Is it OK to Fail First Time?

Improvement Science is about learning from when what actually happens is different to that which we expected to happen.  Is this surprise a failure or is this a success? It depends on our perspective. If we always get what we expect then we could conclude that we have succeeded – yet we have neither learned anything nor improved. So have we failed to learn? In contrast, if we never get what we expected then we could conclude that we  always fail – yet we do not report what we have learned and improved.  Our expectation might be too high! So comparing outcome with expectation seems a poor way to measure our progress with learning and improvement.

When we try something new we should expect to be surprised – otherwise it would not be new.  It is what we learn from that expected surprise that is of most value. Sometime life turns out better than we expected – what can we learn from those experiences and how can we ensure that outcome happens again – predictably? Sometimes life turns out worse than we expected – what can we learn from those experiences and how can we ensure that outcome does not happen again, predictably?  So, yes it is OK for us to fail and to not get what we expected – first time.  What is not OK is for us to fail to learn from the lesson and to make an avoidable mistake more than once or miss an opportunity for improvement more than once.

The Plague of Niggles

Historians tell us that in the Middle Ages about 25 million people, one third of the population of Europe, were wiped out by a series of Plagues! We now know that the cause was probably a bacteria called Yersinia Pestis that was spread by fleas when they bite their human hosts to get a meal of blood. The fleas were carried by rats and ships carried the rats from one country to another.  The unsanitary living conditions of the ports and towns at the time provided the ideal conditions for rats and fleas and, with a superstitious belief that cats were evil, without their natural predator the population of rats increased, so the population of fleas increased, so the likehood of transmission of the lethal bacteria increased, and the number of people decreased. A classic example of a chance combination of factors that together created an unstable and deadly system.

The Black Death was not eliminated by modern hi-tech medicine; it just went away when some of the factors that fuelled the instability were reduced. A tangible one being the enforced rebuilding of London after the Great Fire in Sept 1666 which gutted the medieval city and which followed the year after the last Great Plague in 1665 that killed 20% of the population. 

The story is an ideal illustration of how apparently trivial, albeit  annoying, repeated occurences can ultimately combine and lead to a catastrophic outcome.  I have a name for these apparently trivial, annoying and repeated occurences – I call them Niggles – and we are plagued by them. Every day we are plagued by junk mail, unpredictable deliveries, peak time traffic jams, car parking, email storms, surly staff, always-engaged call centres, bad news, bureaucracy, queues, confusion, stress, disappointment, depression. Need I go on?  The Plague of Niggles saps our spirit just as the Plague of Fleas sucked our ancestors blood.  And the Plague of Niggles infect us with a life-limiting disease – not a rapidly fatal one like the Black Death – instead we are infected with a slow, progressive, wasting disease that affects our attitude and behaviour and which manifests itself as criticism, apathy and cynicism.  A disease that seems as terifying, mysterious and incurable to us today as the Plague was to our ancestors. 

History repeats itself and we now know that complex systems behave in characteristic ways – so our best strategy may the same – prevention. If we use the lesson of history as our guide we should be proactive and focus our attention on the Niggles. We should actively seek them out; see them for what they really are; exercise our amazing ability to understand and solve them; and then share the nuggets of new knowledge that we generate.


How to Kill an Organisation with a Budget.

The primary goal of an organisation is to survive – and to do that it must be financially viable. The income must meet or exceed the expenses; the bottom line must be zero or greater; your financial assets much equal or exceed your financial liabilities.  So, organisations have to make financial plans to ensure finanical survival and as large organisations are usually sub-divided into smaller functional parts the common finanical planning tool is the departmental budget. We all know from experience that the future is not precisely predictable and that costs tend to creep up; and the budget is also commonly used as an expense containment tool.  A perfectly reasonable strategy to help ensure survival.  But by combining the two reasonable requirements intoi one tool have we unintentionally created a potentially lethal combination? The answer is “yes” – and this is why ….

The usual policy for a budget is to set the future budget based on the past performance.  Perfectly reasonable. And to contain costs we say “if our expenses were less than our budget then we didn’t need the extra money and we can remove it from our budget for next year.” Very plausible.  And was also say “if our expenses were more than our budget then we are suffering from cost-creep and the deficit is carried over to next year and our budget is not increased.”  What do we observe?  We observe pain!  The first behaviour is that departments on track to underspend will try to spend the remainder of the budget by the end of the period to ensure the next budget is not reduced … they spend their reserves.  The departments on track to overspend cut all the soft costs they can – such as not recruiting when people leave, buying cheap low quality supplies, cancelling training etc.  The result is that teh departments that impose internal cuts will perform less well – because they do not have the capacity to do their work – and that has a knock on effect on other departments because the revenue generating work is usually crosses several departments.  A constraint in just one will affect the flow through all of them.  The combined result is a fall in throughput, a fall in revenue, more severe budget restrictions, and a self-reinforcing spiral of decline to organisational death! Precisely the opposite intention of the budget design.

If that is the disease then what is the root cause? What is the patholgy?

The problem here is the mismatch between the financial specification (budget available) and the financial capability (cost required).  The solution is to recognise the importance of the difference. The first step is to set the budget specification to match the cost capability at each step along the process in order to stabilise the flow; the second step is to redesign the process to improve the cost capability and only reduce the budget when the process has been shown to be capable of working at a lower cost.  This requires two skills: first to be able to work out the cost capability of every step in the process; and second to design-for-cost. Budgets do neither of these and without these skills a budget transforms from a useful management asset to lethal organisational liability!

What do We Mean by Capacity?

I often hear the statement “Our problem is caused by lack of capacity?” and this is usually followed by a heated debate (i.e. an arugment) about how to get more resources to solve the “capacity problem”: The protagonists are usually Governance who start the debate by raising a safety or quality problem; Operations who are tasked to resolve the problem and Finance who are expected to pay.

But what are they talking about? What exactly is “Capacity”? The reason I ask is because the word is ambiguous – it has several meanings – and unless the precise meaning is made explicit then individuals may unconsciously assume different interpretations and crossed-wires, confusion and conflict will ensue.

From the perspective of a process there are at least two distinct meanings that must not be confused: one is flow capacity and the other is inventory capacity.  To give an example of the distinction consider your household plumbing system: the hot water tank has a capacity that is measured in the volume of the tank – e.g. in litres; the pipe that leads from the tank to your tap has a capacity that is measured by the flow through the pipe – e.g. in litres per minute.  These are clearly NOT the same; they are related by time: A 50 litre capacity tank connected to a 5 litre per minute capacity pipe will empty in 10 minutes. So when you are talking about “capacity” be sure to be explicit about which form you mean … volume or flow; static or dynamic; inventory or activity.  It will avoid a LOT of confusion!!

Do We have a Wealth of Data and a Dearth of Information?

Sustained improvement only follows from effective actions; which follow from well-informed decisions – not from blind guessing.  A well-informed decision imples good information – and good information is not just good data. Good information implies that good data is presented in a format that is both undistorted and meaningful to the recipient.  How we present data is, in my experience, one of the weakest links in the improvement process.  We rarely see data presented in a clear, undistorted, and informative way and commonly we see it presented in a way that obscures or distorts our perception of reality. We are presented with partial facts quoted without context – so we unconsciously fill in the gaps with our own assumptions and prejudices and in so doing distort our perception further.  And the more emotive the subject the more durable the memory that we create – which means it continues to distort our future perception even more.

The primary purpose of the news media is survival – by selling news – so the more emotive and memorable the news the better it sells.  Accuracy and completeness can render news less attractive: by generating the “that’s obvious, it is not news” response.  Catchy headlines sell news and to do that they need to generate a specific emotional reaction quickly – and that emotion is curiosity! Once alerted, they must hold the readers attention by quickly creating a sense of drama and suspense – like a good joke – by being just ambiguous enough to resonate with many different pepole – playing on their prejudices to build the emotional intensity.

The purpose of politicians is survival – to stay in power long enough to achieve their goals – so the less negative press they attract the better – but Politicians and the Press need each other because their purpose is the same – to survive by selling an idea to the masses – and to do that they must distort reality and create ambiguity.  This has the unfortunate side effect of also generating less-than-wise decisions.

So if our goal is to cut through the emotive fog and get to a good decision quickly so that we can act effectively we need just the right data presented in context and in an unambiguous format that we, the decision-maker, can interpret quickly. The most accessible format is as a picture that tells a story – the past, the present and the likely future – a future that is shaped by the actions that come from the decisions we make in the present that we make using information from the past.  The skill is to convert data into a story … and one simple and effective tool for doing that is a process behaviour chart.


There is a common, and often fatal, organisational disease called “egomatosis”.

It starts as a swelling of the Egocentre in the Executive Organ that is triggered by a deficiency in the Humility Feedback Loop (HFL), which in turn is linked to underdevelopment or dysfunction of the phonic sensory input system – selective deafness.

Unfortunately, the Egocentre is located next to other perception centres – specifically insight – so as the egoma develops the visual perception also becomes progressively distorted until a secondary cultural blind-spot develops.

In effect, the Executive organ becomes progressively cut off from objective reality – and this lack of accurate information impairs the Humility Feedback Loop further – accelerating the further enlargement of the egoma.

A dangerous positive feedback loop is now created that leads to a self-amplifying spiral of distorted perception and a progressive decline of judgement and effective decision making.

The external manifestation of this state is a characteristic behaviour called “dystrustosis” – or difficulty in extending trust to others combined with a progressive loss of self-trust.

The unwitting sufferer becomes progressively deaf, blind, fearful, delusional, paranoid and insecure – often distancing themselves emotionally and physically and communicating only via intermediaries using One-Way-Directives.

Those who attempt to communicate with the sufferer of this insidious condition often resort to SHOUTING and using BIG LETTERS which, unfortunately, only mirrors the same behaviour.  As the sufferer’s perception of reality becomes more distorted their lack of insight and humility blocks them from considering themselves as a contributor to the problem.

The ensuing conflict only serves to accelerate their decline and the sufferer progresses to the stage of “fulminant egomatosis”.

“Fulminant egomatosis” is a condition that is easy to identify and to diagnose.  Just listen for the shouting, observe the dystrustosis and feel the fear.

Unfortunately, it is a difficult condition to manage because of the lack of awareness and insight that are the cardinal signs.

Many affected leaders and their organisations now enter a state of Denial – unconsciously hoping that the problem will resolve itself – which is indeed what happens eventually – though not in the way they desperately hope for.

In the interim, the health of the organisation deteriorates and many executives succumb, unaware of, or unwilling to acknowledge the illness that claimed them; meekly accepting the “inevitable fate” and submitting to the terminal option – usually delivered by the Chair of the Board – Retire or Resign!

The circling corporate vultures squabble over the fiscal remains – leaving no tangible sign to mark the passing of the sufferer and their hapless organisation.  There are no graveyards for the victims of fulminant egomatosis and the memory of their passing soon fades from the collective memory.  Failure is a taboo subject – an undiscussable.

Some organisations become aware of their affliction while they are still alive, but only after they have reached the terminal stage and are too sick to save.  The death throes are destructive and unpleasant to watch – and unfortunately fuel the self-justifying delusion of other infected organisations who erroneously conclude that “it could never happen to them” and then unwittingly follow the same path.

Unfortunately, egomatosis is an infectious cultural disease.  The spores, or “memes” as they are called, can spread to other organisations.  Just as Dr Ignaz Semmelweis discovered in 1847, the agents-of-destruction are often carried on the hands of those who perform organisational postmortems.  These meme vectors are often the very people brought into assist the ailing organisation, and so become chronically infected themselves and gravitate to others who share their delusions.  They are excluded by healthy organisations, but their siren-calls sound plausible and they gain entry to weaker organisations who are unaware that they carry the dangerous memes!  Actively employing the services of management consultants in preference to encouraging organisational innovation incurs a high risk of silent infection!  Appearance of the symptoms and signs is often delayed and by then it may be too late. 

The organisations that are naturally immune to egomatosis were “built to last” because they were born with a well-developed sense of purpose, vision, humility, confidence and humour.  They habitually and unconsciously look for, detect, and defuse the early signs of egomatosis.  They do not fear failure, and they have learned to leverage the gap between intent and impact.  These organisations have a strong cultural immune system and are able to both prevent infection and disarm the toxic-memes they inevitably encounter.  They are safe,  fun, challenging, exciting, innovative and motivating, places to work – characteristics that serve to strengthen their immunity, boost their resilience, and secure their future.

Some infected organisations are fortunate enough to become aware of their infection before it is too late, and they are able to escape the vicious cycle of decline.  These “good to great” organisations have enough natural humility to learn by observing the fate of others and are able to detect the early symptoms and to seek help from someone who understands their illness and can guide their diagnosis and treatment.  Such healers facilitate and demonstrate rather than direct and delegate.

All organisations are susceptible to egomatosis, so prevention is preferable to cure.

To prevent the disease, organisations must consciously and actively develop their internal and external feedback loops – using all their senses – including their olfactory organ.  Cultural and political bull**** has a characteristic odour!

They also regularly exercise their Humility Feedback Loop to keep it healthy – and they have discovered that the easiest way to do that is to challenge themselves – to actively look for their own gaps and gaffes – to look for their own positive deviants – to search out opportunities to improve – and to practice the very things that they know they are not good at.

They are prepared to be proved lacking and have learned to stop, look, laugh at themselves – then listen, learn, act, improve and share.

There is no known cure for egomatosis – it is a consequence of the 1.3 kg of ChimpWare between our ears that we have inherited from our ancestors – so vigilance must be maintained throughout the life of the organisation. 

Now is When Infinity Becomes One

Time is an intangible – we can’t touch it, taste it, smell it, hear it or see it – yet we do sense it – and we know it is valuable. A precious commodity we call lifetime. We often treat lifetime as it if were tangible – something that we can see, hear, smell, taste and touch – something like money. We often hear the phrase “time is money” and we say things like “spending time” and “wasting time” – as if it were money. But time is not money; we cannot save time, we cannot buy time, and we all get the same amount of time per day to use.

Another odd thing about time is that we sense that it moves in one direction – from past to future with now as the transition. This creates an interesting discontinuity: if we look forward from now into the future we perceive an infinite number of possibilities; yet if we look backwards from now into the past we see only one actuality. That is really odd – Now is when Infinity becomes One.

So, how does that insight help us make a choice?  Well, suppose we have decided what we want in the future and are now trying to make a choice of what to do next; to plan our route to our future desired goal.  Looking from now forwards presents us with a very large number of paths to choose from, none of which we can be sure will lead us safely to where we want to get to.  So what happens? We may become paralysed by indecision; we may debate and argue about which path to take; we may boldly step out on a plausible path with hope and courage; or we may just guess and stumble on with blind faith.  Which we choose seems more a reflection of our personality than a rational strategy. So let us try something else – let us project ourselves into the future to the place where we want to be; and then let us look backwards in time from the future to the present. Now we see a single path that led to where we are; and by unpicking that path we can see that each step of it had a set of necessary and sufficient pre-conditions which, with the addition of time, moved us forward along the path.  Hindsight is much clearer than foresight and each of us has a lifetime’s worth of hindsight to reflect on; and the cumulative hindsight of history to draw on.  This is not an exercise in fantasy; we already have what we need.

To make our choice we start with the outcome we want and ask the question “What are the immediately preceeding necessary and sufficient conditions?”   Then for each condition we ask the question “Does that condition already exist?” If so then we stop – we need go no further on this side branch; and if not then we repeat the Two Questions and we keep going until we have linked our goal back to pre-conditions that exist.  All the pre-conditions in the map we have drawn are necessary but we do not yet have all of them. Some are only dependent on pre-conditions that exist – these are the important ones because they tell us exactly what to focus on doing next. Our choice is now obvious and simple – though the action may not be easy. No one said the journey would be easy!

It’s Not the People it’s the Process!

Doing the same thing repeatedly and expecting a better result might be called practice, perseverance, persistence, even patience; it might also be called futility or even madness.

We know that sometimes persistence pays off, and sometimes it doesn’t, so how do we know which is which?

Very often this problem is disguised – for example when we want a better outcome of a process.  It is easy to assign blame for poor outcomes to people because of the cause-and-effect chain that you can trace back from an obvious mistake – but it is always valid to do this?

Suppose I repeat the same actions and occasionally get a poor outcome – checking for the mistake and when it happens tracing the audit trail back to the action of a specific person is of little value in this case because it doesn’t expose the true root cause.

Outcomes are usually the result of cumulative actions and it is difficult or impossible to separate out the contributions.

So, the only rational way to improve outcome is to improve every part of the process proactively.  And if there is a bad apple in the barrel it is much easier to spot when the rest of the apples are good than when all the apples are a bit bruised.

Is Good Design Easy to See?

Doh! What a non-question! Good design is obvious. But is it?  Bad design is certainly obvious because it trips you up, it does something you do not expect or doesn’t do something that you do expect – you become consciously aware of bad design and it is a niggle because bad design is effort wasting, time wasting and money wasting.  Bad design generates niggles and toxic emotional waste swamps.  So what was your feeling when you first saw an iPhone, or an iPod, or used iTunes or touched an iPad? Was it was “Wow!” That is the first impact of good design – you notice the difference immediately. However, after that it becomes gradually invisible because the old niggle goes away, and before long you are taking the good design for granted because there is nothing to consciously remind you of it. Your expectation has changed – what previosuly delighted now only satifies. Good design is an invisible nugget. So here is something to try – look around you now and identify all the examples of good and bad design that you can see. What differentiates the two?  For a niggle free existence you will have to actively seek out good design by looking for what is there but not making itself obvious.  Refocus from what doesn’t work to what does work and learn to understand how and why it works. You may find it a humbling experience!!

Which Checkout do We Choose?

When we are approaching the checkout in the supermarket how do we decide which queue to join?  Is it the shortest? Is it the one with the fewest number of full trollies? Is it the one that is staffed by the most competent looking operative? Or is it the new-fangled computerised one that technophobes like me avoid like the plague? If our goal is to get out of the shop as quickly as possible then this is an important yet tricky decision. Once we have committed to a specific queue then we are bound by the social norms to stick it out.

Technically speaking the queue to join is not the shortest one, or the one with the where there are the smallest number of individual items that need to be scanned, or the one with the fastest operative – it is the queue with the smallest load – the cumulative product of the number of items and cycle time of the operative. Hence our quick mental calculation of length of queue * average size of trollies * speed of operative.  Even then it can go wrong if someone throws a spanner in – such as picking up the only item on the shelf with a missing barcode – triggering the need to call a “supervisor”!

Are we completely powerless in this process? Not at all – we each can ensure all our purchases have barcodes and we can also influence the cycle time of the operative. Observe what they are doing – picking up each item in turn, finding the bar code, and turning the item so that the bar code can be easily scanned by the computer.  To shorten the cycle time all we have to do is make the work for the operative as easy as possible by placing each item on the moving belt in the correct orientation and spaced so that the speed of the belt delivers the items at the same rate that the operative can scan.  This sounds counter-intuitive but it works!  It is just like the variable speed limits on some motorways – by slowing down you get there faster because the flow is smoother – there is less “turbulence” created.

There are two potential flaws in this counter-intuitive strategy though – the people in the queue behind you may start “tutting” because they believe you are playing childish games and slowing the process down (which is incorrect but we are social animals and we copy other people’s behaviour and react to “social deviants”).  The other flaw is that, if I am shopping alone I cannot both stream my purchases for optimal scanning and also pack my scanned purchases into my reusable shopping bag!  So, I may only be able to use this strategy when accompanied by a trained assistant and have access to my fast getaway car!  Of course I might get even more radical – and offer to stream the shopping for the person in front of me while they pack their scanned items. But that would mean that we work together to achieve a common goal – to reduce the (life)time we all spend waiting in the shopping queue. This way we do not need an assistant or a getaway car and shopping might even become more sociable.  Everyone wins. What everyone? How is that possible?

Can Chance make Us a Killer?

Imagine you are a hospital doctor. Some patients die. But how many is too many before you or your hospital are labelled killers? If you check out the BBC page

Can We See the Wood for the Trees?

“The Map is not the Territory” but it is a very useful because it provides a sense of perspective; the bigger picture; where you are; and what you would need to do to get from A to B.  A map can also provide the the fine detail, they way-points on your journey, and what to expect to see along the way.  I remember the first computer programs that would find a route from A to B for me and present it as a printed recipe for the journey; how far it was and, best of all, how long it would take – so I knew when to set off to be reasonably confident I could arrive on time.  Of course, there might always be unexpected holdups along the way but it was a big step forward. One problem was using the recipe as I drove, and another was when I accidently took a wrong turn, which is easy in unfamiliar surroundings with only a list of instructions to go by.  If I came off the intended track I would get lost – so I still needed the paper map as a backup. The trouble now was I did not alwasy know where I was on the map – because I was lost.  Two steps forward and one step backwards.  Now we have Google Maps and we can see what we will actually see on the way – before we even leave home!  And with SatNav we can get this map-reading-and-route-planning done for us in real time so if we choose to, are forced to, or accidentially take a wrong turn it can get us back-on-track. The days of heated debate between the map reader and the map needer have gone and it seems the only need we have for a map now is as a backup if the SatNav breaks down. (This did happen to me once, I didn’t have a map in the car and the only information I had was the postcode of my destination. I was pressed for time so I drove around randomly until I passed a shop that sold SatNavs and bought a new/spare one – entered the postcode and arrived at my intended destination just in time!).

So is the map dead?  Not at all – the value of a map in providing a sense of perspective, context and location is just as useful as ever. And there are many sorts of maps apart from the static, structural, geographical maps ones we are used to.  The really exciting maps are the dynamic ones – the functional maps.  These are maps that show how things are working and flowing, not only where they are.  Imagine if your SatNav had both a static map and was able to access a real time dynamic map of traffic flow. Just think how much more useful it could be? However, to achieve that implies that each person on the road would have to contribute both their position and their intended destination to a central system – isn’t that Big Brother back. Air traffic control (ATC) systems have done this for years for a very good reason: aeroplanes full of passengers are perishable goods – they can’t land anywhere they like and they can’t stay up there waiting to land for ever.  You can’t afford to have traffic jams with aeroplanes – so every pilot has to file a flight plan and will only be given ATC clearance to take off if their destination is capable of offering them a landing slot in an acceptable time frame – i.e. before the plane runs out of fuel! Static maps will always be needed to provide us with a sense of perspective – and in the future dynamic maps will revolutionise the way that we do everything – but only if we are prepared to behave collectively and share our data.  We want to see the wood, the trees and even the breeze through the leaves!

What Happens if We Cut the Red Tape?

Later in his career, the famous artist William Heath-Robinson (1872-1944) created works of great ingenuity that showed complex inventions that were created to solve real everyday problems.  The genius of his work was that his held-together-with-string contraptions looked comically plausible. This genre of harmless mad-inventorism has endured, for example as the eccentric Wallace and Grommet characters.

The problem arises when this seat-of-the-pants incremental invent-patch-and-fix approach is applied to real systems – in particular a healthcare system. We end up with the same result – a Heath-Robinson contraption that is held together with Red Tape.

The complex bureaucracy both holds the system together and clogs up the working – and everyone knows it. It is not harmless though – it is expensive, slow and lethal.  How then do we remove the Red Tape to allow the machine to work more quickly, more safely and more affordably – without the whole contraption falling apart?

A good first step would be to stop adding yet more Red Tape. A sensible next step would be to learn how to make the Red Tap redundant before removing it. However, if we knew how to do that already we would not have let the Red Tapeworms infest our healthcare system in the first place!  This uncomfortable conclusion raises some questions …

What insight, knowledge and skill are we missing?
Where do we need to look to find the skills we lack?
Who knows how to safely eliminate the Red Tapeworms?
Can they teach the rest of us?
How long will it take us to learn and apply the knowledge?
Why might we justify continuing as we are?
Why might we want to maintain the status quo?
Why might we ignore the symptoms and not seek advice?
What are we scared of? Having to accept some humility?

That doesn’t sound like a large price to pay for improvement!

Is this just a Clash of Personality?

Have you ever have the experience of trying to work on a common challenge with a team member and it just feels like you are on different planets?  You are using the same language yet are not communicating – they go off at apparently random tangents while you are trying to get a decision; they deluge you with detail when you ask about the big picture; you get upset when their cold logic threatens to damage team unity. The list is endless.  If you experience this sort of confusion and frustration then you may be experiencing a personality clash – or to be more accurate a pyschological type mismatch.

Carl Jung described a theory of psychological types that was later developed into the Myers-Briggs Type Indictator (MBTI).  This extensively validated method classifies people into sixteen broad groups based on four dimensions that are indicated by a letter code. It is important to appreciate that there are no good/bad types or right/wrong types – each describes a mode of thinking: a model of how we gather information, make decisions and act on those decisions.  Everyone uses all the modes of thinking to some degree – we just prefer some more than others and so we get more practice with them.  The purpose of MBTI is not to “correct” someone elses psychologcial type – it is to gain a conscious and shared awareness of the effect of psychological types on interpersonal and team dynamics. For example, some tasks and challenges suit some psychological types better than others – they resonate – and when this happens these tasks are achieved more easily and with greater satisfaction.  “One’s meat is another’s poison” sums the idea up.  Just having insight into this dynamic is helpful because it offers new options to avoid frustrating, futile and wasteful conflict.  So if you are curious find out your MBTI – you can do it on line in a few minutes (for example and with that knowledge you can learn what your psychological type implies.  Mine is INFJ …

Are we Stuck in a Toxic Emotional Waste Swamp?

Have you ever had the uncomfortable experience of joining a new group of people and discovering that your usual modus operandi does not seem to fit?  Have you ever experienced the pain of a behavioural expectation mismatch – a clash of culture? What do we do when that happens? Do we keep quiet, listen and try to work out the expected behaviours by observing others and then mimic their behaviour to fit in? Do we hold our ground, stay true to our norms and habits and challenge the group? Do we just shrug, leave and not return?

The other side of this common experience is the effect on the group of a person who does not match the behavioural norms of the group.  Are they regarded as a threat or an opportunity? Usually a threat. But a threat to whom? It depends. And it primarily depends on the emotional state of the chief, chair or boss of the group – the person who holds the social power. We are social animals and we have evolved over millions of years to be hard-wired to tune in to the emotional state of the pack leader – because it is a proven survival strategy!

If the chief is in a negative emotional state then the group will be too and a newcomer expressing a positive emotional outlook will create an emotional tension. People prefer leaders who broadcast a positive emotional state because it makes them feel happier; and leaders are attracted by power – so in this situation the chief will perceive a challenge to the balance of power and will react by putting the happy newcomer firmly in their place in the pecking order. The group observe the mauling and learn that a positive emotional attitude is an unsuccessful strategy to gain favour with the chief – and so the status quo is maintained. The toxic emotional waste swamp gets a bit deeper, the sides get a bit more slippery, and the emotional crocodiles who lurk in the murk get a tasty snack. Yum yum – that’ll teach you to be happy around here!

If the chief has a uniformly positive emotional approach then the group will echo that and a newcomer expressing a negative emotional state creates a different tension. The whole group makes it clear that this negative behaviour is unwelcome – they don’t want someone spoiling their cosy emotional oasis! And the status quo is maintained again. Unfortunately, the only difference between this and the previous example is that this only-happy-people-allowed-here group is drowning in emotional treacle rather than emotional turds. It is still an emotional swamp and the outcome is the same – you get stuck in it.

This either-or model is not a successful long-term strategy because it does not foster learning – it maintains the status quo – tough-minded or touch-feely – pessimistic or optimistic – but not realistic.

Effective learning only happens when the status quo is challenged in a way that respects both the power and authority of the chief and of the group – and the safest way to do that is to turn to reality for feedback and to provide the challenge to the group.  To do this in practice requires a combination of confidence and humility by both the chief and the group: the confidence to reject complacency and to face up to reality and the humility to employ what is discovered to keep moving on, to keep learning, to keep improving.

Reality will provide both positive and negative feedback (“Nuggets” and “Niggles”) and the future will hold both positive and negative challenges (“Nice-Ifs” and “Noo-Noos”).  Effective leaders know this and are able to maintain the creative tension. For those of us who are learning to be more effective leaders perhaps the routes out of our Toxic Emotional Waste Swamps are drawn on our 4N charts?

Is this Second Nature or Blissful Ignorance?

Four stages of learningI haven’t done a Post-It doodle for a while so here is one of my favourites that I was reminded of this week.  Recently my organisation has mandated that we complete a 360-feedback exercise – which for me generated some anxiety – even fear. Why? What am I scared of? Could it be that I am unconsciously aware that there are things I am not very good – I just don’t know what they are – and by asking for feedback I will become painfully aware of my limitations? What then? Will I able to address those weaknesses or do I have to live with them? And even more painful to consider; what if I believed I was good at something because I have been doing it so long it has become second nature – and I discover that what I was good at is not longer appropriate or needed? Wow! That is not going to feel much fun.  I think I’ll avoid the whole process by keeping too busy to complete the online questionnaire.  That strategy did not work of course – a head-in-the-sand approach often doesn’t.  So I completed it and await my fate with trepidation.

The model of learning that I have sketched is called the Conscious-Competence model or – as I prefer to call it – Capability Awareness.  We all start bottom left – not aware of our lack of capablity – let’s call that Blissful Ignorance.  Then something happens that challenges our complacency – we become aware of our lack of capability – ouch! That is Painful Awareness.  From there we have three choices – retreat (denial), stay where we are (distress) or move forward (discovery).  If we choose the path of discovery we must actively invest time and effort to develop our capability to get to the top right position – where we are aware of what we can do – the state of Know How.  Then as we practice or new capability and build our experience we gradually become less aware of out new capability – it becomes Second Nature.  We can now do it without thinking – it becomes sort of hard-wired.  Of course, this is a very useful place to get to: it does conceal a danger though – we start to take our capability for granted as we focus our attention on new challenges. We become complacent – and as the world around us is constantly changing we may be unaware our once-appropriate capability may be growing less useful.  Being a wizard with a set of log-tables and a slide-rule became an unnecessary skill when digital calculators appeared – that was fairly obvious.  The silent danger is that we slowly slide from Second-Nature to Blissful-Ignorance; usually as we get older, become more senior, acquire more influence, more money and more power.  We now have the dramatic context for a nasty shock when, as a once capable and respected leader, we suddenly and painfully become aware of our irrelevance. Many leaders do not survive the shock and many organisations do not survive it either – especially if a once-powerful leader switches to self-justifying denial and the blame-others behaviour.

To protect ourselves from this unhappy fate just requires that we understand the dynamic of this deceptively simple model; it requires actively fostering a curious mindset; it requires a willingness to continuously challenge ourselves; to openly learn from a wide network of others who have more capability in the area we want to develop; and to be open to sharing with others what we have learned.  Maybe 360 feedback is not such a scary idea?

Can an Old Dog learn New Tricks?

I learned a new trick this week and I am very pleased with myself for two reasons. Firstly because I had the fortune to have been recommended this trick; and secondly because I had the foresight to persevere when the first attempt didn’t work very well.  The trick I learned was using a webinar to provide interactive training. “Oh that’s old hat!” I hear some of you saying. Yes, teleconferencing and webinars have been around for a while – and when I tried it a few years ago I was disappointed and that early experience probably raised my unconscious resistance. The world has moved on – and I hadn’t. High-speed wireless broadband is now widely available and the webinar software is much improved.  It was a breeze to set up (though getting one’s microphone and speakers to work seems a perennial problem!). The training I was offering was for the BaseLine process behaviour chart software – and by being able to share the dynamic image of the application on my computer with all the invitees I was able to talk through what I was doing, how I was doing it and the reasons why I was doing it.  The immediate feedback from the invitees allowed me to pace the demonstration, repeat aspects that were unclear, answer novel queries and to demonstrate features that I had not intended to in my script.  The tried and tested see-do-teach method has been reborn in the Information Age and this old dog is definitely wagging his tail and looking forward to his walk in the park (and maybe a tasty treat, huh?)

What We Need is a Healthy Crisis!

Some years ago I read a book by John Kotter that was about how organisations get themselves into and out of trouble.  Recently I read another book by Patrick Lencioni called “Silos and Politics” which carried similar message – some successful organisations become “unfocussed” and “complacent” to the extent that internal silos and petty politics come to occupy more time than improvement – the politics and silos become a self-sustaining name-shame-blame-game.  John Kotter showed that the path out of this unhealthy state is to realise that organisational survival is at risk – and this provides a compelling reason to align efforts – usually in a dramatic and desperate exercise in organisational survival.  The term Kotter used was “burning platform” which is somewhat prophetic given the ecological, economic and political catastrophe that is currently unfolding in the Gulf of Mexico.  Patrick Lencioni takes a different tack on the same problem – and concludes that organisational silos are the result of the attitudes that filter down from the boardroom. He advocates looking for the “symptoms” and if observed in an organisation then it is a good time to engineer a crisis to focus attention on delivering one collective, qualitative, and audacious goal – something that the whole organisation will need to collaborate to achieve and one that provides a “win” for everyone.  So, before you get sucked into an unhealthy life-and-death crisis look for the early symptoms that indicate the need to create a healthy crisis: one that will require just as much passion and creativity to resolve and which will lead to a sustainable breakthrough improvement!

Are we SELFish enough?

Improvement is selfish behaviour because if I improve (win) it must be at the detriment (lose) of someone else, surely? Ergo – improvement is not an attractive behaviour because we don’t like to be regarded as selfish by others.  What assumptions are driving this conclusion? The obvious one is the zero-sum-game assumption – that if I improve (win) then everyone else must deteriorate (lose).  The Laws of Conservation give us this idea – energy is conserved, momentum is conserved, money is conserved (that’s what accountants are for – to balance the accounts). But do the Laws of Conservation also apply to qualitative measures such as happiness, fun, curiosity, sadness, anger, fear?  If I am having fun does that imply that someone else must be angry?  Our intuition suggests “no” – if we can both be having fun and we can both be angry then the Laws of Conservation does not apply to qualitative measures siuch as feelings.  Therefore, if we focus attention on qualitative improvement then we can be selfish so long as we conciously abandon the Win-Lose constraint and consciously adopt the Win-Win goal.  Selfishness is OK if your goal is qualitative improvement for everyone.  Win-Win-Win.

Sounds great! The trouble is when we look around us we don’t seem to see the Win-Win-Win principle in action very often. What’s missing? Our quantitative measures obey the Conservation Laws, our qualitative measures do not so maybe we are confusing the two somewhere? What measure can be viewed as both qualitative and quantitative? Time maybe? Time is a definitely a quantitative metric and “Time is Money” is a familiar phrase that equates these two quantities. When it is MY time we are referring to it feels different and “Quality of Life” is a phrase that springs to mind.  So is that where I am confusing quality and quantity? When I am talking about my time and my life – my lifetime.  Is it OK for me to be selfish with my life-time so long as the goal is a Win-Win-Win one?

What is so Funny?

One line from the Simpson’s Movie that made me laugh was when Bart says “Dad, this is the worst day of my life!” to which Homer replies “Worst day <dramatic pause> so far!”.  If Bart had said “Dad, this is the best day of my life!” and Homer had replied “Best day <dramatic pause> so far!” it would not have been funny – it would have sounded cheesy. Why is that?  What does this tell us about how we can sometimes confuse humour and pleasure?  If we laugh when we are unexpectedly confronted with someone else’s emotional distress (the basis of slapstick humour); and we also laugh when we see other people laughing; and we also laugh when we have our expectations exceeded (the basis of surprise parties) then by simple association of the feeling (pleasure) with the behaviour (laughter) we have a recipe for collectively laughing at someone else’s distress.  More sinister is that we can unconsciously plan to derive laughter (and by association pleasure) by deliberately engineering distress for others.  Humour, like any process, can become sick.

But Why?

Just two, innocent-looking, three-letter words.

So what is the big deal? If you’ve been a parent of young children you’ll recognise the feeling of desperation that happens when your pre-schooler keeps asking the “But why?” question. You start off patiently attempting to explain in language that you hope they will understand, and the better you do that the more likely you are to get the next “But why?” response. Eventually you reach the point where you’re down to two options: “I don’t know!” or “Just because!”.  How are you feeling now about yourself and your young interrogator?

The troublemaker word is “but”. A common use of the word “but” in normal conversation is “Yes … but …” such as in “I hear what you are saying but …”.

What happens inside your head when you hear that?  Does it niggle? Does the red mist start to rise?

Used in this way the word “but” reveals a mental process called discounting – and the message that you registered unconsciously is closer to “I don’t care about you and your opinion, I only care about me and my opinion and here it comes so listen up!”.  This is a form of disrespectful behaviour that often stimulates a defensive response – even an argument – which only serves to further polarise the separate opinions, to deepen the mutual disrespect, and to erode trust.

It is a self-reinforcing negative-outcome counter-productive behaviour.

The trickster word is “why?”  When someone asks you this open-ended question they are often just using it as a shortcut for a longer series of closed, factual questions such as “how, what, where, when, who …”.  We are tricked because we often unconsciously translate “why?” into “what are your motives for …” which is an emotive question and can unconsciously trigger a negative emotional response. We then associate the negative feeling with the person and that hardens prejudices, erodes trust, reinforces resistance and fuels conflict.

My intention in this post is only to raise conscious awareness of this niggle.

If you are curious to test this youself – try consciously tuning in to the “but” and “why” words in conversation and in emails.  See if you can consciously register your initial emotional response – the one that happens in the split second before your conscious thoughts catch up. Then ask youself the question “Did I just have a positive or a negative feeling?

Why Do We Need Two Ears?

What a curious question! We can hear almost just as well with one ear as two so that is not the reason. Our glasses would fall off obviously though ears evolved long before glasses so that’s probably not the reason.  Just in case we lose one ear by accident? That sounds reasonable but then why don’t we have a have a spare heart or spare brain too – they are more critical organs? Physiologists will explain that we need two ears to accurately determine the direction that a sound is coming from – and we do that by detecting very slight differences between what one ear hears compared with the other. What a neat bit of biodesign! So what relevance does this have for Improvement Science?  Well, to improve a process or system we need to listen to two separate voices – the Voice of the Customer (VoC) and the Voice of the Process (VoP) – and if we compare them the slight difference points us in the direction of improvement. The problem is, when there is a big difference between the two sounds they will interfere with each other and we cannot hear either clearly. In that situation we adopt a policy of selective deafness – some of us choose the Voice of the Process because it can be measured objectively; and some of us choose the Voice of the Customer.  The outcome is disagreement because we are hearing different things. Confusion becomes conflict.

With this insight one way out of this impasse might be for everyone to use both ears alternately: everyone listening to the Voice of the Customer for a while and then everyone changing channel and listening to the Voice of the Process for a while, and back again.  The direction of improvement would become visible and the steps needed to align the Two Voices would emerge naturally.  The Two Voices are trying to tell us something and we only need to learn to tune into both of them. When the Two Voices match we hear harmony not cacophony!

How might some people be offended by performance charting?

Some fabulous new SPC software, called BaseLine© is now available – it’s designed for organizations and individuals who see the advantages in having people use a standard performance charting tool that’s statistically robust yet straight forward to use even for the uninitiated. As well as being highly accessible, at under £50 it is easily the most inexpensive option now available.

There is even a time-unlimited FREE version.

BaseLine© is obtainable via

How might some people be offended by performance charting?

The idea behind BaseLine© is that most every organisation is these days awash with time-series data, usually held in spreadsheet form, yet very little of it is used to diagnose systemic change. Even people who are held accountable for performance are often unaware of the gold that lies beneath their feet – or if they are aware, are for some reason reluctant to make use of it. Because BaseLine© is so accessible – there really is no longer any reason to avoid using SPC, but wait ..

.. observing those who are taking the plunge it’s becoming clearer to me where this reluctance might be coming from. Whilst some of it is due undoubtedly to low organisational expectation, I’m detecting that some of it is also due to low self-perception of capability, and some might even be because BaseLine© somehow confronts the personal value-set of particular managers. Let me refer to these value sets and capabilities as “memes”(1) and allow myself the luxury of speculatively labelling each one – so that I can treat each as a hypothesis that might later be tested – to see if the accumulating evidence either supports or refutes it. So here goes ..

1. The “Accountability-avoidance” meme – Those comfortable and skilled enough to hold a senior position may still however be inhabited by this meme, which can actually apply at any level in an organisational hierarchy. To most people it is an essential underpinning of their self-esteem to be able to feel that they’ve personally made a contribution whilst at work. It’s safer therefore (at least unconsciously) to be able to avoid roles for which any direct or personal performance measurement is attached – and there are plenty of such roles.
2. The “anti-Management” meme – According to this meme there’s something dehumanising about asking anyone to manage a process that delivers an outcome to someone who might appreciate it. Those who embody this value-set may also think that Management sounds altogether too boring when compared to Leadership since not much good happens unless people can feel good about it, and people have to be led to achieve anything meaningful and lasting. If there’s any management to be done it should be done by the followers.
3. The “anti-Control freak” meme – People holding this meme tend to dislike the whole idea of control, unless it’s the empowering of others to be in control – and even this may be considered too dangerous since the power to control anything can so easily be abused.
4. The “anti-Determinism” meme – Inside this meme Albert Einstein is considered as having completely supplanted the Newtonian “predict and control paradigm” as opposed to having merely built upon it. Life is viewed as inherently uncertain, and there’s a preference for believing that little can be reliably predicted, so it’s best to adopt an “act first/ ask questions later” approach. Deepak Chopra fans for example will know that “the past is history, and the future a mystery” and that therefore almost any form of planning is repellent – instead, emergence is the thing most highly valued.
5. The “Numerophobia” meme – so widespread is the tendency to avoid numbers, it may be easier to think of this as a syndrome rather than a meme – indeed, in the extreme it is a medical condition called “dyscalculia.” Whilst few people readily admit to being illiterate, there are many who are relatively happy to announce that they “don’t do numbers” – and some have even learned that it pays to be proud of it. In one recent UK study 11% were designated illiterate, but 40% innumerate.
6. The “iNtuitives rule” meme – People who are inhabited by this meme are those who may well feel comfortable weaving (even spinning) their story without the benefit of data that’s been fully “sensed”. The Myers Briggs Type Indicator – scores around 25% of people as N (iNtuitive), the remaining 75% being Sensors – who prefer to look for and absorb data via their 5 senses, data that to them feels tangibly “real.” On average around 12% people score as having N/T (intuitive thinking) preferences – yet exec teams & boards often score at more than 50%. Is this because they have had to become comfortable feeling disconnected from the customer interface, or because they were always that way inclined and therefore gravitated towards the apex of the hierarchy?
7. The “anti-Science” meme – According to this meme even the fact that I’m labelling these value-sets/ memes at all, will be seen as being antithetical – regardless of whether it might in some way prove to be a useful scientific device for advancing knowledge. People in organisations may behave in a way that’s anti-science in that tasks and projects are typically carried out in a Plan-Do-Review sequence – unaware that Plan-Do-Study-Act represents the scientific method in action, and is an entirely different paradigm.
8. the “protect my group or profession” meme – According to this meme, people are confident that they know what they know – and have spent several years of their life being trained to acquire that knowledge. They less aware of the extent to which this has formed their mental maps and how these in turn direct their opinions. When in doubt, reference is made to the writings and utterances of their personal or professional gurus – and quoted verbatim, frequently out of context. When a new tool arrives, the default position is: if I don’t recognise it, it should be rejected – until one of the gurus authenticates it.

Wow, when I started the list I didn’t think there would be as many as eight.

Individuals and organizations that are already, or can become, comfortable with applying the scientific method in their organisations – and personally – as a system, will see the profundity in a tool like BaseLine©. Others will miss it altogether, and one or more of the memes listed above could be preventing them seeing it. I’ll continue to collect more data, both sensed and intuited, and report on my findings in a future blog.

One source of test data will of course be the comments I solicit from readers of this blog, so having read these labels and descriptions, do you notice any reactive feelings? If so, can you accurately describe what you feel most confronted by? I’d be delighted to hear from you.

(1) Richard Dawkins coined (or adapted) the word “meme” in The Selfish Gene (1976) as a value set, or a postulated unit of cultural ideas, symbols or practices – which can be transmitted from one mind to another through writing, speech, gestures, rituals or other imitable phenomena. It’s sometimes used synonymously with the phrase “world view.” Clare Graves then made the Value meme (vMeme) a core concept in his Spiral Dynamics model – see Beck D.E & Cowan C.C. : “Spiral Dynamics – Mastering Values, Leadership, and Change” – 1996

To Push or Not to Push? Is that the Question?

Improvement implies change;

… change implies learning;

… learning implies asking questions;

… and asking questions implies listening with both humility and confidence.

The humility of knowing that their are many things we do not yet understand; and the confidence of knowing that there are many ways we can grow our understanding.

Change is a force – and when we apply a force to a system we meet resistance.

The natural response to feeling resistance is to push harder; and when we do that the force of resistance increases. With each escalation the amount of effort required for both sides to maintain the stalemate increases and the outcome of the trial is decided by the strength and stamina of the protagonists.

One may break, tire or give up …. eventually.

The counter-intuitive reaction to meeting resistance is to push less and to learn more; and it is more effective strategy.

We can observe this principle in the behaviour of a system that is required to deliver a specific performance – such as a delivery time.  The required performance is often labelled a “target” and is usually enforced with a carrot-flavoured-stick wrapped in a legal contract.

The characteristic sign on the performance chart of pushing against an immovable target is the Horned Gaussian – the natural behaviour of the system painfully distorted by the target.

Our natural reaction is to push harder; and initially we may be rewarded with some progress.  And with a Herculean effort we may actually achieve the target – though at what cost?

Our front-line fighters are engaged in a never-ending trial of strength, holding back the Horn that towers over them and that threatens to tip over the target at any moment.

The effort, time, and money expended is out of all proportion to the improvement gained and just maintaining the status quo is exhausting.

Our unconscious belief is that if we weather the storm and push hard enough we will “break” the resistance, and after that it will be plain sailing. This strategy might work in the affairs of Man – it doesn’t work with Nature.

We won’t break the Laws of Nature by pushing harder. They will break us.

So, consider what might happen if we did the opposite?

When we feel resistance we pull back a bit; we ask questions; we seek to see from the opposite perspective and to broaden our own perspective; we seek to expand our knowledge and to deepen our understanding.

When we redirect our effort, time and money into understanding the source of the resistance we uncover novel options; we get those golden “eureka!” moments that lead to synergism rather than to antagonism; to win-win rather than lose-lose outcomes.

Those options were there all along – they were just not visible with our push mindset.

Change is a force – so “May the 4th be with you“.

Can We See a Story in the Data?

I often hear the comments “I cannot see the wood for the trees”, “I am drowning in an ocean of data” and “I cannot identify the cause of the problem”.  We have data, we know there is a problem and we sense there is a soluton; the gap seems to be using the data to find a solution to the problem.

Most quantitative data is presented as tables of columns and rows of numbers; and is indigestable by the majority of people.  Numbers are a recent invention on a biological timescale and we have not yet evolved to effortlessly process data presented in that format. We are visual animals and we have evolved to be very good at seeing patterns in pictures – because it was critical to survival.  Another recent invention is spoken language and, long before writing was invented, accumulated knowledge and wisdom was passed down by word of mouth as legends, myths and stories. Stories are general descriptions that suggest specific solutions. So why do we have such difficulty in extracting the story from the data? Perhaps it is because we use our ears to hear stories that are communicated in words and we use our eyes to see patterns in pictures.  Presenting quantitative data as streams of printed symbols just doesn’t work as well.  To see the story in the data we need to present it as a picture and then talk about what we perceive.

Here are some data – a series of numbers recorded over a period of time – what is the story?

47, 55, 40, 52, 55, 70, 60, 43, 51, 41, 73, 73, 79, 89, 83, 86, 78, 85, 71, 70

Here is the same data converted into a picture.  You can see the message in the data … something changed between measurement 10 and 11.  The chart does not tell us why it changed – it only tells us when it happened and sugegsts what to look for – anything that is capable of causing the effect we can see.  We now have a story and our curiosity is aroused. We want an explanation; we want to understand; we want to learn; and we want to improve.  (For source of data and image visit

A picture can save a thousand words and ten thousand numbers!

What is the Quickest way to Paralyse a System?

Create confusion by introducing a new factor that the system has little experience of how to manage. And to get the message to spread make it really scary; life-threatening-for-innocent-bystanders-scary; because bad news travels faster than good news. What happens next is predictable; a safety alarm goes off, someone hits the brakes and everything stops. We need time to focus on the new factor, to observe it, investigate it, work out what it is, how it behaves and what to do. We have switched from doing to learning. There is a perfect example of this principle operating on a global scale as I write – a volcano in Iceland that has been dormant since 1821 suddenly spews a cloud of dust high into the sky. There are volcanic eruptions all the time so why is this different? Well, because of a combination of factors that when they combine creates a BIG system-wide impact. First the location of the volcano – on the north-west corner of Europe; then the weather – the prevailing winds are carrying the volcanic plume south and east over the whole of Europe; then the effect – to create a hazard for high altitude commercial jets. Europe is one of the most congested airspaces in the world with around 28,000 flights per day – mostly short haul – but the large European hubs serve as the end points of the trans-global long haul routes. If you want to paralyse global air travel for a completely reversible yet uncontrollable and unpredictable length of time then you probably couldn’t come up with a better plan! The trouble is that the longer the paralysis persists the greater and more irreversible the long term damage. Air travel is an essential component of many industries; so loss of flying capacity not only means loss of revenue and increased costs for airlines – the effects will be felt in every corner of commerce. What triggered this chaos was not just a volcano – it required something else – fear of the unknown. Limited, accidental experience of the interaction of high altitude volcanic plumes and commercial jets shows that all the engines of the jet can shut down – clogged by the volcanic ash. Not an attractive option for anyone. The problem is we simply do not know what the limits of safety are? We are on the horns of an uncomfortable dilemma. The experts and the press who normally feed off each other are uncharacteristically quiet at the moment … everyone is watching, waiting and hoping it will just blow away and we can get back to normal. It won’t and we can’t. Our worldview has just been changed and there is no going back – we have to evolve.

Update 25/04/2010 – I got stranded abroad for a week. It could have been much worse and what was interesting to observe was how the situation was managed. After the initial shock everyone just watched and waited. After a few days it was clear that the problem wasn’t just blowing away. The airlines were haemorrhaging money and were forced to act – by testing if the fear of engine failure was justified. It appeared not to be. A reduction in the volcanic ash being generated, and a shift of the wind, and increasing confidence led to flight activity begin resumed after 7 days. Long before the Authorities could gain any meaningful “scientific” data. The current tasks are to sort out the backlog of displaced passengers; find someone to blame and to sue for compensation. If past behaviour is anything to go by the Authorities will be blamed and the Taxpayers will pick up the bill.  Have we learned anything of lasting benefit from this experience? If not then the same lesson will be repeated; sometime, somewhere, somehow – until we do.

Are your Targets a Pain in the #*&!?

If your delivery time targets are giving you a pain in the #*&! then you may be sitting on a Horned Gaussian and do not realise it. What is a Horned Gaussian? How do you detect one? And what causes it?  To establish the diagnosis you need to gather the data from the most recent couple of hundred jobs and from it calculate the interval from receipt to delivery. Next create a tally chart with Delivery Time on the vertical axis and Counts on the horizontal axis; mark your Delivery Time Target as a horizontal line about two thirds of the way up the vertical axis; draw ten equally spaced lines between it and the X axis and five more above the Target. Finally, sort your delivery times into these “bins” and look at the profile of the histogram that results. If there is a clearly separate “hump” and “horn” and the horn is just under the target then you have confirmed the diagnosis of a Horned Gaussian. The cause is the Delivery Time Target, or more specifically its effect on your behaviour.  If the Target is externally imposed  and enforced using either a reward or a punishment then when the delivery time for a request approaches the Target, you will increase the priority of the request and the job leapfrogs to the front of the queue, pushing all the other jobs back. The order of the jobs is changing and in a severe case the large number of changing priorities generates a lot of extra work to check and reschedule the jobs.  This extra work exacerbates the delays and makes the problem worse, the horn gets taller and sharper, and the pain gets worse. Does that sound a familiar story? So what is the treatment? Well, to decide that you need to create a graph of delivery times in time order and look at the pattern (using charting tool such as BaseLine© makes this easier and quicker). What you do depends on what the chart says to you … it is the Voice of the Process.  Improvement Science is learning to understand the voice of the process.

Are We in Heated Agreement?

Do you ever feel that during a heated debate you are actually arguing the same point? You are in agreement, or rather “heated agreement”. Why does that happen and how can you distinguish this from an real disagreement? Some years ago I came across the concept of “worldviews” while looking for guidance on managing conflict. The idea is that two different people can look at the same thing and see something different; or rather perceive something different. The apparent difference leads to the debate or argument, which if carried to its conclusion demonstrates the zones of both agreement and difference.  When this is done both protagonists can learn from each other and expand their worldviews and their common ground.  If the debate never takes place then their views remain polarised, no exchange happens, no learning takes place and the common ground does not grow. So is heated debate a good thing? Well it depends on the outcome you want.  If you want to improve, learn, change and expand your perspective then “yes”; if you want to change someone else’s opinion to match yours then “no”.  Improvement implies change; change imples learning; and learning implies an altered perspective.  So engaging in heated debate and achieving heated agreement is a sensible improvement strategy!

Am I in a Battle or a Race?

Do you see the challenges that Life presents to you as a series of fight-to-the-death battles or a series of stretch-for-the-finish races? Why does it matter which approach you choose? After all, each has a winner and a loser. Yes, one wins relative to other – but what is the absolute cost for both?  The doodle illustrates the point visually. In a Battle you are in opposition and your effort, time and money are spent and dissipated against each other.  The strong/angry/big will prevail over the weak/timid/small though when the protagnoists are closely matched the outcome takes longer to decide and costs more in absolute terms for both.  One will eventually win while both are weakened from the effort, time and money that is spent.  Contrast this with the race; the investment on both sides is in preparing for the race; in learning, training, and improving.  On the day of the race the more fit/focussed/skilled competitor will win yet both are strengthened from the invested effort, time and money.  In a race the more closely you are matched the more you both improve and get stronger and the quicker the outcome is decided. Exactly the opposite of the battle. It appears that Life will present us with enough new challenges to keep us occupied for the forseeable future; and to rise to those challenges will require that we all learn, train, and practice so that we have the strength, skills and stamina for the challenges we will encounter and cannot yet see.  So, it seems to me to be suicidal to choose to battle with each other and to waste our limited resources of effort, time and money to the point where we are all too weak to survive the inevitable challenges that are over the horizon.  So how would you know which approach you are using?  Well, your feelings are more often sadness, anger or fear then you are probably using the battle metaphor; if in contrast they are feelings of confidence, determination and excitement then you probably see yourself in a race.  The choice is yours.

Anyone Heard of Henry Gantt?

Most managers have heard of Gantt charts and associate them with project management where they are widely used to help coordinate the separate threads of work so that the project finishes on time.

How many know about the man who invented them and why?

Henry Laurence Gantt (1861-1919) was an engineer and he invented the chart for a very different purpose – so that the workers and the managers could see at a glance the progress of the work and to see what was impairing the flow.  Decades before the invention of the computer, Henry Gantt created a simple and incredibly powerful visual tool for enabling workers and managers to improve processes together.

I know how simple and powerful the original Gantt chart is because I use it all the time for capturing the behaviour of a process in a visual form that stimulates constructive conversations which result in win-win-win improvements.  All you need is some squared paper, a pencil, a clock, a Mark I Eyeball or two, and a bit of practice.

Delusional Ratios and Arbitrary Targets

This week a friend of mine shared an interesting story.

They were told that their recent performance data showed that performance was improving. “That sounds good” they thought as they started to look at the data which was presented as a table of numbers, one number per time period, as a percentage ratio, and colour coded red, amber or green. The last number in the sequence was green; the previous ones were either red or amber. “See! Our performance has improved and is now acceptable“.

But it did not feel quite right to my friend who did not want to dampen the celebration without good reason, so enquired further “What is the ratio measuring exactly?” “H’mm, let me check, the number of failures divided by the number of customer requests.”  “And what does the red, amber and green signify?” “Oh that’s easy, whether we are above, near or below our target.” “And how was the target set and by whom?” “Um, I don’t know how it was set, we were just told what the target is and the consequences if we don’t meet it.” “And what are the consequences?” No answer – just a finger-across-the-throat gesture.  “Can I see the raw data used to calculate this ratio?” “Eh? I think so, but no one has ever asked us for that before.

My friend could now see the origin of his niggle of doubt.  The raw data showed that the number of customer requests was falling progressively over time while the number of successful requests was not changing.  They were calculating failures from the difference between demand and activity and then dividing the result by the demand to give a percentage that was intended to show their performance. And then setting an arbitrary target for acceptability.

The raw data told a very different story – their customers were going elsewhere – which meant their future income was progressively walking away.  They were blind to it; their ratio was deluding them.

And by setting an arbitrary target for this “delusional ratio” implied that so long as they were “in the green” they didn’t need to do anything, they could sit back and relax. They could not see the nasty surprise coming.

This story led me to wonder how many organsiations get into trouble by following delusional ratios linked to arbitrary targets? How many never see the storm coming until it is too late to avoid it?  Where do these delusional ratios and arbitrary targets come from?  Do they have a valid and useful purpose? And if so, how do we know when to use a ratio or a target and when not to?

It also gave me a new acronym – D.R.A.T. – which seems rather appropriate.

Inspired by actual events

This Sunday I was listening the Aled Jones on Radio 2 – as he was interviewing Mark Kermode of BBC.TV’s Culture Show. Mark posed a profound question:

When you visit the cinema, do you like to watch the kind of film that starts with a caption saying “This is a True Story” or maybe you prefer the kind with a caption saying “This is a story inspired by Actual Events”?

He suggested that it’s best to assume that the first kind is largely a fiction, whereas the latter is almost completely so. Personally, I don’t mind which ever kind it is, for sometimes I actually enjoy being fooled as long as it’s good harmless fun and it’s entertaining – AND as long as I don’t think someone is deliberately fooling me. But then I started wondering: How would I know if they were trying to fool me? Or more worryingly, whether I was fooling myself?

Since the 1850s there have been various “Realism” movements in the fields of cinema, art and literature – featuring the search for literal truth and pragmatism – a representation of objects, actions, or social conditions as they actually are without idealisation or presentation in abstract form – each of these movements was based upon a philosophy that universals exist independently of their having been thought up, and that physical objects exist independently of their being perceived. In this age of political and media “spin” maybe there’ll come a return to such a philosophy? In the mean time, as long as we are aware that the film we’ve chosen to watch is intended as fiction, and is billed as such, most of us won’t mind – indeed we might even view it as escapism – yet in many situations wouldn’t it be nice to feel that we are connected to a representation of events that’s more real, rather than just some one else’s imagined story?

When a patient in the healthcare system, I think I’d rather be treated by professionals who check and double check what they’re doing, and are working within a system that someone has designed to be fail safe – and is measured to be so. I’m hoping that the medics, nurses and administrators know the difference between what’s real and what is imagined. On this week’s Panorama (BBC March 8th 2010) it was suggested that some hospitals have much higher mortality than others, so this isn’t an insignificant hope. The three hospitals featured had all been flagged as having high mortality rates, yet had all been rated “Fair” or “Good” by the Care Quality Commission. This left me thinking that their may be more imagination around in the NHS than hard data.

The thing is, most everyone relies on data (via their 5 senses or their intuition) as if pure and unfiltered – under the assumption that this is all there is. But there’s always more to be known, and some of that missing knowledge may literally be the difference between life and death.

Numerical data in particular is actively avoided by many – even by professionals, be they the designers of the system or an individual who works within it. Many people left school determined to avoid numbers for the rest of their lives – when confronted by even the simplest statistic or numerical puzzle they will happily tell you “I don’t do numbers.” Since seeing the Panorama programme I’m now wondering how many people (clinicians, managers, inspectors) working within the health sector take such a view. Or maybe there’s a full-proof test that every prospective healthcare worker must pass before they’re allowed to practice? Can anyone reasure me about this?

A few weeks ago some very powerful yet delightfully accessible software was launched – called BaseLine©. It has been created so that people can have a kind of 3rd eye perception that mitigates the tendency to fictionalise – so that people can together assess what’s really happening. It’s designed to be a kind of dispassionate “fly on the wall” or a well-positioned “security camera” – and has been designed to be so easy to use that even the numerophobic will want to use it.

It’s actually free software, and even the full version costs under £50 – this is deliberate in order to maximize the possibility of it becoming a health sector standard. Having a standard tool will mean that people won’t have to debate the validity of the statistics, and can move directly to discussing the reality of what’s been happening, what’s happening now, and more importantly what’s likely to happen if nothing changes. Let’s see how long it takes clinicians and managers to discover its power?

What is the Dis-Ease?

Dis-EaseDo you ever go into places where there is a feeling of uneasiness?

You can feel it almost immediately – there is something in the room that no one is talking about.

An invisible elephant in the room, a rotting something under the table.

This week I have been pondering the cause of this dis-ease and my eureka moment happened while re-reading a book called “The Speed of Trust” by Stephen R. Covey.

A common elephant-in-the-room appears to be distrust and this got me thinking about both the causes of distrust and the effects of distrust.  My doodle captures the output of my musing.  For me, a potent cause of distrust is to be discounted; and discounting comes from disrespect.  This can happen both within yourself and between yourself and others. If you feel un-trust-worthy then you tend to disengage; and by disengaging the system functions less well – it becomes dysfunctional.  Dysfunction erodes respect and so on around the vicious circle.

This then led me to the question: Why haven’t we all drowned in our own distrust by now?  I believe what happens is that we reach an equilibrium where our level of trust is stable; so there must be a counteracting trust-building force that balances the trust-eroding force. That trust-building force seem to comes from our day-to-day social interactions with others.

The Achilles Heel of negative-cause-effect circles is that you can break into them at many points to sap their power and reduce their influence.  So, one strategy might be to identify the Errors of Commission that create the Disease of Distrust.

Consider the question: “If I have developed a high level of trust then what could I do to erode it as quickly as possible?”.

Disrespectful attitude and discounting behaviour would be all that is needed to start the vicious downward spiral of distrust disease.

Who of us never disrespects or discounts others?

Are we all infected with the same disease?

Is there a cure or can we only expect to hold it in remission?

How can we strengthen our emotional immune systems and neutralise the infective agents of the Disease of Distrust?

Do we just need to identify and stop our trust eroding behaviour?

That would be a start.

What Can We Learn From Fish?

A few weeks ago we were asked to look after the class fish during the half-term school holiday. Easy enough, just feed it daily and change the water when it gets murky was our handed-down knowledge of fish-management.  So when we observed the fish swimming at the surface apparently gulping air, even our limited grasp of fish-biology suggested that something was not quite right.  After a short web-surf our anxiety was confirmed: our fish was exhibiting high stress behaviour – it was being poisoned by toxic waste – the waste it makes itself.  We learned that a fish-tank is a delicate and complex eco-system.  Too big a fish in too small a tank, over-feeding, stagnation and infrequent complete water changes with toxic (chlorinated) tap-water are the commonest ways we upset this delicate balance. We were unintentionally killing the fish! The remedy was obvious: we had to learn about fish and learn how to maintain the fish-tank-eco-system. And fast! The fish was delivered back to school in a much bigger tank, complete with light, filter, pump, and the output of our learning – written instructions. The reaction was: “Wow! We can’t believe this is the same fish. It looks and behaves completely differently. It looks happy”.

This life-lesson reminded me of a book that I read some years ago called “Fish!” which involves the Pike Place Fish Market in Seattle and a story of how the fish-mongers inspired others to dramatically improve their own toxic work places.  The message in the story is that we all swim in the emotional toxic waste that we ourselves create; each of us has the choice to commit to reducing our toxic emotional waste emissions; we can contract to hold each other to account on this commitment; and collectively we have the power to drain our own toxic emotional waste swamps. This led to an “eureka” moment: Improvement can not happen in a toxic emotional environment. So how do we know we have one? What are the symptoms and signs? With this insight I believe we can answer that question by just looking and listening.

And if you fancy a diet of near-pure toxic emotional waste all you have to do is read a daily newspaper. Yeuk!

Can the Finance tail wag the Quality dog?

Money is the “fuel” that all organisations need to survive because all endeavours incur costs. It is the flow of money that is important – static money is just a number.  Money is used to buy time – more specifically LIFE-time.  We trade our life-time for money which we then use to buy the goods and services that we need to survive in the modern world.  These goods and services are delivered by processes that require people’s time to design, implement, operate and improve.  So we all want the best value-for-money that we can get; the best value-for-lifetime. So what happens when the flow of money is constrained? Value, Lifetime and Money are interdependent – restrict the flow of any of the three and all three slow down. It is inevitable. With this perspective it does appear that the finance tail can wag the quality dog; and the lifetime tail can wag the quality dog too. So when you experience low quality goods or services try asking this question: “Is it the flow of money, motivation or both that is the root cause?” Stories please ….

What Blocks Improvement?

Learning LoopsMy focus this week has been to ask the question “What blocks improvement?”. The answers that I found most interesting were “I didn’t realise there was a problem.” and “I feel there is a problem but I don’t know where to focus my attention.” This set me pondering and eventually I had a bit of an “eureka” moment.  It isn’t something that is present that creates this blindness – it is something that is missing. And the only way you can see what isn’t there is by comparison with when it is there – just like the game of “Spot the Difference”. When I compared what I saw with what I know is possible the thing I didn’t see was a fast-feedback loop. Hence the doodle.  It appears that there are at least four dimensions to feedback – sign, magnitude, accuracy and timing.  The speed of the feedback needs to be appropriate to the speed of the improvement; so if we want rapid improvement we need a fast-and-accurate feedback loop – a learning loop.  A slow or inaccurate learning loop not only doesn’t work – it can actually make the problem worse.  So, my take-home this week is to actively search for the learning loops and if I don’t see one then I have something to focus on improving.

What do you do when you don’t know what to do?

One of the scariest feelings I experience is when I am asked “What should we do?” or “What would you do?” and there is an expectation that I should know what to do … and I don’t.

Do I say “I don’t know” or do I play for time and spout some b*****t and hope my lack of knowledge is not exposed?

Reflecting on this uncomfortable, and oft repeated, experience I am led to some questions:

1. Where does the expectation come from? The person asking, myself or both?

2. Where does the feeling of fear come from? What am I scared of? Who am I scared of?

Pondering these questions I have the fleeting impression that my fear comes from me.  I am afraid of disappointing myself.  It is me that I am scared of.

Then the impression is replaced by a conscious process of looking for evidence that proves that it can’t be me – it must be someone else making me feel scared – and to feel better I have to shift the blame from myself.

Oooooo … that’s a bit of an “Eureka” moment!

And now I have a new option. Choose to behave like of a victim of myself and shift the blame; or choose to address the problem – my deep fear of part of myself.

Phew!  I feel better already – I have a new opportunity to explore …

The Effect of Feedback?

Feedback?I find that I have to draw pictures when I am thinking – it seems to help.

One thing I have been thinking about this week is how to predict the outcome of an action; because I don’t want to do something that has a negative outcome that I did not anticipate.

I know that whatever I do will change the “system” and may have an ongoing effect that may be positive and negative; and once I have set the ball rolling even reversing my action may not change the course.

So the problem I have is this: although I can work out what I feel is the best thing to do now, I do not seem to be able to predict the knock-on effects of my actions.  I know from experience that I may be the recipient of the future effect of my actions today. I will get feedback one way or the other.

So how do we work out what is the best thing to do now? How do we get good feedback?

Improvement costs more doesn’t it?

We all know the phrase “you get what you pay for” and we all know from experience that higher quality goods and services cost more. So, it follows that if we improve the quality of our product or service then we are always going to have to charge our customers more for it. But is that always the case?

If we add extra value to the product then it is likely that it will cost us more to do that and we may have to pass that cost on; but improvement often comes from removing something that was preventing a higher quality output.

When we remove something our costs are likely to go down and this reduction in cost can be passed on to the customer. Unfortunately the idea that lower costs mean lower quality is also deeply engrained into our thinking – so if a supplier offers what appears to be higher quality at a lower price we get suspicious. There must be a catch or a trick.

So, to avoid disappointing your customers when you make an improvement by removing an impediment to quality – just increase the price a bit.  That way your costs go down, the price goes up, the customers expectation is met and everyone is happy; your customers and especially your accountant! It can’t be that easy surely. There must be catch?

Errors of Omission and Commission

I like doodling on Post-It® Notes and playing with two-by-two tables and recently I came across one that triggered a bit of an “Eureka” moment.

The two dimensions were Action (Nothing-to-Something) and Outcome (Worse-to-Better).  We are all familiar with the good feeling that comes from doing something and seeing things get better; and the not-so-good feeling of doing something and seeing things get worse!  I discovered that this latter option is called the “Error of Commission” and is the one we fear most because we leave an audit trail of evidence that can be traced back to our action. It does not seem to matter that we did not intend the outcome to be worse.

However, the 2 x 2 table also suggests that there are two other combinations. How do we feel when we do nothing and things get better? What do we learn from that experience? And how do we feel when we do nothing and things get worse? This, I discovered, is called the “Error of Omission” and is an error that is more difficult to learn from because there is no audit trail of cause-and-effect evidence. It is also the error that generates the greatest sadness – a feeling of loss of what might have been.

Both the Error of Commission and the Error of Omission can lead to unintended negative consequences.  It appears that our systems are better designed to manage the Errors of Commission. I wonder if we could learn to better protect ourselves from the Errors of Omission?

Seeing the Voice of the Process

Welcome to the blog that is specifically focussed on the Science of Improvement – the growing body of knowledge about how to achieve improvement in any system or process both reliably and safely.