health care systems engineer
It’s a sunny day and I realize that my laptop screen is viewable whilst sitting in the garden!
I am now three quarters the way through my Foundations in Improvement Science for Healthcare (FISH©) course. It has been a revelation to say the least. The last time I blogged on my progress I remarked that memories of operational struggles whilst working within my various senior leadership roles have become clearer as to why we had some success and plenty of failure in terms of sustainable difference around the three key wins. These are improved quality, productivity and motivation. This feeling has most definitely continued!
The course so far has taken me through the general concepts using the Three Wins Design®, plenty of the people stuff that is fundamental to success and on the last few ‘study’ occasions the more technical stuff of what it takes to understand how a system is functioning. In other words how to build up a picture of the root causes for the outcomes from the system, how to analyse the data and present the data so that it is information and finally how potential design changes can be tested to reveal how the root causes can be reduced to achieve a balancing act around the three wins. So I am becoming more confident in the use of value stream maps that set out how work is done and how resources are used and presentation on a process template. What this does is to remove rhetoric; intuition and frankly some guess work that is all too common when tackling operational challenges. The notion of cycle times that can help to explain why outpatient clinics, day case units etc can be a less than positive experience for patients by simply setting out the process on a Gantt chart is wonderful to see as it changes perceived complexity into a simple picture.
I am feeling more motivated than ever to complete the course as the power to resolve challenges becomes more and more obvious. This is despite the fact I am being tested to grasp the concepts of schedules, standard work, hand offs, Pareto analysis, the 80:20 heuristic and how to present demand, workloads and resources in a consistent manner. This is not easy for somebody who does not naturally occupy this type of space!
So why the Chimp in me? Whilst completing the course I am reading an interesting book called the Chimp Paradox by Dr Steve Peters. He sets out his thoughts on how the brain functions and how to manage your chimp. Your chimp is the emotional part of the brain that will tell your human or logical part you can’t do something or ask why would you want to learn something new that could make you look daft. Well my chimp is feeling settled and untroubled at the moment because of the combination of the achievement and the huge potential I see in using improvement science. All this adds up to, I want to learn some more of this stuff. Oh and the sun is still shining!
My head is a buzzing this morning with poems by John Godfrey Saxe, Theory of Constraints, Six Thinking Hats®, managing transitions and discrete event simulations!
It is not because of the rather lovely bottle of red yesterday evening nor as a result of an episode of the hitchhikers guide to the galaxy but rather my start on the Foundations of Improvement Science in Healthcare course.
The Three Wins book that kicks off the course should be offered to all those folks who are trying to bring about improvements to patients but finding it frustrating and about to consider giving it up. You know who you are and I have been there on a few occasions myself. The book plots the journey of the vascular team at Good Hope Hospital who deliver some fantastic changes to improve the service to patients and in doing so achieve the Three Wins: quality, performance and motivation. John’s story fills your heart with joy!
So it is Saturday morning and sporting events are happening around me. I am delighted to have started my course and have an end in mind. My G-R-O-W outline is done and I have my Niggles that I will convert to NoNos and my NiceIfs that I want to end up as Nuggets. I have played the Post It® Note and Six Dice games and begun ‘learning’ the concepts behind improvement science that I know will complement any people skills I might possess. The human side of change, the key goals of quality and performance are all wrapped up together as we all know well and here it is becoming clearer how these things can and must be pulled off simultaneously.
I am excited about all this and having chatted to a cracking CEO leader yesterday I can see more and more clearly how his goals of deeper engagement and involvement with the hospitals teams, his desire to improvement the patient’s view of the services offered and also sorry to say this but how the money can be made to work harder can be delivered.
I have programmed some further time next week to hit the next stage of the course where the more technical bits get explained and illustrated using the exercises, examples and language that thus far are making this fun.
Next Friday sees the arrival of a friend from Australia who has not been seen in 10 years. The next blog might be interesting!
There I was 6 days ago quietly minding mine own business observing a session at the Keele University Clinical Management & Leadership course & now I am writing my first ever blog! How did that happen? The simple truth is that I had one of those OMG or ah ha moments when after years of attempting to tackle difficult and challenging operational matters there was an approach to delivery that seemed to have the potential to bring order, discipline and a sense of hope. I can pin this on an introduction to improvement science led by Simon Dodds. I went home that evening thinking I must have more of this and need to understand the foundations of putting improvement science into practice. I had already committed myself and ‘paid’ Simon a compliment by approaching him after his session and blurting out “where do I learn this stuff”?
In my career to date I have undertaken many operational roles & spent 10 years at Board level including stints as CEO. What this tells you is that I have observed hospitals, how they function or don’t as the case may be and on a number of occasions have failed to make a difference that is sustainable because my tool kit wasn’t up to it. So 6 days on from the ah ha moment and a couple of swift drinks at a hostelry in Warwickshire I have enrolled on the FISH (Foundations in Improvement Science in Healthcare) course, am writing this blog and looking forward to finally having an approach, alongside my other leadership training, to help me resolve the myriad of operational challenges that beset our great NHS. My big hope is to become a practitioner capable of sharing the approach of improvement science to as wider audience as possible. The 24 years of experience in operational leadership in the NHS tells me that very few of us have these skills that would make a very significant difference to the quality, safety, people engagement & efficiency of the services we all want to be proud of.
So I am going to write my thoughts down as I go along my FISH course so that in some small way I might influence others to want to know more. I might even become a better blogger as a result!
Feel free to comment below or email me on email@example.com if you want to comment or question my wave of enthusiasm!
W. Edwards Deming (1900-1993) is sometimes referred to as the Father of Quality. He made such a significant contribution to Japan’s burgeoning post-war reputation for innovative high-quality products, and the rapid development of their economic power, that he is regarded as having made more of a difference than any other individual not of Japanese heritage.
Though best known as a statistician and economist, he was initially educated as an electrical engineer and mathematical physicist. To me however he was more of a social scientist – interested in the science of improvement and the creation of value for customers. A lifelong learner, in his later years (1) he became fascinated by epistemology – the processes by which knowledge is created – and this led him into wanting to know more about the psychology of human behaviour and its underlying motivations.
In his nineties he put his whole life of learning into one model – his System of Profound Knowledge (SoPK). What follows is my brief take on each of the four elements of the SoPK and how they fit together.
THE PSYCHOLOGY OF HUMAN BEHAVIOUR
Everyone is different, and we all SEE things differently. We then DO things based on how we see things – and we GET results – of some kind. Over time we shore up our own particular view of the world – some call this a “paradigm” – our own particular world view – multiple loops of DO-GET-SEE (2) are self-reinforcing and as our sense making becomes increasingly fixed we BEHAVE – BECOME – BELIEVE. The trouble is we each to some extent get divorced from reality, or at least how most others see it – in extreme cases we might even get classified by some people as “insane” – indeed the clinical definition of insanity is doing the same things whilst expecting different results.
THE ACQUISITION OF KNOWLEDGE
So when we DO things it would be helpful if we could do them as little experiments that test our sense of what works and what is real. Even better we might get others to help us interpret the results from the benefit of their particular world view/ paradigm. Did you study science at school? If so you might recognize that learning in this way by experimentation is the “scientific method” in action. Through these cycles of learning knowledge gets continually refined and builds. It is also where improvement comes from and how reality evolves. Deming referred to this as the PLAN-DO-STUDY-ACT Cycle (1) – personally i prefer the words in this adjacent diagram. For me the cycle is as much about good mental health as acquiring knowledge, because effective learning (3) keeps individuals and organizations connected to reality and in control of their lives.
The origins of PDSA lie with Walter Shewhart (4) who in 1925 – invented it to help people in organizations methodically and continually inquire into what is happening. He observed that when workers or managers make changes in their working practices so that their processes run better, the results vary, and that this variation often fools them. So he invented a tool for collecting numbers in real time so that each process can be listened in to as a “system” – much like a doctor uses a stethoscope to collect data and interpret how their patient’s system is behaving, by asking what might be contributing to – actually causing – the system’s outcomes. Shewhart named the tool Statistical Process Control – three words, each of which for many people are an instant turn-off. This means they miss his critical insight that there are two distinct types of variation – noise and signal, and that whilst all systems contain noise, only some contain signals – which if present can be taken to be assignable causes of systemic behaviour. Indeed to make it more palatable the tool might better be referred to as a “system behaviour chart”. It is meant to be interpreted like a doctor or nurse interprets the vital sign graph on the end of a patient’s bed i.e. to decide what action if any to take and when. Here is an example that has been created in BaseLine© which is specifically designed to offer the agnostic direct access to the power of Shewhart’s thinking. (5).
What is meant by the word “system”? It means all the parts connected and interrelated as a whole (3). It is often helpful to get representatives of the various stakeholder groups to map the system – with its parts, the flows and the connections – so they can see how different people make sense of say.. their family system, their work system, a particular process of interest.. indeed any system of any kind that feels important to them. The map shown here is one used that might be used generically by manufacturers to help them investigate the separate causal sources of systemic variation – from the Suppliers of Inputs received, to the Processes that convert those inputs into Outputs, which can then be received by Customers – all made possible by vital support processes. This map (1) was taught by Deming in 1950 to Japan’s leaders. When making sense of their own particular systemic context others may prefer a different kind of map, but why? How come others prefer to make sense of things in their own way? To answer this Peter Senge (3) in his own equivalent to the SoPK says you need 5 distinct disciplines: the ability to think systemically, to learn as a team, to create a shared vision, to understand how our mental models get ingrained, and lastly “personal mastery” … which takes me back to where I started.
Aware that he was at the end of his life of learning, Deming bequeathed his System of Profound Knowledge to us so that we might continue his work. Personally, I love the SoPK because it is so complete. It is hard however to keep such a model, complete and as a whole, continually in the front of our minds – such that everything we think and do can be viewed as a fractal of that elegant whole. Indeed as a system, the system of profound knowledge is seriously – even fatally – undermined if any single part is missing ..
• Without understanding the causes of human behaviour we have no empathy for other people’s worldviews, other value systems. Without empathy our ability to manage change is fundamentally impaired.
• Without being good at experimentation and turning our experience into Knowledge – the very essence of science – we threaten our very mental health.
• Without understanding variation we are all too easily deluded – ask any magician (6). We spin our own reality. In ignoring or falsely interpreting data we are even “wilfully blind” (7). Baseline© for example is designed to help people make more of their time-series data – a window onto the system that their data is representing – using its inherent variation to gain an enhanced sense of what’s actually happened, as well as what’s really happening, and what if things stay the same is most likely to happen.
• Without being able to see how things are connected – as a whole system – and seeing the uniqueness of our own particular context, moment to moment, we miss the importance of our maps – and those of others – for good sense-making. We therefore miss the sharing of our individual realities, and with it the potential to spot what really causes outcomes – which neatly takes us back to the need for empathy and for understanding the psychology of human behaviour.
For me the challenge is to be continually striving for that sense of the SoPK – as a complete whole – and by doing this to see how I might grow my influence in the world.
1. Deming W.E – The New Economics – 1993
2. Covey S.R. – The 7 habits of Highly Effective People – 1989
3. Senge P. M. – The Fifth Discipline: the art and practice of the learning organization – 1990
4. Wheeler D.J. & Poling S.R.– Building Continual Improvement – 1998
5. BaseLine© is available via www.threewinsacademy.co.uk.
6. Macknik S, et al – Sleights of Mind – What the neuroscience of magic reveals about our brains – 2011.
7. Heffernan M. – Wilfully Blind – 2011
Some fabulous new SPC software, called BaseLine© is now available – it’s designed for organizations and individuals who see the advantages in having people use a standard performance charting tool that’s statistically robust yet straight forward to use even for the uninitiated. As well as being highly accessible, at under £50 it is easily the most inexpensive option now available.
There is even a time-unlimited FREE version.
BaseLine© is obtainable via http://www.valuesystemdesign.com
How might some people be offended by performance charting?
The idea behind BaseLine© is that most every organisation is these days awash with time-series data, usually held in spreadsheet form, yet very little of it is used to diagnose systemic change. Even people who are held accountable for performance are often unaware of the gold that lies beneath their feet – or if they are aware, are for some reason reluctant to make use of it. Because BaseLine© is so accessible – there really is no longer any reason to avoid using SPC, but wait ..
.. observing those who are taking the plunge it’s becoming clearer to me where this reluctance might be coming from. Whilst some of it is due undoubtedly to low organisational expectation, I’m detecting that some of it is also due to low self-perception of capability, and some might even be because BaseLine© somehow confronts the personal value-set of particular managers. Let me refer to these value sets and capabilities as “memes”(1) and allow myself the luxury of speculatively labelling each one – so that I can treat each as a hypothesis that might later be tested – to see if the accumulating evidence either supports or refutes it. So here goes ..
1. The “Accountability-avoidance” meme – Those comfortable and skilled enough to hold a senior position may still however be inhabited by this meme, which can actually apply at any level in an organisational hierarchy. To most people it is an essential underpinning of their self-esteem to be able to feel that they’ve personally made a contribution whilst at work. It’s safer therefore (at least unconsciously) to be able to avoid roles for which any direct or personal performance measurement is attached – and there are plenty of such roles.
2. The “anti-Management” meme – According to this meme there’s something dehumanising about asking anyone to manage a process that delivers an outcome to someone who might appreciate it. Those who embody this value-set may also think that Management sounds altogether too boring when compared to Leadership since not much good happens unless people can feel good about it, and people have to be led to achieve anything meaningful and lasting. If there’s any management to be done it should be done by the followers.
3. The “anti-Control freak” meme – People holding this meme tend to dislike the whole idea of control, unless it’s the empowering of others to be in control – and even this may be considered too dangerous since the power to control anything can so easily be abused.
4. The “anti-Determinism” meme – Inside this meme Albert Einstein is considered as having completely supplanted the Newtonian “predict and control paradigm” as opposed to having merely built upon it. Life is viewed as inherently uncertain, and there’s a preference for believing that little can be reliably predicted, so it’s best to adopt an “act first/ ask questions later” approach. Deepak Chopra fans for example will know that “the past is history, and the future a mystery” and that therefore almost any form of planning is repellent – instead, emergence is the thing most highly valued.
5. The “Numerophobia” meme – so widespread is the tendency to avoid numbers, it may be easier to think of this as a syndrome rather than a meme – indeed, in the extreme it is a medical condition called “dyscalculia.” Whilst few people readily admit to being illiterate, there are many who are relatively happy to announce that they “don’t do numbers” – and some have even learned that it pays to be proud of it. In one recent UK study 11% were designated illiterate, but 40% innumerate.
6. The “iNtuitives rule” meme – People who are inhabited by this meme are those who may well feel comfortable weaving (even spinning) their story without the benefit of data that’s been fully “sensed”. The Myers Briggs Type Indicator – scores around 25% of people as N (iNtuitive), the remaining 75% being Sensors – who prefer to look for and absorb data via their 5 senses, data that to them feels tangibly “real.” On average around 12% people score as having N/T (intuitive thinking) preferences – yet exec teams & boards often score at more than 50%. Is this because they have had to become comfortable feeling disconnected from the customer interface, or because they were always that way inclined and therefore gravitated towards the apex of the hierarchy?
7. The “anti-Science” meme – According to this meme even the fact that I’m labelling these value-sets/ memes at all, will be seen as being antithetical – regardless of whether it might in some way prove to be a useful scientific device for advancing knowledge. People in organisations may behave in a way that’s anti-science in that tasks and projects are typically carried out in a Plan-Do-Review sequence – unaware that Plan-Do-Study-Act represents the scientific method in action, and is an entirely different paradigm.
8. the “protect my group or profession” meme – According to this meme, people are confident that they know what they know – and have spent several years of their life being trained to acquire that knowledge. They less aware of the extent to which this has formed their mental maps and how these in turn direct their opinions. When in doubt, reference is made to the writings and utterances of their personal or professional gurus – and quoted verbatim, frequently out of context. When a new tool arrives, the default position is: if I don’t recognise it, it should be rejected – until one of the gurus authenticates it.
Wow, when I started the list I didn’t think there would be as many as eight.
Individuals and organizations that are already, or can become, comfortable with applying the scientific method in their organisations – and personally – as a system, will see the profundity in a tool like BaseLine©. Others will miss it altogether, and one or more of the memes listed above could be preventing them seeing it. I’ll continue to collect more data, both sensed and intuited, and report on my findings in a future blog.
One source of test data will of course be the comments I solicit from readers of this blog, so having read these labels and descriptions, do you notice any reactive feelings? If so, can you accurately describe what you feel most confronted by? I’d be delighted to hear from you.
(1) Richard Dawkins coined (or adapted) the word “meme” in The Selfish Gene (1976) as a value set, or a postulated unit of cultural ideas, symbols or practices – which can be transmitted from one mind to another through writing, speech, gestures, rituals or other imitable phenomena. It’s sometimes used synonymously with the phrase “world view.” Clare Graves then made the Value meme (vMeme) a core concept in his Spiral Dynamics model – see Beck D.E & Cowan C.C. : “Spiral Dynamics – Mastering Values, Leadership, and Change” – 1996
This Sunday I was listening the Aled Jones on Radio 2 – as he was interviewing Mark Kermode of BBC.TV’s Culture Show. Mark posed a profound question:
When you visit the cinema, do you like to watch the kind of film that starts with a caption saying “This is a True Story” or maybe you prefer the kind with a caption saying “This is a story inspired by Actual Events”?
He suggested that it’s best to assume that the first kind is largely a fiction, whereas the latter is almost completely so. Personally, I don’t mind which ever kind it is, for sometimes I actually enjoy being fooled as long as it’s good harmless fun and it’s entertaining – AND as long as I don’t think someone is deliberately fooling me. But then I started wondering: How would I know if they were trying to fool me? Or more worryingly, whether I was fooling myself?
Since the 1850s there have been various “Realism” movements in the fields of cinema, art and literature – featuring the search for literal truth and pragmatism – a representation of objects, actions, or social conditions as they actually are without idealisation or presentation in abstract form – each of these movements was based upon a philosophy that universals exist independently of their having been thought up, and that physical objects exist independently of their being perceived. In this age of political and media “spin” maybe there’ll come a return to such a philosophy? In the mean time, as long as we are aware that the film we’ve chosen to watch is intended as fiction, and is billed as such, most of us won’t mind – indeed we might even view it as escapism – yet in many situations wouldn’t it be nice to feel that we are connected to a representation of events that’s more real, rather than just some one else’s imagined story?
When a patient in the healthcare system, I think I’d rather be treated by professionals who check and double check what they’re doing, and are working within a system that someone has designed to be fail safe – and is measured to be so. I’m hoping that the medics, nurses and administrators know the difference between what’s real and what is imagined. On this week’s Panorama (BBC March 8th 2010) it was suggested that some hospitals have much higher mortality than others, so this isn’t an insignificant hope. The three hospitals featured had all been flagged as having high mortality rates, yet had all been rated “Fair” or “Good” by the Care Quality Commission. This left me thinking that their may be more imagination around in the NHS than hard data.
The thing is, most everyone relies on data (via their 5 senses or their intuition) as if pure and unfiltered – under the assumption that this is all there is. But there’s always more to be known, and some of that missing knowledge may literally be the difference between life and death.
Numerical data in particular is actively avoided by many – even by professionals, be they the designers of the system or an individual who works within it. Many people left school determined to avoid numbers for the rest of their lives – when confronted by even the simplest statistic or numerical puzzle they will happily tell you “I don’t do numbers.” Since seeing the Panorama programme I’m now wondering how many people (clinicians, managers, inspectors) working within the health sector take such a view. Or maybe there’s a full-proof test that every prospective healthcare worker must pass before they’re allowed to practice? Can anyone reasure me about this?
A few weeks ago some very powerful yet delightfully accessible software was launched – called BaseLine©. It has been created so that people can have a kind of 3rd eye perception that mitigates the tendency to fictionalise – so that people can together assess what’s really happening. It’s designed to be a kind of dispassionate “fly on the wall” or a well-positioned “security camera” – and has been designed to be so easy to use that even the numerophobic will want to use it.
It’s actually free software, and even the full version costs under £50 – this is deliberate in order to maximize the possibility of it becoming a health sector standard. Having a standard tool will mean that people won’t have to debate the validity of the statistics, and can move directly to discussing the reality of what’s been happening, what’s happening now, and more importantly what’s likely to happen if nothing changes. Let’s see how long it takes clinicians and managers to discover its power?