Archive for the ‘Reflections’ Category

A few weeks ago I raised the undiscussable issue that the NHS feels like it is on a downward trajectory … and that what might be needed are some better engines … and to design, test, build and install them we will need some health care system engineers (HCSEs) … and that we do not have appear to have enough of those. None in fact.

The feedback shows that many people resonated with this sentiment.


This week I had the opportunity to peek inside the NHS Cockpit and look at the Dashboard … and this is what I saw on the A&E Performance panel.

UK_Type_1_ED_Monthly_4hr_Yield

This is the monthly aggregate A&E 4-hour performance for England (red), Scotland (purple), Wales (brown) and Northern Ireland (grey) for the last six years.

The trajectory looked alarmingly obvious to me – the NHS is on a predictable path to destruction – a controlled flight into terrain (CFIT).

The repeating up-and-down pattern is the annual cycle of seasons; better in the summer and worse in the winter.  This signal is driven by the celestial clock … the movement of the planets … which is beyond our power to influence.

The downward trajectory is the cumulative effect of our current design … which is the emergent effect of our collective beliefs, behaviours, policies and politics … which are completely within our gift to change.

If we chose to and if we knew how to – which we do not appear to.

Our collective ineptitude is not a topic for discussion. It is a taboo subject.


And I know that because if it were for discussion then this dashboard would be on public view on a website hosted by the NHS.

It isn’t.


George_DonaldIt was created by George Donald, a member of the public, a disappointed patient, and a retired IT consultant.  And it was shared, free for all to see and use via Twitter (@GMDonald).

The information source is open, public, shared NHS data, but it takes a lot of work to winkle it out and present it like this.  So well done George … keep up the great work!


Now have a closer look at the Dashboard Display … look at the most recent data for England and Scotland.  What do you see?

Does it look like Scotland is pulling out of the dive and England is heading down even faster?

Hard to say for sure; there are lots of signals and noise all mixed up.


So we need to use some Systems Engineering tools to help us separate the signals from the noise; and for this a statistical process control (SPC) chart is useless.  We need a system behaviour chart (SBC) and its handy helper the deviation from aim (DFA) chart.

I will not bore you with the technical details but, suffice it to say, it is a tried-and-tested technique called the Method of Residuals.

Scotland_A&E_DFA_02 Exhibit #1 is the DFA chart for Scotland.  The middle 4 years (2011-2014) are used to create a ‘predictive model’;  the model projection is then compared with measured performance; and the difference is plotted as the DFA chart.

What this “says” is that the 2015/16 performance in Scotland is significantly better than projected, and the change of direction seemed to start in the first half of 2015.

This evidence seems to support the results of our Mark I Eyeball test.

England_A&E_DFA_02

Exhibit #2 – the DFA for England suggests the 2015/16 performance is significantly worse than projected, and this deterioration appears to have started later in 2015.

Oh dear! I do not believe that was the intention, but it appears to be the impact.


So what are England and Scotland doing differently?
What can we all learn from this?
What can we all do differently in the future?

Isn’t that a question that more people like you, me and George could reasonably ask of those whom we entrust to design, build and fly our NHS?

Isn’t that a reasonable question that could be asked by the 65 million people in the UK who might, at any time, be unlucky enough to require a trip to their local A&E department.

So, let us all grasp the nettle and get the Elephant in the Room into plain view and say in unison “The Emperor Has No Clothes!”

We are suffering from mass ineptitude and hubris, to use Dr Atul Gawande’s language, and we need a better collective strategy.


And there is hope.

Some innovative hospitals have had the courage to grasp the nettle. They have seen what is coming; they have fully accepted the responsibility for their own fate; they have stepped up to the challenge; they have looked-listened-and-learned from others, and they are proving what is possible.

They have a name. They are called positive deviants.

Have a look at this short video … it is jaw-dropping … it is humbling … it is inspiring … and it is challenging … because it shows what has been achieved already.

It shows what is possible. Now, and here in the UK.

Luton and Dunstable

Transformation

It has been another interesting week.  A bitter-sweet mixture of disappointment and delight. And the central theme has been ‘transformation’.


The source of disappointment was the newsreel images of picket lines of banner-waving junior doctors standing in the cold watching ambulances deliver emergencies to hospitals now run by consultants.

So what about the thousands of elective appointments and operations that were cancelled to release the consultants? If the NHS was failing elective delivery time targets before it is going to be failing them even more now. And who will pay for the “waiting list initiatives” needed to just catch up? Depressing to watch.

The mercurial Roy Lilley summed up the general mood very well in his newsletter on Thursday, the day after the strike.

Roy_Lilley_Transformation

What he is saying is we do not have a health care system, we have a sick care system.  Which is the term coined by the acclaimed systems thinker, the late Russell Ackoff (see the video about half way down).

We aspire to a transformation-to-better but we only appear to be able to achieve a transformation-to-worse. That is depressing.


My source of delight was sharing the stories of those who are stepping up and are transforming themselves and their bits of the world; and how they are doing that by helping each other to learn “how to do it” – a small bite at a time.

Here is one excellent example: a diagnostic study looking at the root cause of the waiting time for school-age pupils to receive a health-protecting immunisation.


So what sort of transformation does the NHS need?

A transformation in the way it delivers care by elimination of the fragmentation that is the primary cause of the distrust, queues, waits, frustration, chaos and ever-increasing costs?

A transformation from purposeless and reactive; to purposeful and proactive?

A transformation from the disappointment that flows from the mismatch between intent and impact; to the delight that flows from discovering that there is a way forward; that there is a well understood science that underpins it; and a growing body of evidence that proves its effectiveness.  The Science of Improvement.


In  a recent blog I shared the story of how it is possible to ‘melt queues‘ or more specifically how it is possible to teach anyone, who wants to learn, how to melt queues.

It is possible to do this for an outpatient clinic in one day.

So imagine what could happen if just 1% of consultants decided improve their outpatient clinics using this quick-and-easy-to-learn-and-apply method?  Those courageous and innovative consultants who are not prepared to drown in the  Victim Vortex of despair and cynicism.  And what could happen if they shared their improvement stories with their less optimistic colleagues?  And what could happen if a just a few of them followed the lead of the innovators?

Would that be a small transformation?  Or the start of a much bigger one? Or both?

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?

engineers_turbine_engine_16758The NHS is falling.

All the performance indicators on the NHSE cockpit dashboard show that it is on a downward trajectory.

The NHS engines are no longer effective enough or efficient enough to keep the NHS airship safely aloft.

And many sense the impending crash.

Scuffles are breaking out in the cockpit as scared pilots and anxious politicians wrestle with each other for the controls. The passengers and patients appear to be blissfully ignorant of the cockpit conflict.

But the cockpit chaos only serves to accelerate their collective rate of descent towards the hard reality of the Mountain of Doom.


So what is needed to avoid the crash?

Well, some calm and credible leadership in the cockpit would help; some coordinated crash avoidance would help too; and some much more effective and efficient engines to halt the descent and to lift us back to a safe altitude would help too. In fact the new NHS engines are essential.

But who is able to design, build, test and install these new health care system engines?


We need competent and experienced health care system engineers.


And clearly we do not have enough because if we had, we would not be in a CFIT scenario (cee fit = controlled flight into terrain).

So why do we not have enough health care system engineers?

Surely there are appropriate candidates and surely there are enough accredited courses with proven track records?

I looked.  There are no accredited courses in the UK and there are no proven track records. But there appears to be no shortage of suitable candidates from all corners of the NHS.

How can this be?

The answer seems to be that the complex flow system engineering science needed to do this is actually quite new … it is called Complex Adaptive Systems Engineering (CASE) … and it has not diffused into healthcare.

More worryingly, even basic flow engineering science has not either, and that seems to be because health care is so insular.

So what can we do?

The answer would seem to be clear.  First, we need to find some people who, by chance, are dual-trained in health care and systems engineering.  And there are a few of them, but not many.


People like Dr Kate Silvester who trained as an ophthalmic surgeon then retrained as a manufacturing systems engineer with Lucas and Airbus. Kate brought these novel flow engineering skills back in to the NHS in the days of the Modernisation Agency and since then has proved that they work in practice – as described in the Health Foundation Flow-Cost-Quality Programme Report.


Second, we need to ask this small band of seasoned practitioners to design and to deliver a pragmatic, hands-on, learning-by-doing Health Care Systems Engineer Development Programme.


The good news is that, not surprisingly, they have already diagnosed this skill gap and have been quietly designing, building and testing.

And they have come up with a name: The Phoenix Programme.

And because TPP is a highly disruptive innovation they know that it is too early to give it a price-tag, so they have generously offered a limited number of free tickets to the first part of TPP to clinicians and clinical scientists.

The first step is called the Foundations of Improvement Science in Healthcare online course, and better known to those who have completed it as “FISH”.

This vanguard of innovators have shared their feedback.

And, for those who are frustrated and curious enough to explore outside their comfort zones, there are still some #freeFISH tickets available.


So, if you are attracted by the opportunity of dual-training as a clinician and as a Health Care Systems Engineer (HCSE) then we invite you to step this way.


And not surprisingly, this is not a new idea … see here and here.

The Harvard Business Review is worth reading because many of its articles challenge deeply held assumptions, and then back up the challenge with the pragmatic experience of those who have succeeded to overcome the limiting beliefs.

So the heading on the April 2016 copy that awaited me on my return from an Easter break caught my eye: YOU CAN’T FIX CULTURE.


 

HBR_April_2016

The successful leaders of major corporate transformations are agreed … the cultural change follows the technical change … and then the emergent culture sustains the improvement.

The examples presented include the Ford Motor Company, Delta Airlines, Novartis – so these are not corporate small fry!

The evidence suggests that the belief of “we cannot improve until the culture changes” is the mantra of failure of both leadership and management.


A health care system is characterised by a culture of risk avoidance. And for good reason. It is all too easy to harm while trying to heal!  Primum non nocere is a core tenet – first do no harm.

But, change and improvement implies taking risks – and those leaders of successful transformation know that the bigger risk by far is to become paralysed by fear and to do nothing.  Continual learning from many small successes and many small failures is preferable to crisis learning after a catastrophic failure!

The UK healthcare system is in a state of chronic chaos.  The evidence is there for anyone willing to look.  And waiting for the NHS culture to change, or pushing for culture change first appears to be a guaranteed recipe for further failure.

The HBR article suggests that it is better to stay focussed; to work within our circles of control and influence; to learn from others where knowledge is known, and where it is not – to use small, controlled experiments to explore new ground.


And I know this works because I have done it and I have seen it work.  Just by focussing on what is important to every member on the team; focussing on fixing what we could fix; not expecting or waiting for outside help; gathering and sharing the feedback from patients on a continuous basis; and maintaining patient and team safety while learning and experimenting … we have created a micro-culture of high safety, high efficiency, high trust and high productivity.  And we have shared the evidence via JOIS.

The micro-culture required to maintain the safety, flow, quality and productivity improvements emerged and evolved along with the improvements.

It was part of the effect, not the cause.


So the concept of ‘fix the system design flaws and the continual improvement culture will emerge’ seems to work at macro-system and at micro-system levels.

We just need to learn how to diagnose and treat healthcare system design flaws. And that is known knowledge.

So what is the next excuse?  Too busy?

Pearl_and_OysterThe word pearl is a metaphor for something rare, beautiful, and valuable.

Pearls are formed inside the shell of certain mollusks as a defense mechanism against a potentially threatening irritant.

The mollusk creates a pearl sac to seal off the irritation.


And so it is with change and improvement.  The growth of precious pearls of improvement wisdom – the ones that develop slowly over time – are triggered by an irritant.

Someone asking an uncomfortable question perhaps, or presenting some information that implies that an uncomfortable question needs to be asked.


About seven years ago a question was asked “Would improving healthcare flow and quality result in lower costs?”

It is a good question because some believe that it would and some believe that it would not.  So an experiment to test the hypothesis was needed.

The Health Foundation stepped up to the challenge and funded a three year project to find the answer. The design of the experiment was simple. Take two oysters and introduce an irritant into them and see if pearls of wisdom appeared.

The two ‘oysters’ were Sheffield Hospital and Warwick Hospital and the irritant was Dr Kate Silvester who is a doctor and manufacturing system engineer and who has a bit-of-a-reputation for asking uncomfortable questions and backing them up with irrefutable information.


Two rare and precious pearls did indeed grow.

In Sheffield, it was proved that by improving the design of their elderly care process they improved the outcome for their frail, elderly patients.  More went back to their own homes and fewer left via the mortuary.  That was the quality and safety improvement. They also showed a shorter length of stay and a reduction in the number of beds needed to store the work in progress.  That was the flow and productivity improvement.

What was interesting to observe was how difficult it was to get these profoundly important findings published.  It appeared that a further irritant had been created for the academic peer review oyster!

The case study was eventually published in Age and Aging 2014; 43: 472-77.

The pearl that grew around this seed is the Sheffield Microsystems Academy.


In Warwick, it was proved that the A&E 4 hour performance could be improved by focussing on improving the design of the processes within the hospital, downstream of A&E.  For example, a redesign of the phlebotomy and laboratory process to ensure that clinical decisions on a ward round are based on todays blood results.

This specific case study was eventually published as well, but by a different path – one specifically designed for sharing improvement case studies – JOIS 2015; 22:1-30

And the pearls of wisdom that developed as a result of irritating many oysters in the Warwick bed are clearly described by Glen Burley, CEO of Warwick Hospital NHS Trust in this recent video.


Getting the results of all these oyster bed experiments published required irritating the Health Foundation oyster … but a pearl grew there too and emerged as the full Health Foundation report which can be downloaded here.


So if you want to grow a fistful of improvement and a bagful of pearls of wisdom … then you will need to introduce a bit of irritation … and Dr Kate Silvester is a proven source of grit for your oyster!

Learning how to manage is as vital as learning how to lead.

by Julian Simcox

Recently I blogged to introduce the re-publication of my 10 year old essay:

“Intervening into Personal and Organisational Systems by Powerfully Leading and Wisely Managing”

The key ideas in that essay were seven fold:

  1. Aiming to develop Leadership separately from Management is likely to confuse anyone targeted by a separatist training programme, the reality being that everyone in organisational life is necessarily and simultaneously both Managing and Leading (M/L) and often desperately trying to integrate them as two very different action-logics.
  2. Managing and Leading are not roles but ways of thinking and acting that need to be intently chosen, according to the particular learning context (one of three) that any Managerial Leader (12) is facing.
  3. Like in Stephen Covey’s “Maturity Continuum” (8) M/L capability evolves over time (see the diagram below) and makes possible a transformational outcome, if supported in one’s organisation by sufficient and timely post-conventional thinking.
  4. Such an outcome (9,10,11,14,17,19,20,21,23) occurred in Toyota from 1950, making it possible for the organisation to evolve into what Peter Senge (18) calls a “Learning Organisation” – one in which improvement science (4) ensues continually from the bottom-up, within a structure that has evolved top-down.
  5. In Toyota’s case it was W. Edwards Deming who is most credited with having been the catalyst. Jim Collins (6) evidences eleven other examples of an organisational transformation sparked by an individual with a post-conventional world view that transcended a pre-existing conventional one.
  6. Deming talked a lot about ways of thinking – paradigms – that, like Euclidian geometry, make sense in their own world, but not outside it. When speaking with anyone in a client organisation he always aimed at being empathic to a person’s individual frame of reference. He was interested in how individuals make their own common sense because he had learned that it is this that often negatively impacts an individual’s decision-making process and hence their impact on an organisational system that needs to continually learn – a phenomenon he called “tampering”.
  7. The diagram seeks to capture the ways in which paradigms (world views) collectively and sequentially evolve. It combines the research of several practitioners (2,7,15,16) who sought to empirically trace the archetypal evolution of individual sense-making.

JS_Blog_20160307_Fig1

In 2013, Don Berwick (5) recommended to the UK government that, in order to prioritise quality and safety, the National Health Service must become a Deming-style learning organisation. The NHS however is not one single organisation, it is a thousand organisations – both privately and publically owned.  Yet if structured with “Liberating Disciplines” (22) via appropriately set central standards (e.g. tools that prompt thinking that is scientifically methodical), each can be invited as a single organisation to transform themselves into a body with learning its core value. Berwick seems to appreciate that out of the apparently sufficient conventional thinking, enough post-conventional managerial leadership will then have a chance to take root, and in time bloom.

The purpose of this blog is to introduce a second essay:

“Managerial Leadership: Five action-logics viewed via two developmental lenses.”

In the first essay I used P-D-S-A as the integrative link between Managing and Leading – offering a total of just three learning contexts, but this always felt a little over-simplistic and in 2005 when coaching my daughter Josie – then in her sandwich year as an undergraduate trainee in the hospitality industry – I was persuaded by her to further sub-divide the two M/L modes – replacing two with four:

  1. maintaining
  2. continually improving
  3. innovating
  4. transforming.

Applying this new 4 action-logic model, Josie succeeded in transforming the fortunes of her hotel – winning a national award for her efforts – and this made me wonder if she might be on to something important?

I decided to use the new version of the model to explore what it would look like through first a “conventional” lens, and then second a “post-conventional” lens – illustrating the kinds of paradigm shifts that one might see in action when inside a learning organisation, in particular the way that accountabilities for performance are handled.

It is hard to describe a post-conventional way of seeing things to someone who developmentally has discovered only the conventional way – about 85% of adults. It is as if the instructions about how to get out of the box are on the outside. It is hoped that this essay may help some individuals unlock this conundrum. In a learning organisation for example it turns out that real-time data and feedback are essential for continually prompting individuals and organisations to rapidly evolve a new way of seeing.

BaseLine® for example is a tool that has been designed with this in mind. It allows conventional organisations and individuals, even those considering themselves relatively innumerate, to develop post-conventional habits; simply by using the time-series data that in many cases is already being collected – albeit usually for reasons of top-down accountability rather than methodical improvement. In this way, healthy developmental conversation gets sparked – and at all organisational levels: bottom, middle and top.

It also turns out that Continuous Improvement when seen though the second lens is not the same as Continual Improvement (mode 2) – and this is another one of the paradigm shifts that in the essay gets explained. Here is the model as it then appears:

JS_Blog_20160307_Fig2

Note that a fifth action-logic mode, modelling, is also now included. This emerged out of conversations I was having with Simon Dodds when writing the final draft in 2011. The essence of this mode is embodied in a phrase coined by the late Russell Ackoff – “idealized design” (1) – using modern computing technology to facilitate transformative change within tolerable levels of risk.

People often readily admit to spending much of their life in mode 1 (maintaining), whilst really preferring to be in mode 3 (innovating) – even admitting to seeing mode 1 as relatively boring, or at best as overly bureaucratic. Such individuals are especially prone to tampering, and may even shun regimes in which they feel overly controlled. What the post-conventional worldview offers however is not the prospect of being controlled, but the prospect of being in control – whilst simultaneously letting go – a paradox that is not easy to get unless developmentally ready – hence the 2005 essay. This goes for the tools too – especially when being deployed with the full cultural support that can flow from an organisation imbued with sufficient post-conventional design.

If the organisation can be designed to sufficiently support the right people to take control of each critical process or sub-system, who at the right level (usually the lowest point in the hierarchy that accountability may be accepted), may feel safely equipped to make sound decisions, genuine empowerment then becomes possible. Essentially, people then feel safe enough to self-empower and take charge of their system.

Toyota are an exemplar “learning organisation” – actually a system of organisations that work so harmoniously as a whole that by continually adapting to its changing environment, risk can be smoothly managed. Their preoccupation from bottom to top is understanding in real time what is changing so that changes (to the system) can then be proactively and wisely made. Each employee at each organisational level is educated to both manage and lead.

This approach has enabled them to grow to become the largest volume car maker in the world – and largely via organic growth alone. They have achieved this simply by constantly delivering what the customer wants with low variation (hence high reliability) and by continually studying that variation to uncover the real causes of problems. Performance is continually assessed over time and seen largely as pertaining to the system rather than being down to any one individual. Job hoppers – who though charismatic may also be practiced at being able to avoid having to live with the longer-term consequences of their actions – are not appointed to key roles.

Some will read the essay and say to themselves that little of this applies to me or my organisation – “we’re not Toyota, we’re not a private company, and we’re not even in manufacturing”. That however is likely to be a conventional view. The post-conventional principles described in the essay apply as much to service industries as to the public sector – both commissioners and providers – some of whom would intentionally evolve a post-conventional culture if given the space to do so.

At the very least I hope to have succeeded in convincing you, even if you don’t buy in to the notion of a Berwick-style learning system, that schooling people in management or leadership separately, or without a workable definition of each, is likely to be both cruel to the individual and to court dysfunction in the organisation.

References

  1. Ackoff R. Why so few organisations adopt systems thinking – 2007
  2. Beck D.E & Cowan C.C. – Spiral Dynamics – Mastering Values, Leadership, and Change – 1996
  3. Berwick D. – The Science of Improvement – 2008 : http://www.allhealth.org/BriefingMaterials/JAMA-Berwick-1151.pdf
  4. Berwick D. – The Science of Improvement – 2008 : http://www.allhealth.org/BriefingMaterials/JAMA-Berwick-1151.pdf
  5. Berwick Donald M. – Berwick Review into patient safety – 2013
  6. Collins J.C. – Level 5 Leadership: The triumph of Humility and Fierce Resolve – HBR Jan 2001
  7. Cook-Greuter. S. – Maps for living: ego-Development Stages Symbiosis to Conscious Universal Embeddedness – 1990
  8. Covey. S.R. – The 7 habits of Highly Effective People – 1989   (ISBN 0613191455)
  9. Delavigne K.T & Robertson J. D. – Deming’s profound changes – 1994
  10. Deming W. Edwards – Out of the Crisis – 1986 (ISBN 0-911379-01-0)
  11. Deming W.Edwards – The New Economics – 1993 (ISBN 0-911379-07-X) First edition
  12. Jaques. E. – Requisite Organisation: A Total System for Effective Managerial Organisation and Managerial Leadership for the 21st Century 1998 (ISBN 1886436045)
  13. Kotter. J. P. – A Force for Change: How Leadership Differs from Management – 1990
  14. Liker J.K & Meier D. – The Toyota Way Fieldbook – 2006
  15. Rooke D and Torbert W.R. – Organisational Transformation as a function of CEO’s Development Stage 1998 (Organisation Development Journal, Vol. 6.1)
  16. Rooke D and Torbert W.R. – Seven Transformations of Leadership – Harvard Business Review April 2005
  17. Scholtes Peter R. The Leader’s Handbook: Making Things Happen, Getting Things Done – 1998
  18. Senge. P. M. – The Fifth Discipline 1990 ISBN 10 – 0385260946
  19. Spear. S and Bowen H. K- Decoding the DNA of the Toyota Production System – Harvard Business Review Sept/Oct 1999
  20. Spear. S. – Learning to Lead at Toyota – Harvard Business Review – May 2004
  21. Takeuchi H, Osono E, Shimizu N. The contradictions that drive Toyota’s success. Harvard Business Review: June 2008
  22. Torbert W.R. & Associates – Action Inquiry – The secret of timely and transforming leadership – 2004
  23. Wheeler Donald J. – Advanced Topics in Statistical Process Control – the power of Shewhart Charts – 1995

 

by Julian Simcox

Actually, it doesn’t much matter because everyone needs to be able to choose between managing and leading – as distinct and yet mutually complementary action/ logics – and to argue that one is better than the other, or worse to try to school people about just one of them on its own, is inane. The UK’s National Health Service for example is currently keen on convincing medics that they should become “clinical leaders”, the term “clinical manager” being rarely heard, yet if anything the NHS suffers more from a shortage of management skill.

It is not only healthcare that is short on management. In the first half of my career I held the title “manager” in seven different roles, and in three different organisations, and had even completed an Exec MBA, but still didn’t properly get what it meant. The people I reported into also had little idea about what “managing well” actually meant, and even if they had possessed an inclination to coach me, would have merely added to my confusion.

If however you are fortunate enough to be working in an organisation that over time has been purposefully developed as a “Learning Culture” you will have acquired an appreciation of the vital distinction between managing and leading, and just what a massive difference this makes to your effectiveness, for it requires you, before you act, to understand (11) how your system is really flowing and performing. Only then will you be ready to choose whether to manage or to lead.

It is therefore not your role’s title that matters but whether the system you are running is stable, and whether it is capable of producing the outcomes needed by your customers. It also matters how risk is to be handled by you and your organisation when you are making changes. Outcomes will depend heavily upon you and your team’s accumulated levels of learning – as well, as it turns out, upon your personal world view/ developmental stage (more of which later).

Here is a diagram that illustrates that there are three basic learning contexts that a “managerial leader” (7) needs to be adept at operating within if they are to be able to nimbly choose between them.

JS_Blog_20160221_Fig1

Depending on one’s definitions of the processes of managing and leading, most people would agree that the first learning context pertains to the process of managing, and the third to the process of leading. The second context         (P-D-S-A) which helpfully for NHS employees is core to the NHS “Model of Improvement” turns out to be especially vital for effective managerial leadership for it binds the other two contexts together – as long as you know how?

Following the Mid-Staffs Hospital disaster, David Cameron asked Professor Don Berwick to recommend how to enhance public safety in the UK’s healthcare system. Unusually for a clinician he gets the importance of understanding your system and knowing moment-to-moment whether managing or leading is the right course of action. He recommends that to evolve a system to be as safe as it can be, all NHS employees should “Learn, master and apply the modern methods of quality control, quality improvement and quality planning” (1). He makes this recommendation because without the thinking that accompanies modern quality control methods, clinical managerial leadership is lame.

The Journal of Improvement Science has recently re-published my 10 year old essay called:

“Intervening into Personal and Organisational Systems by Powerfully Leading and Wisely Managing”

Originally written from the perspective of a practising executive coach, and as a retrospective on the work of W. Edwards Deming, the essay describes just what it is that a few extraordinary Managerial Leaders seem to possess that enables them to simultaneously Manage and Lead Transformation – first of themselves, and second of their organisation. The essay culminates in a comparison of “conventional” and “post-conventional” organisations. Toyota (9,12) in which Deming’s influence continues to be profound, is used as an example of the latter. Using the 3 generic intervention modes/ learning contexts, and the way that these corresponds to an executive’s evolving developmental stage I illustrate how this works and with it what a massive difference it makes. It is only in the later (post-conventional) stages for example that the processes of managing and leading are seen as two sides of the same coin. Dee Hock (6) called these heightened levels of awareness “chaordic” and Jim Collins (2) calls the level of power this brings “Level 5 Leadership”.

JS_Blog_20160221_Fig2

Berwick, borrowing from Deming (4,5) knows that to be structured-to-learn organisations need systems thinking (11) – and that organisations need Managerial Leaders who are sufficiently developed to know how to think and intervene systemically – in other words he recognises the need for personally developing the capability to lead and manage.

Deming in particular seemed to understand the importance of developing empathy for different worldviews – he knew that each contains coherence, just as in its own flat-earth world Euclidian geometry makes perfect sense. When consulting he spent much of his time listening and asking people questions that might develop paradigmatic understanding – theirs and his. Likewise in my own work, primed with knowledge about the developmental stage of key individual players, I am more able to give my interventions teeth.

Possessing a definition of managerial leadership that can work at all the stages is also vital:

Managing =  keeping things flowing, and stable – and hence predictable – so you can consistently and confidently deliver what you’re promising. Any improvement comes from noticing what causes instability and eliminating that cause, or from learning what causes it via experimentation.

Leading  =  changing things, or transforming them, which risks a temporary loss of stability/ predictability in order to shift performance to a new and better level – a level that can then be managed and sustained.

If you resonate with the first essay you need to know that after publishing it I continued to develop the managerial leadership model into one that would work equally well for Managerial Leaders in either developmental epoch – conventional and post-conventional – whilst simultaneously balancing the level of change needed with the level of risk that’s politically tolerable – and all framed by the paradigm-shifts that typically characterise these two epochs. This revised model is described in detail in the essay:

Managerial Leadership: Five action logics viewed via two developmental lenses

– also soon to be made available via the Journal of Improvement Science.

References

  1. Berwick Donald M. – Berwick Review into patient safety (2013)
  2. Collins J.C. – Level 5 Leadership: The triumph of Humility and Fierce Resolve – HBR Jan 2001
  3. Covey. S.R. – The 7 habits of Highly Effective People – 1989 (ISBN 0613191455)
  4. Deming W. Edwards – Out of the Crisis – 1986   (ISBN 0-911379-01-0)
  5. Deming W.E – The New Economics – 1993 (ISBN 0-911379-07-X) First edition
  6. Hock. D. – The birth of the Chaordic Age 2000 (ISBN: 1576750744)
  7. Jaques. E. – Requisite Organisation: A Total System for Effective Managerial Organisation and Managerial Leadership for the 21st Century 1998 (ISBN 1886436045)
  8. Kotter. J. P. – A Force for Change: How Leadership Differs from Management – 1990
  9. Liker J.K & Meier D. – The Toyota Way Fieldbook. 2006
  10. Scholtes Peter R. The Leader’s Handbook: Making Things Happen, Getting Things Done. 1998
  11. Senge. P. M. – The Fifth Discipline 1990   ISBN 10-0385260946
  12. Spear. S. – Learning to Lead at Toyota – Harvard Business Review – May 2004

FreshMeatOldBonesEvolution is an amazing process.

Using the same building blocks that have been around for a lot time, it cooks up innovative permutations and combinations that reveal new and ever more useful properties.

Very often a breakthrough in understanding comes from a simplification, not from making it more complicated.

Knowledge evolves in just the same way.

Sometimes a well understood simplification in one branch of science is used to solve an ‘impossible’ problem in another.

Cross-fertilisation of learning is a healthy part of the evolution process.


Improvement implies evolution of knowledge and understanding, and then application of that insight in the process of designing innovative ways of doing things better.


And so it is in healthcare.  For many years the emphasis on healthcare improvement has been the Safety-and-Quality dimension, and for very good reasons.  We need to avoid harm and we want to achieve happiness; for everyone.

But many of the issues that plague healthcare systems are not primarily SQ issues … they are flow and productivity issues. FP. The safety and quality problems are secondary – so only focussing on them is treating the symptoms and not the cause.  We need to balance the wheel … we need flow science.


Fortunately the science of flow is well understood … outside healthcare … but apparently not so well understood inside healthcare … given the queues, delays and chaos that seem to have become the expected norm.  So there is a big opportunity for cross fertilisation here.  If we choose to make it happen.


For example, from computer science we can borrow the knowledge of how to schedule tasks to make best use of our finite resources and at the same time avoid excessive waiting.

It is a very well understood science. There is comprehensive theory, a host of techniques, and fit-for-purpose tools that we can pick of the shelf and use. Today if we choose to.

So what are the reasons we do not?

Is it because healthcare is quite introspective?

Is it because we believe that there is something ‘special’ about healthcare?

Is it because there is no evidence … no hard proof … no controlled trials?

Is it because we assume that queues are always caused by lack of resources?

Is it because we do not like change?

Is it because we do not like to admit that we do not know stuff?

Is it because we fear loss of face?


Whatever the reasons the evidence and experience shows that most (if not all) the queues, delays and chaos in healthcare systems are iatrogenic.

This means that they are self-generated. And that implies we can un-self-generate them … at little or no cost … if only we knew how.

The only cost is to our egos of having to accept that there is knowledge out there that we could use to move us in the direction of excellence.

New meat for our old bones?

take_a_walk_text_10710One of the barriers to improvement is jumping to judgment too quickly.

Improvement implies innovation and action …

doing something different …

and getting a better outcome.

Before an action is a decision.  Before a decision is a judgment.

And we make most judgments quickly, intuitively and unconsciously.  Our judgments are a reflection of our individual, inner view of the world. Our mental model.

So when we judge intuitively and quickly then we will actually just reinforce our current worldview … and in so doing we create a very effective barrier to learning and improvement.

We guarantee the status quo.


So how do we get around this barrier?

In essence we must train ourselves to become more consciously aware of the judgment step in our thinking process.  And one way to flush it up to the surface is to ask the deceptively powerful question … And?

When someone is thinking through a problem then an effective contribution that we can offer is to listen, reflect, summarize, clarify and to encourage by asking “And?”

This process has a name.  It is called a coaching conversation.

And anyone can learn to how do it. Anyone.

idea_bulbs_pop_up_150_wht_16515Quality is subjective. It is in the head and the heart of the beholder.

We feel quality when our experience exceeds our expectation.

And this simple definition of quality has some profound implications.


The first is that to measure quality we need to know both parts of the quality equation … we need to know both the expectation and the experience.

Why is that?

One reason is because we can set expectation much more easily than we can set the experience.

Example:  Suppose I am a hospital and I am interested in the perceived quality of the service that I provide to patients.  So I implement a quality survey and I ask the patients one question as they leave.  I ask “Were you satisfied?” The exit poll data is assiduously collected, processed and presented at the monthly Quality Committee meeting. If our average satisfaction score this month is better than last month we “high five” and if it is less then we “deep dive”.

Q1: What is the relationship between the satisfaction score and the actual experience?
A1: Satisfied means that experience equals expectation. That’s all.

Q2: What is the easier way to improve satisfaction scores? Improve experience or reduce expectation?
A2: Reduce expectation.

And that is what we do. We take the path of low resistance to improving satisfaction. We set low expectations. We talk only about what might go wrong. Never about what will go right.


The message here is that to understand quality we have to measure both expectation and experience.  And when harvesting feedback we need to ask both questions.

Compare these two alternatives:
Q: Were you satisfied with the service you received in outpatients today?
A: Yes.

Q: What did you experience in outpatients today and what was your expectation?
A: I struggled to find a parking place and I was a bit worried that I would be late for my appointment, but I ended up waiting over two hours anyway. I did not know how long the wait would be and I was then worried that I had not put enough time on the parking ticket. But it is what I expected because the appointment letter said that I need to allow up to three hours. My appointment took ten minutes and the doctor was nice.


We assume that because we usually experience queues and delays then it would be much more difficult to improve patient satisfaction by actually improving their experience … in other words … eliminating the avoidable root causes of the queues and delays.

So we don’t bother trying. We just reinforce the low expectation.


Another reason we need to know both expectation and experience is because it is our expectation that drives our decision.

If we expect a poor experience we are much less likely to choose that option.

Here is how we learn this avoidance behavior:
Step 1. We start with a reasonable expectation and no experience.
Step 2. We have a poor experience, we feel disappointed, and we lower our expectation.
Step 3. If we have a choice then we avoid the experience. If we have no choice then we accept it.
Step 4. We experience what we expected (but at least have avoided further disappointment).

But are we actually satisfied? Or are we just resigned to the fact that is all we can hope to expect.

Have we learned to become helpless, skeptical or even cynical?


Knowing the patient expectation provides a goldmine of opportunity for a healthcare organization that wants to improve the quality of its service.

Engagement in change does not follow from disappointment – it follows from delight – or more specifically delight accompanied by surprise.

We feel surprised and delighted when we experience something that exceeds our expectation.


So recall the story of the satisfied outpatient with the sense of resigned acceptance.

Then read the feedback below that was shared with me this week … feedback from a doctor in training who has just completed the Foundations of Improvement Science in Healthcare (FISH) course … the free offer.

“To be honest, I was very surprised with the content of the course … in a  good way – so much so that I sat and completed it over two days! 

I was fully expecting a generic online management course filled with the usual buzz words and with no real substance or learning point to take away from it (I’m generally very sceptical of such things as I feel many courses are primarily money making exercises with little real value as the developers are well aware that healthcare professionals need to tick off the management box at their appraisals).

What I actually found was a course that presented the problems of a chaotic department (that I’m all too familiar with as a radiologist) and actually broke down the problem into its root causes and fundamental components in a logical way with simple and effective strategies to improve a service. Considering each process in terms of a series of streams and stages and presenting these functions as a Gantt chart is brilliantly simple, demystifies what actually happens in a process, and is a simple way of identifying all the faff that goes on around the real value work that we – something that I was all to aware of prior to the course but didn’t really know how to tackle. What I have learned is definitely a valuable foundation in managing the various processes of a department such as my own and I will certainly make use of these tools in the future.”

Does that sound like a surprised-and-delighted reaction?

business_race__PA_150_wht_3222There is a widely held belief that competition is the only way to achieve improvement.

This is a limiting belief.

But our experience tells us that competition is an essential part of improvement!

So which is correct?


When two athletes compete they both have to train hard to improve their individual performance. The winner of the race is the one who improves the most.  So by competing with each other they are forced to improve.

The goal of improvement is excellence and the test-of-excellence is performed in the present and is done by competing with others. The most excellent is labelled the “best” or “winner”. Everyone else is branded “second best” or “loser”.

This is where we start to see the limiting belief of competition.

It has a crippling effect.  Many competitive people will not even attempt the race if they do not feel they can win.  Their limiting belief makes them too fearful. They fear loss of self-esteem. Their ego is too fragile. They value hubris more than humility. And by not taking part they abdicate any opportunity to improve. They remain arrogantly mediocre and blissfully ignorant of it. They are the real losers.


So how can we keep the positive effect of competition and at the same time escape the limiting belief?

There are two ways:

First we drop the assumption that the only valid test of excellence is a comparison of us with others in the present.  And instead we adopt the assumption that it is equally valid to compare us with ourselves in the past.

We can all improve compared with what we used to be. We can all be winners of that race.

And as improvement happens our perspective shifts.  What becomes normal in the present would have been assumed to be impossible in the past.


This week I sat at my desk in a state of wonder.

I held in my hand a small plastic widget about the size of the end of my thumb.  It was a new USB data stick that had just arrived, courtesy of Amazon, and on one side in small white letters it proudly announced that it could hold 64 Gigabytes of data (that is 64 x 1024 x 1024 x 1024). And it cost less than a take-away curry.

About 30 years ago, when I first started to learn how to design, build and program computer system, a memory chip that was about the same size and same cost could hold 4 kilobytes (4 x 1024).  

So in just 30 years we have seen a 16-million-fold increase in data storage capacity. That is astounding! Our collective knowledge of how to design and build memory chips has improved so much. And yet we take it for granted.


The second way to side-step the limiting belief is even more powerful.

It is to drop the belief that individual improvement is enough.

Collective improvement is much, much, much more effective.


Cell_StructureEvidence:

The human body is made up of about 50 trillion (50 x 1000 x 1000 x 1000 x 1000) cells – about the same as the number of bytes could store on 1000 of my wonderful new 64 Gigabyte data sticks!

And each cell is a microscopic living individual. A nano-engineered adaptive system of wondrous complexity and elegance.

Each cell breathes, eats, grows, moves, reproduces, senses, learns and remembers. These cells are really smart too! And they talk to each other, and they learn from each other.

And what makes the human possible is that its community of 50 trillion smart cells are a collaborative community … not a competitive community.

If all our cells started to compete with each other we would be very quickly reduced to soup (which is what the Earth was bathed in for about 2.7 billions years).

The first multi-celled organisms gained a massive survival advantage when they learned how to collaborate.

The rest is the Story of Evolution.  Even Charles Darwin missed the point – evolution is more about collaboration than competition – and we are only now beginning to learn that lesson. The hard way.  


come_join_the_team_150_wht_10876So survival is about learning and improving.

And survival of the fittest does not mean the fittest individual … it means the fittest group.

Collaborative improvement is the process through which we can all achieve win-win-win excellence.

And the understanding of how to do this collaborative improvement has a name … it is called Improvement Science.

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)

Nerve_CurveThe emotional journey of change feels like a roller-coaster ride and if we draw as an emotion versus time chart it looks like the diagram above.

The toughest part is getting past the low point called the Well of Despair and doing that requires a combination of inner strength and external support.

The external support comes from an experienced practitioner who has been through it … and survived … and has the benefit of experience and hindsight.

The Improvement Science coach.


What happens as we  apply the IS principles, techniques and tools that we have diligently practiced and rehearsed? We discover that … they work!  And all the fence-sitters and the skeptics see it too.

We start to turn the corner and what we feel next is that the back pressure of resistance falls a bit. It does not go away, it just gets less.

And that means that the next test of change is a bit easier and we start to add more evidence that the science of improvement does indeed work and moreover it is a skill we can learn, demonstrate and teach.

We have now turned the corner of disbelief and have started the long, slow, tough climb through mediocrity to excellence.


This is also a time of risks and there are several to be aware of:

  1. The objective evidence that dramatic improvements in safety, flow, quality and productivity are indeed possible and that the skills can be learned will trigger those most threatened by the change to fight harder to defend their disproved rhetoric. And do not underestimate how angry and nasty they can get!
  2. We can too easily become complacent and believe that the rest will follow easily. It doesn’t.  We may have nailed some of the easier niggles to be sure … but there are much more challenging ones ahead.  The climb to excellence is a steep learning curve … all the way. But the rewards get bigger and bigger as we progress so it is worth it.
  3. We risk over-estimating our capability and then attempting to take on the tougher improvement assignments without the necessary training, practice, rehearsal and support. If we do that we will crash and burn.  It is like a game of snakes and ladders.  Our IS coach is there to help us up the ladders and to point out where the slippery snakes are lurking.

So before embarking on this journey be sure to find a competent IS coach.

They are easy to identify because they will have a portfolio of case studies that they have done themselves. They have the evidence of successful outcomes and that they can walk-the-talk.

And avoid anyone who talks-the-walk but does not have a portfolio of evidence of their own competence. Their Siren song will lure you towards the submerged Rocks of Disappointment and they will disappear like morning mist when you need them most – when it comes to the toughest part – turning the corner. You will be abandoned and fall into the Well of Despair.

So ask your IS coach for credentials, case studies and testimonials and check them out.

DiamondAs systems become bigger and more complicated they may fragment into a larger number of smaller parts.

There are many reasons for this behaviour but the essence is that the integrity of a system requires the parts to be connected to each other in some way.  Bonds that hold them together – bonds that are stronger than the forces of disruption that are always battering them.

In some systems these bonds are physical and chemical.

A diamond does not fragment, even under extreme pressure, because the chemical bonds between the carbon atoms in the crystal lattice are very strong . A diamond is not alive – the atoms cannot move around – and that is the secret of its extreme strength. So a diamond cannot adapt either … it is durable but it is dead.


Cell_StructureIn biological systems the bonds are informational.

A cell maintains its integrity because the nanoscale component parts are held together physically, chemically and with information.

Inside a cell the atoms and molecules move around – and that is the secret of its survival. It is alive. It senses. It responds. It evolves. It endures. And it is mortal.

So are the organisms made from cells. A lichen, a tree, an animal and a person.


And so are the organisations built by and from people. A couple, a family, a tribe, a nation, the world.

And it is informational bonds that hold people together – it is how they share data with each other.

These bonds manifest in many ways. Our senses – especially sight, sound and touch. Our language – body, verbal and visual. Our learning – individual and collective. And our emotions, beliefs and behaviours that emerge and evolve over time.

We all know we are mortal. We strive to protect our identity; and we yearn for longevity. We do not want to die. We want and need integrity – at all levels from chemical to cultural.

And to achieve that degree of synergy we need to share that which we have in common:

1) Shared purpose.
2) Shared language.
3) Shared pledge of acceptable behaviours.
4) Shared pool of data, information, knowledge, understanding and wisdom.

Everything else is dynamic. What we believe, what we decide, how we learn, what we do. It is that variability and adaptability that is part of our collective strength along with our shared commitment.

And the balance is critical.

Too rigid and we cannot flex quickly enough to a changing environment; too fluid and we fall apart at the first challenge. We need both stability and agility – so our system of information flows must be fit-for-purpose.

And the price we will all pay for not achieving that critical balance is death-by-fragmentation.

Dr_Bob_ThumbnailDr Bob runs a Clinic for Sick Systems and is sharing the Case of St Elsewhere’s® Hospital which is suffering from chronic pain in their A&E department.

The story so far: The history and examination of St.Elsewhere’s® Emergency Flow System have revealed that the underlying disease includes carveoutosis multiforme.  StE has consented to a knowledge transplant but is suffering symptoms of disbelief – the emotional rejection of the new reality. Dr Bob prescribed some loosening up exercises using the Carveoutosis Game.  This is the appointment to review the progress.


<Dr Bob> Hello again. I hope you have done the exercises as we agreed.

<StE> Indeed we have.  Many times in fact because at first we could not believe what we were seeing. We even modified the game to explore the ramifications.  And we have an apology to make. We discounted what you said last week but you were absolutely correct.

<Dr Bob> I am delighted to hear that you have explored further and I applaud you for the curiosity and courage in doing that.  There is no need to apologize. If this flow science was intuitively obvious then we we would not be having this conversation. So, how have you used the new understanding?

<StE> Before we tell the story of what happened next we are curious to know where you learned about this?

<Dr Bob> The pathogenesis of carveoutosis spatialis has been known for about 100 years but in a different context.  The story goes back to the 1870s when Alexander Graham Bell invented the telephone.  He was not an engineer or mathematician by background; he was interested in phonetics and he was a pragmatist and experimented by making things. He invented the telephone and the Bell Telephone Co. was born.  This innovation spread like wildfire, as you can imagine, and by the early 1900’s there were many telephone companies all over the world.  At that time the connections were made manually by telephone operators using patch boards and the growing demand created a new problem.  How many lines and operators were needed to provide a high quality service to bill paying customers? In other words … to achieve an acceptably low chance of hearing the reply “I’m sorry but all lines are busy, please try again later“.  Adding new lines and more operators was a slow and expensive business so they needed a way to predict how many would be needed – and how to do that was not obvious!  In 1917, a Danish mathematician, statistician and engineer called Agner Krarup Erlang published a paper with the solution.  A complicated formula that described the relationship and his Erlang B equation allowed telephone exchanges to be designed, built and staffed and to provide a high quality service at an acceptably low cost.  Mass real-time voice communication by telephone became affordable and has transformed the world.

<StE> Fascinating! We sort of sense there is a link here and certainly the “high quality and low cost” message resonates for us. But how does designing telephone exchanges relate to hospital beds?

<Dr Bob> If we equate an emergency admission needing a bed to a customer making a phone call, and we equate the number of telephone lines to the number of beds, then the two systems are very similar from the flow physics perspective. Erlang’s scary-looking equation can be used to estimate the minimum number of beds needed to achieve any specified level of admission service quality if you know the average rate of demand and average the length of stay.  That is how I made the estimate last week. It is this predictable-within-limits behaviour that you demonstrated to yourself with the Carveoutosis Game.

<StE> And this has been known for nearly 100 years but we have only just learned about it!

<Dr Bob> Yes. That is a bit annoying isn’t it?

<StE> And that explains why when we ‘ring-fence’ our fixed stock of beds the 4-hour performance falls!

<Dr Bob> Yes, that is a valid assertion. By doing that you are reducing your space-capacity resilience and the resulting danger, chaos, disappointment and escalating cost is completely predictable.

<StE> So our pain is iatrogenic as you said! We have unwittingly caused this. That is uncomfortable news to hear.

<Dr Bob> The root cause is actually not what you have done wrong, it is what you have not done right. It is an error of omission. You have not learned to listen to what your system is telling you. You have not learned how that can help you to deepen your understanding of how your system works. It is that information, knowledge, understanding and wisdom that you need to design a safer, calmer, higher quality and more affordable healthcare system.

<StE> And now we can see our omission … before it was like a blind spot … and now we can see the fallacy of our previously deeply held belief: that it was impossible to solve this without more beds, more staff and more money.  The gap is now obvious where before it was invisible. It is like a light has been turned on.  Now we know what to do and we are on the road to recovery. We need to learn how to do this ourselves … but not by guessing and meddling … we need to learn to diagnose and then to design and then to deliver safety, flow, quality and productivity.  All at the same time.

<Dr Bob> Welcome to the world of Improvement Science. And here I must sound a note of caution … there is a lot more to it than just blindly applying Erlang’s B equation. That will get us into the ball-park, which is a big leap forward, but real systems are not just simple, passive games of chance; they are complicated, active and adaptive.  Applying the principles of flow design in that context requires more than just mathematics, statistics and computer models.  But that know-how is available and accessible too … and waiting for when you are ready to take that leap of learning.

OK. I do not think you require any more help from me at this stage. You have what you need and I wish you well.  And please let me know the outcome.

<StE> Thank you and rest assured we will. We have already started writing our story … and we wanted to share the that with you today … but with this new insight we will need to write a few more chapters first.  This is really exciting … thank you so much.


St.Elsewhere’s® is a registered trademark of Kate Silvester Ltd,  and to read more real cases of 4-hour A&E pain download Kate’s: The Christmas Crisis


Part 1 is here. Part 2 is here. Part 3 is here. Part 4 is here. Part 5 is here.

Dr_Bob_ThumbnailDr Bob runs a Clinic for Sick Systems and is sharing the Case of St Elsewhere’s® Hospital which is suffering from chronic pain in their A&E department.

The story so far: The history and examination of St.Elsewhere’s® Emergency Flow System have revealed the footprint of a Horned Gaussian in their raw A&E data. This characteristic sign suggests that the underlying disease includes carveoutosis.  StE has signed up for treatment and has started by installing learning loops. This is the one week follow up appointment.


<Dr Bob> Hi there. How are things? What has changed this week?

<StE> Lots! We shared the eureka moment we had when you described the symptoms, signs and pathogenesis of carvoutosis temporalis using the Friday Afternoon Snail Mail story.  That resonated strongly with lots of people. And as a result that symptom has almost gone – as if by magic!  We are now keeping on top of our emails by doing a few each day and we are seeing decisions and actions happening much more quickly.

<Dr Bob> Excellent. Many find it surprising to see such a large beneficial impact from such an apparently small change. And how are you feeling overall? How is the other pain?

<StE> Still there unfortunately. Our A&E performance has not really improved but we do feel a new sense of purpose, determination and almost optimism.  It is hard to put a finger on it.

<Dr Bob> Does it feel like a paradoxical combination of “feels subjectively better but looks objectively the same”?

<StE> Yes, that’s exactly it. And it is really confusing. Are we just fire-fighting more quickly but still not putting out the fire?

<Dr Bob> Possibly. It depends on your decisions and actions … you may be unwittingly both fighting and fanning the fire at the same time.  It may be that you are suffering from carveoutosis multiforme.

<StE> Is that bad?

<Dr Bob> No. Just trickier to diagnose and treat. It implies that there is more than one type of carveoutosis active at the same time and they tend to amplify each other. The other common type is called carveoutosis spatialis. Shall we explore that hypothesis?

<StE> Um, OK. Does it require more painful poking?

<Dr Bob> A bit. Do you want to proceed? I cannot do so without your consent.

<StE> I suppose so.

<Dr Bob> OK. Can you describe for me what happens to emergency patients after they are admitted. Where do they go to?

<StE> That’s easy.  The medical emergencies go to the medical wards and the others go to the surgical wards. Or rather they should. Very often there is spillover from one to the other because the specialty wards are full. That generates a lot of grumbling from everyone … doctors, nurses and patients. We call them outliers.

<Dr Bob> And when a patient gets to a ward where do they go? Into any available empty bed?

<StE> No.  We have to keep males and females separate, to maintain privacy and dignity.  We get really badly beaten up if we mix them.  Our wards are split up into six-bedded bays and a few single side-rooms, and we are constantly juggling bays and swapping them from male to female and back. Often moving patients around in the process, and often late at night. The patients do not like it and it creates lots of extra work for the nurses.

<Dr Bob> And when did these specialty and gender segregation policies come into force?

<StE> The specialty split goes back decades, the gender split was introduced after StE was built. We were told that it wouldn’t make any difference because we are still admitting the same proportion of males and females so it would average out, but it causes us a lot of headaches!  Maybe we are now having to admit more patients than the hospital was designed to hold!

<Dr Bob> That is possible, but even if you were admitting the same number for the same length of time the symptoms of carveoutosis spatialis are quite predictable. When there is any form of variation in demand, casemix, or gender then if you split your space-capacity into ‘ring-fenced’ areas you will always need more total space-capacity to achieve the same waiting time performance. Always. It is mandated by the Laws of Physics. It is not negotiable. And it does not average out.

<StE> What! So we were mis-informed?  The chaos we are seeing was predictable?

<Dr Bob> The effect of carveoutosis spatialis is predictable. But knowing that does not prove it is the sole cause of the chaos you are experiencing. It may well be a contributory factor though.

<StE> So how big an effect are we talking about here? A few percent?

<Dr Bob> I can estimate it for you.  What are your average number of emergency admissions per day, the split between medical and surgical, the split between gender, and the average length of stay in each group?

<StE> We have an average of sixty emergency admissions per day, the split between medicine and surgery is 50:50 on average;  the gender split is 50:50 on average and the average LoS in each of those 4 groups is 8 days.  We worked out using these number that we should need 480 beds but even now we have about 540 and even that doesn’t seem to be enough!

<Dr Bob> OK, let me work this out … with those parameters and assuming that the LoS does not change then the Laws of Flow Physics predict that you would need about 25% more beds than 480 – nearer six hundred – to be confident that there will always be a free bed for the next emergency admission in all four categories of  patient.

<StE> What! Our Director of Finance has just fallen off his chair! That can’t be correct!

[pause]

But that is exactly what we are seeing.

[pause]

If we we were able to treated this carvoutosis spatialis … if, just for the sake of argument, we could put any patient into any available bed … what effect would that have?  Would we then only need 480 beds?

<Dr Bob> You would if there was absolutely zero variation of any sort … but that is impossible. If nothing else changed the Laws of Physics predict that you would need about 520 beds.

<StE> What! But we have 540 beds now. Are you saying our whole A&E headache would evaporate just by doing that … and we would still have beds to spare?

<Dr Bob> That would be my prognosis, assuming there are no other factors at play that we have not explored yet.

<StE> Now the Head of Governance has just exploded! This is getting messy! We cannot just abandon the privacy and dignity policy.  But there isn’t much privacy or dignity lying on a trolley in the A&E corridor for hours!  We’re really sorry Dr Bob but we cannot believe you. We need proof.

<Dr Bob> And so would I were I in your position. Would you like to prove it to yourselves?  I have a game you can play that will demonstrate this unavoidable consequence of the Laws of Physics. Would you like to play it?

<StE> We would indeed!

<Dr Bob> OK. Here are the instructions for the game. This is your homework for this week.  See you next week.


St.Elsewhere’s® is a registered trademark of Kate Silvester Ltd,  and to read more real cases of 4-hour A&E pain download Kate’s: The Christmas Crisis


Part 1 is here. Part 2 is here. Part 3 is here. Part 4 is here.

Dr_Bob_ThumbnailDr Bob runs a Clinic for Sick Systems and is sharing the Case of St Elsewhere’s ® Hospital which is suffering from chronic pain in the A&E department.

Dr Bob is presenting the case study in weekly bite-sized bits that are ample food for thought.

Part 1 is here. Part 2 is here. Part 3 is here.

The story so far:

The history and initial examination of St.Elsewhere’s® Emergency Flow System have revealed the footprint of a Horned Gaussian in their raw A&E data.  That characteristic sign suggests that the underlying disease complex includes one or more forms of carveoutosis.  So that is what Dr Bob and StE will need to explore together.


<Dr Bob> Hello again and how are you feeling since our last conversation?

<StE> Actually, although the A&E pain continues unabated, we feel better. More optimistic. We have followed your advice and have been plotting our daily A&E time-series charts and sharing those with the front-line staff.  And what is interesting to observe is the effect of just doing that.  There are fewer “What you should do!” statements and more “What we could do …” conversations starting to happen – right at the front line.

<Dr Bob> Excellent. That is what usually happens when we switch on the fast feedback loop. I detect that you are already feeling the emotional benefit.  So now we need to explore carveoutosis.  Are you up for that?

<StE> You betcha! 

<Dr Bob> OK. The common pathology in carveoutosis is that we have some form of resource that we, literally, carve up into a larger number of smaller pieces.  It does not matter what the resource is.  It can be time, space, knowledge, skill, cash.  Anything.

<StE> Um, that is a bit abstract.  Can you explain with a real example?

<Dr Bob> OK. I will use the example of temporal carveoutosis.  Do you use email?  And if so what are your frustrations with it … your Niggles?

<StE> Ouch! You poked a tender spot with that question!  Email is one of our biggest sources of frustration.  A relentless influx of dross that needs careful scanning to filter out the important stuff. We waste hours every week on this hamster wheel.  And if we do not clear our Inboxes by close of play on Friday then the following week is even worse!

<Dr Bob> And how many of you put time aside on Friday afternoon to ‘Clear-the-Inbox’?

<StE> We all do. It does at least give us some sense of control amidst the chaos. 

<Dr Bob> OK. This is a perfect example of temporal carveoutosis.  Suppose we consider the extreme case where we only process our emails on a Friday afternoon in a chunk of protected time carved out of our diary.  Now consider the effect of our carved-out-time-policy on the flow of emails. What happens?

<StE> Well, if we all do this then we will only send emails on a Friday afternoon and the person we are sending them to will only read them the following Friday afternoon and if we need a reply we will read that the Friday after.  So the time from sending an email to getting a reply will be two weeks. And it does not make any difference how many emails we send!

<Dr Bob> Yes. That is the effect on the lead-time … but I asked what the effect was on flow?

<StE> Oops! So our answer was correct but that was not the question you asked.  Um, the effect on flow is that it will be very jerky.  Emails will only flow on Friday afternoons … so all the emails for the week will try to flow around in a few hours or minutes.  Ah! That may explain why the email system seems to slow down on Friday afternoons and that only delays the work and adds to our frustration! We naturally assumed it was because the IT department have not invested enough in hardware! Faster computers and bigger mailboxes!

<Dr Bob> What you are seeing is the inevitable and predictable effect of one form of temporal carveoutosis.  The technical name for this is a QBQ time trap and it is an iatrogenic disease. Self-inflicted. (QBQ=queue-batch-queue).

<StE> So if the IT Department actually had the budget, and if they had actually treated the ear-ache we were giving them, and if they had actually invested in faster and bigger computers then the symptom of Friday Snail Mail would go away – but the time trap would remain.  And it might actually reinforce our emails-only-on-a-Friday-afternoon behaviour! Wow! That was not obvious until you forced us to think it through logically.

<Dr Bob> Well. I think that insight is enough to chew over for now. One eureka reaction at a time is enough in my experience. Food for thought requires time to digest.  This week your treatment plan is to share your new insight with the front-line teams.  You can use this example because email Niggles are very common.  And remember … Focus on the Flow.  Repeat that mantra to yourselves until it becomes a little voice in your head that reminds you what to do when you are pricked by the feelings of disappointment, frustration and fear.  Next week


St.Elsewhere’s® is a registered trademark of Kate Silvester Ltd. And to read more real cases of 4-hour A&E pain download Kate’s: The Christmas Crisis


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?

There is a wonderful invention called the retrospectoscope which is designed to provide clarity of hindsight.

on_top_of_the_books_150_wht_17482And there is an art to retrospectoscopy.

The key to the art is to carefully avoid committing to precise purpose at the start – in the prospectus; then after the actual outcome is demonstrated, to claim that it was predicted and using the ambiguity of the prospectus to hide the sleight-of-hand.

The purpose is to gain a reputation to have foresight and to be able to predict the future … because oracles, sages and soothsayers are much valued in society.


Retrospectoscopy has gained a tarnished reputation but it does have an important role … it provides the ability to learn from experience … but to be effective we have to use the retrospectoscope correctly. It is too easy to abuse it and to fall into the trap of self-justification  by distorting and deleting what we see.

To avoid the trap we need to do several things:

  1. Write down and share our clear diagnosis, plan and prediction at the start … ‘the prospectus’.
  2. Record and share the information that we will need to test our prediction robustly … ‘the evidence’.
  3. Compare our prospective rhetoric with the retrospective reality and share what we find … ‘the learning’.

It is unlikely that our prediction will be 100% accurate … and any deviation from aim is a valuable source of learning … better than predicted, worse than predicted and not predicted are all opportunities for new insights, deeper understanding,  new opportunities, wiser decisions and better outcomes.

If we fail to use the retrospectoscope correctly then we will be caught in a perpetual cycle of self-justifying delusion that is manifest as the name-shame-blame-game.  And if we side-step the expected discomfort of learning we will condemn ourselves to endlessly repeating the painful lessons that history can teach us to avoid.


The common theme in the self-justifying-delusion trap-avoiding recipe is share … if we are not prepared to learn in public then we should accept the inevitable consequences with grace.

Both courage and humility and are leadership assets.


 

figure_turning_a_custom_page_15415

Telling a compelling story of improvement is an essential skill for a facilitator and leader of change.

A compelling story has two essential components: cultural and technical. Otherwise known as emotional and factual.

Many of the stories that we hear are one or the other; and consequently are much less effective.


Some prefer emotive language and use stories of dismay and distress to generate an angry reaction: “That is awful we must DO something about that!”

And while emotion is the necessary fuel for action,  an angry mob usually attacks the assumed cause rather than the actual cause and can become ‘mindless’ and destructive.

Those who have observed the dangers of the angry mob opt for a more reflective, evidence-based, scientific, rational, analytical, careful, risk-avoidance approach.

And while facts are the necessary informers of decision, the analytical mind often gets stuck in the ‘paralysis of analysis’ swamp as layer upon layer of increasing complexity is exposed … more questions than answers.


So in a compelling story we need a bit of both.

We need a story that fires our emotions … and … we need a story that engages our intellect.

A bit of something for everyone.

And the key to developing this compelling-story-telling skill this is to start with something small enough to be doable in a reasonable period of time.  A short story rather than a lengthy legend.

A story, tale or fable.

Aesop’s Fables and Chaucer’s Canterbury Tales are still remembered for their timeless stories.


And here is a taste of such a story … one that has been published recently for all to read and to enjoy.

A Story of Learning Improvement Science

It is an effective blend of cultural and technical, emotional and factual … and to read the full story just follow the ‘Continue’ link.

Rogers_CurveThe early phases of a transformation are where most fall by the wayside.

And the failure rate is horrifying – an estimated 80% of improvement initiatives fail to achieve their goals.

The recent history of the NHS is littered with the rusting wreckage of a series of improvement bandwagons.  Many who survived the crashes are too scarred and too scared to try again.


Transformation and improvement imply change which implies innovation … new ways of thinking, new ways of behaving, new techniques, new tools, and new ways of working.

And it has been known for over 50 years that innovation spreads in a very characteristic way. This process was described by Everett Rogers in a book called ‘Diffusion of Innovations‘ and is described visually in the diagram above.

The horizontal axis is a measure of individual receptiveness to the specific innovation … and the labels are behaviours: ‘I exhibit early adopter behaviour‘ (i.e. not ‘I am an early adopter’).

What Roger’s discovered through empirical observation was that in all cases the innovation diffuses from left-to-right; from innovation through early adoption to the ‘silent’ majority.


Complete diffusion is not guaranteed though … there are barriers between the phases.

One barrier is between innovation and early adoption.

There are many innovations that we never hear about and very often the same innovation appears in many places and often around the same time.

This innovation-adoption barrier is caused by two things:
1) most are not even aware of the problem … they are blissfully ignorant;
2) news of the innovation is not shared widely enough.

Innovators are sensitive people.  They sense there is a problem long before others do. They feel the fear and the excitement of need for innovation. They challenge their own assumptions and they actively seek solutions. They swim against the tide of ignorance, disinterest, skepticism and often toxic cynicism.  So when they do discover a way forward they often feel nervous about sharing it. They have learned (the hard way) that the usual reaction is to be dismissed and discounted.  Most people do not like to learn about unknown problems and hazards; and they like it even less to learn that there are solutions that they neither recognise nor understand.


But not everyone.

There is a group called the early adopters who, like the innovators, are aware of the problem. They just do not share the innovator’s passion to find a solution … irrespective of the risks … so they wait … their antennae tuned for news that a solution has been found.

Then they act.

And they act in one of two ways:

1) Talkers … re-transmit the news of the problem and the discovery of a generic solution … which is essential in building awareness.

2) Walkers … try the innovative approach themselves and in so doing learn a lot about their specific problem and the new ways to solving it.

And it is the early adopters that do both of these actions that are the most effective and the most valuable to everyone else.  Those that talk-the-new-walk and walk-the-new-talk.

And we can identify who they are because they will be able to tell stories of how they have applied the innovation in their world; and the results that they have achieved; and how they achieved them; and what worked well; and what did not; and what they learned; and how they evolved and applied the innovation to meet their specific needs.

They are the leaders, the coaches and the teachers of improvement and transformation.

They See One, Do Some, and Teach Many.

The early adopters are the bridge across the Innovation and Transformation Chasm.

by Julian Simcox & Terry Weight

Ben Goldacre has spent several years popularizing the idea that we all ought all to be more interested in science.

Every day he writes and tweets examples of “bad science”, and about getting politicians and civil servants to be more evidence-based; about how governmental interventions should be more thoroughly tested before being rolled-out to the hapless citizen; about how the development and testing of new drugs should be more transparent to ensure the public get drugs that actually make a difference rather than risk harm; and about bad statistics – the kind that “make clever people do stupid things”(8).

Like Ben we would like to point the public sector, in particular the healthcare sector and its professionals, toward practical ways of doing more of the good kind of science, but just what is GOOD science?

In collaboration with the Cabinet Office’s behaviour insights team, Ben has recently published a polemic (9) advocating evidence-based government policy. For us this too is commendable, yet there is a potentially grave error of omission in their paper which seems to fixate upon just a single method of research, and risks setting-up the unsuspecting healthcare professional for failure and disappointment – as Abraham Maslow once famously said

.. it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail”(17)

We question the need for the new Test, Learn and Adapt (TLA) model he offers because the NHS already possesses such a model – one which in our experience is more complete and often simpler to follow – it is called the “Improvement Model”(15) – and via its P-D-S-A mnemonic (Plan-Do-Study-Act) embodies the scientific method.

Moreover there is a preexisting wealth of experience on how best to embed this thinking within organisations – from top-to-bottom and importantly from bottom-to-top; experience that has been accumulating for fully nine decades – and though originally established in industrial settings has long since spread to services.

We are this week publishing two papers, one longer and one shorter, in which we start by defining science, ruing the dismal way in which it is perennially conveyed to children and students, the majority of whom leave formal education without understanding the power of discovery or gaining any first hand experience of the scientific method.

View Shorter Version Abstract

We argue that if science were to be defined around discovery, and learning cycles, and built upon observation, measurement and the accumulation of evidence – then good science could vitally be viewed as a process rather than merely as an externalized entity. These things comprise the very essence of what Don Berwick refers to as Improvement Science (2) as embodied by the Institute of Healthcare Improvement (IHI) and in the NHS’s Model for Improvement.

We also aim to bring an evolutionary perspective to the whole idea of science, arguing that its time has been coming for five centuries, yet is only now more fully arriving. We suggest that in a world where many at school have been turned-off science, the propensity to be scientific in our daily lives – and at work – makes a vast difference to the way people think about outcomes and their achievement. This is especially so if those who take a perverse pride in saying they avoided science at school, or who freely admit they do not do numbers, can get switched on to it.

The NHS Model for Improvement has a pedigree originating with Walter Shewhart in the 1920’s, then being famously applied by Deming and Juran after WWII. Deming in particular encapsulates the scientific method in his P-D-C-A model (three decades later he revised it to P-D-S-A in order to emphasize that the Check stage must not be short-changed) – his pragmatic way of enabling a learning/improvement to evolve bottom-up in organisations.

After the 1980’s Dr Don Berwick , standing on these shoulders, then applied the same thinking to the world of healthcare – initially in his native America. Berwick’s approach is to encourage people to ask questions such as: What works? .. and How would we know? His method, is founded upon a culture of evidence-based learning, providing a local context for systemic improvement efforts. A new organisational culture, one rooted in the science of improvement, if properly nurtured, may then emerge.

Yet, such a culture may initially jar with the everyday life of a conventional organisation, and the individuals within it. One of several reasons, according to Yuval Harari (21), is that for hundreds of generations our species has evolved such that imagined reality has been lorded over objective reality. Only relatively recently in our evolution has the advance of science been leveling up this imbalance, and in our papers we argue that a method is now needed that enables these two realities to more easily coexist.

We suggest that a method that enables data-rich evidence-based storytelling – by those who most know about the context and intend growing their collective knowledge – will provide the basis for an approach whereby the two realities may do just that.

In people’s working lives, a vital enabler is the 3-paradigm “Accountability/Improvement/Research” measurement model (AIRmm), reflecting the three archetypal ways in which people observe and measure things. It was created by healthcare professionals (23) to help their colleagues and policy-makers to unravel a commonly prevailing confusion, and to help people make better sense of the different approaches they may adopt when needing to evidence what they’re doing – depending on the specific purpose. An amended version of this model is already widely quoted inside the NHS, though this is not to imply that it is yet as widely understood or applied as it needs to be.

goodscience_AIR_model

This 3-paradigm A-I-R measurement model underpins the way that science can be applied by, and has practical appeal for, the stretched healthcare professional, managerial leader, civil servant.

Indeed for anyone who intuitively suspects there has to be a better way to combine goals that currently feel disconnected or even in conflict: empowerment and accountability; safety and productivity; assurance and improvement; compliance and change; extrinsic and intrinsic motivation; evidence and action; facts and ideas; logic and values; etc.

Indeed for anyone who is searching for ways to unify their actions with the system-based implementation of those actions as systemic interventions. Though widely quoted in other guises, we are returning to the original model (23) because we feel it better connects to the primary aim of supporting healthcare professionals make best sense of their measurement options.

In particular the model makes it immediately plain that a way out of the apparent Research/Accountability dichotomy is readily available to anyone willing to “Learn, master and apply the modern methods of quality control, quality improvement and quality planning” – the recommendation made for all staff in the Berwick Report (3).

In many organisations, and not just in healthcare, the column 1 paradigm is the only game in town. Column 3 may feel attractive as a way-out, but it also feels inaccessible unless there is a graduate in statistician on hand. Moreover, the mainstay of the Column 3 worldview: the Randomized Controlled Trial (RCT) can feel altogether overblown and lacking in immediacy. It can feel like reaching for a spanner and finding a lump hammer in your hand – as Berwick says “Fans of traditional research methods view RCTs as the gold standard, but RCTs do not work well in many healthcare contexts” (2).

Like us, Ben is frustrated by the ways that healthcare organisations conduct themselves – not just the drug companies that commercialize science and publish only the studies likely to enhance sales, but governments too who commonly implement politically expedient policies only to then have to subsequently invent evidence to support them.

Policy-based evidence rather than evidence-based policy.

Ben’s recommended Column 3-style T-L-A approach is often more likely to make day-to-day sense to people and teams on the ground if complemented by Column 2-style improvement science.
One reason why Improvement Science can sometimes fail to dent established cultures is that it gets corralled by organisational “experts” – some of whom then use what little knowledge they have gathered merely to make themselves indispensable, not realising the extent to which everyone else as a consequence gets dis-empowered.

In our papers we take the opportunity to outline the philosophical underpinnings, and to do this we have borrowed the 7-point framework from a recent paper by Perla et al (35) who suggest that Improvement Science:

1. Is grounded in testing and learning cycles – the aim is collective knowledge and understanding about cause & effect over time. Some scientific method is needed, together with a way to make the necessary inquiry a collaborative one. Shewhart realised this and so invented the concept “continual improvement”.

2. Embraces a combination of psychology and logic – systemic learning requires that we balance myth and received wisdom with logic and the conclusions we derive from rational inquiry. This balance is approximated by the Sensing-Intuiting continuum in the Jungian-based MBTI model (12) reminding us that constructing a valid story requires bandwidth.

3. Has a philosophical foundation of conceptualistic pragmatism (16) – it cannot be expected that two scientists when observing, experiencing, or experimenting will make the same theory-neutral observations about the same event – even if there is prior agreement about methods of inference and interpretation. The normative nature of reality therefore has to be accommodated. Whereas positivism ultimately reduces the relation between meaning and experience to a matter of logical form, pragmatism allows us to ground meaning in conceived experience.

4. Employs Shewhart’s “theory of cause systems” – Walter Shewhart created the Control Chart for tuning-in to systemic behaviour that would otherwise remain unnoticed. It is a diagnostic tool, but by flagging potential trouble also aids real time prognosis. It might have been called a “self-control chart” for he was especially interested in supporting people working in and on their system being more considered (less reactive) when taking action to enhance it without over-reacting – avoiding what Deming later referred to as “Tampering” (4).

5. Requires the use of Operational Definitions – Deming warned that some of the most important aspects of a system cannot be expressed numerically, and those that can require care because “there is no true value of anything measured or observed” (5). When it comes to metric selection therefore it is essential to understand the measurement process itself, as well as the “operational definition” that each metric depends upon – the aim being to reduce ambiguity to zero.

6. Considers the contexts of both justification and discovery – Science can be defined as a process of discovery – testing and learning cycles built upon observation, measurement and accumulating evidence or experience – shared for example via a Flow Chart or a Gantt chart in order to justify a belief in the truth of an assertion. To be worthy of the term “science” therefore, a method or procedure is needed that is characterised by collaborative inquiry.

7. Is informed by Systems Theory – Systems Theory is the study of systems, any system: as small as a quark or as large as the universe. It aims to uncover archetypal behaviours and the principles by which systems hang together – behaviours that can be applied across all disciplines and all fields of research. There are several types of systems thinking, but Jay Forrester’s “System Dynamics” has most pertinence to Improvement Science because of its focus on flows and relationships – recognising that the behaviour of the whole may not be explained by the behaviour of the parts.

In the papers, we say more about this philosophical framing, and we also refer to the four elements in Deming’s “System of Profound Knowledge”(5). We especially want to underscore that the overall aim of any scientific method we employ is contextualised knowledge – which is all the more powerful if continually generated in context-specific experimental cycles. Deming showed that good science requires a theory of knowledge based upon ever-better questions and hypotheses. We two aim now to develop methods for building knowledge-full narratives that can work well in healthcare settings.

We wholeheartedly agree with Ben that for the public sector – not just in healthcare – policy-making needs to become more evidence-based.

In a poignant blog from the Health Foundation’s (HF) Richard Taunt (24), he recently describes attending two recent conferences on the same day. At the first one, policymakers from 25 countries had assembled to discuss how national policy can best enhance the quality of health care. When collectively asked which policies they would retain and repeat, their list included: use of data, building quality improvement capability, ensuring senior management are aware of improvement approaches, and supporting and spreading innovations.

In a different part of London, UK health politicians happened also to be debating Health and Care in order to establish the policy areas they would focus on if forming the next government. This second discussion brought out a completely different set of areas: the role of competition, workforce numbers, funding, and devolution of commissioning. These two discussions were supposedly about the same topic, but a Venn diagram would have contained next to no overlap.

Clare Allcock, also from the HF, then blogged to comment that “in England, we may think we are fairly advanced in terms of policy levers, but (unlike, for example in Scotland or the USA) we don’t even have a strategy for implementing health system quality.” She points in particular to Denmark who recently have announced they are phasing out their hospital accreditation scheme in favour of an approach strongly focused around quality improvement methodology and person-centred care. The Danes are in effect taking the 3-paradigm model and creating space for Column 2: improvement thinking.

The UK needs to take a leaf out of their book, for without changing fundamentally the way the NHS (and the public sector as a whole) thinks about accountability, any attempt to make column 2 the dominant paradigm is destined to be still born.

It is worth noting that in large part the AIRmm Column 2 paradigm was actually central to the 2012 White Paper’s values, and with it the subsequent Outcomes Framework consultation – both of which repeatedly used the phrase “bottom-up” to refer to how the new system of accountability would need to work, but somehow this seems to have become lost in legislative procedures that history will come to regard as having been overly ambitious. The need for a new paradigm of accountability however remains – and without it health workers and clinicians – and the managers who support them – will continue to view metrics more as something intrusive than as something that can support them in delivering enhancements in sustained outcomes. In our view the Stevens’ Five Year Forward View makes this new kind of accountability an imperative.

“Society, in general, and leaders and opinion formers, in particular, (including national and local media, national and local politicians of all parties, and commentators) have a crucial role to play in shaping a positive culture that, building on these strengths, can realise the full potential of the NHS.
When people find themselves working in a culture that avoids a predisposition to blame, eschews naïeve or mechanistic targets, and appreciates the pressures that can accumulate under resource constraints, they can avoid the fear, opacity, and denial that will almost inevitably lead to harm.”
Berwick Report (3)

Changing cultures means changing our habits – it starts with us. It won’t be easy because people default to the familiar, to more of the same. Hospitals are easier to build than relationships; operations are easier to measure than knowledge, skills and confidence; and prescribing is easier than enabling. The two of us do not of course possess a monopoly on all possible solutions, but our experience tells us that now is the time for: evidence-rich storytelling by front line teams; by pharmaceutical development teams; by patients and carers conversing jointly with their physicians.

We know that measurement is not a magic bullet, but what frightens us is that the majority of people seem content to avoid it altogether. As Oliver Moody recently noted in The Times ..

Call it innumeracy, magical thinking or intrinsic mental laziness, but even intelligent members of the public struggle, through no fault of their own, to deal with statistics and probability. This is a problem. People put inordinate amounts of trust in politicians, chief executives, football managers and pundits whose judgment is often little better than that of a psychic octopus.     Short of making all schoolchildren study applied mathematics to A level, the only thing scientists can do about this is stick to their results and tell more persuasive stories about them.

Too often, Disraeli’s infamous words: “Lies, damned lies, and statistics” are used as the refuge of busy professionals looking for an excuse to avoid numbers.

If Improvement Science is to become a shared language, Berwick’s recommendation that all NHS staff “Learn, master and apply the modern methods of quality control, quality improvement and quality planning” has to be taken seriously.

As a first step we recommend enabling teams to access good data in as near to real time as possible, data that indicates the impact that one’s intervention is having – this alone can prompt a dramatic shift in the type of conversation that people working in and on their system may have. Often this can be initiated simply by converting existing KPI data into System Behaviour Chart form which, using a tool like BaseLine® takes only a few mouse clicks.

In our longer paper we offer three examples of Improvement Science in action – combining to illustrate how data may be used to evidence both sustained systemic enhancement, and to generate engagement by the people most directly connected to what in real time is systemically occurring.

1. A surgical team using existing knowledge established by column 3-type research as a platform for column 2-type analytic study – to radically reduce post-operative surgical site infection (SSI).

2. 25 GP practices are required to collect data via the Friends & Family Test (FFT) and decide to experiment with being more than merely compliant. In two practices they collectively pilot a system run by their PPG (patient participation group) to study the FFT score – patient by patient – as they arrive each day. They use IS principles to separate signal from noise in a way that prompts the most useful response to the feedback in near to real time. Separately they summarise all the comments as a whole and feed their analysis into the bi-monthly PPG meeting. The aim is to address both “special cause” feedback and “common cause” feedback in a way that, in what most feel is an over-loaded system, can prompt sensibly prioritised improvement activity.

3. A patient is diagnosed with NAFLD and receives advice from their doctor to get more exercise e.g. by walking more. The patient uses the principles of IS to monitor what happens – using the data not just to show how they are complying with their doctor’s advice, but to understand what drives their personal mind/body system. The patient hopes that this knowledge can lead them to better decision-making and sustained motivation.

The landscape of NHS improvement and innovation support is fragmented, cluttered, and currently pretty confusing. Since May 2013 Academic Health Science Networks (AHSNs) funded by NHS England (NHSE) have been created with the aim of bringing together health services, and academic and industry members. Their stated purpose is to improve patient outcomes and generate economic benefits for the UK by promoting and encouraging the adoption of innovation in healthcare. They have a 5 year remit and have spent the first 2 years establishing their structures and recruiting, it is not yet clear if they will be able to deliver what’s really needed.

Patient Safety Collaboratives linked with AHSN areas have also been established to improve the safety of patients and ensure continual patient safety learning. The programme, coordinated by NHSE and NHSIQ will provide safety improvements across a range of healthcare settings by tackling the leading causes of avoidable harm to patients. The intention is to empower local patients and healthcare staff to work together to identify safety priorities and develop solutions – implemented and tested within local healthcare organisations, then later shared nationally.

We hope our papers will significantly influence the discussions about how improvement and innovation can assist with these initiatives. In the shorter paper to echo Deming, we even include our own 14 points for how healthcare organisations need to evolve. We will know that we have succeeded if the papers are widely read; if we enlist activists like Ben to the definition of science embodied by Improvement Science; and if we see a tidal wave of improvement science methods being applied across the NHS?

As patient volunteers, we each intend to find ways of contributing in any way that appears genuinely helpful. It is our hope that Improvement Science enables the cultural transformation we have envisioned in our papers and with our case studies. This is what we feel most equipped to help with. When in your sixties it easy to feel that time is short, but maybe people of every age should feel this way? In the words of Francis Bacon, the father of the scientific method.

goodscience_francisbaconquote

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References

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custom_life_balance_13780A common challenge is the need to balance the twin constraints of safety and cost.

Very often we see that making a system safer will increase its cost; and cutting costs leads to increased risk of harm.

So when budgets are limited and allowing harm to happen is a career limiting event then we feel stuck between a Rock and a Hard Place.


One root cause of this problem is the incorrect belief that ‘utilisation of capacity’ is a measure of ‘efficiency’ and the association of high efficiency with low cost. This then leads to another invalid belief that if we drive up utilisation then we will get a lower cost solution.

Let us first disprove the invalid belief with a simple thought experiment.

Suppose I have a surgical department with 100 beds and I want to run it at 100% utilisation but I also need to be able to admit urgent surgical patients without delay.  How would I do that?

Simple … just delay the discharge of all the patients who are ready for discharge until a new admission needs a bed … then do a ‘hot swap’.

This is a tried and tested tactic that surgeons have used for decades to ensure their wards are full with their patients and to prevent ‘outliers’ spilling over from other wards. It is called bed blocking.

The effect is that the length of stay of patients is artifically expanded which means that more bed days are used to achieve the same outcome. So it is a less efficient design.

It also disproves the belief that utilisation is a measure of efficiency … in the example above utilisation went up while efficiency went down and without also causing a safety problem.


So what is the problem here?

The problem is that we are confusing two different sorts of ‘capacity’ … space-capacity and flow-capacity.

And when we do that we invent and implement plausible sounding plans that are doomed to fail as soon as they hit the reality test.

So why do we continue to confuse these different sorts of capacity?

Because (a) we do not know any better and (b) we copy others who do not know any better and (c) we collectively fail to learn from the observable fact that our plausible plans do not seem to work in practice.

Is there a way out of this blind-leading-the-blind mess?

For sure there is.

But it requires a willingness to unlearn our invalid assumptions and replace them with valid (i.e. tested) ones.  And it is the unlearning that is the most uncomfortable bit.

Lack of humility is what prevents us from unlearning … our egos get in the way … they quite literally blind us to what is plain to see.

We also fear loss of face … and so we avoid threats to our reputations … we simply ignore the evidence of our ineptitude.  The problem of ‘hubris’ that Atul Gawande eloquently pointed out in the 2014 Reith Lectures.

And by so doing we achieve the very outcome we are so desperately trying to avoid … we fail.

Which is sad really because with just a pinch of humility we can so easily succeed.

Dr_Bob_ThumbnailA recurring theme this week has been the concept of ‘quality’.

And it became quickly apparent that a clear definition of quality is often elusive.

Which seems to have led to a belief that quality is difficult to measure because it is subjective and has no precise definition.

The science of quality improvement is nearly 100 years old … and it was shown a long time ago, in 1924 in fact, that it is rather easy to measure quality – objectively and scientifically.

The objective measure of quality is called “yield”.

To measure yield we simply ask all our customers this question:

Did your experience meet your expectation?” 

If the answer is ‘Yes’ then we count this as OK; if it is ‘No’ then we count it as Not OK.

Yield is the ratio of the OKs divided by the number of customers who answered.


But this tried-and-tested way of measuring quality has a design flaw:

Where does a customer get their expectation from?

Because if a customer has an unrealistically high expectation then whatever we do will be perceived by them as Not OK.

So to consistently deliver a high quality service (i.e. high yield) we need to be able to influence both the customer experience and the customer expectation.


If we set our sights on a worthwhile and realistic expectation and we broadcast that to our customers, then we also need a way of avoiding their disappointment … that our objective quality outcome audit may reveal.

One way to defuse disappointment is to set a low enough expectation … which is, sadly, the approach adopted by naysayers,  complainers, cynics and doom-mongers. The inept.

That is not the path to either improvement or to excellence. It is the path to apathy.

A better approach is to set ourselves some internal standards of expectation and to check at each step if our work meets our own standard … and if it fails then we know we need have some more work to do.

This commonly used approach to maintaining quality is called a check-and-correct design.

So let us explore the ramifications of this check-and-correct approach to quality.


Suppose the quality of the product or service that we deliver is influenced by many apparently random factors. And when we actually measure our yield we discover that the chance of getting a right-first-time outcome is about 50%.  This amounts to little more than a quality lottery and we could simulate that ‘random’ process by tossing a coin.

So to set a realistic expectation for future customers there are two further questions we need to answer:
1. How long can an typical customer expect to wait for our product or service?
2. How much can an typical customer expect to pay for our product or service?

It is not immediately and intuitively obvious what the answers to these questions are … so we need to perform an experiment to find out.

Suppose we have five customers who require our product or service … we could represent them as Post It Notes; and suppose we have a clock … we could measure how long the process is taking; and suppose we have our coin … we can simulate the yield of the step; … and suppose we do not start the lead time clock until we start the work for each customer.

We now have the necessary and sufficient components to assemble a simple simulation model of our system … a model that will give us realistic answers to our questions.

So let us see what happens … just click the ‘Start Game’ button.

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It is worth running this exercise about a dozen times and recording the data for each run … then plotting the results on a time-series chart.

The data to plot is the make-time (which is the time displayed on the top left) and the cost (which is display top middle).

The make-time is the time from starting the first game to completing the last task.

The cost is the number of coin tosses we needed to do to deliver all work to the required standard.

And here are the charts from my dozen runs (yours will be different).

PostItNote_MakeTimeChart

PostItNote_CostChart

The variation from run to run is obvious; as is the correlation between a make-time and a high cost.

The charts also answer our two questions … a make time up to 90 would not be exceptional and an average cost of 10 implies that is the minimum price we need to charge in order to stay in business.

Our customers are waiting while we check-and-correct our own errors and we are expecting them to pay for the extra work!

In the NHS we have a name for this low-quality high-cost design: Payment By Results.


The charts also show us what is possible … a make time of 20 and a cost of 5.

That happened when, purely by chance, we tossed five heads in a row in the Quality Lottery.

So with this insight we could consider how we might increase the probability of ‘throwing a head’ i.e. doing the work right-first-time … because we can see from our charts what would happen.

The improved quality and cost of changing ourselves and our system to remove the root causes of our errors.

Quality Improvement-by-Design.

That something worth learning how to do.

And can we honestly justify not doing it?

stick_figure_balance_mind_heart_150_wht_9344Improvement implies learning.  And to learn we need feedback from reality because without it we will continue to believe our own rhetoric.

So reality feedback requires both sensation and consideration.

There are many things we might sense, measure and study … so we need to be selective … we need to choose those things that will help us to make the wise decisions.


Wise decisions lead to effective actions which lead to intended outcomes.


Many measures generate objective data that we can plot and share as time-series charts.  Pictures that tell an evolving story.

There are some measures that matter – our intended outcomes for example. Our safety, flow, quality and productivity charts.

There are some measures that do not matter – the measures of compliance for example – the back-covering blame-avoiding management-by-fear bureaucracy.


And there are some things that matter but are hard to measure … objectively at least.

We can sense them subjectively though.  We can feel them. If we choose to.

And to do that we only need to go to where the people are and the action happens and just watch, listen, feel and learn.  We do not need to do or say anything else.

And it is amazing what we learn in a very short period of time. If we choose to.


If we enter a place where a team is working well we will see smiles and hear laughs. It feels magical.  They will be busy and focused and they will show synergism. The team will be efficient, effective and productive.

If we enter place where is team is not working well we will see grimaces and hear gripes. It feels miserable. They will be busy and focused but they will display antagonism. The team will be inefficient, ineffective and unproductive.


So what makes the difference between magical and miserable?

The difference is the assumptions, attitudes, prejudices, beliefs and behaviours of those that they report to. Their leaders and managers.

If the culture is management-by-fear (a.k.a bullying) then the outcome is unproductive and miserable.

If the culture is management-by-fearlessness (a.k.a. inspiring) then the outcome is productive and magical.

It really is that simple.