Archive for the ‘ChimpWare’ Category

This is the now-infamous statement that Donald Rumsfeld made at a Pentagon Press Conference which triggered some good-natured jesting from the assembled journalists.

But there is a problem with it.

There is a fourth combination that he does not mention: the Unknown-Knowns.

Which is a shame because they are actually the most important because they cause the most problems.  Avoidable problems.


Suppose there is a piece of knowledge that someone knows but that someone else does not; then we have an unknown-known.

None of us know everything and we do not need to, because knowledge that is of no value to us is irrelevant for us.

But what happens when the unknown-known is of value to us, and more than that; what happens when it would be reasonable for someone else to expect us to know it; because it is our job to know.


A surgeon would be not expected to know a lot about astronomy, but they would be expected to know a lot about anatomy.


So, what happens if we become aware that we are missing an important piece of knowledge that is actually already known?  What is our normal human reaction to that discovery?

Typically, our first reaction is fear-driven and we express defensive behaviour.  This is because we fear the potential loss-of-face from being exposed as inept.

From this sudden shock we then enter a characteristic emotional pattern which is called the Nerve Curve.

After the shock of discovery we quickly flip into denial and, if that does not work then to anger (i.e. blame).  We ignore the message and if that does not work we shoot the messenger.


And when in this emotionally charged state, our rationality tends to take a back seat.  So, if we want to benefit from the discovery of an unknown-known, then we have to learn to bite-our-lip, wait, let the red mist dissipate, and then re-examine the available evidence with a cool, curious, open mind.  A state of mind that is receptive and open to learning.


Recently, I was reminded of this.


The context is health care improvement, and I was using a systems engineering framework to conduct some diagnostic data analysis.

My first task was to run a data-completeness-verification-test … and the data I had been sent did not pass the test.  There was some missing.  It was an error of omission (EOO) and they are the hardest ones to spot.  Hence the need for the verification test.

The cause of the EOO was an unknown-known in the department that holds the keys to the data warehouse.  And I have come across this EOO before, so I was not surprised.

Hence the need for the verification test.

I was not annoyed either.  I just fed back the results of the test, explained what the issue was, explained the cause, and they listened and learned.


The implication of this specific EOO is quite profound though because it appears to be ubiquitous across the NHS.

To be specific it relates to the precise details of how raw data on demand, activity, length of stay and bed occupancy is extracted from the NHS data warehouses.

So it is rather relevant to just about everything the NHS does!

And the error-of-omission leads to confusion at best; and at worst … to the following sequence … incomplete data =>  invalid analysis => incorrect conclusion => poor decision => counter-productive action => unintended outcome.

Does that sound at all familiar?


So, if would you like to learn about this valuable unknown-known is then I recommend the narrative by Dr Kate Silvester, an internationally recognised expert in healthcare improvement.  In it, Kate re-tells the story of her emotional roller-coaster ride when she discovered she was making the same error.


Here is the link to the full abstract and where you can download and read the full text of Kate’s excellent essay, and help to make it a known-known.

That is what system-wide improvement requires – sharing the knowledge.

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

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

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

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

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


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

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

Why is that?


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

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

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

So why do we laugh when we are learning?

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

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

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

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

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

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

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


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

And the results are clear.

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

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

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

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

… the Flow Design Practical Skills One Day Workshop.

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


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

Sometimes change is dramatic. A big improvement appears very quickly. And when that happens we are caught by surprise (and delight).

Our emotional reaction is much faster than our logical response. “Wow! That’s a miracle!


Our logical Tortoise eventually catches up with our emotional Hare and says “Hare, we both know that there is no such thing as miracles and magic. There must be a rational explanation. What is it?

And Hare replies “I have no idea, Tortoise.  If I did then it would not have been such a delightful surprise. You are such a kill-joy! Can’t you just relish the relief without analyzing the life out of it?

Tortoise feels hurt. “But I just want to understand so that I can explain to others. So that they can do it and get the same improvement.  Not everyone has a ‘nothing-ventured-nothing-gained’ attitude like you! Most of us are too fearful of failing to risk trusting the wild claims of improvement evangelists. We have had our fingers burned too often.


The apparent miracle is real and recent … here is a snippet of the feedback:

Notice carefully the last sentence. It took a year of discussion to get an “OK” and a month of planning to prepare the “GO”.

That is not a miracle and some magic … that took a lot of hard work!

The evangelist is the customer. The supplier is an engineer.


The context is the chronic niggle of patients trying to get an appointment with their GP, and the chronic niggle of GPs feeling overwhelmed with work.

Here is the back story …

In the opening weeks of the 21st Century, the National Primary Care Development Team (NPDT) was formed.  Primary care was a high priority and the government had allocated £168m of investment in the NHS Plan, £48m of which was earmarked to improve GP access.

The approach the NPDT chose was:

harvest best practice +
use a panel of experts +
disseminate best practice.

Dr (later Sir) John Oldham was the innovator and figure-head.  The best practice was copied from Dr Mark Murray from Kaiser Permanente in the USA – the Advanced Access model.  The dissemination method was copied from from Dr Don Berwick’s Institute of Healthcare Improvement (IHI) in Boston – the Collaborative Model.

The principle of Advanced Access is “today’s-work-today” which means that all the requests for a GP appointment are handled the same day.  And the proponents of the model outlined the key elements to achieving this:

1. Measure daily demand.
2. Set capacity so that is sufficient to meet the daily demand.
3. Simple booking rule: “phone today for a decision today”.

But that is not what was rolled out. The design was modified somewhere between aspiration and implementation and in two important ways.

First, by adding a policy of “Phone at 08:00 for an appointment”, and second by adding a policy of “carving out” appointment slots into labelled pots such as ‘Dr X’ or ‘see in 2 weeks’ or ‘annual reviews’.

Subsequent studies suggest that the tweaking happened at the GP practice level and was driven by the fear that, by reducing the waiting time, they would attract more work.

In other words: an assumption that demand for health care is supply-led, and without some form of access barrier, the system would be overwhelmed and never be able to cope.


The result of this well-intended tampering with the Advanced Access design was to invalidate it. Oops!

To a systems engineer this is meddling was counter-productive.

The “today’s work today” specification is called a demand-led design and, if implemented competently, will lead to shorter waits for everyone, no need for urgent/routine prioritization and slot carve-out, and a simpler, safer, calmer, more efficient, higher quality, more productive system.

In this context it does not mean “see every patient today” it means “assess and decide a plan for every patient today”.

In reality, the actual demand for GP appointments is not known at the start; which is why the first step is to implement continuous measurement of the daily number and category of requests for appointments.

The second step is to feed back this daily demand information in a visual format called a time-series chart.

The third step is to use this visual tool for planning future flow-capacity, and for monitoring for ‘signals’, such as spikes, shifts, cycles and slopes.

That was not part of the modified design, so the reasonable fear expressed by GPs was (and still is) that by attempting to do today’s-work-today they would unleash a deluge of unmet need … and be swamped/drowned.

So a flood defense barrier was bolted on; the policy of “phone at 08:00 for an appointment today“, and then the policy of  channeling the over spill into pots of “embargoed slots“.

The combined effect of this error of omission (omitting the measured demand visual feedback loop) and these errors of commission (the 08:00 policy and appointment slot carve-out policy) effectively prevented the benefits of the Advanced Access design being achieved.  It was a predictable failure.

But no one seemed to realize that at the time.  Perhaps because of the political haste that was driving the process, and perhaps because there were no systems engineers on the panel-of-experts to point out the risks of diluting the design.

It is also interesting to note that the strategic aim of the NPCT was to develop a self-sustaining culture of quality improvement (QI) in primary care. That didn’t seem to have happened either.


The roll out of Advanced Access was not the success it was hoped. This is the conclusion from the 300+ page research report published in 2007.


The “Miracle on Tavanagh Avenue” that was experienced this week by both patients and staff was the expected effect of this tampering finally being corrected; and the true potential of the original demand-led design being released – for all to experience.

Remember the essential ingredients?

1. Measure daily demand and feed it back as a visual time-series chart.
2. Set capacity so that is sufficient to meet the daily demand.
3. Use a simple booking rule: “phone anytime for a decision today”.

But there is also an extra design ingredient that has been added in this case, one that was not part of the original Advanced Access specification, one that frees up GP time to provide the required “resilience” to sustain a same-day service.

And that “secret” ingredient is how the new design worked so quickly and feels like a miracle – safe, calm, enjoyable and productive.

This is health care systems engineering (HCSE) in action.


So congratulations to Harry Longman, the whole team at GP Access, and to Dr Philip Lusty and the team at Riverside Practice, Tavangh Avenue, Portadown, NI.

You have demonstrated what was always possible.

The fear of failure prevented it before, just as it prevented you doing this until you were so desperate you had no other choices.

To read the fuller story click here.

PS. Keep a close eye on the demand time-series chart and if it starts to rise then investigate the root cause … immediately.


stick_figure_superhero_anim_150_wht_1857Have you heard the phrase “Pride comes before a fall“?

What does this mean? That the feeling of pride is the reason for the subsequent fall?

So by following that causal logic, if we do not allow ourselves to feel proud then we can avoid the fall?

And none of us like the feeling of falling and failing. We are fearful of that negative feeling, so with this simple trick we can avoid feeling bad. Yes?

But we all know the positive feeling of achievement – we feel pride when we have done good work, when our impact matches our intent.  Pride in our work.

Is that bad too?

Should we accept under-achievement and unexceptional mediocrity as the inevitable cost of avoiding the pain of possible failure?  Is that what we are being told to do here?


The phrase comes from the Bible, from the Book of Proverbs 16:18 to be precise.

proverb

And the problem here is that the phrase “pride comes before a fall” is not the whole proverb.

It has been simplified. Some bits have been omitted. And those omissions lead to ambiguity and the opportunity for obfuscation and re-interpretation.

pride_goes_before_a_fall
In the fuller New International Version we see a missing bit … the “haughty spirit” bit.  That is another way of saying “over-confident” or “arrogant”.


But even this “authorised” version is still ambiguous and more questions spring to mind:

Q1. What sort of pride are we referring to? Just the confidence version? What about the pride that follows achievement?

Q2. How would we know if our feeling of confidence is actually justified?

Q3. Does a feeling of confidence always precede a fall? Is that how we diagnose over-confidence? Retrospectively? Are there instances when we feel confident but we do not fail? Are there instances when we do not feel confident and then fail?

Q4. Does confidence cause the fall or it is just a temporal association? Is there something more fundamental that causes both high-confidence and low-competence?


There is a well known model called the Conscious-Competence model of learning which generates a sequence of four stages to achieving a new skill. Such as one we need to achieve our intended outcomes.

We all start in the “blissful ignorance” zone of unconscious incompetence.  Our unknowns are unknown to us.  They are blind spots.  So we feel unjustifiably confident.

hierarchy_of_competence

In this model the first barrier to progress is “wrong intuition” which means that we actually have unconscious assumptions that are distorting our perception of reality.

What we perceive makes sense to us. It is clear and obvious. We feel confident. We believe our own rhetoric.

But our unconscious assumptions can trick us into interpreting information incorrectly.  And if we derive decisions from unverified assumptions and invalid analysis then we may do the wrong thing and not achieve our intended outcome.  We may unintentionally cause ourselves to fail and not be aware of it.  But we are proud and confident.

Then the gap between our intent and our impact becomes visible to all and painful to us. So we are tempted to avoid the social pain of public failure by retreating behind the “Yes, But” smokescreen of defensive reasoning. The “doom loop” as it is sometimes called. The Victim Vortex. “Don’t name, shame and blame me, I was doing my best. I did not intent that to happen. To err is human”.


The good news is that this learning model also signposts a possible way out; a door in the black curtain of ignorance.  It suggests that we can learn how to correct our analysis by using feedback from reality to verify our rhetorical assumptions.  Those assumptions which pass the “reality check” we keep, those which fail the “reality check” we redesign and retest until they pass.  Bit by bit our inner rhetoric comes to more closely match reality and the wisdom of our decisions will improve.

And what we then see is improvement.  Our impact moves closer towards our intent. And we can justifiably feel proud of that achievement. We do not need to be best-compared-with-the-rest; just being better-than-we-were-before is OK. That is learning.

the_learning_curve

And this is how it feels … this is the Learning Curve … or the Nerve Curve as we call it.

What it says is that to be able to assess confidence we must also measure competence. Outcomes. Impact.

And to achieve excellence we have to be prepared to actively look for any gap between intent and impact.  And we have to be prepared to see it as an opportunity rather than as a threat. And we will need to be able to seek feedback and other people’s perspectives. And we need to be to open to asking for examples and explanations from those who have demonstrated competence.

It says that confidence is not a trustworthy surrogate for competence.

It says that we want the confidence that flows from competence because that is the foundation of trust.

Improvement flows at the speed of trust and seeing competence, confidence and trust growing is a joyous thing.

Pride and Joy are OK.

Arrogance and incompetence comes before a fall would be a better proverb.

focus_on_sfqpThe theme of the week has been “focus” and by that I mean the amazing ability of the human mind to concentrate on one thing to the exclusion of almost all else.

To illustrate what I mean, just reflect on what happens when we watch a television program.  We do not see the TV screen, controls, or the “stuff” around it.  Or to be more precise … we do see it but we do not perceive it.

Even our Mark I Eyeballs have evolved to “focus” and I do not mean just the clear bits that create a sharp image on the light-sensitive layer at the back (the retina).

Our retinas are not like a video camera … not at all … they have a very high resolution bit at the center which is quite small, and a rather low resolution bit that surrounds it and that is much bigger.

But we do not perceive that … because we have some very advanced data processing wetware … and the process actually starts in the retina.


And our eyes are always moving … just observe someone else’s eyes when they are looking at a picture or reading a book.  If the cameras in a TV studio did that we would complain!

So what is happening here?

The answer is that our advanced data processing wetware is scanning, but not in the way that a radar scans … in a mindless cycle.  Our eye scanning has purpose … it is driven by the mental model inside our heads that is looking for information, and the search is based on what we already believe and perceive.


Psychologists have studied this using cool technology that tracks the eye position and works out what the person is looking at.  And what they found was surprising.

facescanIf we are presented with a picture of a face we will scan it in a very consistent way.  We look at the nose first and then we look at eyes, mouth and we pattern-match to answer the question “Do I recognize this person?

If we do then we can draw on past memories of them to help inform our interpretation of what we see.  If we do not then we need to keep watching and learning.  We need an answer to the question “Is this person an opportunity or a threat?


And it is a very fast process, and it happens out of awareness, and it is hard-wired and it is automatic.

After initial recognition we will focus on the eyes and mouth because, as the Greeks said, “the eyes are the window to the soul“.  We need to infer what the other person is thinking … unconsciously.


And the good news is that this amazing ability to focus is not completely automatic … it can be directed … rather like a radio can be tuned to specific frequency.

And when we learn how to do that as individuals the effect is surprising.

And when we learn how to do that as a group, in synergy, the effect is amazing!

monkey_on_back_anim_150_wht_11200

About 25 years ago a paper was published in the Harvard Business Review with the interesting title of “Teaching Smart People How To Learn

The uncomfortable message was that many people who are top of the intellectual rankings are actually very poor learners.

This sounds like a paradox.  How can people be high-achievers and yet be unable to learn?


Health care systems are stuffed full of super-smart, high-achieving professionals. The cream of educational crop. The top 2%. They are called “doctors”.

And we have a problem with improvement in health care … a big problem … the safety, delivery, quality and affordability of the NHS is getting worse. Not better.

Improvement implies change and change implies learning, so if smart people struggle to learn then could that explain why health care systems find self-improvement so difficult?

This paragraph from the 1991 HBR paper feels uncomfortably familiar:

defensive_reasoning_2

The author, Chris Argyris, refers to something called “single-loop learning” and if we translate this management-speak into the language of medicine it would come out as “treating the symptom and ignoring the disease“.  That is poor medicine.

Chris also suggests an antidote to this problem and gave it the label “double-loop learning” which if translated into medical speak becomes “diagnosis“.  And that is something that doctors can relate to because without a diagnosis, a justifiable treatment is difficult to formulate.


We need to diagnose the root cause(s) of the NHS disease.


The 1991 HBR paper refers back to an earlier 1977 HBR paper called Double Loop Learning in Organisations where we find the theory that underpins it.

The proposed hypothesis is that we all have cognitive models that we use to decide our actions (and in-actions), what I have referred to before as ChimpWare.  In it is a reference to a table published in a 1974 book and the message is that Single-Loop learning is a manifestation of a Model 1 theory-in-action.

defensive_reasoning_models


And if we consider the task that doctors are expected to do then we can empathize with their dominant Model 1 approach.  Health care is a dangerous business.  Doctors can cause a lot of unintentional harm – both physical and psychological.  Doctors are dealing with a very, very complex system – a human body – that they only partially understand.  No two patients are exactly the same and illness is a dynamic process.  Everyone’s expectations are high. We have come a long way since the days of blood-letting and leeches!  Failure is not tolerated.

Doctors are intelligent and competitive … they had to be to win the education race.

Doctors must make tough decisions and have to have tough conversations … many, many times … and yet not be consumed in the process.  They often have to suppress emotions to be effective.

Doctors feel the need to protect patients from harm – both physical and emotional.

And collectively they do a very good job.  Doctors are respected and trusted professionals.


But …  to quote Chris Argyris …

“Model I blinds people to their weaknesses. For instance, the six corporate presidents were unable to realize how incapable they were of questioning their assumptions and breaking through to fresh understanding. They were under the illusion that they could learn, when in reality they just kept running around the same track.”

This blindness is self-reinforcing because …

“All parties withheld information that was potentially threatening to themselves or to others, and the act of cover-up itself was closed to discussion.”


How many times have we seen this in the NHS?

The Mid-Staffordshire Hospital debacle that led to the Francis Report is all the evidence we need.


So what is the way out of this double-bind?

Chris gives us some hints with his Model II theory-in-use.

  1. Valid information – Study.
  2. Free and informed choice – Plan.
  3. Constant monitoring of the implementation – Do.

The skill required is to question assumptions and break through to fresh understanding and we can do that with design-led approach because that is what designers do.

They bring their unconscious assumptions up to awareness and ask “Is that valid?” and “What if” questions.

It is called Improvement-by-Design.

And the good news is that this Model II approach works in health care, and we know that because the evidence is accumulating.

 

thinker_figure_unsolve_puzzle_150_wht_18309Many of the challenges that we face in delivering effective and affordable health care do not have well understood and generally accepted solutions.

If they did there would be no discussion or debate about what to do and the results would speak for themselves.

This lack of understanding is leading us to try to solve a complicated system design challenge in our heads.  Intuitively.

And trying to do it this way is fraught with frustration and risk because our intuition tricks us. It was this sort of challenge that led Professor Rubik to invent his famous 3D Magic Cube puzzle.

It is difficult enough to learn how to solve the Magic Cube puzzle by trial and error; it is even more difficult to attempt to do it inside our heads! Intuitively.


And we know the Rubik Cube puzzle is solvable, so all we need are some techniques, tools and training to improve our Rubik Cube solving capability.  We can all learn how to do it.


Returning to the challenge of safe and affordable health care, and to the specific problem of unscheduled care, A&E targets, delayed transfers of care (DTOC), finance, fragmentation and chronic frustration.

This is a systems engineering challenge so we need some systems engineering techniques, tools and training before attempting it.  Not after failing repeatedly.

se_vee_diagram

One technique that a systems engineer will use is called a Vee Diagram such as the one shown above.  It shows the sequence of steps in the generic problem solving process and it has the same sequence that we use in medicine for solving problems that patients present to us …

Diagnose, Design and Deliver

which is also known as …

Study, Plan, Do.


Notice that there are three words in the diagram that start with the letter V … value, verify and validate.  These are probably the three most important words in the vocabulary of a systems engineer.


One tool that a systems engineer always uses is a model of the system under consideration.

Models come in many forms from conceptual to physical and are used in two main ways:

  1. To assist the understanding of the past (diagnosis)
  2. To predict the behaviour in the future (prognosis)

And the process of creating a system model, the sequence of steps, is shown in the Vee Diagram.  The systems engineer’s objective is a validated model that can be trusted to make good-enough predictions; ones that support making wiser decisions of which design options to implement, and which not to.


So if a systems engineer presented us with a conceptual model that is intended to assist our understanding, then we will require some evidence that all stages of the Vee Diagram process have been completed.  Evidence that provides assurance that the model predictions can be trusted.  And the scope over which they can be trusted.


Last month a report was published by the Nuffield Trust that is entitled “Understanding patient flow in hospitals”  and it asserts that traffic flow on a motorway is a valid conceptual model of patient flow through a hospital.  Here is a direct quote from the second paragraph in the Executive Summary:

nuffield_report_01
Unfortunately, no evidence is provided in the report to support the validity of the statement and that omission should ring an alarm bell.

The observation that “the hospitals with the least free space struggle the most” is not a validation of the conceptual model.  Validation requires a concrete experiment.


To illustrate why observation is not validation let us consider a scenario where I have a headache and I take a paracetamol and my headache goes away.  I now have some evidence that shows a temporal association between what I did (take paracetamol) and what I got (a reduction in head pain).

But this is not a valid experiment because I have not considered the other seven possible combinations of headache before (Y/N), paracetamol (Y/N) and headache after (Y/N).

An association cannot be used to prove causation; not even a temporal association.

When I do not understand the cause, and I am without evidence from a well-designed experiment, then I might be tempted to intuitively jump to the (invalid) conclusion that “headaches are caused by lack of paracetamol!” and if untested this invalid judgement may persist and even become a belief.


Understanding causality requires an approach called counterfactual analysis; otherwise known as “What if?” And we can start that process with a thought experiment using our rhetorical model.  But we must remember that we must always validate the outcome with a real experiment. That is how good science works.

A famous thought experiment was conducted by Albert Einstein when he asked the question “If I were sitting on a light beam and moving at the speed of light what would I see?” This question led him to the Theory of Relativity which completely changed the way we now think about space and time.  Einstein’s model has been repeatedly validated by careful experiment, and has allowed engineers to design and deliver valuable tools such as the Global Positioning System which uses relativity theory to achieve high positional precision and accuracy.


So let us conduct a thought experiment to explore the ‘faster movement requires more space‘ statement in the case of patient flow in a hospital.

First, we need to define what we mean by the words we are using.

The phrase ‘faster movement’ is ambiguous.  Does it mean higher flow (more patients per day being admitted and discharged) or does it mean shorter length of stage (the interval between the admission and discharge events for individual patients)?

The phrase ‘more space’ is also ambiguous. In a hospital that implies physical space i.e. floor-space that may be occupied by corridors, chairs, cubicles, trolleys, and beds.  So are we actually referring to flow-space or storage-space?

What we have in this over-simplified statement is the conflation of two concepts: flow-capacity and space-capacity. They are different things. They have different units. And the result of conflating them is meaningless and confusing.


However, our stated goal is to improve understanding so let us consider one combination, and let us be careful to be more precise with our terminology, “higher flow always requires more beds“. Does it? Can we disprove this assertion with an example where higher flow required less beds (i.e. space-capacity)?

The relationship between flow and space-capacity is well understood.

The starting point is Little’s Law which was proven mathematically in 1961 by J.D.C. Little and it states:

Average work in progress = Average lead time  X  Average flow.

In the hospital context, work in progress is the number of occupied beds, lead time is the length of stay and flow is admissions or discharges per time interval (which must be the same on average over a long period of time).

(NB. Engineers are rather pedantic about units so let us check that this makes sense: the unit of WIP is ‘patients’, the unit of lead time is ‘days’, and the unit of flow is ‘patients per day’ so ‘patients’ = ‘days’ * ‘patients / day’. Correct. Verified. Tick.)

So, is there a situation where flow can increase and WIP can decrease? Yes. When lead time decreases. Little’s Law says that is possible. We have disproved the assertion.


Let us take the other interpretation of higher flow as shorter length of stay: i.e. shorter length of stay always requires more beds.  Is this correct? No. If flow remains the same then Little’s Law states that we will require fewer beds. This assertion is disproved as well.

And we need to remember that Little’s Law is proven to be valid for averages, does that shed any light on the source of our confusion? Could the assertion about flow and beds actually be about the variation in flow over time and not about the average flow?


And this is also well understood. The original work on it was done almost exactly 100 years ago by Agner Arup Erlang and the problem he looked at was the quality of customer service of the early telephone exchanges. Specifically, how likely was the caller to get the “all lines are busy, please try later” response.

What Erlang showed was there there is a mathematical relationship between the number of calls being made (the demand), the probability of a call being connected first time (the service quality) and the number of telephone circuits and switchboard operators available (the service cost).


So it appears that we already have a validated mathematical model that links flow, quality and cost that we might use if we substitute ‘patients’ for ‘calls’, ‘beds’ for ‘telephone circuits’, and ‘being connected’ for ‘being admitted’.

And this topic of patient flow, A&E performance and Erlang queues has been explored already … here.

So a telephone exchange is a more valid model of a hospital than a motorway.

We are now making progress in deepening our understanding.


The use of an invalid, untested, conceptual model is sloppy systems engineering.

So if the engineering is sloppy we would be unwise to fully trust the conclusions.

And I share this feedback in the spirit of black box thinking because I believe that there are some valuable lessons to be learned here – by us all.


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chimpwareOne of the recurring themes in this narrative is the realisation that we are all subject to the emergent effects of millions of years of adaptive evolution.

We all know about genes, the chemical code called DNA, that holds the instructions for building a person.

We are less aware of memes, the cultural code that holds the instructions for building a society.

And we are even less aware of the complex interaction between genes and memes.


One of the emergent properties of this gene/meme interaction is our ability to use symbolic language and causal reasoning.

But this amazing ability only developed recently, in the last few million years, and that means evolution has not had time to finish the job.  So we are left with prototype hardware and software.


The prototype hardware is called ChimpWare and it is the 1.3 kg of wetware between our ears.  On the surface it looks a bit like the wetware of other animals, but appearances are deceptive.

Our ChimpWare is a multi-level-parallel-multi-processor! Amazing engineering.

And rather than evolving a completely new design (which is rather difficult for a reactive evolutionary process), we have evolved newer prototypes that sit on top of the older wetware.

This build-on-the-old-foundations approach has a downside … the newer parts and the older parts need to talk to each other and they use different languages.

Different software.


The newer part uses sequential, causal logic and communicates using symbolic language.  The older part uses parallel, associative logic and communicates using emotions.  Thinking and feeling.  Rational and irrational.

The software is ChimpOS 1.0 and we are not going to get an update … because it too is a work-in-progress.


When we are forced by circumstance to grapple with the challenge of improving a complex adaptive system such as health care, we have no choice but to use ChimpWare and ChimpOS both individually and collectively.  And it is not well designed for this job.

invisible_gorillaSo we make mistakes, and we are often not aware of the errors we are making.  All we become aware of is the gap between our intent and our impact.

Our intuition deceives us, which also implies that some concepts that are valid and useful feel counter-intuitive.  So we discount them.

The Invisible Gorilla” is well worth a read because it describes many of the illusions that our ChimpWare and ChimpOS generate.

Illusions such as the illusion of attention,  the illusion of memory,  the illusion of confidence,  the illusion of knowledge, and the illusion of cause.


But with a conscious insight into the limitations of the legacy of evolution, we can actually learn to avoid many of the pitfalls, and to develop our individual and collective capability for improving the complex adaptive systems that we live in.

For the benefit of everyone and everything.

In fact, our long term survival depends on it – both collectively and individually.

So doing nothing is not an option.


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reading_a_book_pa_150_wht_3136An effective way to improve is to learn from others who have demonstrated the capability to achieve what we seek.  To learn from success.

Another effective way to improve is to learn from those who are not succeeding … to learn from failures … and that means … to learn from our own failings.

But from an early age we are socially programmed with a fear of failure.

The training starts at school where failure is not tolerated, nor is challenging the given dogma.  Paradoxically, the effect of our fear of failure is that our ability to inquire, experiment, learn, adapt, and to be resilient to change is severely impaired!

So further failure in the future becomes more likely, not less likely. Oops!


Fortunately, we can develop a healthier attitude to failure and we can learn how to harness the gap between intent and impact as a source of energy, creativity, innovation, experimentation, learning, improvement and growing success.

And health care provides us with ample opportunities to explore this unfamiliar terrain. The creative domain of the designer and engineer.


The scatter plot below is a snapshot of the A&E 4 hr target yield for all NHS Trusts in England for the month of July 2016.  The required “constitutional” performance requirement is better than 95%.  The delivered whole system average is 85%.  The majority of Trusts are failing, and the Trust-to-Trust variation is rather wide. Oops!

This stark picture of the gap between intent (95%) and impact (85%) prompts some uncomfortable questions:

Q1: How can one Trust achieve 98% and yet another can do no better than 64%?

Q2: What can all Trusts learn from these high and low flying outliers?

[NB. I have not asked the question “Who should we blame for the failures?” because the name-shame-blame-game is also a predictable consequence of our fear-of-failure mindset.]


Let us dig a bit deeper into the information mine, and as we do that we need to be aware of a trap:

A snapshot-in-time tells us very little about how the system and the set of interconnected parts is behaving-over-time.

We need to examine the time-series charts of the outliers, just as we would ask for the temperature, blood pressure and heart rate charts of our patients.

Here are the last six years by month A&E 4 hr charts for a sample of the high-fliers. They are all slightly different and we get the impression that the lower two are struggling more to stay aloft more than the upper two … especially in winter.


And here are the last six years by month A&E 4 hr charts for a sample of the low-fliers.  The Mark I Eyeball Test results are clear … these swans are falling out of the sky!


So we need to generate some testable hypotheses to explain these visible differences, and then we need to examine the available evidence to test them.

One hypothesis is “rising demand”.  It says that “the reason our A&E is failing is because demand on A&E is rising“.

Another hypothesis is “slow flow”.  It says that “the reason our A&E is failing is because of the slow flow through the hospital because of delayed transfers of care (DTOCs)“.

So, if these hypotheses account for the behaviour we are observing then we would predict that the “high fliers” are (a) diverting A&E arrivals elsewhere, and (b) reducing admissions to free up beds to hold the DTOCs.

Let us look at the freely available data for the highest flyer … the green dot on the scatter gram … code-named “RC9”.

The top chart is the A&E arrivals per month.

The middle chart is the A&E 4 hr target yield per month.

The bottom chart is the emergency admissions per month.

Both arrivals and admissions are increasing, while the A&E 4 hr target yield is rock steady!

And arranging the charts this way allows us to see the temporal patterns more easily (and the images are deliberately arranged to show the overall pattern-over-time).

Patterns like the change-for-the-better that appears in the middle of the winter of 2013 (i.e. when many other trusts were complaining that their sagging A&E performance was caused by “winter pressures”).

The objective evidence seems to disprove the “rising demand”, “slow flow” and “winter pressure” hypotheses!

So what can we learn from our failure to adequately explain the reality we are seeing?


The trust code-named “RC9” is Luton and Dunstable, and it is an average district general hospital, on the surface.  So to reveal some clues about what actually happened there, we need to read their Annual Report for 2013-14.  It is a public document and it can be downloaded here.

This is just a snippet …

… and there are lots more knowledge nuggets like this in there …

… it is a treasure trove of well-known examples of good system flow design.

The results speak for themselves!


Q: How many black swans does it take to disprove the hypothesis that “all swans are white”.

A: Just one.

“RC9” is a black swan. An outlier. A positive deviant. “RC9” has disproved the “impossibility” hypothesis.

And there is another flock of black swans living in the North East … in the Newcastle area … so the “Big cities are different” hypothesis does not hold water either.


The challenge here is a human one.  A human factor.  Our learned fear of failure.

Learning-how-to-fail is the way to avoid failing-how-to-learn.

And to read more about that radical idea I strongly recommend reading the recently published book called Black Box Thinking by Matthew Syed.

It starts with a powerful story about the impact of human factors in health care … and here is a short video of Martin Bromiley describing what happened.

The “black box” that both Martin and Matthew refer to is the one that is used in air accident investigations to learn from what happened, and to use that learning to design safer aviation systems.

Martin Bromiley has founded a charity to support the promotion of human factors in clinical training, the Clinical Human Factors Group.

So if we can muster the courage and humility to learn how to do this in health care for patient safety, then we can also learn to how do it for flow, quality and productivity.

Our black swan called “RC9” has demonstrated that this goal is attainable.

And the body of knowledge needed to do this already exists … it is called Health and Social Care Systems Engineering (HSCSE).


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Postscript: And I am pleased to share that Luton & Dunstable features in the House of Commons Health Committee report entitled Winter Pressures in A&E Departments that was published on 3rd Nov 2016.

Here is part of what L&D shared to explain their deviant performance:

luton_nuggets

These points describe rather well the essential elements of a pull design, which is the antidote to the rather more prevalent pressure cooker design.

Chimp_NoHear_NoSee_NoSpeakLast week I shared a link to Dr Don Berwick’s thought provoking presentation at the Healthcare Safety Congress in Sweden.

Near the end of the talk Don recommended six books, and I was reassured that I already had read three of them. Naturally, I was curious to read the other three.

One of the unfamiliar books was “Overcoming Organizational Defenses” by the late Chris Argyris, a professor at Harvard.  I confess that I have tried to read some of his books before, but found them rather difficult to understand.  So I was intrigued that Don was recommending it as an ‘easy read’.  Maybe I am more of a dimwit that I previously believed!  So fear of failure took over my inner-chimp and I prevaricated. I flipped into denial. Who would willingly want to discover the true depth of their dimwittedness!


Later in the week, I was forwarded a copy of a recently published paper that was on a topic closely related to a key thread in Dr Don’s presentation:

understanding variation.

The paper was by researchers who had looked at the Board reports of 30 randomly selected NHS Trusts to examine how information on safety and quality was being shared and used.  They were looking for evidence that the Trust Boards understood the importance of variation and the need to separate ‘signal’ from ‘noise’ before making decisions on actions to improve safety and quality performance.  This was a point Don had stressed too, so there was a link.

The randomly selected Trust Board reports contained 1488 charts, of which only 88 demonstrated the contribution of chance effects (i.e. noise). Of these, 72 showed the Shewhart-style control charts that Don demonstrated. And of these, only 8 stated how the control limits were constructed (which is an essential requirement for the chart to be meaningful and useful).

That is a validity yield of 8 out of 1488, or 0.54%, which is for all practical purposes zero. Oh dear!


This chance combination of apparently independent events got me thinking.

Q1: What is the reason that NHS Trust Boards do not use these signal-and-noise separation techniques when it has been demonstrated, for at least 12 years to my knowledge, that they are very effective for facilitating improvement in healthcare? (e.g. Improving Healthcare with Control Charts by Raymond G. Carey was published in 2003).

Q2: Is there some form of “organizational defense” system in place that prevents NHS Trust Boards from learning useful ‘new’ knowledge?


So I surfed the Web to learn more about Chris Argyris and to explore in greater depth his concept of Single Loop and Double Loop learning.  I was feeling like a dimwit again because to me it is not a very descriptive title!  I suspect it is not to many others too.

I sensed that I needed to translate the concept into the language of healthcare and this is what emerged.

Single Loop learning is like treating the symptoms and ignoring the disease.

Double Loop learning is diagnosing the underlying disease and treating that.


So what are the symptoms?
The pain of NHS Trust  failure on all dimensions – safety, delivery, quality and productivity (i.e. affordability for a not-for-profit enterprise).

And what are the signs?
The tell-tale sign is more subtle. It’s what is not present that is important. A serious omission. The missing bits are valid time-series charts in the Trust Board reports that show clearly what is signal and what is noise. This diagnosis is critical because the strategies for addressing them are quite different – as Julian Simcox eloquently describes in his latest essay.  If we get this wrong and we act on our unwise decision, then we stand a very high chance of making the problem worse, and demoralizing ourselves and our whole workforce in the process! Does that sound familiar?

And what is the disease?
Undiscussables.  Emotive subjects that are too taboo to table in the Board Room.  And the issue of what is discussable is one of the undiscussables so we have a self-sustaining system.  Anyone who attempts to discuss an undiscussable is breaking an unspoken social code.  Another undiscussable is behaviour, and our social code is that we must not upset anyone so we cannot discuss ‘difficult’ issues.  But by avoiding the issue (the undiscussable disease) we fail to address the root cause and end up upsetting everyone.  We achieve exactly what we are striving to avoid, which is the technical definition of incompetence.  And Chris Argyris labelled this as ‘skilled incompetence’.


Does an apparent lack of awareness of what is already possible fully explain why NHS Trust Boards do not use the tried-and-tested tool called a system behaviour chart to help them diagnose, design and deliver effective improvements in safety, flow, quality and productivity?

Or are there other forces at play as well?

Some deeper undiscussables perhaps?

figure_pointing_out_chart_data_150_clr_8005It was the time for Bob and Leslie’s regular Improvement Science coaching session.

<Leslie> Hi Bob, how are you today?

<Bob> I am getting over a winter cold but otherwise I am good.  And you?

<Leslie> I am OK and I need to talk something through with you because I suspect you will be able to help.

<Bob> OK. What is the context?

<Leslie> Well, one of the projects that I am involved with is looking at the elderly unplanned admission stream which accounts for less than half of our unplanned admissions but more than half of our bed days.

<Bob> OK. So what were you looking to improve?

<Leslie> We want to reduce the average length of stay so that we free up beds to provide resilient space-capacity to ease the 4-hour A&E admission delay niggle.

<Bob> That sounds like a very reasonable strategy.  So have you made any changes and measured any improvements?

<Leslie> We worked through the 6M Design® sequence. We studied the current system, diagnosed some time traps and bottlenecks, redesigned the ones we could influence, modified the system, and continued to measure to monitor the effect.

<Bob> And?

<Leslie> It feels better but the system behaviour charts do not show an improvement.

<Bob> Which charts, specifically?

<Leslie> The BaseLine XmR charts of average length of stay for each week of activity.

<Bob> And you locked the limits when you made the changes?

<Leslie> Yes. And there still were no red flags. So that means our changes have not had a significant effect. But it definitely feels better. Am I deluding myself?

<Bob> I do not believe so. Your subjective assessment is very likely to be accurate. Our Chimp OS 1.0 is very good at some things! I think the issue is with the tool you are using to measure the change.

<Leslie> The XmR chart?  But I thought that was THE tool to use?

<Bob> Like all tools it is designed for a specific purpose.  Are you familiar with the term Type II Error.

<Leslie> Doesn’t that come from research? I seem to remember that is the error we make when we have an under-powered study.  When our sample size is too small to confidently detect the change in the mean that we are looking for.

<Bob> A perfect definition!  The same error can happen when we are doing before and after studies too.  And when it does, we see the pattern you have just described: the process feels better but we do not see any red flags on our BaseLine© chart.

<Leslie> But if our changes only have a small effect how can it feel better?

<Bob> Because some changes have cumulative effects and we omit to measure them.

<Leslie> OMG!  That makes complete sense!  For example, if my bank balance is stable my average income and average expenses are balanced over time. So if I make a small-but-sustained improvement to my expenses, like using lower cost generic label products, then I will see a cumulative benefit over time to the balance, but not the monthly expenses; because the noise swamps the signal on that chart!

<Bob> An excellent analogy!

<Leslie> So the XmR chart is not the tool for this job. And if this is the only tool we have then we risk making a Type II error. Is that correct?

<Bob> Yes. We do still use an XmR chart first though, because if there is a big enough and fast enough shift then the XmR chart will reveal it.  If there is not then we do not give up just yet; we reach for our more sensitive shift detector tool.

<Leslie> Which is?

<Bob> I will leave you to ponder on that question.  You are a trained designer now so it is time to put your designer hat on and first consider the purpose of this new tool, and then create the outline a fit-for-purpose design.

<Leslie> OK, I am on the case!

smack_head_in_disappointment_150_wht_16653The NHS appears to be suffering from some form of obsessive-compulsive disorder.

OCD sufferers feel extreme anxiety in certain situations. Their feelings drive their behaviour which is to reduce the perceived cause of their feelings. It is a self-sustaining system because their perception is distorted and their actions are largely ineffective. So their anxiety is chronic.

Perfectionists demonstrate a degree of obsessive-compulsive behaviour too.


In the NHS the triggers are called ‘targets’ and usually take the form of failure metrics linked to arbitrary performance specifications.

The anxiety is the fear of failure and its unpleasant consequences: the name-shame-blame-game.


So a veritable industry has grown around ways to mitigate the fear. A very expensive and only partially effective industry.

Data is collected, cleaned, manipulated and uploaded to the Mothership (aka NHS England). There it is further manipulated, massaged and aggregated. Then the accumulated numbers are posted on-line, every month for anyone with a web-browser to scrutinise and anyone with an Excel spreadsheet to analyse.

An ocean of measurements is boiled and distilled into a few drops of highly concentrated and sanitized data and, in the process, most of the useful information is filtered out, deleted or distorted.


For example …

One of the failure metrics that sends a shiver of angst through a Chief Operating Officer (COO) is the failure to deliver the first definitive treatment for any patient within 18 weeks of referral from a generalist to a specialist.

The infamous and feared 18-week target.

Service providers, such as hospitals, are actually fined by their Clinical Commissioning Groups (CCGs) for failing to deliver-on-time. Yes, you heard that right … one NHS organisation financially penalises another NHS organisation for failing to deliver a result over which they have only partial control.

Service providers do not control how many patients are referred, or a myriad of other reasons that delay referred patients from attending appointments, tests and treatments. But the service providers are still accountable for the outcome of the whole process.

This ‘Perform-or-Pay-The-Price Policy‘ creates the perfect recipe for a lot of unhappiness for everyone … which is exactly what we hear and what we see.


So what distilled wisdom does the Mothership share? Here is a snapshot …

RTT_Data_Snapshot

Q1: How useful is this table of numbers in helping us to diagnose the root causes of long waits, and how does it help us to decide what to change in our design to deliver a shorter waiting time and more productive system?

A1: It is almost completely useless (in this format).


So what actually happens is that the focus of management attention is drawn to the part just before the speed camera takes the snapshot … the bit between 14 and 18 weeks.

Inside that narrow time-window we see a veritable frenzy of target-failure-avoiding behaviour.

Clinical priority is side-lined and management priority takes over.  This is a management emergency! After all, fines-for-failure are only going to make the already bad financial situation even worse!

The outcome of this fire-fighting is that the bigger picture is ignored. The focus is on the ‘whip’ … and avoiding it … because it hurts!


Message from the Mothership:    “Until morale improves the beatings will continue”.


The good news is that the undigestible data liquor does harbour some very useful insights.  All we need to do is to present it in a more palatable format … as pictures of system behaviour over time.

We need to use the data to calculate the work-in-progress (=WIP).

And then we need to plot the WIP in time-order so we can see how the whole system is behaving over time … how it is changing and evolving. It is a dynamic living thing, it has vitality.

So here is the WIP chart using the distilled wisdom from the Mothership.

RTT_WIP_RunChart

And this picture does not require a highly trained data analyst or statistician to interpret it for us … a Mark I eyeball linked to 1.3 kg of wetware running ChimpOS 1.0 is enough … and if you are reading this then you must already have that hardware and software.

Two patterns are obvious:

1) A cyclical pattern that appears to have an annual frequency, a seasonal pattern. The WIP is higher in the summer than in the winter. Eh? What is causing that?

2) After an initial rapid fall in 2008 the average level was steady for 4 years … and then after March 2012 it started to rise. Eh? What is causing is that?

The purpose of a WIP chart is to stimulate questions such as:

Q1: What happened in March 2012 that might have triggered this change in system behaviour?

Q2: What other effects could this trigger have caused and is there evidence for them?


A1: In March 2012 the Health and Social Care Act 2012 became Law. In the summer of 2012 the shiny new and untested Clinical Commissioning Groups (CCGs) were authorised to take over the reins from the exiting Primary care Trusts (PCTs) and Strategic Health Authorities (SHAs). The vast £80bn annual pot of tax-payer cash was now in the hands of well-intended GPs who believed that they could do a better commissioning job than non-clinicians. The accountability for outcomes had been deftly delegated to the doctors.  And many of the new CCG managers were the same ones who had collected their redundancy checks when the old system was shut down. Now that sounds like a plausible system-wide change! A massive political experiment was underway and the NHS was the guinea-pig.

A2: Another NHS failure metric is the A&E 4-hour wait target which, worringly, also shows a deterioration that appears to have started just after July 2010, i.e. just after the new Government was elected into power.  Maybe that had something to do with it? Maybe it would have happened whichever party won at the polls.

A&E_Breaches_2004-15

A plausible temporal association does not constitute proof – and we cannot conclude a political move to a CCG-led NHS has caused the observed behaviour. Retrospective analysis alone is not able to establish the cause.

It could just as easily be that something else caused these behaviours. And it is important to remember that there are usually many causal factors combining together to create the observed effect.

And unraveling that Gordian Knot is the work of analysts, statisticians, economists, historians, academics, politicians and anyone else with an opinion.


We have a more pressing problem. We have a deteriorating NHS that needs urgent resuscitation!


So what can we do?

One thing we can do immediately is to make better use of our data by presenting it in ways that are easier to interpret … such as a work in progress chart.

Doing that will trigger different conversions; ones spiced with more curiosity and laced with less cynicism.

We can add more context to our data to give it life and meaning. We can season it with patient and staff stories to give it emotional impact.

And we can deepen our understanding of what causes lead to what effects.

And with that deeper understanding we can begin to make wiser decisions that will lead to more effective actions and better outcomes.

This is all possible. It is called Improvement Science.


And as we speak there is an experiment running … a free offer to doctors-in-training to learn the foundations of improvement science in healthcare (FISH).

In just two weeks 186 have taken up that offer and 13 have completed the course!

And this vanguard of curious and courageous innovators have discovered a whole new world of opportunity that they were completely unaware of before. But not anymore!

So let us ease off applying the whip and ease in the application of WIP.


PostScript

Here is a short video describing how to create, animate and interpret a form of diagnostic Vitals Chart® using the raw data published by NHS England.  This is a training exercise from the Improvement Science Practitioner (level 2) course.

How to create an 18 weeks animated Bucket Brigade Chart (BBC)

Monitor_Summary


This week an interesting report was published by Monitor – about some possible reasons for the A&E debacle that England experienced in the winter of 2014.

Summary At A Glance

“91% of trusts did not  meet the A&E 4-hour maximum waiting time standard last winter – this was the worst performance in 10 years”.


So it seems a bit odd that the very detailed econometric analysis and the testing of “Ten Hypotheses” did not look at the pattern of change over the previous 10 years … it just compared Oct-Dec 2014 with the same period for 2013! And the conclusion: “Hospitals were fuller in 2014“.  H’mm.


The data needed to look back 10 years is readily available on the various NHS England websites … so here it is plotted as simple time-series charts.  These are called system behaviour charts or SBCs. Our trusted analysis tools will be a Mark I Eyeball connected to the 1.3 kg of wetware between our ears that runs ChimpOS 1.0 …  and we will look back 11 years to 2004.

A&E_Arrivals_2004-15First we have the A&E Arrivals chart … about 3.4 million arrivals per quarter. The annual cycle is obvious … higher in the summer and falling in the winter. And when we compare the first five years with the last six years there has been a small increase of about 5% and that seems to associate with a change of political direction in 2010.

So over 11 years the average A&E demand has gone up … a bit … but only by about 5%.


A&E_Admissions_2004-15In stark contrast the A&E arrivals that are admitted to hospital has risen relentlessly over the same 11 year period by about 50% … that is about 5% per annum … ten times the increase in arrivals … and with no obvious step in 2010. We can see the annual cycle too.  It is a like a ratchet. Click click click.


But that does not make sense. Where are these extra admissions going to? We can only conclude that over 11 years we have progressively added more places to admit A&E patients into.  More space-capacity to store admitted patients … so we can stop the 4-hour clock perhaps? More emergency assessment units perhaps? Places to wait with the clock turned off perhaps? The charts imply that our threshold for emergency admission has been falling: Admission has become increasingly the ‘easier option’ for whatever reason.  So why is this happening? Do more patients need to be admitted?


In a recent empirical study we asked elderly patients about their experience of the emergency process … and we asked them just after they had been discharged … when it was still fresh in their memories. A worrying pattern emerged. Many said that they had been admitted despite them saying they did not want to be.  In other words they did not willingly consent to admission … they were coerced.

This is anecdotal data so, by implication, it is wholly worthless … yes?  Perhaps from a statistical perspective but not from an emotional one.  It is a red petticoat being waved that should not be ignored.  Blissful ignorance comes from ignoring anecdotal stuff like this. Emotionally uncomfortable anecdotal stories. Ignore the early warning signs and suffer the potentially catastrophic consequences.


A&E_Breaches_2004-15And here is the corresponding A&E 4-hour Target Failure chart.  Up to 2010 the imposed target was 98% success (i.e. 2% acceptable failure) and, after bit of “encouragement” in 2004-5, this was actually achieved in some of the summer months (when the A&E demand was highest remember).

But with a change of political direction in 2010 the “hated” 4-hour target was diluted down to 95% … so a 5% failure rate was now ‘acceptable’ politically, operationally … and clinically.

So it is no huge surprise that this is what was achieved … for a while at least.

In the period 2010-13 the primary care trusts (PCTs) were dissolved and replaced by clinical commissioning groups (CCGs) … the doctors were handed the ignition keys to the juggernaut that was already heading towards the cliff.

The charts suggest that the seeds were already well sown by 2010 for an evolving catastrophe that peaked last year; and the changes in 2010 and 2013 may have just pressed the accelerator pedal a bit harder. And if the trend continues it will be even worse this coming winter. Worse for patients and worse for staff and worse for commissioners and  worse for politicians. Lose lose lose lose.


So to summarise the data from the NHS England’s own website:

1. A&E arrivals have gone up 5% over 11 years.
2. Admissions from A&E have gone up 50% over 11 years.
3. Since lowering the threshold for acceptable A&E performance from 98% to 95% the system has become unstable and “fallen off the cliff” … but remember, a temporal association does not prove causation.

So what has triggered the developing catastrophe?

Well, it is important to appreciate that when a patient is admitted to hospital it represents an increase in workload for every part of the system that supports the flow through the hospital … not just the beds.  Beds represent space-capacity. They are just where patients are stored.  We are talking about flow-capacity; and that means people, consumables, equipment, data and cash.

So if we increase emergency admissions by 50% then, if nothing else changes, we will need to increase the flow-capacity by 50% and the space-capacity to store the work-in-progress by 50% too. This is called Little’s Law. It is a mathematically proven Law of Flow Physics. It is not negotiable.

So have we increased our flow-capacity and our space-capacity (and our costs) by 50%? I don’t know. That data is not so easy to trawl from the websites. It will be there though … somewhere.

What we have seen is an increase in bed occupancy (the red box on Monitor’s graphic above) … but not a 50% increase … that is impossible if the occupancy is already over 85%.  A hospital is like a rigid metal box … it cannot easily expand to accommodate a growing queue … so the inevitable result in an increase in the ‘pressure’ inside.  We have created an emergency care pressure cooker. Well lots of them actually.

And that is exactly what the staff who work inside hospitals says it feels like.

And eventually the relentless pressure and daily hammering causes the system to start to weaken and fail, gradually at first then catastrophically … which is exactly what the NHS England data charts are showing.


So what is the solution?  More beds?

Nope.  More beds will create more space and that will relieve the pressure … for a while … but it will not address the root cause of why we are admitting 50% more patients than we used to; and why we seem to need to increase the pressure inside our hospitals to squeeze the patients through the process and extrude them out of the various exit nozzles.

Those are the questions we need to have understandable and actionable answers to.

Q1: Why are we admitting 5% more of the same A&E arrivals each year rather than delivering what they need in 4 hours or less and returning them home? That is what the patients are asking for.

Q2: Why do we have to push patients through the in-hospital process rather than pulling them through? The staff are willing to work but not inside a pressure cooker.


A more sensible improvement strategy is to look at the flow processes within the hospital and ensure that all the steps and stages are pulling together to the agreed goals and plan for each patient. The clinical management plan that was decided when the patient was first seen in A&E. The intended outcome for each patient and the shortest and quickest path to achieving it.


Our target is not just a departure within 4 hours of arriving in A&E … it is a competent diagnosis (study) and an actionable clinical management plan (plan) within 4 hours of arriving; and then a process that is designed to deliver (do) it … for every patient. Right, first time, on time, in full and at a cost we can afford.

Q: Do we have that?
A: Nope.

Q: Is that within our gift to deliver?
A: Yup.

Q: So what is the reason we are not already doing it?
A: Good question.  Who in the NHS is trained how to do system-wide flow design like this?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

<Leslie> And what happened next?

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

<Leslie> Niggles you mean?

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

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

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

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

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

<Leslie> Constructive actions such as?

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

<Leslie> More learning loops!

<Bob> Yup.

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

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

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

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

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

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

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

NHS_Legal_CostsThis heading in the the newspaper today caught my eye.

Reading the rest of the story triggered a strong emotional response: anger.

My inner chimp was not happy. Not happy at all.

So I took my chimp for a walk and we had a long chat and this is the story that emerged.

The first trigger was the eye-watering fact that the NHS is facing something like a £26 billion litigation cost.  That is about a quarter of the total NHS annual budget!

The second was the fact that the litigation bill has increased by over £3 billion in the last year alone.

The third was that the extra money will just fall into a bottomless pit – the pockets of legal experts – not to where it is intended, to support overworked and demoralised front-line NHS staff. GPs, nurses, AHPs, consultants … the ones that deliver care.

That is why my chimp was so upset.  And it sounded like righteous indignation rather than irrational fear.


So what is the root cause of this massive bill? A more litigious society? Ambulance chasing lawyers trying to make a living? Dishonest people trying to make a quick buck out of a tax-funded system that cannot defend itself?

And what is the plan to reduce this cost?

Well in the article there are three parts to this:
“apologise and learn when you’re wrong,  explain and vigorously defend when we’re right, view court as a last resort.”

This sounds very plausible but to achieve it requires knowing when we are wrong or right.

How do we know?


Generally we all think we are right until we are proved wrong.

It is the way our brains are wired. We are more sure about our ‘rightness’ than the evidence suggests is justified. We are naturally optimistic about our view of ourselves.

So to be proved wrong is emotionally painful and to do it we need:
1) To make a mistake.
2) For that mistake to lead to psychological or physical harm.
3) For the harm to be identified.
4) For the cause of the harm to be traced back to the mistake we made.
5) For the evidence to be used to hold us to account, (to apologise and learn).

And that is all hunky-dory when we are individually inept and we make avoidable mistakes.

But what happens when the harm is the outcome of a combination of actions that individually are harmless but which together are not?  What if the contributory actions are sensible and are enforced as policies that we dutifully follow to the letter?

Who is held to account?  Who needs to apologise? Who needs to learn?  Someone? Anyone? Everyone? No one?

The person who wrote the policy?  The person who commissioned the policy to be written? The person who administers the policy? The person who follows the policy?

How can that happen if the policies are individually harmless but collectively lethal?


The error here is one of a different sort.

It is called an ‘error of omission’.  The harm is caused by what we did not do.  And notice the ‘we’.

What we did not do is to check the impact on others of the policies that we write for ourselves.

Example:

The governance department of a large hospital designs safety policies that if not followed lead to disciplinary action and possible dismissal.  That sounds like a reasonable way to weed out the ‘bad apples’ and the policies are adhered to.

At the same time the operations department designs flow policies (such as maximum waiting time targets and minimum resource utilisation) that if not followed lead to disciplinary action and possible dismissal.  That also sounds like a reasonable way to weed out the layabouts whose idleness cause queues and delays and the policies are adhered to.

And at the same time the finance department designs fiscal policies (such as fixed budgets and cost improvement targets) that if not followed lead to disciplinary action and possible dismissal. Again, that sounds like a reasonable way to weed out money wasters and the policies are adhered to.

What is the combined effect? The multiple safety checks take more time to complete, which puts extra workload on resources and forces up utilisation. As the budget ceiling is lowered the financial and operational pressures build, the system heats up, stress increases, corners are cut, errors slip through the safety checks. More safety checks are added and the already over-worked staff are forced into an impossible position.  Chaos ensues … more mistakes are made … patients are harmed and justifiably seek compensation by litigation.  Everyone loses (except perhaps the lawyers).


So why was my inner chimp really so unhappy?

Because none of this is necessary. This scenario is avoidable.

Reducing the pain of complaints and the cost of litigation requires setting realistic expectations to avoid disappointment and it requires not creating harm in the first place.

That implies creating healthcare systems that are inherently safe, not made not-unsafe by inspection-and-correction.

And it implies measuring and sharing intended and actual outcomes not  just compliance with policies and rates of failure to meet arbitrary and conflicting targets.

So if that is all possible and all that is required then why are we not doing it?

Simple. We never learned how. We never knew it is possible.

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

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

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

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

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

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

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

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

It is actually their primary goal.

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


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

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

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

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


And we need a coach as well as a trainer.

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

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

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

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

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


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

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

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

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

For our own safety and survival.

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

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

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


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

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

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

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

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

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


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


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

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

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

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


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

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

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

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

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


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

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

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

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

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

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

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

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

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

Metronome[Beep, Beep, Beep, Beep, Beeeeep] The reminder roused Bob from deep reflection and he clicked the Webex link on his desktop to start the meeting. Leslie was already online.

<Bob> Hi Leslie. How are you? And what would you like to share and explore today?

<Leslie> Hi Bob, I am well thank you and I would like to talk about chaos again.

<Bob> OK. That is always a rich mine of new insights!  Is there a specific reason?

<Leslie>Yes. The story I want to share is of the chaos that I have been experiencing just trying to get a new piece of software available for my team to use.  You would not believe the amount of time, emails, frustration and angst it has taken to negotiate this through the ‘proper channels’.

<Bob> Let me guess … about six months?

<Leslie> Spot on! How did you know?

<Bob> Just prior experience of similar stories.  So what is your diagnosis of the cause of the chaos?

<Leslie> My intuition shouts at me that people are just being deliberately difficult and that makes me feel angry and want to shout at them … but I have learned that behaviour is counter-productive.

<Bob> So what did you do?

<Leslie> I escalated the ‘problem’ to my line manager.

<Bob> And what did they do?

<Leslie> I am not sure, I was not copied in, but it seemed to clear the ‘obstruction’.

<Bob> And were the ‘people’ you mentioned suddenly happy and willing to help?

<Leslie> Not really … they did what we needed but they did not seem very happy about it.

<Bob> OK.  You are describing a Drama Triangle, a game, and your behaviour was from the Persecutor role.

<Leslie>What! But I deliberately did not send any ANGRY emails or get into a childish argument. I escalated the issue I could not solve because that is what we are expected to do.

<Bob> Yes I know. If you had engaged in a direct angry conversation, by whatever means, that would have been an actively aggressive act.  By escalating the issue and someone Bigger having the angry conversation you have engaged in a passive aggressive act. It is still playing the game from the Persecutor role and in fact is the more common mode of Persecution.

<Leslie> But it got the barrier cleared and the problem sorted?

<Bob> And did it leave everyone feeling happier than before?

<Leslie> I guess not. I certainly felt like a bit of a ‘tale teller’ and the IT technician probably hates me and fears for his job, and the departmental heads probably distrust each other even more than before.

<Bob> So this approach may appear to work in the short term but it creates a much bigger long term problem – and it is that long term problem of ‘distrust’ that creates the chaos. So it is a self-sustaining design.

<Leslie> Oh dear! Is there a way to avoid this and to defuse the chronic distrust?

<Bob> Yes.  You have demonstrated a process that you would like to improve – you want the same short term outcome, your software installed and working, and you want it quicker and with less angst and leaving everyone feeling good about how they have played a part in achieving that objective.

<Leslie>Yes. That would be my ideal.

<Bob>So what is different between what you did and your ‘ideal’ scenario?  What did you do that you should not have and what did you not do that you could have?

<Leslie> Well I triggered off a drama  triangle which I should not have. I also assumed that the IT people would know what to do because I do not understand the technical nuances of getting new software procured and installed. What I could have done is make it much clearer for them what I needed, why I needed it and how and when I needed it.  I could have done a lot more homework before asking them for assistance. I could also have given my inner Chimp a banana and gone to talk to them face-to-face and ask their opinion  early on so I could see the problem from  their perspective as well as mine.

<Bob> Yes – that all sounds reasonable and respectful.  What you are doing is ‘synchronising‘.  You are engaging in understanding the process well enough so that you can align all the actions that need to be done, in the correct order and then sharing that.  It is rather like being the composer of a piece of music – you share the score so that the individual players know what to do and when.  There is one other task you need to do.

<Leslie>I need to be the conductor!

<Bob> Yes.  You are the metronome.  You set the pace and guide the orchestra. They are the specialists with their instruments – that is not your role.

<Leslie> And when I do that then the music is harmonious and pleasing-to-the-ear; not a chaotic cacophony!

<Bob> Indeed … and the music is the voice of the system – and is the feedback that everyone hears – and not only do the musicians derive pleasure from contributing then the wider audience will hear what can be achieved and see how it is achieved.

<Leslie> Wow!  That musical metaphor works really well for me. Thanks Bob, I need to go and work on my communicating, composing and conducting capabilities.

hold_your_ground_rope_300_wht_6223[Dring Dring] The telephone soundbite announced the start of the coaching session.

<Bob> Good morning Leslie. How are you today?

<Leslie> I have been better.

<Bob> You seem upset. Do you want to talk about it?

<Leslie> Yes, please. The trigger for my unhappiness is that last week I received an email demanding that I justify the time I spend doing improvement work and  a summons to a meeting to ‘discuss some issues that have been raised‘.

<Bob> OK. I take it that you do not know what or who has triggered this inquiry.

<Leslie> You are correct. My working hypothesis is that it is the end of the financial year and budget holders are looking for opportunities to do some pruning – to meet their cost improvement program targets!

<Bob> So what is the problem? You have shared the output of your work. You have demonstrated significant improvements in safety, flow, quality and productivity and you have described both them and the methodology clearly.

<Leslie> I know. That us why I was so upset to get this email. It is as if everything that we have achieved has been ignored. It is almost as if it is resented.

<Bob> Ah! You may well be correct.  This is the nature of paradigm shifts. Those who have the greatest vested interest in the current paradigm get spooked when they feel it start to wobble. Each time you share the outcome of your improvement work you create emotional shock-waves. The effects are cumulative and eventually there will be is a ‘crisis of confidence’ in those who feel most challenged by the changes that you are demonstrating are possible.  The whole process is well described in Thomas Kuhn’s The Structure of Scientific Revolutions. That is not a book for an impatient reader though – for those who prefer something lighter I recommend “Our Iceberg is Melting” by John Kotter.

<Leslie> Thanks Bob. I will get a copy of Kotter’s book – that sounds more my cup of tea. Will that tell me what to do?

<Bob> It is a parable – a fictional story of a colony of penguins who discover that their iceberg is melting and are suddenly faced with a new and urgent potential risk of not surviving the storms of the approaching winter. It is not a factual account of a real crisis or a step-by-step recipe book for solving all problems  – it describes some effective engagement strategies in general terms.

<Leslie> I will still read it. What I need is something more specific to my actual context.

<Bob> This is an improvement-by-design challenge. The only difference from the challenges you have done already is that this time the outcome you are looking for is a smooth transition from the ‘old’ paradigm to the ‘new’ one.  Kuhn showed that this transition will not start to happen until there is a new paradigm because individuals choose to take the step from the old to the new and they do not all do that at the same time.  Your work is demonstrating that there is a new paradigm. Some will love that message, some will hate it. Rather like Marmite.

<Leslie> Yes, that make sense.  But how do I deal with an unseen enemy who is stirring up trouble behind my back?

<Bob> Are you are referring to those who have ‘raised some issues‘?

<Leslie> Yes.

<Bob> They will be the ones who have most invested in the current status quo and they will not be in senior enough positions to challenge you directly so they are going around spooking the inner Chimps of those who can. This is expected behaviour when the relentlessly changing reality starts to wobble the concrete current paradigm.

<Leslie> Yes! That is  exactly how it feels.

<Bob> The danger lurking here is that your inner Chimp is getting spooked too and is conjuring up Gremlins and Goblins from the Computer! Left to itself your inner Chimp will steer you straight into the Victim Vortex.  So you need to take it for a long walk, let it scream and wave its hairy arms about, listen to it, and give it lots of bananas to calm it down. Then put your put your calmed-down Chimp into its cage and your ‘paradigm transition design’ into the Computer. Only then will you be ready for the ‘so-justify-yourself’ meeting.  At the meeting your Chimp will be out of its cage like a shot and interpreting everything as a threat. It will disable you and go straight to the Computer for what to do – and it will read your design and follow the ‘wise’ instructions that you have put in there.

<Leslie> Wow! I see how you are using the Chimp Paradox metaphor to describe an incredibly complex emotional process in really simple language. My inner Chimp is feeling happier already!

<Bob> And remember that you are in all in the same race. Your collective goal is to cross the finish line as quickly as possible with the least chaos, pain and cost.  You are not in a battle – that is lose-lose inner Chimp thinking.  The only message that your interrogators must get from you is ‘Win-win is possible and here is how we can do it‘. That will be the best way to soothe their inner Chimps – the ones who fear that you are going to sink their boat by rocking it.

<Leslie> That is really helpful. Thank you again Bob. My inner Chimp is now snoring gently in its cage and while it is asleep I have some Improvement-by-Design work to do and then some Computer programming.

Chimp_BattleImprovement implies change.
Change implies action.
Action implies decision.

So how is the decision made?
With Urgency?
With Understanding?

Bitter experience teaches us that often there is an argument about what to do and when to do it.  An argument between two factions. Both are motivated by a combination of anger and fear. One side is motivated more by anger than fear. They vote for action because of the urgency of the present problem. The other side is motivated more by fear than anger. They vote for inaction because of their fear of future failure.

The outcome is unhappiness for everyone.

If the ‘action’ party wins the vote and a failure results then there is blame and recrimination. If the ‘inaction’ party wins the vote and a failure results then there is blame and recrimination. If either party achieves a success then there is both gloating and resentment. Lose Lose.

The issue is not the decision and how it is achieved.The problem is the battle.

Dr Steve Peters is a psychiatrist with 30 years of clinical experience.  He knows how to help people succeed in life through understanding how the caveman wetware between their ears actually works.

In the run up to the 2012 Olympic games he was the sports psychologist for the multiple-gold-medal winning UK Cycling Team.  The World Champions. And what he taught them is described in his book – “The Chimp Paradox“.

Chimp_Paradox_SmallSteve brilliantly boils the current scientific understanding of the complexity of the human mind down into a simple metaphor.

One that is accessible to everyone.

The metaphor goes like this:

There are actually two ‘beings’ inside our heads. The Chimp and the Human. The Chimp is the older, stronger, more emotional and more irrational part of our psyche. The Human is the newer, weaker, logical and rational part.  Also inside there is the Computer. It is just a memory where both the Chimp and the Human store information for reference later. Beliefs, values, experience. Stuff like that. Stuff they use to help them make decisions.

And when some new information arrives through our senses – sight and sound for example – the Chimp gets first dibs and uses the Computer to look up what to do.  Long before the Human has had time to analyse the new information logically and rationally. By the time the Human has even started on solving the problem the Chimp has come to a decision and signaled it to the Human and associated it with a strong emotion. Anger, Fear, Excitement and so on. The Chimp operates on basic drives like survival-of-the-self and survival-of-the-species. So if the Chimp gets spooked or seduced then it takes control – and it is the stronger so it always wins the internal argument.

But the human is responsible for the actions of the Chimp. As Steve Peters says ‘If your dog bites someone you cannot blame the dog – you are responsible for the dog‘.  So it is with our inner Chimps. Very often we end up apologising for the bad behaviour of our inner Chimp.

Because our inner Chimp is the stronger we cannot ‘control’ it by force. We have to learn how to manage the animal. We need to learn how to soothe it and to nurture it. And we need to learn how to remove the Gremlins that it has programmed into the Computer. Our inner Chimp is not ‘bad’ or ‘mad’ it is just a Chimp and it is an essential part of us.

Real chimpanzees are social, tribal and territorial.  They live in family groups and the strongest male is the boss. And it is now well known that a troop of chimpanzees in the wild can plan and wage battles to acquire territory from neighbouring troops. With casualties on both sides.  And so it is with people when their inner Chimps are in control.

Which is most of the time.

Scenario:
A hospital is failing one of its performance targets – the 18 week referral-to-treatment one – and is being threatened with fines and potential loss of its autonomy. The fear at the top drives the threat downwards. Operational managers are forced into action and do so using strategies that have not worked in the past. But they do not have time to learn how to design and test new ones. They are bullied into Plan-Do mode. The hospital is also required to provide safe care and the Plan-Do knee-jerk triggers fear-of-failure in the minds of the clinicians who then angrily oppose the diktat or quietly sabotage it.

This lose-lose scenario is being played out  in  100’s if not 1000’s of hospitals across the globe as we speak.  The evidence is there for everyone to see.

The inner Chimps are in charge and the outcome is a turf war with casualties on all sides.

So how does The Chimp Paradox help dissolve this seemingly impossible challenge?

First it is necessary to appreciate that both sides are being controlled by their inner Chimps who are reacting from a position of irrational fear and anger. This means that everyone’s behaviour is irrational and their actions likely to be counter-productive.

What is needed is for everyone to be managing their inner Chimps so that the Humans are back in control of the decision making. That way we get wise decisions that lead to effective actions and win-win outcomes. Without chaos and casualties.

To do this we all need to learn how to manage our own inner Chimps … and that is what “The Chimp Paradox” is all about. That is what helped the UK cyclists to become gold medalists.

In the scenario painted above we might observe that the managers are more comfortable in the Pragmatist-Activist (PA) half of the learning cycle. The Plan-Do part of PDSA  – to translate into the language of improvement. The clinicians appear more comfortable in the Reflector-Theorist (RT) half. The Study-Act part of PDSA.  And that difference of preference is fueling the firestorm.

Improvement Science tells us that to achieve and sustain improvement we need all four parts of the learning cycle working  smoothly and in sequence.

So what at first sight looks like it must be pitched battle which will result in two losers; in reality is could be a three-legged race that will result in everyone winning. But only if synergy between the PA and the RT halves can be achieved.

And that synergy is achieved by learning to respect, understand and manage our inner Chimps.

hurry_with_the_SFQP_kit[Dring] Bob’s laptop signaled the arrival of Leslie for their regular ISP remote coaching session.

<Bob> Hi Leslie. Thanks for emailing me with a long list of things to choose from. It looks like you have been having some challenging conversations.

<Leslie> Hi Bob. Yes indeed! The deepening gloom and the last few blog topics seem to be polarising opinion. Some are claiming it is all hopeless and others, perhaps out of desperation, are trying the FISH stuff for themselves and discovering that it works.  The ‘What Ifs’ are engaged in war of words with the ‘Yes Buts’.

<Bob> I like your metaphor! Where would you like to start on the long list of topics?

<Leslie> That is my problem. I do not know where to start. They all look equally important.

<Bob> So, first we need a way to prioritise the topics to get the horse-before-the-cart.

<Leslie> Sounds like a good plan to me!

<Bob> One of the problems with the traditional improvement approaches is that they seem to start at the most difficult point. They focus on ‘quality’ first – and to be fair that has been the mantra from the gurus like W.E.Deming. ‘Quality Improvement’ is the Holy Grail.

<Leslie>But quality IS important … are you saying they are wrong?

<Bob> Not at all. I am saying that it is not the place to start … it is actually the third step.

<Leslie>So what is the first step?

<Bob> Safety. Eliminating avoidable harm. Primum Non Nocere. The NoNos. The Never Events. The stuff that generates the most fear for everyone. The fear of failure.

<Leslie> You mean having a service that we can trust not to harm us unnecessarily?

<Bob> Yes. It is not a good idea to make an unsafe design more efficient – it will deliver even more cumulative harm!

<Leslie> OK. That makes perfect sense to me. So how do we do that?

<Bob> It does not actually matter.  Well-designed and thoroughly field-tested checklists have been proven to be very effective in the ‘ultra-safe’ industries like aerospace and nuclear.

<Leslie> OK. Something like the WHO Safe Surgery Checklist?

<Bob> Yes, that is a good example – and it is well worth reading Atul Gawande’s book about how that happened – “The Checklist Manifesto“.  Gawande is a surgeon who had published a lot on improvement and even so was quite skeptical that something as simple as a checklist could possibly work in the complex world of surgery. In his book he describes a number of personal ‘Ah Ha!’ moments that illustrate a phenomenon that I call Jiggling.

<Leslie> OK. I have made a note to read Checklist Manifesto and I am curious to learn more about Jiggling – but can we stick to the point? Does quality come after safety?

<Bob> Yes, but not immediately after. As I said, Quality is the third step.

<Leslie> So what is the second one?

<Bob> Flow.

There was a long pause – and just as Bob was about to check that the connection had not been lost – Leslie spoke.

<Leslie> But none of the Improvement Schools teach basic flow science.  They all focus on quality, waste and variation!

<Bob> I know. And attempting to improve quality before improving flow is like papering the walls before doing the plastering.  Quality cannot grow in a chaotic context. The flow must be smooth before that. And the fear of harm must be removed first.

<Leslie> So the ‘Improving Quality through Leadership‘ bandwagon that everyone is jumping on will not work?

<Bob> Well that depends on what the ‘Leaders’ are doing. If they are leading the way to learning how to design-for-safety and then design-for-flow then the bandwagon might be a wise choice. If they are only facilitating collaborative agreement and group-think then they may be making an unsafe and ineffective system more efficient which will steer it over the edge into faster decline.

<Leslie>So, if we can stabilize safety using checklists do we focus on flow next?

<Bob>Yup.

<Leslie> OK. That makes a lot of sense to me. So what is Jiggling?

<Bob> This is Jiggling. This conversation.

<Leslie> Ah, I see. I am jiggling my understanding through a series of ‘nudges’ from you.

<Bob>Yes. And when the learning cogs are a bit rusty, some Improvement Science Oil and a bit of Jiggling is more effective and much safer than whacking the caveman wetware with a big emotional hammer.

<Leslie>Well the conversation has certainly jiggled Safety-Flow-Quality-and-Productivity into a sensible order for me. That has helped a lot. I will sort my to-do list into that order and start at the beginning. Let me see. I have a plan for safety, now I can focus on flow. Here is my top flow niggle. How do I design the resource capacity I need to ensure the flow is smooth and the waiting times are short enough to avoid ‘persecution’ by the Target Time Police?

<Bob> An excellent question! I will send you the first ISP Brainteaser that will nudge us towards an answer to that question.

<Leslie> I am ready and waiting to have my brain-teased and my niggles-nudged!

single_file_line_PA_150_wht_3113The modern era in science started about 500 years ago when an increasing number of people started to challenge the dogma that our future is decided by Fates and Gods. That we had no influence. And to appease the ‘Gods’ we had to do as we were told. That was our only hope of Salvation.

This paradigm came under increasing pressure as the evidence presented by Reality did not match the Rhetoric.  Many early innovators paid for their impertinence with their fortunes, their freedom and often their future. They were burned as heretics.

When the old paradigm finally gave way and the Age of Enlightenment dawned the pendulum swung the other way – and the new paradigm became the ‘mechanical universe’. Isaac Newton showed that it was possible to predict, with very high accuracy, the motion of the planets just by adopting some simple rules and a new form of mathematics called calculus. This opened a door into a more hopeful world – if Nature follows strict rules and we know what they are then we can learn to control Nature and get what we need without having to appease any Gods (or priests).

This was the door to the Industrial Revolutions – there have been more that one – each lasting about 100 years (18th C, 19th C and 20th C). Each was associated with massive population growth as we systematically eliminated the causes of early mortality – starvation and infectious disease.

But not everything behaved like the orderly clockwork of the planets and the pendulums. There was still the capricious and unpredictable behaviour that we call Lady Luck.  Had the Gods retreated but were still playing dice?

Progress was made here too – and the history of the ‘understanding of chance’ is peppered with precocious and prickly mathematical savants who discovered that chance follows rules too. Probability theory was born and that spawned a troublesome child called Statistics. This was a trickier one to understand. To most people statistics is just mathematical gobbledygook.

But from that emerged a concept called the Rational Man – which underpinned the whole of Economic Theory for 250 years. Until very recently.  The RM hypothesis stated that we make unconscious but rational judgements when presented with uncertain win/lose choices.  And from that seed sprouted concepts such as the Law of Supply and Demand – when the supply of things we  demand are limited then we (rationally) value them more and will choose to pay more so prices go up so fewer can afford them so demand drops. Foxes and Rabbits. A negative feedback loop. The economic system becomes self-adjusting and self-stabilising.  The outcome of this assumption is a belief that ‘because people are collectively rational the economic system will be self-stabilising and it will correct the adverse short term effects of any policy blunders we make‘.  The ‘let-the-market-decide’ belief that experimental economic meddling is harmless over the long term and what is learned from ‘laissez-faire’ may even be helpful. It is a no-lose long term improvement strategy. Losers are just unlucky, stupid or both.

In 2002 the Nobel Prize for Economics was not awarded to an economist. It was awarded to a psychologist – Daniel Kahneman – who showed that the model of the Rational Man did not stand up to rigorous psychological experiment.  Reality demonstrated we are Irrational Chimps. The economists had omitted to test their hypothesis. Oops!


This lesson has many implications for the Science of Improvement.  One of which is a deeper understanding of the nemesis of improvement – resistance to change.

One of the surprising findings is that our judgements are biased – and our bias operates at an unconscious level – what Kahneman describes as the System One level. Chimp level. We are not aware we are making biased decisions.

For example. Many assume that we prefer certainty to uncertainty. We fear the unpredictable. We avoid it. We seek the predictable and the stable. And we will put up with just about anything so long as it is predictable. We do not like surprises.  And when presented with that assertion most people nod and say ‘Yes’ – that feels right.

We also prefer gain to loss.  We love winning. We hate losing. This ‘competitive spirit’ is socially reinforced from day one by our ‘pushy parents’ – we all know the ones – but we all do it to some degree. Do better! Work harder! Be a success! Optimize! Be the best! Be perfect! Be Perfect! BE PERFECT.

So which is more important to us? Losing or uncertainty? This is one question that Kahneman asked. And the answer he discovered was surprising – because it effectively disproved the Rational Man hypothesis.  And this is how a psychologist earned a Nobel Prize for Economics.

Kahneman discovered that loss is more important to us than uncertainty.

To demonstrate this he presented subjects with a choice between two win/lose options; and he presented the choice in two ways. To a statistician and a Rational Man the outcomes were exactly the same in terms of gain or loss.  He designed the experiment to ensure that it was the unconscious judgement that was being measured – the intuitive gut reaction. So if our gut reactions are Rational then the choice and the way the choice was presented would have no significant effect.

There was an effect. The hypothesis was disproved.

The evidence showed that our gut reactions are biased … and in an interesting way.

If we are presented with the choice between a certain gain and an uncertain gain/loss (so the average gain is the same) then we choose the certain gain much more often.  We avoid uncertainty. Uncertainly =1 Loss=0.

BUT …

If we are presented with a choice between certain loss and an uncertain loss/gain (so the average outcome is again the same) then we choose the uncertain option much more often. This is exactly the opposite of what was expected.

And it did not make any difference if the subject knew the results of the experiment before doing it. The judgement is made out of awareness and communicated to our consciousness via an emotion – a feeling – that biases our slower, logical, conscious decision process.

This means that the sense of loss has more influence on our judgement than the sense of uncertainty.

This behaviour is hard-wired. It is part of our Chimp brain design. And once we know this we can see the effect of it everywhere.

1. We will avoid the pain of uncertainty and resist any change that might deliver a gain when we believe that future loss is uncertain. We are conservative and over-optimistic.

2. We will accept the pain of uncertainty and only try something new (and risky) when we believe that to do otherwise will result in certain loss. The Backs Against The Wall scenario.  The Cornered Rat is Unpredictable and Dangerous scenario.

This explains why we resist any change right up until the point when we see Reality clearly enough to believe that we are definitely going to lose something important if we do nothing. Lose our reputation, lose our job, lose our security, lose our freedom or lose our lives. That is a transformational event.  A Road to Damascus moment.

monkey_on_back_anim_150_wht_11200Understanding that we behave like curious, playful, social but irrational chimps is one key to unlocking significant and sustained improvement.

We need to celebrate our inner chimp – it is key to innovation.

And we need to learn how to team up with our inner chimp rather than be hijacked by it.

If we do not we will fail – the Laws of Physics, Probability and Psychology decree it.

boxes_group_PA4_150_wht_4916There are only four ingredients required to create Chaos.

The first is Time.

All processes and systems are time-dependent.

The second ingredient is a Metric of Interest (MoI).

That means a system performance metric that is important to all – such as a Safety or Quality or Cost; and usually all three.

The third ingredient is a feedback loop of a specific type – it is called a Negative Feedback Loop.  The NFL  is one that tends to adjust, correct and stabilise the behaviour of the system.

Negative feedback loops are very useful – but they have a drawback. They resist change and they reduce agility. The name is also a disadvantage – the word ‘negative feedback’ is often associated with criticism.

The fourth and final ingredient in our Recipe for Chaos is also a feedback loop but one of a different design – a Positive Feedback Loop (PFL)- one that amplifies variation and change.

Positive feedback loops are also very useful – they are required for agility – quick reactions to unexpected events. Fast reflexes.

The downside of a positive feedback loop is that increases instability.

The name is also confusing – ‘positive feedback’ is associated with encouragement and praise.

So in this context it is better to use the terms ‘stabilizing feedback’ and ‘destabilizing feedback’  loops.

When we mix these four ingredients in just the right amounts we get a system that may behave chaotically. That is surprising. It is counter-intuitive. It is also how the Universe works.

For example:

Suppose our Metric of Interest is the amount of time that patients spend in a Accident and Emergency Department. We know that the longer this time is the less happy they are and the higher the risk of avoidable harm – so it is a reasonable goal to reduce it.

Longer-than-possible waiting times have many root causes – it is a non-specific metric.  That means there are many things that could be done to reduce waiting time and the most effective actions will vary from case-to-case, day-to-day and even minute-to-minute.  There is no one-size-fits-all solution.

This implies that those best placed to correct the causes of the delays are the people who know the specific system well – because they work in it. Those who actually deliver urgent care. They are the stabilizing ingredient in our Recipe for Chaos.

The destabilizing ingredient is the hit-the-arbitrary-target policy feedback loop.

This policy typically involves:
(1) Setting a performance target that is desirable but impossible for the current design to achieve reliably;
(2) inspecting how close to the target we are; then
(3) using the real-time data to justify threats of dire consequences for failure.

Now we have a perfect Recipe for Chaos.

The higher the failure rate the more inspection, reports, meetings, exhortation, threats, interruptions, and interventions that are generated.  Fear-fuelled management meddling. This behaviour consumes valuable time – so leaves less time to do the worthwhile work. Less time to devote to safety, flow, and quality. The queues build and the pressure increases and the system becomes even more sensitive to small changes. Delays multiply and errors are more likely and spawn more workload, more delays and more errors.  Tempers become frayed and molehills become magnified into mountains. Irritations become arguments.  And all of this makes the problem worse rather than better. Less stable. More variable. More chaotic.

It is actually possible to write a simple equation that captures this complex dynamic behaviour characteristic of real systems.  And that was a very surprising finding when it was discovered in 1976 by a mathematician called Robert May.

This equation is called the logistic equation.

Here is the abstract of his seminal paper.

Nature 261, 459-467 (10 June 1976)

Simple mathematical models with very complicated dynamics

First-order difference equations arise in many contexts in the biological, economic and social sciences. Such equations, even though simple and deterministic, can exhibit a surprising array of dynamical behaviour, from stable points, to a bifurcating hierarchy of stable cycles, to apparently random fluctuations. There are consequently many fascinating problems, some concerned with delicate mathematical aspects of the fine structure of the trajectories, and some concerned with the practical implications and applications. This is an interpretive review of them.

The fact that this chaotic behaviour is completely predictable and does not need any ‘random’ element was a big surprise. Chaotic is not the same as random. The observed chaos in the urgent healthcare care system is the result of the design of the system – or more specifically the current healthcare system management policies.

This has a number of profound implications – the most important of which is this:

If the chaos we observe in our health care systems is the predictable and inevitable result of the management policies we ourselves have created and adopted – then eliminating the chaos will only require us to re-design these policies.

In fact we only need to tweak one of the ingredients of the Recipe for Chaos – such as to reduce the strength of the destabilizing feedback loop. The gain. The volume control on the variation amplifier!

This is called the MM factor – otherwise known as ‘Management Meddling‘.

We need to keep all four ingredients though – because we need our system to have both agility and dynamic stability.  It is the balance of ingredients that that is critical.

The flaw is not the Managers themselves – it is their learned behaviour – the Meddling.  This is learned so it can be unlearned. We need to keep the Managers but “tweak” their role slightly. As they unlearn their old habits they move from being ‘Policy-Enforcers and Fire-Fighters’ to becoming ‘Policy-Engineers and Chaos-Calmers’. They focus on learning to understand the root causes of variation that come from outside the circle of influence of the non-Managers.   They learn how to rationally and radically redesign system policies to achieve both agility and stability.

And doing that requires developing systemic-thinking and learning Improvement Science skills – because the causes of chaos are counter-intuitive. If it were intuitively-obvious we would have discovered the nature of chaos thousands of years ago. The fact that it was not discovered until 1976 demonstrates this fact.

It is our homo sapiens intuition that got us into this mess!  The inherent flaws of the chimp-ware between our ears.  Our current management policies are intuitively-obvious, collectively-agreed, rubber-stamped and wrong! They are part of the Recipe for Chaos.

And when we learn to re-design our system policies and upload the new system software then the chaos evaporates as if a magic wand had been waved.

And that comes as a big surprise!

What also comes as a big surprise is just how small the counter-intuitive policy design tweaks often are.

Safe, smooth, effective, efficient, and productive flow is restored. Calm confidence reigns. Safety, Flow, Quality and Productivity all increase – at the same time.  The emotional storm clouds dissipate and the cultural sun shines again.

Everyone feels better. Everyone. Patients, managers, and non-managers.

This is Win-Win-Win improvement by design. Improvement Science.

[Beep Beep] Bob tapped the “Answer” button on his smartphone – it was Lesley calling in for their regular ISP coaching session.

<Bob>Hi Lesley. How are you today? And which tunnel in the ISP Learning Labyrinth shall we explore today?

<Lesley>Hi Bob. I am OK thank you. Can we invest some time in the Engagement Maze?

<Bob>OK. Do you have a specific example?

<Lesley>Sort of. This week I had a conversation with our Chief Executive about the potential of Improvement Science and the reply I got was “I am convinced by what you say but it is your colleagues who need to engage. If you have not succeeded in convincing them then how can I?” I was surprised by that response and slightly niggled because it had an uncomfortable nugget of truth in it.

<Bob>That sounds like the wisdom of a leader who understands that the “power” to make things happen does not sit wholly in the lap of those charged with accountability.

<Lesley> I agree.  And at the same time everything that the “Top Team” suggest gets shot down in flames by a small and very vocal group of my more skeptical colleagues.

<Bob>Ah ha!  It sounds like the Victim Vortex is causing trouble here.

<Lesley>The Victim Vortex?

<Bob>Yes.  Let me give you an example.  One of the common initiators of the Victim Vortex is the data flow part of a complex system design.  The Sixth Flow.  So can I ask you: “How are new information systems developed in your organization?

<Lesley>Wow!  You hit the nail on the head first time!  Just this week there has been another firestorm of angry emails triggered by yet another silver-bullet IT system being foisted on us!

<Bob>Interesting use of language Lesley.  You sound quite “niggled”.

<Lesley>I am.  Not by the constant “drizzle of IT magic” – that is irritating enough – but more by the vehemently cynical reaction of my peers.

<Bob>OK.  This sounds like good enough example of the Victim Vortex.  What do you expect the outcome will be?

<Lesley>Well, if past experience is a predictor for future performance – an expensive failure, more frustration and a deeper well of cynicism.

<Bob>Frustrating for whom?

<Lesley>Everyone.  The IT department as well.  It feels like we are all being sucked into a lose-lose-lose black hole of depression and despair!

<Bob>A very good description of the Victim Vortex.

<Lesley>So the Victim Vortex is an example of the Drama Triangle acting on an organizational level?

tornada_150_wht_10155<Bob>Yes. Visualize a cultural tornado.  The energy that drives it is the emotional  currency spent in playing the OK – Not OK Games.  It is a self-fueling system, a stable design, very destructive and very resistant to change.

<Lesley>That metaphor works really well for me!

<Bob>A similar one is a whirlpool – a water vortex.  If you were out swimming and were caught up in a whirlpool what are your exit strategy options?

<Lesley>An interesting question.  I have never had that experience and would not want it – it sounds rather hazardous.  Let me think.  If I do nothing I will just get swept around in the chaos and I am at risk of  getting bashed, bruised and then sucked under.

<Bob>Yes – you would probably spend all your time and energy just treading water and dodging the flotsam and jetsam that has been sucked into the Vortex.  That is what most people do.  It is called the Hamster Wheel effect.

<Lesley>So another option is to actively swim towards the middle of the Vortex – the end would at least be quick! But that is giving up and adopting the Hopelessness attitude of burned out Victim.  That would be the equivalent of taking voluntary redundancy or early retirement.  It is not my style!

<Bob>Yes.  It does not solve the problem either.  The Vortex is always hoovering up new Victims.  It is insatiable.

<Lesley> And another option would be to swim with the flow to avoid being “got” from behind.  That would be seem sensible and is possible; and at least I would feel better for doing something. I might even escape if I swim fast enough!

<Bob>That is indeed what some try.  The movers and shakers.  The pace setters.  The optimists.  The extrovert leaders.  The problem is that it makes the Vortex spin even faster.  It actually makes the Vortex bigger,  more chaotic and more dangerous than before.

<Lesley>Yes – I can see that.  So my other option is to swim against the flow in an attempt to slow the Vortex down.  Would that work?

<Bob>If everyone did that at the same time it might but that is unlikely to happen spontaneously.  If you could achieve that degree of action alignment you would not have a Victim Vortex in the first place.  Trying to do it alone is ineffective, you tire very quickly, the other Victims bash into you, you slow them down, and then you all get sucked down the Plughole of Despair.

<Lesley>And I suppose a small group of like-minded champions who try to swim-against the flow might last longer if they stick together but even then eventually they would get bashed up and broken up too.  I have seen that happen.  And that is probably where our team are heading at the moment.  I am out of options.  Is it impossible to escape the Victim Vortex?

<Bob>There is one more direction you can swim.

<Lesley>Um?  You mean across the flow heading directly away from the center?

<Bob>Exactly.  Consider that option.

<Lesley>Well, it would still be hard work and I would still be going around with the Vortex and I would still need to watch out for flotsam but every stroke I make would take me further from the center.  The chaos would get gradually less and eventually I would be in clear water and out of danger.  I could escape the Victim Vortex!

<Bob>Yes. And what would happen if others saw you do that and did the same?

<Lesley>The Victim Vortex would dissipate!

<Bob>Yes.  So that is your best strategy.  It is a win-win-win strategy too. You can lead others out of the Victim Vortex.

<Lesley>Wow!  That is so cool!  So how would I apply that metaphor to the Information System niggle?

<Bob>I will leave you to ponder on that.  Think about it as a design assignment.  The design of the system that generates IT solutions that are fit-for-purpose.

<Lesley> Somehow I knew you were going to say that!  I have my squared-paper and sharpened pencil at the ready.  Yes – an improvement-by-design assignment.  Thank you once again Bob.  This ISP course is the business!

stick_figure_open_cupboard_150_wht_8038Improvement implies change.

Change requires motivation.

And there are two flavours of motivation juice – Fear and Fuel

Fear is the emotion that comes from anticipated loss in the future.  Loss means some form of damage. Physical, psychological or social harm.  We fear loss of peer-esteem and we fear loss of self-esteem … almost more than we fear physical harm.

Our fear of anticipated loss may be based on reality. Our experience of actual loss in the past.  We remember the emotional pain and we learn from past pain to fear future loss.

Our fear of anticipated loss may also be fueled by rhetoric.  The doom-mongering of the Shroud-Wavers, the Nay-Sayers, the Skeptics and the Cynics.


And there are examples where the rhetorical fear is deliberately generated to drive the fear-of-reality to “the solution” – which of course we have to pay dearly for. This is Machiavellian mass manipulation for commercial gain.

“Fear of germs, fear of fatness, fear of the invisible enemies outside and inside”.

Generating and ameliorating fear is big business. It is a Burn-and-Scrape design.

What we are seeing here is the Drama Triangle operating on a massive scale. The Persecutors create the fear, the Victims run away and the Persecutors then switch role to Rescuers and offer to sell the terrified-and-now-compliant Victims “the  solution” to their fear.  The Victims do not learn.  That is not the purpose – because that would end the Game and derail the Gravy Train.


So fear is not an effective way to motivate for sustained improvement,  and we have ample evidence to support that statement!  It might get us started, but it won’t keep us going.

The Burn-and-Scrape design that we see everywhere is a fear-driven-design.

Any improvements are transitory and usually only achieved at the emotional expense of a passionate idealist. When they get too tired to push any more the toast gets burnt again because the toaster is perfectly designed to burn toast.  Not intentionally designed to burn the toast but perfectly designed to nevertheless.

The use of Delusional Ratios and Arbitrary Targets (DRATs) is a fear-based-design-strategy. It ensures the Fear Game and Gravy Train continue.

And fear has a frightening cost. The cost of checking-and-correcting. The cost of the defensive-bureaucracy that may catch errors before too much local harm results but which itself creates unmeasurable global harm in a different way – by hoovering up the priceless human resource of life-time – like an emotional black hole.

The cost of errors. The cost of queues. The list of fear-based-design costs is long.

A fear-based-design for delivering improvement is a poor design.


So we need a better design.


And a better one is based on a positive-attractive-emotional force pulling us forwards into the future. The anticipation of gains for all. A win-win-win design.

Win-win-win design starts with the Common Purpose: the outcomes that everyone wants; and the outcomes that no-one wants.  We need both.  This balance creates alignment of effort on getting the NiceIfs (the wants) while avoiding the NoNos (the do not wants).

Then we ask the simple question: “What is preventing us having our win-win-win outcome now?

The blockers are the parts of our current design that we need to change: our errors of omission and our errors of commission.  Our gaps and our gaffes.

And to change them we need to be clear what they are; where they are and how they came to be there … and that requires a diagnostic skill that is one of our errors of omission. We have never learned how to diagnose our process design flaws.

Another common blocker is that we believe that a win-win-win outcome is impossible. This is a learned belief. And it is a self-fulfilling prophesy.

We may also believe that all swans are white because we have never seen a black swan – even though we know, in principle, that a black swan could be possible.

Rhetoric and Reality are not the same thing.  Feeling it could be possible and knowing that it actually is possible are different emotions. We need real evidence to challenge our life-limiting rhetoric.

Weary and wary skeptics crave real evidence not rhetorical exhortation.

So when that evidence is presented – and the Impossibility Hypothesis is disproved – then an emotional shock is inevitable.  We are now on the emotional roller-coaster called the Nerve Curve.  And the deeper our skepticism the bigger the shock.


After the shock we characteristically do one of three things:

1. We discount the evidence and go into denial.  We refuse to challenge our own rhetoric. Blissful ignorance is attractive.  The gap between intent and impact is scary.

2. We go quiet because we are now stuck in the the painful awareness of the transition zone between the past and the future. The feelings associated with the transition are anxiety and depression. We don’t want to go back and we don’t know how to go forwards.

3. We sit up, we take notice, we listen harder, we rub our chins, our minds race as we become more and more excited. The feelings associated with the stage of resolution are curiosity, excitement and hope.

It is actually a sequence and it is completely normal.


And those who reach Stage 3 of the Nerve Curve say things like “We have food for thought;  we feel inspired; our passion is re-ignited; we now have a beacon of hope for the future.

That is the flavour of motivation-juice that is needed to fuel the improvement-by-design engine and to deliver win-win-win designs that are both surprising and self-sustaining.

And what actually changes our belief of what is possible is when we learn to do it for ourselves. For real.

That is Improvement Science in action. It is a pragmatic science.

Improvement is not easy. If it were this blog would not attract any vistors.  The data says that the hit rate is increasing. So what questions are visitors asking?

What makes improvement so difficult?

In a word – disappointment.

Or rather the cumulative effect of repeated disappointments.

Over time we become emotionally damaged by disappointment. Our youthful mountain of optimism is slowly eroded and washed away by the stormy reality that life throws at us.

Is this emotional erosion inevitable? I believe not. Some seem to avoid it with innate ability – the rest of us have to learn how. To do that we need to understand how the emotional erosion happens and with that insight we can design an anti-disappointment defense for ourselves.

I see it as a time-dependent process with five phases. The divisions are somewhat artificial because it is a continuous process; the phases overlap and we do not all progress at the same rate. Each phase lasts about 10-15 years it seems.

The First Age – Tender Idealism

Tender_Idealist

The natural child-like behaviour that we are born with is curious, playful, happy, and optimistic.  We arrive with no knowledge of the real world.  Our starting expectation is high because all we have experienced is the safe, warm, fuzzy redness of the womb. Birth is our first big disappointment! Ouch! It is cold out here and suddenly we have to do lots more for ourselves such as breathing, keeping warm, eating, weeing, and pooing. Waaaaaah!

Some claim that we spend our whole lives trying in vain to regain that wonderful, warm womb-like feeling of security and comfort.

But after our birthday surprise we activate our innate curiosity and we learn quickly as we explore the real world. We do not forget though –  we dream about how the world could be more womb-like. We are natural idealists. We all want to recreate a reliable comfort-zone. And anything that gets in our way needs to be removed! The old ideas and the old farts who cling on to them need to go! The problems and solutions are obvious; crystal clear; black-or-white; day-or-night; all-or-nothing; either-or. We start as Tender Idealists.

And we learn quickly that reality resists us.

The Second Age  – Tearful Optimism

Tearful_Optimist

As our experience grows the perfectly sharp edges of our idealism become smoothed off: eroded by the emotional impacts of numerous small disappointments. We remain optimists but our expectations are lowered and our frustrations are elevated. We are told by the Older-and-Wiser that when we fall off our bikes or horses we should brush ourselves down, get back on and try again. “No Pain No Gain” they preach. But it really hurts when we fall off – we graze our knees and we bruise our egos. We cry tears of frustration, pain and fear. But we strive to retain our optimism. We try again, and again, and again. And we are young so we have energy and stamina. We are not too damaged – not yet. We are Tearful Optimists.

The Third Age – Tired Realism

Tired_RealistBut reality is relentless. The battering by the sunshine and storms of life continue – apparently unaffected by our strenuous efforts to create calm.  And we keep slipping as the complexity mud gets thicker, deeper and stickier. We become more, and more tired. We try less and we sit on the fence more. It is less difficult, less tiring, less self-disappointing. We develop a taste for spectator sports. We adopt a team. We cheer when they win and we chide when they lose. Reality has eroded our optimism to the point where it has become so fragile that we dare not pit it against new challenges. We fear the seemingly inevitable failure and the consequent disappointment. Just one more tumble could break us completely. We have become Tired Realists.

The Fourth Age – Turgid Skepticism

Turgid_SkepticNow the rules of the life-game change. We must now protect the last precious vestiges of our hope and we must defend our life-dream from despair. So we build barriers that block the new Idealists and the new Optimists from blindly generating more disappointments for themselves – and for us.  We do not want to lose all hope. We exercise our intellect and our experience and we become experts in the “Yes … but” game.  We dispell new ideas and we say that they are not new and they are not worth trying. We say “Yes, but we tried that and it did not work“. We create a red-taped morass of bureaucracy to slow them down and to tire them out. And we can do that because by now we have gravitated to Positions of Authority. We write the Rules. And our rules all start with the word “No”.

The Tired Realists sit on the fence to watch the New Optimists battle with us Old Skeptics. Just as they had done when they still had the energy. It becomes their favourite spectator sport. A few optimists navigate the bureaucracy swamp and have their innovations implemented. Some even succeed and shine for a while. All fade and fail eventually. The emotional erosion continues relentlessly.

The skeptics are well-intentioned though – they want to prevent avoidable disappointment – but their strategy is non-specific. It blocks all innovation – both the worthwhile and the worthless. And their preferred tool is the simple question “Where is the evidence?” No evidence means “game over” but having evidence is no guarantor of success. Evidence means rich opportunities for nit-picking. The more academic skeptics discard what cannot be proved statistically beyond all reasonable doubt and unintentionally create an unwinnable game of Catch-22.  And over time their examination of the evidence becomes less and less rigorous. They become increasingly Turgid Skeptics.

The Fifth Age – Toxic Cynicism

Toxic_CynicThe final age starts when the skeptic suffers dream failure and enters the Land of the Hopeless. Here any idealism, optimism and realism are discounted by default and without respect. Their Pavlovian reflex is now fully established – every one and every thing is discounted without conscious thought. This is the Creed of the Cynics. The continuous discounting acts as an oily emotional toxin. It is called cynicide – and it poisons the whole organisation. It greases the slippery slope from Realist through Skeptic to Cynic – who may be a minority but the damage they create is disproportionately large. The Toxic Cynics create the waves that trigger the storms that drive the whole disappointment process.

And Toxic Cynics are indiscriminate. A Tender Idealiss can have their fragile and nascent curiosity and optimism destroyed by just one poisonous barb fired accurately but unwittingly by a habitually cynical parent figure.

stick_figure_drawing_three_check_marks_150_wht_5283So what does an experienced Improvement Scientist do to avoid the decline to Cynicism? What strategies do they employ to deflect and dissipate the storms and to defend themselves from their emotionally erosive action?

First they learn of the weathering process and the damage it does and they actively remove themselves from the most toxic parts of their organisations. Why be exposed to cynicide for no good reason? They avoid the cynics,  their congregations and their conversations. They avoid the emotional hooks-and-lines that cynics cast and use to draw others into the Drama Triangle – the negative emotional maelstrom from which the unwitting victims may never escape.

Second they learn to channel their own disappointment into improvement. They learn that after they have failed to meet their own expectation they must step back, reflect, understand what happened, formulate a new design, and then try again. Not just to blindly repeat the same action in the hope that just determination and repetition is sufficient. It is not. They also learn to do the same after a success – they reflect and understand what delivered the delight and how to make that happen more often.

Third they learn to engage the skeptics in a constructive dialog. Skeptics are useful – their sharp questions can help to improve an innovation as much as to destroy one. And they learn how to disarm the cynics. They learn how to neutralise the cynicide poison – by exposing it to the antidote – Respectful Challenge of the Cynical Behaviour.

leaderEffective leaders are de facto improvement scientists. Effective leaders carve an alternative groove for the Idealists, Optimists and Realists – the path to Capability, Credibility, and Sagacity. Effective leaders nurture the Idealists because they are the  future Optimists. Effective leaders support the Optimists because they are the future leaders. Effective leaders coax the Realists out of passive observation and into active participation. Effective leaders respect the Skeptics for their skills and restrict their bureaucracy.  Effective leaders block cynicide production by offering the Cynics a simple binary choice: healthy skepticism or The Door.

The Five Ages represent learned roles not inherited attributes. We can all choose our behaviour. We can all choose to play any of the five roles at any time. We are not Saints or Sinners. We are all fallible; we are all on the same life path and we all have the same choices:

Do we choose the path of continual improvement or do we choose the path of constant disappointment?

A wise decision is required.

And for the Optimists, Realists and Skeptics out there – hard evidence that Improvement Science works in practice – even when the participants are highly skeptical – the six week update on the real example described in The Writing On The Wall – Part I