Archive for the ‘Questions’ Category

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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



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

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

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

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

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


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


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


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


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


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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Improvement implies change;

… change implies learning;

… learning implies asking questions;

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

This week a friend of mine shared an interesting story.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Who of us never disrespects or discounts others?

Are we all infected with the same disease?

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

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

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

That would be a start.

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

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

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

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

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

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