The phone announced the arrival of Leslie for the weekly ISP mentoring conversation with Bob.
<Leslie> Hi Bob.
<Bob> Hi Leslie. What would you like to talk about today?
<Leslie> A new challenge – one that I have not encountered before.
<Bob>Excellent. As ever you have pricked my curiosity. Tell me more.
<Leslie> OK. Up until very recently whenever I have demonstrated the results of our improvement work to individuals or groups the usual response has been “Yes, but“. The habitual discount as you call it. “Yes, but your service is simpler; Yes, but your budget is bigger; Yes, but your staff are less militant.” I have learned to expect it so I do not get angry any more.
<Bob> OK. The mantra of the skeptics is to be expected and you have learned to stay calm and maintain respect. So what is the new challenge?
<Leslie>There are two parts to it. Firstly, because the habitual discounting is such an effective barrier to diffusion of learning; our system has not changed; the performance is steadily deteriorating; the chaos is worsening and everything that is ‘obvious’ has been tried and has not worked. More red lights are flashing on the patient-harm dashboard and the Inspectors are on their way. There is an increasing turnover of staff at all levels – including Executive. There is an anguished call for “A return to compassion first” and “A search for new leaders” and “A cultural transformation“.
<Bob> OK. It sounds like the tipping point of awareness has been reached, enough people now appreciate that their platform is burning and radical change of strategy is required to avoid the ship sinking and them all drowning. What is the second part?
<Leslie> I am getting more emails along the line of “What would you do?”
<Bob> And your reply?
<Leslie> I say that I do not know because I do not have a diagnosis of the cause of the problem. I do know a lot of possible causes but I do not know which plausible ones are the actual ones.
<Bob> That is a good answer. What was the response?
<Leslie>The commonest one is “Yes, but you have shown us that Plan-Do-Study-Act is the way to improve – and we have tried that and it does not work for us. So we think that improvement science is just more snake oil!”
<Bob>Ah ha. And how do you feel about that?
<Leslie>I have learned the hard way to respect the opinion of skeptics. PDSA does work for me but not for them. And I do not understand why that is. I would like to conclude that they are not doing it right but that is just discounting them and I am wary of doing that.
<Bob>OK. You are wise to be wary. We have reached what I call the Mirror-on-the-Wall moment. Let me ask what your understanding of the history of PDSA is?
<Leslie>It was called Plan-Do-Check-Act by Walter Shewhart in the 1930’s and was presented as a form of the scientific method that could be applied on the factory floor to improving the quality of manufactured products. W Edwards Deming modified it to PDSA where the “Check” was changed to “Study”. Since then it has been the key tool in the improvement toolbox.
<Bob>Good. That is an excellent summary. What the Zealots do not talk about are the limitations of their wonder-tool. Perhaps that is because they believe it has no limitations. Your experience would seem to suggest otherwise though.
<Leslie>Spot on Bob. I have a nagging doubt that I am missing something here. And not just me.
<Bob>The reason PDSA works for you is because you are using it for the purpose it was designed for: incremental improvement of small bits of the big system; the steps; the points where the streams cross the stages. You are using your FISH training to come up with change plans that will work because you understand the Physics of Flow better. You make wise improvement decisions. In fact you are using PDSA in two separate modes: discovery mode and delivery mode. In discovery mode we use the Study phase to build your competence – and we learn most when what happens is not what we expected. In delivery mode we use the Study phase to build our confidence – and that grows most when what happens is what we predicted.
<Leslie>Yes, that makes sense. I see the two modes clearly now you have framed it that way – and I see that I am doing both at the same time, almost by second nature.
<Bob>Yes – so when you demonstrate it you describe PDSA generically – not as two complimentary but contrasting modes. And by demonstrating success you omit to show that there are some design challenges that cannot be solved with either mode. That hidden gap attracts some of the “Yes, but” reactions.
<Leslie>Do you mean the challenges that others are trying to solve and failing?
<Bob>Yes. The commonest error is to discount the value of improvement science in general; so nothing is done and the inevitable crisis happens because the system design is increasingly unfit for the evolving needs. The toast is not just burned it is on fire and is now too late to use the discovery mode of PDSA because prompt and effective action is needed. So the delivery mode of PDSA is applied to a emergent, ill-understood crisis. The Plan is created using invalid assumptions and guesswork so it is fundamentally flawed and the Do then just makes the chaos worse. In the ensuing panic the Study and Act steps are skipped so all hope of learning is lost and and a vicious and damaging spiral of knee-jerk Plan-Do-Plan-Do follows. The chaos worsens, quality falls, safety falls, confidence falls, trust falls, expectation falls and depression and despair increase.
<Leslie>That is exactly what is happening and why I feel powerless to help. What do I do?
<Bob>The toughest bit is past. You have looked squarely in the mirror and can now see harsh reality rather than hasty rhetoric. Now you can look out of the window with different eyes. And you are now looking for a real-world example of where complex problems are solved effectively and efficiently. Can you think of one?
<Leslie>Well medicine is one that jumps to mind. Solving a complex, emergent clinical problems requires a clear diagnosis and prompt and effective action to stabilise the patient and then to cure the underlying cause: the disease.
<Bob>An excellent example. Can you describe what happens as a PDSA sequence?
<Leslie>That is a really interesting question. I can say for starters that it does not start with P – we have learned are not to have a preconceived idea of what to do at the start because it badly distorts our clinical judgement. The first thing we do is assess the patient to see how sick and unstable they are – we use the Vital Signs. So that means that we decide to Act first and our first action is to Study the patient.
<Bob>OK – what happens next?
<Leslie>Then we will do whatever is needed to stabilise the patient based on what we have observed – it is called resuscitation – and only then we can plan how we will establish the diagnosis; the root cause of the crisis.
<Bob> So what does that spell?
<Leslie> A-S-D-P. It is the exact opposite of P-D-S-A … the mirror image!
<Bob>Yes. Now consider the treatment that addresses the root cause and that cures the patient. What happens then?
<Leslie>We use the diagnosis is used to create a treatment Plan for the specific patient; we then Do that, and we Study the effect of the treatment in that specific patient, using our various charts to compare what actually happens with what we predicted would happen. Then we decide what to do next: the final action. We may stop because we have achieved our goal, or repeat the whole cycle to achieve further improvement. So that is our old friend P-D-S-A.
<Bob>Yes. And what links the two bits together … what is the bit in the middle?
<Leslie>Once we have a diagnosis we look up the appropriate treatment options that have been proven to work through research trials and experience; and we tailor the treatment to the specific patient. Oh I see! The missing link is design. We design a specific treatment plan using generic principles.
<Bob>Yup. The design step is the jam in the improvement sandwich and it acts like a mirror: A-S-D-P is reflected back as P-D-S-A
<Leslie>So I need to teach this backwards: P-D-S-A and then Design and then A-S-P-D!
<Bob>Yup – and you know that by another name.
<Leslie> 6M Design®! That is what my Improvement Science Practitioner course is all about.
<Leslie> If you had told me that at the start it would not have made much sense – it would just have confused me.
<Bob>I know. That is the reason I did not. The Mirror needs to be discovered in order for the true value to appreciated. At the start we look in the mirror and perceive what we want to see. We have to learn to see what is actually there. Us. Now you can see clearly where P-D-S-A and Design fit together and the missing A-S-D-P component that is needed to assemble a 6M Design® engine. That is Improvement-by-Design in a nine-letter nutshell.
<Leslie> Wow! I can’t wait to share this.
<Bob> And what do you expect the response to be?
<Bob> From the die hard skeptics – yes. It is the ones who do not say “Yes, but” that you want to engage with. The ones who are quiet. It is always the quiet ones that hold the key.