Improvement Science is about solving problems – so looking at how we solve problems is a useful exercise – and there is a continuous spectrum from 100% reactive to 100% proactive.
The reactive paradigm implies waiting until the problem is real and urgent and then acting quickly and decisively – hence the picture of the fire-fighter. Observe the equipment that the fire-fighter needs: a hat and suit to keep him safe and a big axe! It is basically a destructive and unsafe job based on the “our purpose is to stop the problem getting worse”.
The proactive paradigm implies looking for the earliest signs of the problem and planning the minimum action required to prevent the problem – hence the picture of the clinician. Observe the equipment that the clinician needs: a clean white coat to keep her patients safe and a stethoscope – a tool designed to increase her sensitivity so that subtle diagnostic sounds can be detected.
If we never do the proactive we will only ever do the reactive – and that is destructive and unsafe. If we never do the reactive we run the risk of losing everything – and that is destructive and unsafe too.
To practice safe and effective Improvement Science we must be able to do both in any combination and know which and when: we need to be impatient, decisive and reactive when a system is unstable, and we need to be patient, reflective and proactive when the system is stable. To choose our paradigm we must listen to the voice of the process. It will speak to us if we are prepared to listen and if we are prepared to learn it’s language.
Improvement Science is about learning from when what actually happens is different to that which we expected to happen. Is this surprise a failure or is this a success? It depends on our perspective. If we always get what we expect then we could conclude that we have succeeded – yet we have neither learned anything nor improved. So have we failed to learn? In contrast, if we never get what we expected then we could conclude that we always fail – yet we do not report what we have learned and improved. Our expectation might be too high! So comparing outcome with expectation seems a poor way to measure our progress with learning and improvement.
When we try something new we should expect to be surprised – otherwise it would not be new. It is what we learn from that expected surprise that is of most value. Sometime life turns out better than we expected – what can we learn from those experiences and how can we ensure that outcome happens again – predictably? Sometimes life turns out worse than we expected – what can we learn from those experiences and how can we ensure that outcome does not happen again, predictably? So, yes it is OK for us to fail and to not get what we expected – first time. What is not OK is for us to fail to learn from the lesson and to make an avoidable mistake more than once or miss an opportunity for improvement more than once.
Sustained improvement only follows from effective actions; which follow from well-informed decisions – not from blind guessing. A well-informed decision imples good information – and good information is not just good data. Good information implies that good data is presented in a format that is both undistorted and meaningful to the recipient. How we present data is, in my experience, one of the weakest links in the improvement process. We rarely see data presented in a clear, undistorted, and informative way and commonly we see it presented in a way that obscures or distorts our perception of reality. We are presented with partial facts quoted without context – so we unconsciously fill in the gaps with our own assumptions and prejudices and in so doing distort our perception further. And the more emotive the subject the more durable the memory that we create – which means it continues to distort our future perception even more.
The primary purpose of the news media is survival – by selling news – so the more emotive and memorable the news the better it sells. Accuracy and completeness can render news less attractive: by generating the “that’s obvious, it is not news” response. Catchy headlines sell news and to do that they need to generate a specific emotional reaction quickly – and that emotion is curiosity! Once alerted, they must hold the readers attention by quickly creating a sense of drama and suspense – like a good joke – by being just ambiguous enough to resonate with many different pepole – playing on their prejudices to build the emotional intensity.
The purpose of politicians is survival – to stay in power long enough to achieve their goals – so the less negative press they attract the better – but Politicians and the Press need each other because their purpose is the same – to survive by selling an idea to the masses – and to do that they must distort reality and create ambiguity. This has the unfortunate side effect of also generating less-than-wise decisions.
So if our goal is to cut through the emotive fog and get to a good decision quickly so that we can act effectively we need just the right data presented in context and in an unambiguous format that we, the decision-maker, can interpret quickly. The most accessible format is as a picture that tells a story – the past, the present and the likely future – a future that is shaped by the actions that come from the decisions we make in the present that we make using information from the past. The skill is to convert data into a story … and one simple and effective tool for doing that is a process behaviour chart.
I learned a new trick this week and I am very pleased with myself for two reasons. Firstly because I had the fortune to have been recommended this trick; and secondly because I had the foresight to persevere when the first attempt didn’t work very well. The trick I learned was using a webinar to provide interactive training. “Oh that’s old hat!” I hear some of you saying. Yes, teleconferencing and webinars have been around for a while – and when I tried it a few years ago I was disappointed and that early experience probably raised my unconscious resistance. The world has moved on – and I hadn’t. High-speed wireless broadband is now widely available and the webinar software is much improved. It was a breeze to set up (though getting one’s microphone and speakers to work seems a perennial problem!). The training I was offering was for the BaseLine process behaviour chart software – and by being able to share the dynamic image of the application on my computer with all the invitees I was able to talk through what I was doing, how I was doing it and the reasons why I was doing it. The immediate feedback from the invitees allowed me to pace the demonstration, repeat aspects that were unclear, answer novel queries and to demonstrate features that I had not intended to in my script. The tried and tested see-do-teach method has been reborn in the Information Age and this old dog is definitely wagging his tail and looking forward to his walk in the park (and maybe a tasty treat, huh?)
What a curious question! We can hear almost just as well with one ear as two so that is not the reason. Our glasses would fall off obviously though ears evolved long before glasses so that’s probably not the reason. Just in case we lose one ear by accident? That sounds reasonable but then why don’t we have a have a spare heart or spare brain too – they are more critical organs? Physiologists will explain that we need two ears to accurately determine the direction that a sound is coming from – and we do that by detecting very slight differences between what one ear hears compared with the other. What a neat bit of biodesign! So what relevance does this have for Improvement Science? Well, to improve a process or system we need to listen to two separate voices – the Voice of the Customer (VoC) and the Voice of the Process (VoP) – and if we compare them the slight difference points us in the direction of improvement. The problem is, when there is a big difference between the two sounds they will interfere with each other and we cannot hear either clearly. In that situation we adopt a policy of selective deafness – some of us choose the Voice of the Process because it can be measured objectively; and some of us choose the Voice of the Customer. The outcome is disagreement because we are hearing different things. Confusion becomes conflict.
With this insight one way out of this impasse might be for everyone to use both ears alternately: everyone listening to the Voice of the Customer for a while and then everyone changing channel and listening to the Voice of the Process for a while, and back again. The direction of improvement would become visible and the steps needed to align the Two Voices would emerge naturally. The Two Voices are trying to tell us something and we only need to learn to tune into both of them. When the Two Voices match we hear harmony not cacophony!
If your delivery time targets are giving you a pain in the #*&! then you may be sitting on a Horned Gaussian and do not realise it. What is a Horned Gaussian? How do you detect one? And what causes it? To establish the diagnosis you need to gather the data from the most recent couple of hundred jobs and from it calculate the interval from receipt to delivery. Next create a tally chart with Delivery Time on the vertical axis and Counts on the horizontal axis; mark your Delivery Time Target as a horizontal line about two thirds of the way up the vertical axis; draw ten equally spaced lines between it and the X axis and five more above the Target. Finally, sort your delivery times into these “bins” and look at the profile of the histogram that results. If there is a clearly separate “hump” and “horn” and the horn is just under the target then you have confirmed the diagnosis of a Horned Gaussian. The cause is the Delivery Time Target, or more specifically its effect on your behaviour. If the Target is externally imposed and enforced using either a reward or a punishment then when the delivery time for a request approaches the Target, you will increase the priority of the request and the job leapfrogs to the front of the queue, pushing all the other jobs back. The order of the jobs is changing and in a severe case the large number of changing priorities generates a lot of extra work to check and reschedule the jobs. This extra work exacerbates the delays and makes the problem worse, the horn gets taller and sharper, and the pain gets worse. Does that sound a familiar story? So what is the treatment? Well, to decide that you need to create a graph of delivery times in time order and look at the pattern (using charting tool such as BaseLine© www.valuesystemdesign.com makes this easier and quicker). What you do depends on what the chart says to you … it is the Voice of the Process. Improvement Science is learning to understand the voice of the process.