_spooked_400_wht_13421There seems to be a belief among some people that the “optimum” average bed occupancy for a hospital is around 85%.

More than that risks running out of beds and admissions being blocked, 4 hour breaches appearing and patients being put at risk. Less than that is inefficient use of expensive resources. They claim there is a ‘magic sweet spot’ that we should aim for.

Unfortunately, this 85% optimum occupancy belief is a myth.

So, first we need to dispel it, then we need to understand where it came from, and then we are ready to learn how to actually prevent queues, delays, disappointment, avoidable harm and financial non-viability.

Disproving this myth is surprisingly easy.   A simple thought experiment is enough.

Suppose we have a policy where  we keep patients in hospital until someone needs their bed, then we discharge the patient with the longest length of stay and admit the new one into the still warm bed – like a baton pass.  There would be no patients turned away – 0% breaches.  And all our the beds would always be full – 100% occupancy. Perfection!

And it does not matter if the number of admissions arriving per day is varying – as it will.

And it does not matter if the length of stay is varying from patient to patient – as it will.

We have disproved the hypothesis that a maximum 85% average occupancy is required to achieve 0% breaches.

The source of this specific myth appears to be a paper published in the British Medical Journal in 1999 called “Dynamics of bed use in accommodating emergency admissions: stochastic simulation model“

So it appears that this myth was cooked up by academic health economists using a computer model.

And then amateur queue theory zealots jump on the band-wagon to defend this meaningless mantra and create a smoke-screen by bamboozling the mathematical muggles with tales of Poisson processes and Erlang equations.

And they are sort-of correct … the theoretical behaviour of the “ideal” stochastic demand process was described by Poisson and the equations that describe the theoretical behaviour were described by Agner Krarup Erlang.  Over 100 years ago before we had computers.

BUT …

The academics and amateurs conveniently omit one minor, but annoying,  fact … that real world systems have people in them … and people are irrational … and people cook up policies that ride roughshod over the mathematics, the statistics and the simplistic, stochastic mathematical and computer models.

And when creative people start meddling then just about anything can happen!

So what went wrong here?

One problem is that the academic hefalumps unwittingly stumbled into a whole minefield of pragmatic process design traps.

Here are just some of them …

1. Occupancy is a ratio – it is a meaningless number without its context – the flow parameters.

2. Using linear, stochastic models is dangerous – they ignore the non-linear complex system behaviours (chaos to you and me).

3. Occupancy relates to space-capacity and says nothing about the flow-capacity or the space-capacity and flow-capacity scheduling.

4. Space-capacity utilisation (i.e. occupancy) and systemic operational efficiency are not equivalent.

5. Queue theory is a simplification of reality that is needed to make the mathematics manageable.

6. Ignoring the fact that our real systems are both complex and adaptive implies that blind application of basic queue theory rhetoric is dangerous.

And if we recognise and avoid these traps and we re-examine the problem a little more pragmatically then we discover something very  useful:

That the maximum space capacity requirement (the number of beds needed to avoid breaches) is actually easily predictable.

It does not need a black-magic-box full of scary queue theory equations or rather complicated stochastic simulation models to do this … all we need is our tried-and-trusted tool … a spreadsheet.

And we need something else … some flow science training and some simulation model design discipline.

When we do that we discover something else …. that the expected average occupancy is not 85%  … or 65%, or 99%, or 95%.

There is no one-size-fits-all optimum occupancy number.

And as we explore further we discover that:

The expected average occupancy is context dependent.

And when we remember that our real system is adaptive, and it is staffed with well-intended, well-educated, creative people (who may have become rather addicted to reactive fire-fighting),  then we begin to see why the behaviour of real systems seems to defy the predictions of the 85% optimum occupancy myth:

Our hospitals seem to work better-than-predicted at much higher occupancy rates.

And then we realise that we might actually be able to design proactive policies that are better able to manage unpredictable variation; better than the simplistic maximum 85% average occupancy mantra.

And finally another penny drops … average occupancy is an output of the system …. not an input. It is an effect.

And so is average length of stay.

Which implies that setting these output effects as causal inputs to our bed model creates a meaningless, self-fulfilling, self-justifying delusion.

Ooops!

Now our challenge is clear … we need to learn proactive and adaptive flow policy design … and using that understanding we have the potential to deliver zero delays and high productivity at the same time.

And doing that requires a bit more than a spreadsheet … but it is possible.

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Purpose-Process-Pilot-Policy-Police

inspector_searching_around_150_wht_14757When it comes to light that things are not going well a common reaction from the top is to send in more inspectors.

This may give the impression that something decisive is being done but it almost never works … for two reasons.

The first is because it is attempting to treat the symptom and not the cause.

The second is because the inspectors are created in the same paradigm that that created the problem.

That is not so say that inspectors are not required … they are … when the system is working … not when it is failing.

The inspection police actually come last – and just before them comes the Policy that the Police enforce.

Policy comes next to last. Not first.

A rational Policy can only be written once there is proof of  effectiveness … and that requires a Pilot study … in the real world.

A small scale reality check of the rhetoric.

Cooking up Policy and delivery plans based on untested rhetoric from the current paradigm is a recipe for disappointment.

Working backwards we can see that the Pilot needs something to pilot … and that is a new Process; to replace the old process that is failing to deliver.

And any Process needs to be designed to be fit-for-purpose.  Cutting-and-pasting someone else’s design usually does not work. The design process is more important than the design it creates.

So thus brings us to the first essential requirement … the Purpose.

And that is where we very often find a big gap … an error of omission … no clarity or constancy of common Purpose.

And that is where leaders must start. It is their job to clarify and communicate the common Purpose. And if the leaders are not cohesive and the board cannot agree the Purpose then the political cracks will spread through the whole organisation and destabilize it.

And with a Purpose the system and process designers can get to work.

But here we hit another gap. There is virtually no design capability in most organisations.

There is usually lots of delivery capability … but efficiently delivering an ineffective design will amplify the chaos not dissolve it.

So in parallel with clarifying the purpose, the leaders must  endorse the creation of a cohort of process designers.

And from the organisation a cohort of process inspectors … but of a different calibre … inspectors who are able to find the root causes and able to guide the improvement process because they have done this themselves many times before.

And perhaps to draw a line between the future and the past we could give them a different name – Mentors.

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Big Data

database_transferring_data_150_wht_10400The Digital Age is changing the context of everything that we do – and that includes how we use information for improvement.

Historically we have used relatively small, but carefully collected, samples of data and we subjected these to rigorous statistical analysis. Or rather the statisticians did.  Statistics is a dark and mysterious art to most people.

As the digital age ramped up in the 1980’s the data storage, data transmission and data processing power became cheap and plentiful.  The World Wide Web appeared; desktop computers with graphical user interfaces appeared; data warehouses appeared, and very quickly we were all drowning in the data ocean.

Our natural reaction was to centralise but it became quickly obvious that even an army of analysts and statisticians could not keep up.

So our next step was to automate and Business Intelligence was born; along with its beguiling puppy-faced friend, the Performance Dashboard.

The ocean of data could now be boiled down into a dazzling collection of animated histograms, pie-charts, trend-lines, dials and winking indicators. We could slice-and-dice,  we could zoom in-and-out, and we could drill up-and-down until our brains ached.

And none of it has helped very much in making wiser decisions that lead to effective actions that lead to improved outcomes.

Why?

The reason is that the missing link was not a lack of data processing power … it was a lack of an effective data processing paradigm.

The BI systems are rooted in the closed, linear, static, descriptive statistics of the past … trend lines, associations, correlations, p-values and so on.

Real systems are open, non-linear and dynamic; they are eternally co-evolving. Nothing stays still.

And it is real systems that we live in … so we need a new data processing paradigm that suits our current reality.

Some are starting to call this the Big Data Era and it is very different.

  • Business Intelligence uses descriptive statistics and data with high information density to measure things, detect trends etc.;
  • Big Data uses inductive statistics and concepts from non-linear system identification to infer laws (regressions, non-linear relationships, and causal effects) from large data sets to reveal relationships, dependencies and perform predictions of outcomes and behaviours.

And each of us already has a powerful Big Data processor … the 1.3 kg of caveman wet-ware sitting between our ears.

Our brain processes billions of bits of data every second and looks for spatio-temporal relationships to identify patterns, to derive models, to create action options, to predict short-term outcomes and to make wise survival decisions.

The problem is that our Brainy Big Data Processor is easily tricked when we start looking at time-dependent systems … data from multiple simultaneous flows that are interacting dynamically with each other.

It did not evolve to do that … it evolved to help us to survive in the Wild – as individuals.

And it has been very successful … as the burgeoning human population illustrates.

But now we have a new collective survival challenge  and we need new tools … and the out-of-date Business Intelligence Performance Dashboard is just not going to cut the mustard!

Big Data on TED Talks

 

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The Productive Meeting

networking_people_PA_300_wht_1844The engine of improvement is a productive meeting.

Complex adaptive systems (CAS) are those that  learn and change themselves.

The books of ‘rules’ are constantly revised and refreshed as the CAS co-evolves with its environment.

System improvement is the outcome of effective actions.

Effective actions are the outcomes of wise decisions.

Wise decisions are the output of productive meetings.

So the meeting process must be designed to be productive: which means both effective and efficient.

One of the commonest niggles that individuals report is ‘Death by Meeting’.

That alone is enough evidence that our current design for meetings is flawed.

One common error of omission is lack of clarity about the purpose of the meeting.

This cause has two effects:

1. The wrong sort of meeting design is used for the problem(s) under consideration.

A meeting designed for tactical  (how to) planning will not work well for strategic (why to) problems.

2. A mixed bag of problems is dumped into the all-purpose-less meeting.

Mixing up short term tactical and long term strategic problems on a single overburdened agenda is doomed to fail.

Even when the purpose of  a meeting  is clear and agreed it is common to observe an unproductive meeting process.

The process may be unproductive because it is ineffective … there are no wise decisions made and so no effective actions implemented.

Worse even than that … decisions are made that are unwise and the actions that follow lead to unintended negative consequences.

The process may also be unproductive because it is inefficient … it requires too much input to get any output.

Of course we want both an effective and an efficient meeting process … and we need to be aware that effectiveness  comes first.  Designing the meeting process to be a more efficient generator of unwise decisions is not a good idea! The result is an even bigger problem!

So our meeting design focus is ‘How could we make wise decisions as a group?’

But if we knew the answer to that we would probably already be doing it!

So we can ask the same question another way: ‘How do we make unwise decisions as a group?

The second question is easier to answer. We just reflect on our current experience.

Some ways we appear to unintentionally generate unwise decisions are:

a) Ensure we have no clarity of purpose – confusion is a good way to defuse effective feedback.
b) Be selective in who we invite to the meeting – group-think facilitates consensus.
c) Ignore the pragmatic, actual, reality and only use academic, theoretical, rhetoric.
d) Encourage the noisy – quiet people are non-contributors.
e) Engage in manipulative styles of behaviour – people cannot be trusted.
f) Encourage the  sceptics and cynics to critique and cull innovative suggestions.
g) Have a trump card – keep the critical ‘any other business’ to the end – just in case.

If we adopt all these tactics we can create meetings that are ‘lively’, frustrating, inefficient and completely unproductive. That of course protects us from making unwise decisions.

So one approach to designing meetings to be more productive is simply to recognise and challenge the unproductive behaviours – first as individuals and then as groups.

The place to start is within our own circle of influence – with those we trust – and to pledge to each other to consciously monitor for unproductive behaviours and to respectfully challenge them.

These behaviours are so habitual that we are often unaware that we are doing them.

And it feels strange at first but it get easier with practice and when you see the benefits.

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Perfect Storm

lightning_strike_150_wht_5809[Drrrrring Drrrrring]

<Bob> Hi Lesley! How are you today?

<Leslie> Hi Bob.  Really good.  I have just got back from a well earned holiday so I am feeling refreshed and re-energised.

<Bob> That is good to hear.  It has been a bit stormy here over the past few weeks.  Apparently lots of  hot air hitting cold reality and forming a fog of disillusionment and storms of protest.

<Leslie> Is that a metaphor?

<Bob> Yes!  A good one do you think? And it leads us into our topic for this week. Perfect storms.

<Leslie> I am looking forward to it.  Can you be a bit more specific?

<Bob> Sure.  Remember the ISP exercise where I asked you to build a ‘chaos generator’?

<Leslie> I sure do. That was an eye-opener!  I had no idea how easy it is to create chaotic performance in a system – just by making the Flaw of Averages error and adding a pinch of variation. Booom!

<Bob> Good. We are going to use that model to demonstrate another facet of system design.  How to steer out of chaos.

<Leslie> OK – what do I need to do.

<Bob> Start up that model and set the cycle time to 10 minutes with a sigma of 1.5 minutes.

<Leslie> OK.

<Bob> Now set the demand interval to 10 minutes and the sigma of that to 2.0 minutes.

<Leslie> OK. That is what I had before.

<Bob> Set the lead time upper specification limit to 30 minutes. Run that 12 times and record the failure rate.

<Leslie> OK.  That gives a chaotic picture!  All over the place.

<Bob> OK now change just the average of the demand interval.  Start with a value of 8 minutes, run 12 times, and then increase to 8.5 minutes and repeat that up to 12 minutes.

<Leslie> OK. That will repeat the run for 10 minutes. Is that OK.

<Bob> Yes.

<Leslie> OK … it will take me a few minutes to run all these.  Do you want to get a cup of tea while I do that?

<Bob> Good idea.

[5 minutes later]

<Leslie> OK I have done all that – 108 data points. Do I plot that as a run chart?

<Bob> You could.  I suggest plotting as a scattergram.

<Leslie> With the average demand interval on the X axis and the Failure % on the  Y axis?

<Bob> Yes. Exactly so. And just the dots, no lines.

<Leslie> OK. Wow! That is amazing!  Now I see why you get so worked up about the Flaw of Averages!

<Bob> What you are looking at is called a performance curve.  Notice how steep and fuzzy it is. That is called a chaotic transition. The perfect storm.  And when fall into the Flaw of Averages trap we design our systems to be smack in the middle of it.

<Leslie> Yes I see what you are getting at.  And that implies that to calm the chaos we do not need very much resilient flow capacity … and we could probably release that just from a few minor design tweaks.

<Bob> Yup.

<Leslie> That is so cool. I cannot wait to share this with the team. Thanks again Bob.

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Seeing-by-Doing

OneStopBeforeGanttFlow improvement-by-design requires being able to see the flows; and that is trickier than it first appears.

We can see movement very easily.

Seeing flows is not so easy – particularly when they are mixed-up and unsteady.

One of the most useful tools for visualising flow was invented over 100 years ago by Henry Laurence Gantt (1861-1919).

Henry Gantt was a mechanical engineer from Johns Hopkins University and an early associate of Frederick Taylor. Gantt parted ways with Taylor because he disagreed with the philosophy of Taylorism which was that workers should be instructed what to do by managers (=parent-child).  Gantt saw that workers and managers could work together for mutual benefit of themselves and their companies (=adult-adult).  At one point Gantt was invited to streamline the production of munitions for the war effort and his methods were so successful that the Ordinance Department was the most productive department of the armed forces.  Gantt favoured democracy over autocracy and is quoted to have said “Our most serious trouble is incompetence in high places. The manager who has not earned his position and who is immune from responsibility will fail time and again, at the cost of the business and the workman“.

Henry Gantt invented a number of different charts – not just the one used in project management which was actually invented 20 years earlier by Karol Adamieki and re-invented by Gantt. It become popularised when it was used in the Hoover Dam project management; but that was after Gantt’s death in 1919.

The form of Gantt chart above is called a process template chart and it is designed to show the flow of tasks through  a process. Each horizontal line is a task; each vertical column is an interval of time. The colour code in each cell indicates what the task is doing and which resource the task is using during that time interval. Red indicates that the task is waiting. White means that the task is outside the scope of the chart (e.g. not yet arrived or already departed).

The Gantt chart shows two “red wedges”.  A red wedge that is getting wider from top to bottom is the pattern created by a flow constraint.  A red wedge that is getting narrower from top to bottom is the pattern of a policy constraint.  Both are signs of poor scheduling design.

A Gantt chart like this has three primary uses:
1) Diagnosis – understanding how the current flow design is creating the queues and delays.
2) Design – inventing new design options.
3) Prognosis – testing the innovative designs so the ‘fittest’ can be chosen for implementation.

These three steps are encapsulated in the third “M” of 6M Design® – the Model step.

In this example the design flaw was the scheduling policy.  When that was redesigned the outcome was zero-wait performance. No red on the chart at all.  The same number of tasks were completed in the same with the same resources used. Just less waiting. Which means less space is needed to store the queue of waiting work (i.e. none in this case).

That this is even possible comes as a big surprise to most people. It feels counter-intuitive. It is however an easy to demonstrate fact. Our intuition tricks us.

And that reduction in the size of the queue implies a big cost reduction when the work-in-progress is perishable and needs constant attention [such as patients lying on A&E trolleys and in hospital beds].

So what was the cost of re-designing this schedule?

A pinch of humility. A few bits of squared paper and some coloured pens. A couple hours of time. And a one-off investment in learning how to do it.  Peanuts in comparison with the recurring benefit gained.

 

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Competent and Conscious

Conscious_and_CompetentThis week I was made mindful again of a simple yet powerful model that goes a long way to explaining why we find change so difficult.

It is the conscious-competent model.

There are two dimensions which gives four combinations that are illustrated in the diagram.

We all start in the bottom left corner. We do not know what we do not know.  We are ignorant and incompetent and unconscious of the  fact.

Let us call that Blissful Ignorance.

Then suddenly we get a reality check. A shock. A big enough one to start us on the emotional roller coaster ride we call the Nerve Curve.

We become painfully aware of our ignorance (and incompetence). Conscious of it.

That is not a happy place to be and we have a well-developed psychological first line of defence to protect us. It is called Denial.

“That’s a load of rubbish!” we say.

But denial does not change reality and eventually we are reminded. Reality does not go away.

Our next line of defence is to shoot the messenger. We get angry and aggressive.

“Who the **** are you to tell me that I do not know what I am doing!” we say.

Sometimes we are openly aggressive.  More often we use passive aggressive tactics. We resort to below-the-belt behind-the-back corridor-gossip behaviour.

But that does not change reality either.  And we are slowly forced to accept that we need to change. But not yet …

Our next line of defence is to bargain for more time (in the hope that reality will swing back in our favour).

“There may be something in this but I am too busy at the moment … I will look at this  tomorrow/next week/next month/after my holiday/next quarter/next financial year/in my next job/when I retire!” we wheedle.

Our strategy usually does not work – it just wastes time – and while we prevaricate the crisis deepens. Reality is relentless.

Our last line of defence has now been breached and now we sink into depression and despair.

“It is too late. Too difficult for me. I need rescuing. Someone help me!” we wail.

That does not work either. There is no one there. It is up to us. It is sink-or-swim time.

What we actually need now is a crumb of humility.

And with that we can start on the road to Know How. We start by unlearning the old stuff and then we can  replace it with the new stuff.  Step-by-step we climb out of the dark depths of Painful Awareness.

And then we get a BIG SURPRISE.

It is not as difficult as we assumed. And we discover that learning-by-doing is fun. And we find that demonstrating to others what we are learning is by far the most effective way to consolidate our new conscious competence.

And by playing to our strengths, with persistence, with practice and with reality-feedback our new know how capability gradually becomes second nature. Business as usual. The way we do things around here. The culture.

Then, and only then, will the improvement sustain … and spread … and grow.

 

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N-N-N-N Feedback

4NChartOne of the essential components of an adaptive system is effective feedback.

Without feedback we cannot learn – we can only guess and hope.

So the design of our feedback loops is critical-to-success.

Many people do not like getting feedback because they live in a state of fear: fear of criticism. This is a learned behaviour.

Many people do not like giving feedback because they too live in a state of fear: fear of conflict. This is a learned behaviour.

And what is learned can be unlearned; with training, practice and time.

But before we will engage in unlearning our current habit we need to see the new habit that will replace it. The one that will work better for us. The one that is more effective.  The one that will require less effort. The one that is more efficient use of our most precious resource: life-time.

There is an effective and efficient feedback technique called The 4N Chart®.  And I know it works because I have used it and demonstrated to myself and others that  it works. And I have seen others use it and demonstrate to themselves and others that it works too.

The 4N Chart® has two dimensions – Time (Now and Future) and Emotion (Happy and Unhappy).

This gives four combinations each of which is given a label that begins with the letter ‘N’ – Niggles, Nuggets, NoNos and NiceIfs.

The N has a further significance … it reminds us which order to move through the  chart.

We start bottom left with the Niggles.  What is happening now that causes us to feel unhappy. What are these root causes of our niggles? And more importantly, which of these do we have control over?  Knowing that gives us a list of actions that we can do that will have the effect of reducing our niggles. And we can start that immediately because we do not need permission.

Next we move top-left to the Nuggets. What is happening now that causes us to feel happy? What are the root causes of our nuggets? Which of these do we control? We need to recognise these too and to celebrate them.  We need to give ourselves a pat on the back for them because that helps reinforce the habit to keep doing them.

Now we look to the future – and we need to consider two things: what we do not want to feel in the future and what we do want to feel in the future. These are our NoNos and our NiceIfs. It does not matter which order we do this … but  we must consider both.

Many prefer to consider dangers and threats first … that is SAFETY FIRST  thinking and is OK. First Do No Harm. Primum non nocere.

So with the four corners of our 4N Chart® filled in we have a balanced perspective and we can set off on the journey of improvement with confidence. Our 4N Chart® will help us stay on track. And we will update it as we go, as we study, as we plan and as we do things. As we convert NiceIfs into Nuggets and  Niggles into NoNos.

It sounds simple.  It is in theory. It is not quite as easy to do.

It takes practice … particularly the working backwards from the effect (the feeling) to the cause (the facts). This is done step-by-step using Reality as a guide – not our rhetoric. And we must be careful not to make assumptions in lieu of evidence. We must be careful not to jump to unsupported conclusions. That is called pre-judging.  Prejudice.

But when you get the hang of using The 4N Chart® you will be amazed at how much more easily and more quickly you make progress.

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A Bit Of A Shock

egg_face_spooked_400_wht_13421It comes as a bit of a shock to learn that some of our habitual assumptions and actions are worthless.

Improvement implies change. Change requires doing things differently. That requires making different decisions. And that requires innovative thinking. And that requires new knowledge.

We are comfortable with the idea of adding  new knowledge to the vast store we have already accumulated.

We are less comfortable with the idea of removing old knowledge when it has grown out-of-date.

We are shocked when we discover that some of our knowledge is just wrong and it always has been. Since the start of time.

So we need to prepare ourselves for those sorts of shocks. We need to be resilient so that we are not knocked off our feet by them.  We need to practice a different emotional reaction to our habitual fright-flight-or-fight reaction.

We need to cultivate our curiosity.

For example:

It comes as a big shock to many when they learn that it is impossible to determine the cause from an analysis of the observed effect.  Not just difficult. Impossible.

“No Way!”  We shout angrily.  “We do that all the time!”

But do we?

What we do is we observe temporal associations.  We notice that Y happened after X and we conclude that X caused Y.

This is an incorrect conclusion.  We can only conclude from this observation that ‘X may have played a part in causing Y’ but we cannot prove it.

Not by observation alone.

What we can definitely say is that Y did not cause X – because time does not go backwards. At least it does not appear to.

Another thing that does not go backwards is information.

Q: What is 2 + 2?  Four. Easy. There is only one answer. Two numbers become one.

Let us try this in reverse …

Q: What two numbers when added together give 4? Tricky. There are countless answers.  One number cannot become two without adding uncertainty. Guessing.

So when we look at the information coming out of a system – the effects and we attempt to analyse it to reveal the causes we hit a problem. It is impossible.

And learning that is a big shock to people who describe themselves as ‘information analysts’ …. the whole foundation of what they do appears to evaporate.

So we need to outline what we can reasonably do with the retrospective analysis of effect data.

We can look for patterns.

Patterns that point to plausible causes.

Just like patterns of symptoms that point to possible diseases.

But how do we learn what patterns to look for?

Simple. We experiment. We do things and observe what happens immediately afterwards – the immediate effects. We conduct lots and lots of small experiments. And we learn the repeating patterns. “If the context is this and I do that then I always see this effect”.

If we observe a young child learning that is what we see … they are experimenting all the time.  They are curious. They delight in discovery. Novelty is fun. Learning to walk is a game.  Learning to talk is a game.  Learning to be a synergistic partner in a social group is a game.

And that same child-like curiosity is required for effective improvement.

And we know when we are doing improvement right: it feels good. It is fun. Learning is fun.

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A Stab At The Vitals

pirate_flag_anim_150_wht_12881[Drrring Drrring] The phone heralded the start of the weekly ISP mentoring session.

<Bob> Hi Leslie, how are you today?

<Leslie> Hi Bob. To be honest I am not good. I am drowning. Drowning in data!

<Bob> Oh dear! I am sorry to hear that. Can I help? What led up to this?

<Leslie> Well, it was sort of triggered by our last chat and after you opened my eyes to the fact that we habitually throw most of our valuable information away by thresholding, aggregating and normalising.  Then we wonder why we make poor decisions … and then we get frustrated because nothing seems to improve.

<Bob> OK. What happened next?

<Leslie> I phoned our Performance Team and asked for some raw data. Three months worth.

<Bob> And what was their reaction?

<Leslie> They said “OK, here you go!” and sent me a twenty megabyte Excel spreadsheet that clogged my email inbox!  I did manage to unclog it eventually by deleting loads of old junk.  But I could swear that I heard the whole office laughing as they hung up the phone! Maybe I am paranoid?

<Bob> OK. And what happened next?

<Leslie> I started drowning!  The mega-file had a row of data for every patient that has attended A&E for the last three months as I had requested, but there were dozens of columns!  Trying to slice-and-dice it was a nightmare! My computer was smoking and each step took ages for it to complete.  In the end I gave up in frustration.  I now have a lot more respect for the Performance Team I can tell you! They do this for a living?

<Bob> OK.  It sounds like you are ready for a Stab At the Vitals.

<Leslie> What?  That sounds rather piratical!  Are you making fun of my slicing-and-dicing metaphor?

<Bob> No indeed.  I am deadly serious!  Before we leap into the data ocean we need to be able to swim; and we also need a raft that will keep us afloat;  and we need a sail to power our raft; and we need a way to navigate our raft to our desired destination.

<Leslie> OK. I like the nautical metaphor but how does it help?

<Bob> Let me translate. Learning to use system behaviour charts is equivalent to learning the skill of swimming. We have to do that first and practice until we are competent and confident.  Let us call our raft “ISP” – you are already aboard.  The sail you also have already – your Excel software.  The navigation aid is what I refer to as Vitals. So we need to have a “stab at the vitals”.

<Leslie> Do you mean we use a combination of time-series charts, ISP and Excel to create a navigation aid that helps avoid the Depths of Data and the Rocks of DRAT?

<Bob> Exactly.

<Leslie> Can you demonstrate with an example?

<Bob> Sure. Send me some of your data … just the arrival and departure events for one day – a typical one.

<Leslie> OK … give me a minute!  …  It is on its way.  How long will it take for you to analyse it?

<Bob> About 2 seconds. OK, here is your email … um … copy … paste … copy … reply

Vitals_Charts<Leslie> What the ****? That was quick! Let me see what this is … the top left chart is the demand, activity and work-in-progress for each hour; the top right chart is the lead time by patient plotted in discharge order; the table bottom left includes the 4 hour breach rate.  Those I do recognise. What is the chart on the bottom right?

<Bob> It is a histogram of the lead times … and it shows a problem.  Can you see the spike at 225 to 240 minutes?

<Leslie> Is that the fabled Horned Gaussian?

<Bob> Yes.  That is the sign that the 4-hour performance target is distorting the behaviour of the system.  And this is yet another reason why the  Breach Rate is a dangerous management metric. The adaptive reaction it triggers amplifies the variation and fuels the chaos.

<Leslie> Wow! And you did all that in Excel using my data in two seconds?  That must need a whole host of clever macros and code!

<Bob> “Yes” it was done in Excel and “No” it does not need any macros or code.  It is all done using simple formulae.

<Leslie> That is fantastic! Can you send me a copy of your Excel file?

<Bob> Nope.

<Leslie>Whaaaat? Why not? Is this some sort of evil piratical game?

<Bob> Nope. You are going to learn how to do this yourself – you are going to build your own Vitals Chart Generator – because that is the only way to really understand how it works.

<Leslie> Phew! You had me going for a second there! Bring it on! What do I do next?

<Bob> I will send you the step-by-step instructions of how to build, test and use a Vitals Chart Generator.

<Leslie> Thanks Bob. I cannot wait to get started! Weigh anchor and set the sails! Ha’ harrrr me hearties.

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Economy-of-Scale vs Economy-of-Flow

We_Need_Small_HospitalsThis was an interesting headline to see on the front page of a newspaper yesterday!

The Top Man of the NHS is openly challenging the current Centralisation-is-The-Only-Way-Forward Mantra;  and for good reason.

Mass centralisation is poor system design – very poor.

Q: So what is driving the centralisation agenda?

A: Money.

Or to be more precise – rather simplistic thinking about money.

The misguided money logic goes like this:

1. Resources (such as highly trained doctors, nurses and AHPs) cost a lot of money to provide.
[Yes].

2. So we want all these resources to be fully-utilised to get value-for-money.
[No, not all – just the most expensive].

3. So we will gather all the most expensive resources into one place to get the Economy-of-Scale.
[No, not all the most expensive – just the most specialised]

4. And we will suck /push all the work through these super-hubs to keep our expensive specialist resources busy all the time.
[No, what about the growing population of older folks who just need a bit of expert healthcare support, quickly, and close to home?]

This flawed logic confuses two complementary ways to achieve higher system productivity/economy/value-for-money without  sacrificing safety:

Economies of Scale (EoS) and Economies of Flow (EoF).

Of the two the EoF is the more important because by using EoF principles we can increase productivity in huge leaps at almost no cost; and without causing harm and disappointment. EoS are always destructive.

“But that is impossible. You are talking rubbish … because if it were possible we would be doing it!“

It is not impossible and we are doing it … but not at scale and pace in healthcare … and the reason for that is we are not trained in Economy-of-Flow methods.

And those who are trained and who have have experienced the effects of EoF would not do it any other way.

Example:

In a recent EoF exercise an ISP (Improvement Science Practitioner) helped a surgical team to increase their operating theatre productivity by 30% overnight at no cost.  The productivity improvement was measured and sustained for most of the last year. [it did dip a bit when the waiting list evaporated because of the higher throughput, and again after some meddlesome middle management madness was triggered by end-of-financial-year target chasing].  The team achieved the improvement using Economy of Flow principles and by re-designing some historical scheduling policies. The new policies  were less antagonistic. They were designed to line the ducks up and as a result the flow improved.

So the specific issue of  Super Hospitals vs Small Hospitals is actually an Economy of Flow design challenge.

But there is another critical factor to take into account.

Specialisation.

Medicine has become super-specialised for a simple reason: it is believed that to get ‘good enough’ at something you have to have a lot of practice. And to get the practice you have to have high volumes of the same stuff – so you need to specialise and then to sort undifferentiated work into separate ‘speciologist’ streams or sequence the work through separate speciologist stages.

Generalists are relegated to second-class-citizen status; mere tripe-skimmers and sign-posters.

Specialisation is certainly one way to get ‘good enough’ at doing something … but it is not the only way.

Another way to learn the key-essentials from someone who already knows (and can teach) and then to continuously improve using feedback on what works and what does not – feedback from everywhere.

This second approach is actually a much more effective and efficient way to develop expertise – but we have not been taught this way.  We have only learned the scrape-the-burned-toast-by-suck-and-see method.

We need to experience another way.

We need to experience rapid acquisition of expertise!

And being able to gain expertise quickly means that we can become expert generalists.

There is good evidence that the broader our skill-set the more resilient we are to change, and the more innovative we are when faced with novel challenges.

In the Navy of the 1800’s sailors were “Jacks of All Trades and Master of One” because if only one person knew how to navigate and they got shot or died of scurvy the whole ship was doomed.  Survival required resilience and that meant multi-skilled teams who were good enough at everything to keep the ship afloat – literally.

Specialisation has another big drawback – it is very expensive and on many dimensions. Not just Finance.

Example:

Suppose we have six-step process and we have specialised to the point where an individual can only do one step to the required level of performance (safety/flow/quality/productivity).  The minimum number of people we need is six and the process only flows when we have all six people. Our minimum costs are high and they do not scale with flow.

If any one of the six are not there then the whole process stops. There is no flow.  So queues build up and smooth flow is sacrificed.

Out system behaves in an unstable and chaotic feast-or-famine manner and rapidly shifting priorities create what is technically called ‘thrashing’.

And the special-six do not like the constant battering.

And the special-six have the power to individually hold the whole system to ransom – they do not even need to agree.

And then we aggravate the problem by paying them the high salary that it is independent of how much they collectively achieve.

We now have the perfect recipe for a bigger problem!  A bunch of grumpy, highly-paid specialists who blame each other for the chaos and who incessantly clamour for ‘more resources’ at every step.

This is not financially viable and so creates the drive for economy-of-scale thinking in which to get us ‘flow resilience’ we need more than one specialist at each of the six steps so that if one is on holiday or off sick then the process can still flow.  Let us call these tribes of ‘speciologists’ there own names and budgets, and now we need to put all these departments somewhere – so we will need a big hospital to fit them in – along with the queues of waiting work that they need.

Now we make an even bigger design blunder.  We assume the ‘efficiency’ of our system is the same as the average utilisation of all the departments – so we trim budgets until everyone’s utilisation is high; and we suck any-old work in to ensure there is always something to do to keep everyone busy.

And in so doing we sacrifice all our Economy of Flow opportunities and we then scratch our heads and wonder why our total costs and queues are escalating,  safety and quality are falling, the chaos continues, and our tribes of highly-paid specialists are as grumpy as ever they were!   It must be an impossible-to-solve problem!

Now contrast that with having a pool of generalists – all of whom are multi-skilled and can do any of the six steps to the required level of expertise.  A pool of generalists is a much more resilient-flow design.

And the key phrase here is ‘to the required level of expertise‘.

That is how to achieve Economy-of-Flow on a small scale without compromising either safety or quality.

Yes, there is still a need for a super-level of expertise to tackle the small number of complex problems – but that expertise is better delivered as a collective-expertise to an individual problem-focused process.  That is a completely different design.

Designing and delivering a system that that can achieve the synergy of the pool-of-generalists and team-of-specialists model requires addressing a key error of omission first: we are not trained how to do this.

We are not trained in Complex-Adaptive-System Improvement-by-Design.

So that is where we must start.