It was the time for Bob and Leslie’s regular coaching session. Dr_Bob_ThumbnailBob was already on line when Leslie dialed in to the teleconference.

<Leslie> Hi Bob, sorry I am a bit late.

<Bob> No problem Leslie. What aspect of improvement science shall we explore today?

<Leslie> Well, I’ve been working through the Safety-Flow-Quality-Productivity cycle in my project and everything is going really well.  The team are really starting to put the bits of the jigsaw together and can see how the synergy works.

<Bob> Excellent. And I assume they can see the sources of antagonism too.

<Leslie> Yes, indeed! I am now up to the point of considering productivity and I know it was introduced at the end of the Foundation course but only very briefly.

<Bob> Yes,  productivity was described as a system metric. A ratio of a steam metric and a stage metric … what we get out of the streams divided by what we put into the stages.  That is a very generic definition.

<Leslie> Yes, and that I think is my problem. It is too generic and I get it confused with concepts like efficiency.  Are they the same thing?

<Bob> A very good question and the short answer is “No”, but we need to explore that in more depth.  Many people confuse efficiency and productivity and I believe that is because we learn the meaning of words from the context that we see them used in. If  others use the words imprecisely then it generates discussion, antagonism and confusion and we are left with the impression of that it is a ‘difficult’ subject.  The reality is that it is not difficult when we use the words in a valid way.

<Leslie> OK. That reassures me a bit … so what is the definition of efficiency?

<Bob> Efficiency is a stream metric – it is the ratio of the minimum cost of the resources required to complete one task divided by the actual cost of the resources used to complete one task.

<Leslie> Um.  OK … so how does time come into that?

<Bob> Cost is a generic concept … it can refer to time, money and lots of other things.  If we stick to time and money then we know that if we have to employ ‘people’ then time will cost money because people need money to buy essential stuff that the need for survival. Water, food, clothes, shelter and so on.

<Leslie> So we could use efficiency in terms of resource-time required to complete a task?

<Bob> Yes. That is a very useful way of looking at it.

<Leslie> So how is productivity different? Completed tasks out divided by cash in to pay for resource time would be a productivity metric. It looks the same.

<Bob> Does it?  The definition of efficiency is possible cost divided by actual cost. It is not the as our definition of system productivity.

<Leslie> Ah yes, I see. So do others define productivity the same way?

<Bob> Try looking it up on Wikipedia …

<Leslie> OK … here we go …

Productivity is an average measure of the efficiency of production. It can be expressed as the ratio of output to inputs used in the production process, i.e. output per unit of input”.

Now that is really confusing!  It looks like efficiency and productivity are the same. Let me see what the Wikipedia definition of efficiency is …

“Efficiency is the (often measurable) ability to avoid wasting materials, energy, efforts, money, and time in doing something or in producing a desired result”.

But that is closer to your definition of efficiency – the actual cost is the minimum cost plus the cost of waste.

<Bob> Yes.  I think you are starting to see where the confusion arises.  And this is because there is a critical piece of the jigsaw missing.

<Leslie> Oh …. and what is that?

<Bob> Worth.

<Leslie> Eh?

<Bob> Efficiency has nothing to do with whether the output of the stream has any worth.  I can produce a worthless product with low waste … in other words very efficiently.  And what if we have the situation where the output of my process is actually harmful.  The more efficiently I use my resources the more harm I will cause from a fixed amount of resource … and in that situation it is actually safer to have a very inefficient process!

<Leslie> Wow!  That really hits the nail on the head … and the implications are … profound.  Efficiency is onbective and relates only to flow … and between flow and productivity we have to cross the Safety-Quality line. Productivity also includes the subjective concept of worth or value. That all makes complete sense now. A productive system is a subjectively and objectively win-win-win design.

<Bob> Yup.  Get the safety. flow and quality perspectives of the design in synergy and productivity will sky-rocket. It is called a Fit-4-Purpose design.

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.

smack_head_in_disappointment_150_wht_16653Many organisations proclaim that their mission is to achieve excellence but then proceed to deliver mediocre performance.

Why is this?

It is certainly not from lack of purpose, passion or people.

So the flaw must lie somewhere in the process.


The clue lies in how we measure performance … and to see the collective mindset behind the design of the performance measurement system we just need to examine the key performance indicators or KPIs.

Do they measure failure or success?


Let us look at some from the NHS …. hospital mortality, hospital acquired infections, never events, 4-hour A&E breaches, cancer wait breaches, 18 week breaches, and so on.

In every case the metric reported is a failure metric. Not a success metric.

And the focus of action is getting away from failure.

Damage mitigation, damage limitation and damage compensation.


So we have the answer to our question: we know we are doing a good job when we are not failing.

But are we?

When we are not failing we are not doing a bad job … is that the same as doing a good job?

Q: Does excellence  = not excrement?

A: No. There is something between these extremes.

The succeed-or-fail dichotomy is a distorting simplification created by applying an arbitrary threshold to a continuous measure of performance.


And how, specifically, have we designed our current system to avoid failure?

Usually by imposing an arbitrary target connected to a punitive reaction to failure. Management by fear.

This generates punishment-avoidance and back-covering behaviour which is manifest as a lot of repeated checking and correcting of the inevitable errors that we find.  A lot of extra work that requires extra time and that requires extra money.

So while an arbitrary-target-driven-check-and-correct design may avoid failing on safety, the additional cost may cause us to then fail on financial viability.

Out of the frying pan and into the fire.

No wonder Governance and Finance come into conflict!

And if we do manage to pull off a uneasy compromise … then what level of quality are we achieving?


Studies show that if take a random sample of 100 people from the pool of ‘disappointed by their experience’ and we ask if they are prepared to complain then only 5% will do so.

So if we use complaints as our improvement feedback loop and we react to that and make changes that eliminate these complaints then what do we get? Excellence?

Nope.

We get what we designed … just good enough to avoid the 5% of complaints but not the 95% of disappointment.

We get mediocrity.


And what do we do then?

We start measuring ‘customer satisfaction’ … which is actually asking the question ‘did your experience meet your expectation?’

And if we find that satisfaction scores are disappointingly low then how do we improve them?

We have two choices: improve the experience or reduce the expectation.

But as we are very busy doing the necessary checking-and-correcting then our path of least resistance to greater satisfaction is … to lower expectations.

And we do that by donning the black hat of the pessimist and we lay out the the risks and dangers.

And by doing that we generate anxiety and fear.  Which was not the intended outcome.


Our mission statement proclaims ‘trusted to achieve excellence’ not ‘designed to deliver mediocrity’.

But mediocrity is what the evidence says we are delivering. Just good enough to avoid a smack from the Regulators.

And if we are honest with ourselves then we are forced to conclude that:

A design that uses failure metrics as the primary feedback loop can achieve no better than mediocrity.


So if we choose  to achieve excellence then we need a better feedback design.

We need a design that uses success metrics as the primary feedback loop and we use failure metrics only in safety critical contexts.

And the ideal people to specify the success metrics are those who feel the benefit directly and immediately … the patients who receive care and the staff who give it.

Ask a patient what they want and they do not say “To be treated in less than 18 weeks”.  In fact I have yet to meet a patient who has even heard of the 18-week target!

A patient will say ‘I want to know what is wrong, what can be done, when it can be done, who will do it, what do I need to do, and what can I expect to be the outcome’.

Do we measure any of that?

Do we measure accuracy of diagnosis? Do we measure use of best evidenced practice? Do we know the possible delivery time (not the actual)? Do we inform patients of what they can expect to happen? Do we know what they can expect to happen? Do we measure outcome for every patient? Do we feed that back continuously and learn from it?

Nope.


So …. if we choose and commit to delivering excellence then we will need to start measuring-4-success and feeding what we see back to those who deliver the care.

Warts and all.

So that we know when we are doing a good job, and we know where to focus further improvement effort.

And if we abdicate that commitment and choose to deliver mediocrity-by-default then we are the engineers of our own chaos and despair.

We have the choice.

We just need to make it.

beehive_bees_150_wht_12723There is a condition called SFQPosis which is an infection that is transmitted by a vector called an ISP.

The primary symptom of SFQPosis is sudden clarity of vision and a new understanding of how safety, flow, quality and productivity improvements can happen at the same time …

… when they are seen as partners on the same journey.


There are two sorts of ISP … Solitary and Social.

Solitary ISPs infect one person at a time … often without them knowing.  And there is often a long lag time between the infection and the appearance of symptoms. Sometimes years – and often triggered by an apparently unconnected event.

In contrast the Social ISPs will tend to congregate together and spend their time foraging for improvement pollen and nectar and bringing it back to their ‘hive’ to convert into delicious ‘improvement honey’ which once tasted is never forgotten.


It appears that Jeremy Hunt, the Secretary of State for Health, has recently been bitten by an ISP and is now exhibiting the classic symptoms of SFQPosis.

Here is the video of Jeremy describing his symptoms at the recent NHS Confederation Conference. The talk starts at about 4 minutes.

His account suggests that he was bitten while visiting the Virginia Mason Hospital in the USA and on return home then discovered some Improvement hives in the UK … and some of the Solitary ISPs that live in England.

Warwick and Sheffield NHS Trusts are buzzing with ISPs … and the original ISP that infected them was one Kate Silvester.

The repeated message in Jeremy’s speech is that improved safety, quality and productivity can happen at the same time and are within our gift to change – and the essence of achieving that is to focus on flow.

SFQPThe sequence is safety first (eliminate the causes of avoidable harm), then flow second (eliminate the causes of avoidable chaos), then quality (measure both expectation and experience) and then productivity will soar.

And everyone will  benefit.

This is not a zero-sum win-lose game.


So listen for the buzz of the ISPs …. follow it and ask them to show you how … ask them to innoculate you with SFQPosis.


And here is a recent video of Dr Steve Allder, a consultant neurologist and another ISP that Kate infected with SFQPosis a few years ago.  Steve is describing his own experience of learning how to do Improvement-by-Design.

chained_to_big_weight_ball_anim_10331One of the traps for the less experienced improvement scientist is to take on a project that is too ambitious, too early.

The success with a “small” project will attract the attention of those with an eye on a bigger prize and it is easy to be wooed by the Siren call to sail closer to their Rocks.

This is a significant danger and a warning flag needs to be waved.


 

Organisations can only take on these bigger challenges after they have developed enough improvement capability themselves … and that takes time and effort.  It is not a quick fix.

And it makes no difference how much money is thrown at the problem.  The requirement is for the leaders to learn how to do it first and that does not take long to do … but it does require some engagement and effort.

And this is difficult for busy people to do …but it is not impossible.


The questions that need to be asked repeatedly are:

1. Is this important enough to dedicate some time to?  If not then do not start.

2. What can I do in the time I can dedicate to this? Delegation is abdication when it comes to improvement.

Those who take on too big a project too early will find it is like being chained to a massive weight … and it gets heavier over time as others add their problems to your heap in the belief that delegating a problem is the same as solving it. It isn’t.


 

So if your inner voice says “This feels too big for me” then listen to it and ask it what specifically is creating that feeling … work backwards from the feeling.  And only after you have identified the root causes can you make a rational decision.

Then make the decision and stick to it … explaining your reasons.

 

knee_jerk_reflexA commonly used technique for continuous improvement is the Plan-Do-Study-Act or PDSA cycle.

This is a derivative of the PDCA cycle first described by Walter Shewhart in the 1930’s … where C is Check.

The problem with PDSA is that improvement does not start with a plan, it starts with some form of study … so SPDA would be a better name.


IHI_MFITo illustrate this point if we look at the IHI Model for Improvement … the first step is a pair of questions related to purpose “What are we trying to accomplish?” and “How will we know a change is an improvement?

With these questions we are stepping back and studying our shared perspective of our desired future.

It is a conscious and deliberate act.

We are examining our mental models … studying them … and comparing them.  We have not reached a diagnosis or a decision yet, so we cannot plan or do yet.

The third question is a combination of diagnosis and design … we need to understand our current state in order to design changes that will take up to our improved future state.

We cannot plan what to do or how to do it until we have decided and agreed what the future design will look like, and tested that our proposed future design is fit-4-purpose.


So improvement by discovery or by design does not start with plan, it starts with study.


And another word for study is ‘sense’ which may be a better one … because study implies a deliberate, conscious, often slow process … while sense is not so restrictive.

Very often our actions are not the result of a deliberative process … they are automatic, and reflex. We do not think about them. They just sort of happen.

The image of the knee-jerk reflex illustrates the point.

In fact we have little conscious control over these automatic reflexes which respond much more quickly than our conscious thinking process can.  We are aware of the knee jerk after it has happened, not before, so we may be fooled into thinking that we ‘Do’ without a ‘Plan’.  But when we look in more detail we can see the sensory input and the hard-wired plan that links to to motor output.  Study-Plan-Do.


The same is true for many other actions – our unconscious mind senses, processes, decides, plans and acts long before we are consciously aware … and often the only clue we have is a brief flash of emotion … and usually not even that.  Our behaviour is largely habitual.


And even in situations when we need to make choices the sense-recognise-act process is fast … such as when a patient suddenly becomes very ill … we switch to the Resuscitate mode which is a pre-planned sequence of steps that is guided by what are sensing … but it is not made up on the spot. There is no committee. No meetings. We just do what we have learned and practiced how to do … because it was designed to.   It still starts with Study … it is just that the Study phase is very short … we just need enough information to trigger the pre-prepared plan. ABC – Airway … Breathing … Circulation. No discussion. No debate.


So, improvement starts with Study … and depending on what we sense what happens next will vary … and it will involve some form of decision and plan.

1. Unconscious, hard-wired, knee jerk reflex.
2. Unconscious, learned, habitual behaviour.
3. Conscious, pre-planned, steered response.
4. Conscious, deliberation-diagnosis-design then delivery.

The difference is just the context and the timing.   They are all Study-Plan-Do.

 And the Plan may be to Do Nothing …. the Deliberate Act of Omission.

 

 

 

missing_custom_puzzle_completionSystems are made up of inter-dependent parts. And each part is a smaller system made up of inter-dependent parts. And so on.

But there is a limit … eventually we reach a size where we only have a small number of independent parts … and that is called a micro-system.

It is part of a meso-system which in turn is part of a macro-system.


And it appears that in human systems the manageable size of a micro-system is about seven people – enough to sit around a table and work together on a problem.


So the engine of organisational improvement is many micro-systems of about seven people who are able to solve the problems that fall within their collective circles of control.

And that means the vast majority of problems are solvable at the micro-system level.

In fact, without this foundation level of competent and collaborative micro-teams, the meso-systems and the macro-systems cannot get a grip on the slippery problem of systemic change for the better.


The macro-system is also critical to success because it has the strategic view and it sets the vision and values to which every other part of the system aligns.  A dysfunctional macro-system sends cracks down through the whole organisation … fragmenting it into antagonistic, competiting silos.


The meso-system level is equally critical to success because it translates the strategy into tactics and creates the context for the multitude of micro-systems to engage.

The meso-system is the nervous system of the organisation … the informal communication network that feeds data and decisions around.

And if the meso-system is dysfunctional then the organisation can see, feel and move … but it is uncoordinated, chaotic, inefficient, ineffective and largely unproductive.


So the three levels are different, essential and inter-dependent.

The long term viability of a complex adaptive system is the emergent effect of a system design that is effective and efficient. Productive. Collaborative. Synergistic.

And achieving that is not easy … but it is possible.

And for each of us it starts with just us … Mono. 

figure_slipping_on_water_custom_sign_14210System behaviour is often rather variable over the short term.  We have ‘good’ days and ‘bad’ days and we weather the storm because we know the sun will shine again soon.

We are resilient and adaptable. And our memories are poor.

So when the short-term variation sits on top of a long-term trend then we do not feel the trend …

… because we are habituating. We do not notice that we are on a slippery slope.


And slippery slopes are more difficult to climb up than to slide down.


In organisational terms the slippery slope is from Calm to Chaos.  Success to Failure.  Competent to Incompetent. Complacent to  Contrite.  Top of the pops to top of the flops!

The primary reason for this is we are all part of a perpetual dynamic between context and content.  We are affected by the context we find ourselves in. We sense it and that influences our understanding, our decisions and our actions. These actions then change our context … nothing is ever the same.

So our hard-won success sows the seeds of its own failure … and unless we realise that then we are doomed to a boom-bust cycle.  To sustain success we must learn to constantly redefine our future and redesign our present.


If we do not then we are consigned to the Slippery Slope … and when we eventually accept that chaos has engulfed us then we may also discover that it may be late.  To leap from chaos to calm is VERY difficult without a deep understanding of how systems work … and if we had that wisdom then we would have avoided the slippery slope in the first place.


The good news is that there is hope … we can learn to climb out of the Swamp of Chaos … and we can develop our capability to scale the slippery slope from  Chaos through Complex, and then to Complicated, and finally back to Calm.  Organised complexity.

It requires effort and it takes time … but it is possible.

business_race__PA_150_wht_3222When we start the process of learning to apply the Science of Improvement in practice we need to start within our circle of influence.

It is just easier, quicker and safer to begin there – and to build our capability, experience and confidence in steps.

And when we get the inevitable ‘amazing’ result it is natural and reasonable for us to want to share the good news with others.  We crossed the finish line first and we want to celebrate.   And that is exactly what we need to do.


We just need to be careful how we do it.

We need to be careful not to unintentionally broadcast an “I am Great (and You are Not)” message – because if we do that we will make further change even more difficult.


Competition can be healthy or unhealthy  … just as scepticism can be.

We want to foster healthy competition … and to do that we have to do something that can feel counter-intuitive … we have to listen to our competitors; and we have to learn from them; and we have to share our discoveries with them.

Eh?


Just picture these two scenarios in your mind’s eye:

Scenario One: The competition is a war. There can only be one winner … the strongest, most daring, most cunning, most ruthless, most feared competitor. So secrecy and ingenuity are needed. Information must be hoarded. Untruths and confusion must be spread.

Scenario Two: The competition is a race. There can only be one winner … the strongest, most resilient, hardest working, fastest learning, most innovative, most admired competitor.  So openness and humility are needed. Information must be shared. Truths and clarity must be spread.

Compare the likely outcomes of the two scenarios.

Which one sounds the more productive, more rewarding and more enjoyable?


So the challenge for the champions of improvement is to appreciate and to practice a different version of the “I’m Great … ” mantra …

I’m Great (And So Are You).

top_surgeon_400_wht_7589All healthcare organisations strive for excellence, which is good, and most achieve mediocrity, which is not so good.

Why is that?

One cause is the design of their model for improvement … the one that is driven by targets, complaints, near misses, serious untoward incidents (SUIs) and never events (which are not never).

A model for improvement that is driven by failure feedback loops can only ever achieve mediocrity, not excellence.

Whaaaaaat?!* That’s rubbish”  I hear you cry … so let us see.


Try this simple test …. just ask any employee in your organisation this question (and start with yourself):

How do you know you are doing a good job?

If the first answer heard is “When no one is complaining” then you have a Mediocrity Design.


When customers have a disappointing experience most do not pen a letter or write an email to complain.  Most just sigh and lower their expectations to avoid future disappointment; many will grumble to family and friends; and only a few (about 5%) will actually complain. They are the really angry extreme.  So they can easily be fobbed off with platitudes … just being earnestly listened to and unreservedly apologised to is usually enough to take the wind out of their sails.  It will escort them back to the silent but disappointed majority whose expectation is being gradually eroded by relentless disappointment. Nothing fundamental needs to change because eventually the complaints dry up, apathy is re-established and chronic mediocrity is assured.


To achieve excellence we need a better answer to the “How do you know you are doing a good job?” question.

We need to be able to say “I know I am doing a good job because this is what a good outcome looks like; this is my essential contribution to achieving that outcome; and here are the measures of the intended outcomes that we are achieving.

In short we need a clear purpose, a defined part in the process that delivers that purpose, and we need an objective feedback loop that tells us that the purpose has been achieved and that our work is worthwhile.

And if  any of those components are missing then we know we have some improvement work to do.

The first step is usually answering the question “What is our purpose?

The second step is using the purpose to design and install the how-are-we-doing feedback loop.

And the  third step is to learn to use the success feedback loop to ensure that we are always working to have a necessary-and-sufficient process that delivers the intended outcome and that we are playing a part in that.

And when we are reliably achieving our purpose, we set ourselves an even better outcome – an even safer, calmer, higher quality and more productive one … and doing that will generate more improvement work to do.  We will not be idle.


That is the essence of Excellence-by-Design.

There comes a point in every improvement journey when it is time to celebrate and share. This is the most rewarding part of the Improvement Science Practitioner (ISP) coaching role so I am going to share a real celebration that happened this week.

The picture shows Chris Jones holding his well-earned ISP-1 Certificate of Competence.  The “Maintaining the Momentum of Medicines”  redesign project is shown on the poster on the left and it is the tangible Proof of Competence. The hard evidence that the science of improvement delivers.

Chris_Jones_Poster_and_Certificate

Behind us are the A3s for one of the Welsh Health Boards;  ABMU in fact.


An A3 is a way of summarising an improvement project very succinctly – the name comes from the size of paper used.  A3 is the biggest size that will go through an A4 fax machine (i.e. folded over) and the A3 discipline is to be concise and clear at the same time.

The three core questions that the A3 answers are:
Q1: What is the issue?
Q2: What would improvement need to look like?
Q3: How would we know that a change is an improvement?

This display board is one of many in the room, each sharing a succinct story of a different improvement journey and collectively a veritable treasure trove of creativity and discovery.

The A3s were of variable quality … and that is OK and is expected … because like all skills it takes practice. Lots of practice. Perfection is not the goal because it is unachievable. Best is not the goal because only one can be best. Progress is the goal because everyone can progress … and so progress is what we share and what we celebrate.


The event was the Fifth Sharing Event in the Welsh Flow Programme that has been running for just over a year and Chris is the first to earn an ISP-1 Certificate … so we all celebrated with him and shared the story.  It is a team achievement – everyone in the room played a part in some way – as did many more who were not in the room on the day.


stick_figure_look_point_on_cliff_anim_8156Improvement is like mountain walking.

After a tough uphill section we reach a level spot where we can rest; catch our breath; take in the view; reflect on our progress and the slips, trips and breakthroughs along the way; perhaps celebrate with drink and nibble of our chocolate ration; and then get up, look up, and square up for the next uphill bit.

New territory for us.  New challenges and new opportunities to learn and to progress and to celebrate and share our improvement stories.

IS_PyramidDeveloping productive improvement capability in an organisation is like building a pyramid in the desert.

It is not easy and it takes time before there is any visible evidence of success.

The height of the pyramid is a measure of the level of improvement complexity that we can take on.

An improvement of a single step in a system would only require a small pyramid.

Improving the whole system will require a much taller one.


But if we rush and attempt to build a sky-scraper on top of the sand then we will not be surprised when it topples over before we have made very much progress.  The Egyptians knew this!

First, we need to dig down and to lay some foundations.  Stable enough and strong enough to support the whole structure.  We will never see the foundations so it is easy to forget them in our rush but they need to be there and they need to be there first.

It is the same when developing improvement science capability  … the foundations are laid first and when enough of that foundation knowledge is in place we can start to build the next layer of the pyramid: the practitioner layer.


It is the the Improvement Science Practitioners (ISPs) who start to generate tangible evidence of progress.  The first success stories help to spur us all on to continue to invest effort, time and money in widening our foundations to be able to build even higher – more layers of capability -until we can realistically take on a system wide improvement challenge.

So sharing the first hard evidence of improvement is an important milestone … it is proof of fitness for purpose … and that news should be shared with those toiling in the hot desert sun and with those watching from the safety of the shade.

So here is a real story of a real improvement pyramid achieving this magical and motivating milestone.


figure_pointing_out_chart_data_150_wht_8005It was the appointed time for the ISP coaching session and both Bob and Leslie were logged on and chatting about their Easter breaks.

<Bob> OK Leslie, I suppose we had better do some actual work, which seems a shame on such a wonderful spring day.

<Leslie> Yes, I suppose so. There is actually something I would like to ask you about because I came across it by accident and it looked very pertinent to flow design … but you have never mentioned it.

<Bob> That sounds interesting. What is it?

<Leslie> V.U.T.

<Bob> Ah ha!  You have stumbled across the Queue Theorists and the Factory Physicists.  So, what was your take on it?

<Leslie> Well it all sounded very impressive. The context is I was having a chat with a colleague who is also getting into the improvement stuff and who had been to a course called “Factory Physics for Managers” – and he came away buzzing about the VUT equation … and claimed that it explained everything!

<Bob> OK. So what did you do next?

<Leslie> I looked it up of course and I have to say the more I read the more confused I got. Maybe I am just a bid dim and not up to understanding this stuff.

<Bob> Well you are certainly not dim so your confusion must be caused by something else. Did your colleague describe how the VUT equation is applied in practice?

<Leslie> Um. No, I do not remember him describing an example – just that it explained why we cannot expect to run resources at 100% utilisation.

<Bob> Well he is correct on that point … though there is a bit more to it than that.  A more accurate statement is “We cannot expect our system to be stable if there is variation and we run flow-resources at 100% utilisation”.

<Leslie> Well that sounds just like the sort of thing we have been talking about, what you call “resilient design”, so what is the problem with the VUT equation?

<Bob> The problem is that it gives an estimate of the average waiting time in a very simple system called a G/G/1 system.

<Leslie> Eh? What is a G/G/1 system?

<Bob> Arrgh … this is the can of queue theory worms that I was hoping to avoid … but as you brought it up let us grasp the nettle.  This is called Kendall’s Notation and it is a short cut notation for describing the system design. The first letter refers to the arrivals or demand and G means a general distribution of arrival times; the second G refers to the size of the jobs or the cycle time and again the distribution is general; and the last number refers to the number of parallel resources pulling from the queue.

<Leslie> OK, so that is a single queue feeding into a single resource … the simplest possible flow system.

<Bob> Yes. But that isn’t the problem.  The problem is that the VUT equation gives an approximation to the average waiting time. It tells us nothing about the variation in the waiting time.

<Leslie> Ah I see. So it tells us nothing about the variation in the size of the queue either … so does not help us plan the required space-capacity to hold the varying queue.

<Bob> Precisely.  There is another problem too.  The ‘U’ term in the VUT equation refers to utilisation of the resource … denoted by the symbol ρ or rho.  The actual term is ρ / (1-ρ) … so what happens when rho approaches one … or in practical terms the average utilisation of the resource approaches 100%?

<Leslie> Um … 1 divided by (1-1) is 1 divided by zero which is … infinity!  The average waiting time becomes infinitely long!

<Bob> Yes, but only if we wait forever – in reality we cannot and anyway – reality is always changing … we live in a dynamic, ever-changing, unstable system called Reality. The VUT equation may be academically appealing but in practice it is almost useless.

<Leslie> Ah ha! Now I see why you never mentioned it. So how do we design for resilience in practice? How do we get a handle on the behaviour of even the G/G/1 system over time?

<Bob> We use an Excel spreadsheet to simulate our G/G/1 system and we find a fit-for-purpose design using an empirical, experimental approach. It is actually quite straightforward and does not require any Queue Theory or VUT equations … just a bit of basic Excel know-how.

<Leslie> Phew!  That sounds more up my street. I would like to see an example.

<Bob> Welcome to the first exercise in ISP-2 (Flow).

FISH_ISP_eggs_jumpingResistance-to-change is an oft quoted excuse for improvement torpor. The implied sub-message is more like “We would love to change but They are resisting“.

Notice the Us-and-Them language.  This is the observable evidence of an “We‘re OK and They’re Not OK” belief.  And in reality it is this unstated belief and the resulting self-justifying behaviour that is an effective barrier to systemic improvement.

This Us-and-Them language generates cultural friction, erodes trust and erects silos that are effective barriers to the flow of information, of innovation and of learning.  And the inevitable reactive solutions to this Us-versus-Them friction create self-amplifying positive feedback loops that ensure the counter-productive behaviour is sustained.

One tangible manifestation are DRATs: Delusional Ratios and Arbitrary Targets.


So when a plausible, rational and well-evidenced candidate for an alternative approach is discovered then it is a reasonable reaction to grab it and to desperately spray the ‘magic pixie dust’ at everything.

This a recipe for disappointment: because there is no such thing as ‘improvement magic pixie dust’.

The more uncomfortable reality is that the ‘magic’ is the result of a long period of investment in learning and the associated hard work in practising and polishing the techniques and tools.

It may look like magic but is isn’t. That is an illusion.

And some self-styled ‘magicians’ choose to keep their hard-won skills secret … because by sharing them know that they will lose their ‘magic powers’ in a flash of ‘blindingly obvious in hindsight’.

And so the chronic cycle of despair-hope-anger-and-disappointment continues.


System-wide improvement in safety, flow, quality and productivity requires that the benefits of synergism overcome the benefits of antagonism.  This requires two changes to the current hope-and-despair paradigm.  Both are necessary and neither are sufficient alone.

1) The ‘wizards’ (i.e. magic folk) share their secrets.
2) The ‘muggles’ (i.e. non-magic folk) invest the time and effort in learning ‘how-to-do-it’.


The transition to this awareness is uncomfortable so it needs to be managed pro-actively … by being open about the risk … and how to mitigate it.

That is what experienced Practitioners of Improvement Science (and ISP) will do. Be open about the challenged ahead.

And those who desperately want the significant and sustained SFQP improvements; and an end to the chronic chaos; and an end to the gaming; and an end to the hope-and-despair cycle …. just need to choose. Choose to invest and learn the ‘how to’ and be part of the future … or choose to be part of the past.


Improvement science is simple … but it is not intuitively obvious … and so it is not easy to learn.

If it were we would be all doing it.

And it is the behaviour of a wise leader of change to set realistic and mature expectations of the challenges that come with a transition to system-wide improvement.

That is demonstrating the OK-OK behaviour needed for synergy to grow.

running_walking_150_wht_8351Improvement is not a continuous process. It has starts and stops, and ups and downs.  Improvement implies change, and that is intentionally disruptive. So the context will determine the progress as much as the change.

A commonly observed behaviour is probably at the root of why the majority of improvements initiatives fail to achieve a significant and sustained improvement.  Trying to run before mastering the skill of walking.


An experienced improvement coach will not throw learners into the deep end and watch them sink or swim.  That is not coaching; it is cruelty.

So the first improvement projects must be doable and done with lots of hands-off support, encouragement and praise for progress.

This has the benefit of developing confidence and capability.

It has a danger of leading to over-confidence though.  Confidence that exceeds capability.

There is a risk that the growing learner will take on a future improvement project that is outside their capability zone.


The danger of doing this is that they fall at the second hurdle and their new confidence can be damaged and even smashed. This can leave the learner feeling less motivated and more fearful than before.


There are a number of ways that an improvement coach can  mitigate this risk:

1. Make the learners aware up front that this is a risk.
2. Scope each project to stretch but not scare.
3. Be prepared to stop and reduce scope if necessary.
4. Set the expectation to consolidate the basics by teaching others.

These are not mutually exclusive options.  Seeing, doing and teaching can happen in parallel and that is actually the most productive way to learn.


As children we learned to walk with confidence before we learned to run … because falling flat on our face hurts both physically and emotionally!

This is just the same.

Dr_Bob_ThumbnailBob and Leslie were already into the dialogue of their regular ISP coaching session when Bob saw an incoming text from one of his other ISPees. It was simply marked: “Very Urgent”.

<Bob> Leslie, I have just received an urgent SMS that I think I need to investigate immediately. Could we put this conversation on ice for 10 minutes and I will call you back?

<Leslie> Of course. I have lots to do. Please do not rush back if it requires more time.

<Bob> Thank you.

Ten minutes later Leslie saw that Bob was phoning and picked up.

<Leslie> Hi Bob.  I hope you were able to sort out the urgent problem. The fact that you are back suggests you did.

<Bob> Hi Leslie.  Thank you for your understanding and patience. The issue was urgent and the root cause is not yet solved, but lessons are being learned.  And this is one you are going to come up against too so it may be an opportune time to explore it.

<Leslie> H’mm. Now you have pricked my curiosity. But you can’t discuss someone else’s problem with me surely!

<Bob> No indeed.  Strict confidentiality is essential.  We can talk about the generic issue though, without disclosing any details.  Do you remember that project you were doing last year where you achieved an initial success and then it all seemed to go wobbly?

<Leslie> Yes. At the time you said that I needed to put that one on the shelf and to press on with other projects. I think the phrase you used was “it needs to stew for a while“.

<Bob> And what happened?

<Leslie> The hard won improvement in performance slipped back and I felt like a failure and started to lose confidence. You said not to blame myself but to learn and  move on.  The lesson was I did not appreciate the difference between circles of control and circles of influence. I was trying to influence others before I had mastered self-control.

<Bob> Yes. There was another factor too but I did not feel it was the time to explore it. Now feels like a better time.

<Leslie> OK … now my curiosity is really fired up.

<Bob> Do you remember last week’s blog about the Improvement Gearbox?

<Leslie> Yes. I really liked the mechanical metaphor.  It resonated with so many things. I have used it several times this week in conversations.

<Bob> Well, there is a close relationship between the level of challenge and the gearbox.  As complexity increases we need to be able to use more of the gears, and to change up and down with ease and according to need.

<Leslie> Change down? I sort of assumed that once you got to fourth gear you stay there.

<Bob> That is true if the terrain is level and everyone is on board the bus with the same destination in mind.  In reality the terrain goes up and down and as we learn we need to stop and let some people get off and take others on board.

<Leslie> So we need to change down gears on the uphill bits, change up gears on the downhill, and go through the whole gear sequence when we deliberately slow to a halt, and then get on our way again.

<Bob> Yes. Well put. The world is changing all the time and the team on board is in dynamic flux. Some arrive, some leave and others stay on the bus but change seats as we move along.  Not all seats suit all people. What is comfortable for one may be painful for another.

<Leslie> So how come the urgent call?

<Bob> A fight had broken out on their bus, the tribes were arguing because the improvements they have made have blown away some of the fog and exposed some deeper cultural cracks. Cracks that had been there all the time but were concealed by the fog of the daily chaos and the smoke of the burning martyrs. They had taken their eye off the road and were heading for a blind bend unaware of what was around the corner.

<Leslie> So your intervention was to shout “Pay attention to the road and make a decision … steer or stop!

<Bob> Yes, that about sums it up.  A co-labor-ation call.

<Leslie> Eh? Dis you just say collaboration in a weird way?

<Bob> Yes. I chopped it up into concepts … “co” means together, “labor” means work and “ation” means action or process.  If they do not learn to co-labor-ate then they will come off the road, crash, and burn. And join the graveyard of improvement train wrecks that litter the verges of the rocky road of change.

<Leslie> Fourth gear stuff?

<Bob> Whole gearbox stuff. All gears between first and fourth because they are all necessary at different times.  Each gear builds on those which go before. There are no good or bad gears just fit-for-current-purpose or not.  Bad driving is ineptitude. Not using the vehicle’s gearbox effectively and efficiently and risking the safety and comfort of the passengers and other road users. Poor leadership is analogous to poor driving. Dangerous.

<Leslie> So an effective leader of change needs to be able to use all the gears competently and to know when to use which and when to change. And in doing so demonstrate what a safe pair of leadership hands looks like and what it can achieve … through collaborative effort.

<Bob> Perfect!  It is time for you to tear up your L plates.

GearboxOne of the most rewarding experiences for an improvement science coach is to sense when an individual or team shift up a gear and start to accelerate up their learning curve.

It is like there is a mental gearbox hidden inside them somewhere.  Before they were thrashing themselves by trying to go too fast in a low gear. Noisy, ineffective, inefficient and at high risk of blowing a gasket!

Then, they discover that there is a higher gear … and that to get to it they have to take a risk … depress the emotional clutch, ease back on the gas, slip into neutral, and trust themselves to find the new groove and … click … into the higher gear, and then ease up the power while letting out the clutch.  And then accelerate up the learning  curve.  More effective, more efficient. More productive. More fun.


Organisations appear to behave in much the same way.

Some scream along in the slow-lane … thrashing their employee engine. The majority chug complacently in the middle-lane of mediocrity. A few accelerate past in the fast-lane to excellence.

And they are all driving exactly the same model of car.

So it is not the car that is making the difference … it is the driving.


Those who have studied organisations have observed five cultural “gears”; and which gear an organisation is in most of the time can be diagnosed by listening to the sound of the engine – the conversations of the employees.

If they are muttering “work sucks” then they are in first gear.  The sense of hopelessness, futility, despair and anger consumes all their emotional fuel. Fortunately this is uncommon.

If we mainly hear “my work sucks” then they are in second gear.  The feeling is of helplessness and apathy and the behaviour is Victim-like.  They believe that they cannot solve their own problems … someone else must do it for them or tell them what to do. They grumble a lot.

If the dominant voice is “I’m great but you lot suck” then we are hearing third gear attitudes. The selfishly competitive behaviour of the individualist achiever. The “keep your cards close to your chest” style of dyadic leadership.  The advocate of “it is OK to screw others to get ahead”. They grumble a lot too – about the apathetic bunch.

And those who have studied organisations suggest that about 80% of healthcare organisations are stuck in first, second or third cultural gear.  And we can tell who they are … the lower 80% of the league tables. The ones clamouring for more … of everything.


So how come so many organisations are so stuck? Unable to find fourth gear?

One cause is the design of their feedback loops. Their learning loops.

If an organisation only uses failure as a feedback loop then it is destined to get no more than mediocrity.  Third gear at best, and usually only second.

Example.
We all feel disappointment when our experience does not live up to our expectation.  But only the most angry of us will actually do something and complain.  Especially when we have no other choice of provider!

Suppose we are commissioners of healthcare services and we are seeing a rising tide of patient and staff complaints. We want to improve the safety and quality of the services that we are paying for; so we draw up a league table using complaints as feedback fodder and we focus on the worst performing providers … threatening them with dire consequences for being in the bottom 20%.  What happens? Fear of failure motivates them to ‘pull up their socks’ and the number of complaints falls.

Job done?

Unfortunately not.

All we have done is to bully those stuck in first or second gear into thrashing their over-burdened employee engine even harder.  We have not helped anyone find their higher gear. We have hit the target, missed the point, and increased the risk of system failure!

So what about those organisations stuck in third gear?

Well they are ticking their performance boxes, meeting our targets, keeping their noses clean.  Some are just below, and some just above the collective mean of barely acceptable mediocrity.

But expectation is changing.

The 20% who have discovered fourth gear are accelerating ahead and are demonstrating what is possible. And they are raising expectation, increasing the variation of service quality … for the better.

And the other 80% are falling further and further behind; thrashing their tired and demoralised staff harder and harder to keep up.  Complaining increasingly that life is unfair and that they need more, time, money and staff engagement. Eventually their executive head gaskets go “pop” and they fall by the wayside.


Finding cultural fourth gear is possible but it is not easy. There are no short cuts.  We have to work our way up the gears and we have to learn when and how to make smooth transitions from first to second, second to third and then third to fourth.

And when we do that the loudest voice we hear is “We are OK“.

We need to learn how to do a smooth cultural hill start on the steep slope from apathy to excellence.

And we need to constantly listen to the sound of our improvement engine; to learn to understand what it is saying; and learn how and when to change to the next cultural gear.

SFQP_enter_circle_middle_15576For a system to be both effective and efficient the parts need to work in synergy. This requires both alignment and collaboration.

Systems that involve people and processes can exhibit complex behaviour. The rules of engagement also change as individuals learn and evolve their beliefs and their behaviours.

The values and the vision should be more fixed. If the goalposts are obscure or oscillate then confusion and chaos is inevitable.


So why is collaborative alignment so difficult to achieve?

One factor has been mentioned. Lack of a common vision and a constant purpose.

Another factor is distrust of others. Our fear of exploitation, bullying, blame, and ridicule.

Distrust is a learned behaviour. Our natural inclination is trust. We have to learn distrust. We do this by copying trust-eroding behaviours that are displayed by our role models. So when leaders display these behaviours then we assume it is OK to behave that way too.  And we dutifully emulate.

The most common trust eroding behaviour is called discounting.  It is a passive-aggressive habit characterised by repeated acts of omission:  Such as not replying to emails, not sharing information, not offering constructive feedback, not asking for other perspectives, and not challenging disrespectful behaviour.


There are many causal factors that lead to distrust … so there is no one-size-fits-all solution to dissolving it.

One factor is ineptitude.

This is the unwillingness to learn and to use available knowledge for improvement.

It is one of the many manifestations of incompetence.  And it is an error of omission.


Whenever we are unable to solve a problem then we must always consider the possibility that we are inept.  We do not tend to do that.  Instead we prefer to jump to the conclusion that there is no solution or that the solution requires someone else doing something different. Not us.

The impossibility hypothesis is easy to disprove.  If anyone has solved the problem, or a very similar one, and if they can provide evidence of what and how then the problem cannot be impossible to solve.

The someone-else’s-fault hypothesis is trickier because proving it requires us to influence others effectively.  And that is not easy.  So we tend to resort to easier but less effective methods … manipulation, blame, bullying and so on.


A useful way to view this dynamic is as a set of four concentric circles – with us at the centre.

The outermost circle is called the ‘Circle of Ignorance‘. The collection of all the things that we do not know we do not know.

Just inside that is the ‘Circle of Concern‘.  These are things we know about but feel completely powerless to change. Such as the fact that the world turns and the sun rises and falls with predictable regularity.

Inside that is the ‘Circle of Influence‘ and it is a broad and continuous band – the further away the less influence we have; the nearer in the more we can do. This is the zone where most of the conflict and chaos arises.

The innermost is the ‘Circle of Control‘.  This is where we can make changes if we so choose to. And this is where change starts and from where it spreads.


SFQP_enter_circle_middle_15576So if we want system-level improvements in safety, flow, quality and productivity (or cost) then we need to align these four circles. Or rather the gaps in them.

We start with the gaps in our circle of control. The things that we believe we cannot do … but when we try … we discover that we can (and always could).

With this new foundation of conscious competence we can start to build new relationships, develop trust and to better influence others in a win-win-win conversation.

And then we can collaborate to address our common concerns – the ones that require coherent effort. We can agree and achieve our common purpose, vision and goals.

And from there we will be able to explore the unknown opportunities that lie beyond. The ones we cannot see yet.

Dr_Bob_Thumbnail[Bing] Bob logged in for the weekly Webex coaching session. Leslie was not yet on line, but joined a few minutes later.

<Leslie> Hi Bob, sorry I am a bit late, I have been grappling with a data analysis problem and did not notice the time.

<Bob> Hi Leslie. Sounds interesting. Would you like to talk about that?

<Leslie> Yes please! It has been driving me nuts!

<Bob> OK. Some context first please.

<Leslie> Right, yes. The context is an improvement-by-design assignment with a primary care team who are looking at ways to reduce the unplanned admissions for elderly patients by 10%.

<Bob> OK. Why 10%?

<Leslie> Because they said that would be an operationally very significant reduction.  Most of their unplanned admissions, and therefore costs for admissions, are in that age group.  They feel that some admissions are avoidable with better primary care support and a 10% reduction would make their investment of time and effort worthwhile.

<Bob> OK. That makes complete sense. Setting a new design specification is OK.  I assume they have some baseline flow data.

<Leslie> Yes. We have historical weekly unplanned admissions data for two years. It looks stable, though rather variable on a week-by-week basis.

<Bob> So has the design change been made?

<Leslie> Yes, over three months ago – so I expected to be able to see something by now but there are no red flags on the XmR chart of weekly admissions. No change.  They are adamant that they are making a difference, particularly in reducing re-admissions.  I do not want to disappoint them by saying that all their hard work has made no difference!

<Bob> OK Leslie. Let us approach this rationally.  What are the possible causes that the weekly admissions chart is not signalling a change?

<Leslie> If there has not been a change in admissions. This could be because they have indeed reduced readmissions but new admissions have gone up and is masking the effect.

<Bob> Yes. That is possible. Any other ideas?

<Leslie> That their intervention has made no difference to re-admissions and their data is erroneous … or worse still … fabricated!

<Bob> Yes. That is possible too. Any other ideas?

<Leslie> Um. No. I cannot think of any.

<Bob> What about the idea that the XmR chart is not showing a change that is actually there?

<Leslie> You mean a false negative? That the sensitivity of the XmR chart is limited? How can that be? I thought these charts will always signal a significant shift.

<Bob> It depends on the degree of shift and the amount of variation. The more variation there is the harder it is to detect a small shift.  In a conventional statistical test we would just use bigger samples, but that does not work with an XmR chart because the run tests are all fixed length. Pre-defined sample sizes.

<Leslie> So that means we can miss small but significant changes and come to the wrong conclusion that our change has had no effect! Isn’t that called a Type 2 error?

<Bob> Yes, it is. And we need to be aware of the limitations of the analysis tool we are using. So, now you know that how might you get around the problem?

<Leslie> One way would be to aggregate the data over a longer time period before plotting on the chart … we know that will reduce the sample variation.

<Bob> Yes. That would work … but what is the downside?

<Leslie> That we have to wait a lot longer to show a change, or not. We do not want that.

<Bob> I agree. So what we do is we use a chart that is much more sensitive to small shifts of the mean.  And that is called a cusum chart. These were not invented until 30 years after Shewhart first described his time-series chart.  To give you an example, do you recall that the work-in-progress chart is much more sensitive to changes in flow than either demand or activity charts?

<Leslie> Yes, and the WIP chart also reacts immediately if either demand or activity change. It is the one I always look at first.

<Bob> That is because a WIP chart is actually a cusum chart. It is the cumulative sum of the difference between demand and activity.

<Leslie> OK! That makes sense. So how do I create and use a cusum chart?

<Bob> I have just emailed you some instructions and a few examples. You can try with your unplanned admissions data. It should only take a few minutes. I will get a cup of tea and a chocolate Hobnob while I wait.

[Five minutes later]

<Leslie> Wow! That is just brilliant!  I can see clearly on the cusum chart when the shifts happened and when I split the XmR chart at those points the underlying changes become clear and measurable. The team did indeed achieve a 10% reduction in admissions just as they claimed they had.  And I checked with a statistical test which confirmed that it is statistically significant.

<Bob> Good work.  Cusum charts take a bit of getting used to and we have be careful about the metric we are plotting and a few other things but it is a useful trick to have up our sleeves for situations like this.

<Leslie> Thanks Bob. I will bear that in mind.  Now I just need to work out how to explain cusum charts to others! I do not want to be accused of using statistical smoke-and-mirrors! I think a golf metaphor may work with the GPs.

magnify_text_anim_16253(1)There is no doubt about it …

… change is not easy.

If it were we would all be doing it …

… all of the time.

So one skill that an effective agent of change demonstrates is persistence.

And also patience. And also reflective learning.


A recent change project demonstrated objective, measurable outcomes which showed that the original design goal was achieved. In budget. It took two years from first contact to final report.

Why two years? Could it have been done quicker?

In principle – ‘Emphatically, yes’.  In practice – ‘Evidently, no’.


With the benefit of hindsight it is always clearer what might have caused the delay.  Maybe the experience-based advice of those guiding the process was discounted.  Maybe the repeated recommendation that an initial investment in learning the basic science of improvement would deliver a quicker return was ignored.  Maybe.


So the reflective learning from the first wave was re-invested in the second wave.

And the second wave delivered a significant and objectively measurable improvement in one year.

And the reflective learning from the second wave was re-invested in the third wave.

And the third wave delivered a significant and objectively measurable improvement in six months.

And the three improvement projects were of comparable complexity.


So what is happening here?

The process of improvement is itself being improved.  Experience and learning are being re-invested.

And two repeating themes emerge ….

Patience is needed to await outcomes and to learn from them.

Persistence is needed to re-examine old paradigms with this new knowledge and new understanding.


Patience and Persistence. And these principles apply as much to the teacher as to the taught.

Troublemaker_vs_RebelSystem-wide, significant, and sustained improvement implies system-wide change.

And system-wide change implies more than 20% of the people commit to action. This is the cultural tipping point.

These critical 20% have a badge … they call themselves rebels … and they are perceived as troublemakers by those who profit most from the status quo.

But troublemakers and rebels are radically different … as shown in the summary by Lois Kelly.


Rebels share a common, future-focussed purpose.  A mission.  They are passionate, optimistic and creative.  They understand synergy and how to release and align the stored emotional energy of both themselves and others.  And most importantly they are value-led and that makes them attractive.  Values such as honesty, integrity and industry are what make leaders together-effective.

SHCR_logoAnd as we speak there is school for rebels in healthcare gaining momentum …  and their programme is current, open to all and free to access. And the change agent development materials are excellent!

Click here to download their study guide.


Converting possibilities into realities is the essence of design … so our merry band of rebels will also need to learn how to convert their positive rhetoric into practical reality. And that is more physics than psychology.

Streams flow because of physics not because of passion.SFQP_Compass

And this is why the science of improvement is important because it is the synthesis of the people dimension and the process dimension – into a system that delivers significant and sustained improvement.

On all dimensions. Safety, Flow, Quality and Productivity.

The lighthouse is our purpose; the whale represents the magnitude of our challenge; the blue sky is the creative thinking we need … to avoid trying to boil the ocean.

And the noisy, greedy, s****y seagulls are the troublemakers who always will plague us.

[Image by Malaika Art].


Nanny_McPheeThere comes a point in every improvement-by-design journey when it is time for the improvement guide to leave.

An experienced coach knows when that time has arrived and the expected departure is in the contract.

The Nanny McPhee Coaching Contract:

“When you need me but do not want me then I have to stay. And when you want me but do not need me then I have to leave.”


The science of improvement can appear like ‘magic’ at first because seemingly impossible simultaneous win-win-win benefits are seen to happen with minimal effort.

It is not magic.  It requires years of training and practice to become a ‘magician’.  So those who have invested in learning the know-how are just catalysts.  When their catalysts-of-change work is done then they must leave to do it elsewhere.

The key to managing this transition is to set this expectation clearly and right at the start; so it does not come as a surprise. And to offer reminders along the way.

And it is important to follow through … when the time is right.


It is not always easy though.

There are three commonly encountered situations that will test the temptation of the guide.

1) When things are going very badly because the coaching contract is being breached, usually by old habitual trust-eroding error-of-omission behaviours such as not communicating; not sharing learning; and not delivering on commitments. The coach, fearing loss of reputation and face, is tempted to stay and to try harder. Often getting angry and frustrated in the process.  This is an error of judgement. If the coaching contract is being persistently breached then the Exit Clause should be activated clearly and cleanly.

2) When things are going OK it is easy to become complacent and the temptation then is to depart too soon, only to hear later that the solo flyers crashed and burned, because they were not quite ready and could or would not see it.  This is the “need but do not want” part of the Nanny McPhee Coaching Contract. One role of the ISP coach is to respectfully challenge the assertion that ‘We can do it ourselves‘ … by saying ‘OK, please demonstrate‘.

3) When things are going very well it is tempting to blow the Trumpet of Success too early, attracting the attention of others who want to take a short cut; to bypass the effort of learning for themselves; and to jump on someone else’s improvement bus.  The danger here is that they bring their counter-productive behavioural baggage with them. This can cause the improvement bus to veer off course on the twists and turns; or grind to a halt on the steeper parts of improvement-by-design learning curve.


An experienced coach will respectfully challenge the individuals and the teams to help them develop their competence, experience and confidence. And just as they start to become too comfortable with having someone to defer to for all decisions, the coach will announce the departure and depart as announced. This is the “want but do not need” part of the Nanny McPhee Coaching Contract.


And experience shows that this mutually respectful behaviour works better for all.

count_this_vote_400_wht_9473The question that is foremost in the mind of a designer is “What is the purpose?”   It is a future-focussed question.  It is a question of intent and outcome. It raises the issues of worth and value.

Without a purpose it impossible to answer the question “Is what we have fit-for-purpose?

And without a clear purpose it is impossible for a fit-for-purpose design to be created and tested.

In the absence of a future-purpose all that remains are the present-problems.

Without a future-purpose we cannot be proactive; we can only be reactive.

And when we react to problems we generate divergence.  We observe heated discussions. We hear differences of opinion as to the causes and the solutions.  We smell the sadness, anger and fear. We taste the bitterness of cynicism. And we are touched to our core … but we are paralysed.  We cannot act because we cannot decide which is the safest direction to run to get away from the pain of the problems we have.


And when the inevitable catastrophe happens we look for somewhere and someone to place and attribute blame … and high on our target-list are politicians.


So the prickly question of politics comes up and we need to grasp that nettle and examine it with the forensic lens of the system designer and we ask “What is the purpose of a politician?”  What is the output of the political process? What is their intent? What is their worth? How productive are they? Do we get value for money?

They will often answer “Our purpose is to serve the public“.  But serve is a verb so it is a process and not a purpose … “To serve the public for what purpose?” we ask. “What outcome can we expect to get?” we ask. “And when can we expect to get it?

We want a service (a noun) and as voters and tax-payers we have customer rights to one!

On deeper reflection we see a political spectrum come into focus … with Public at one end and Private at the other.  A country generates wealth through commerce … transforming natural and human resources into goods and services. That is the Private part and it has a clear and countable measure of success: profit.  The Public part is the redistribution of some of that wealth for the benefit of all – the tax-paying public. Us.

Unfortunately the Public part does not have quite the same objective test of success: so we substitute a different countable metric: votes. So the objectively measurable outcome of a successful political process is the most votes.

But we are still talking about process … not purpose.  All we have learned so far is that the politicians who attract the most votes will earn for themselves a temporary mandate to strive to achieve their political purpose. Whatever that is.

So what do the public, the voters, the tax-payers (and remember whenever we buy something we pay tax) … the customers of this political process … actually get for their votes and cash?  Are they delighted, satisfied or disappointed? Are they getting value-for-money? Is the political process fit-for-purpose? And what is the purpose? Are we all clear about that?

And if we look at the current “crisis” in health and social care in England then I doubt that “delight” will feature high on the score-sheet for those who work in healthcare or for those that they serve. The patients. The long-suffering tax-paying public.


Are politicians effective? Are they delivering on their pledge to serve the public? What does the evidence show?  What does their portfolio of public service improvement projects reveal?  Welfare, healthcare, education, police, and so on.The_Whitehall_Effect

Well the actual evidence is rather disappointing … a long trail of very expensive taxpayer-funded public service improvement failures.

And for an up-to-date list of some of the “eye-wateringly”expensive public sector improvement train-wrecks just read The Whitehall Effect.

But lurid stories of public service improvement failures do not attract precious votes … so they are not aired and shared … and when they are exposed our tax-funded politicians show their true skills and real potential.

Rather than answering the questions they filter, distort and amplify the questions and fire them at each other.  And then fall over each other avoiding the finger-of-blame and at the same time create the next deceptively-plausible election manifesto.  Their food source is votes so they have to tickle the voters to cough them up. And they are consummate masters of that art.

Politicians sell dreams and serve disappointment.


So when the-most-plausible with the most votes earn the right to wield the ignition keys for the engine of our national economy they deflect future blame by seeking the guidance of experts. And the only place they can realistically look is into the private sector who, in manufacturing anyway, have done a much better job of understanding what their customers need and designing their processes to deliver it. On-time, first-time and every-time.

Politicians have learned to be wary of the advice of academics – they need something more pragmatic and proven.  And just look at the remarkable rise of the manufacturing phoenix of Jaguar-Land-Rover (JLR) from the politically embarrassing ashes of the British car industry. And just look at Amazon to see what information technology can deliver!

So the way forward is blindingly obvious … combine manufacturing methods with information technology and build a dumb-robot manned production-line for delivering low-cost public services via a cloud-based website and an outsourced mega-call-centre manned by standard-script-following low-paid operatives.


But here we hit a bit of a snag.

Designing a process to deliver a manufactured product for a profit is not the same as designing a system to deliver a service to the public.  Not by a long chalk.  Public services are an example of what is now known as a complex adaptive system (CAS).

And if we attempt to apply the mechanistic profit-focussed management mantras of “economy of scale” and “division of labour” and “standardisation of work” to the messy real-world of public service then we actually achieve precisely the opposite of what we intended. And the growing evidence is embarrassingly clear.

We all want safer, smoother, better, and more affordable public services … but that is not what we are experiencing.

Our voted-in politicians have unwittingly commissioned complicated non-adaptive systems that ensure we collectively fail.

And we collectively voted the politicians into power and we are collectively failing to hold them to account.

So the ball is squarely in our court.


Below is a short video that illustrates what happens when politicians and civil servants attempt complex system design. It is called the “Save the NHS Game” and it was created by a surgeon who also happens to be a system designer.  The design purpose of the game is to raise awareness. The fundamental design flaw in this example is “financial fragmentation” which is the the use of specific budgets for each part of the system together with a generic, enforced, incremental cost-reduction policy (the shrinking budget).  See for yourself what happens …


In health care we are in the improvement business and to do that we start with a diagnosis … not a dream or a decision.

We study before we plan, and we plan before we do.

And we have one eye on the problem and one eye on the intended outcome … a healthier patient.  And we often frame improvement in the negative as a ‘we do not want a not sicker patient’ … physically or psychologically. Primum non nocere.  First do no harm.

And 99.9% of the time we do our best given the constraints of the system context that the voted-in politicians have created for us; and that their loyal civil servants have imposed on us.


Politicians are not designers … that is not their role.  Their part is to create and sell realistic dreams in return for votes.

Civil servants are not designers … that is not their role.  Their part is to enact the policy that the vote-seeking politicians cook up.

Doctors are not designers … that is not their role.  Their part is to make the best possible clinical decisions that will direct actions that lead, as quickly as possible, to healthier and happier patients.

So who is doing the complex adaptive system design?  Whose role is that?

And here we expose a gap.  No one.  For the simple reason that no one is trained to … so no one is tasked to.

But there is a group of people who are perfectly placed to create the context for developing this system design capability … the commissioners, the executive boards and the senior managers of our public services.

So that is where we might reasonably start … by inviting our leaders to learn about the science of complex adaptive system improvement-by-design.

And there are now quite a few people who can now teach this science … they are the ones who have done it and can demonstrate and describe their portfolios of successful and sustained public service improvement projects.

Would you vote for that?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

<Leslie> And what happened next?

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

<Leslie> Niggles you mean?

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

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

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

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

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

<Leslie> Constructive actions such as?

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

<Leslie> More learning loops!

<Bob> Yup.

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

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

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

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

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

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

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

SFQPThe flavour of the week has been “chaos”. Again!

Chaos dissipates energy faster than calm so chaotic behaviour is a symptom of an inefficient design.

And we would like to improve our design to restore a state of ‘calm efficiency’.

Chaos is a flow phenomenon … but that is not where the improvement by design process starts. There is a step before that … Safety.


Safety First
If a design is unsafe it generates harm. So we do not want to improve the smooth efficiency of the harm generator … that will produce more harm!  First we must consider if our system is safe enough.

Despite what many claim our healthcare systems are actually very safe. Sure there are embarrassing exceptions and we can always improve safety further, but we actually have quite a safe design.

It is not a very efficient one though. There is a lot of checking and correcting which uses up time and resources … but safety is good enough for now.

Having done the safety sanity check we can move on to Flow.


Flow Second
Flow comes before quality because it is impossible to deliver a high quality experience in a chaotic system. First we need to calm any chaos.  Or rather we need to diagnose the root causes of the chaotic behaviour and do some flow re-design to restore the calm.

Chaos is funny stuff. It does not behave intuitively. Time is always a factor. The butterflies wing effect is ever present.  Small causes can have big effects, both good and bad. Big causes can have no effect. Causes can be synergistic and they can be antagonistic. The whole is not the sum of the parts. This confusing and counter-intuitive behaviour is called “non linear” and we are all rubbish at getting a mental handle on it.

The good news is that when chaos reigns it is usually possible to calm it with a small number of carefully placed, carefully timed,  carefully designed, synergistic, “tweaks”.

The problem is that when we do what intuitively feels “right” we can easily make poor improvement decisions that lead to ineffective actions. The chaos either does not go away or it gets worse. So we have learned from our ineptitude to just put up with it and accept the inefficiency. The high cost of chaos.

To calm the chaos we have to learn to use the tools designed to do that. And they do exist.


Quality
Safety and Flow represent the “absolute” half of the SFQP cycle.  Harm is an absolute metric. We can devise absolute definitions and count harmful events. Mortality. Mistakes. Hospital  acquired infections.  That sort of stuff.   Flow is absolute too in the sense that the Laws of Physics determine what happens, and they are absolute too. Non negotiable.

Quality is relative.  It is the ratio of experience and expectation.  Both of these are subjective but that is not the point. The point is that it is a ratio. That makes it a relative metric. My expectation influences my perception of quality – so does what I experience.  And this has important implications.  For example we can reduce disappointment by lowering expectation; or we can reduce disappointment by improving experience.  Lowering expectation is the easier option though because to do that we only have to don the “black hat” and paint a grisly picture of a worst case scenario.  Some call it “informed consent”; I call it “abdication of empathy” and “fear-mongering”.

Variable quality can  come from variable experience, variable expectation or both.  So to reduce quality variation we can focus on either part of the ratio; and the easiest is expectation.  Setting a realistic expectation just requires measuring experience retrospectively and sharing it prospectively. Not satisfaction mind you. Experience. Satisfaction surveys are meaningless as an improvement tool because setting a lower expectation will improve satisfaction!

And this is why quality follows flow … because if flow is chaotic then expectation becomes a lottery, and quality does too.  The chaotic behaviour of the St.Elsewhere’s® A&E Department that we saw last week implies that we cannot set any other expectation than “It might be OK or it might be Not OK … we cannot predict. So fingers crossed.” It is a quality lottery!

But with calm and efficient flow we will experience less variation and with that we can set a reasonable expectation. Quality becomes predictable-within-limits.


Productivity
Productivity is also a relative concept. It is the ratio of what we get out of the system divided by what we put in.  Revenue divided by expense for example.

And it does not actually appear last.  As soon as safety, flow or quality improve then they will have an immediate impact on productivity.  Work gets easier.  The cost of harm, chaos and disappointment will fall. And they are surprisingly large costs!

The reason that productivity-by-design comes last is because we are talking about focussed productivity improvement-by-design.  Better value for money for example.  And that requires a specific design focus. It comes last because we need some head-space and some life-time to learn and do good design.

And SFQP is a cycle so after doing the Productivity improvement we go back to Safety and ask “How can we make our design even safer and even simpler?” And so on, round and round the SFQP cycle.

Do no harm, restore the calm, delight for all, and costs will fall.

And if you would like a full-size copy of the SFQP cycle diagram to use and share just click here.

Magnum_ChaosThe title of this alter piece by Lorenzo Lotto is Magnum Chaos. It was painted in the first half of the 16th Century.

Chaos was the Greek name for the primeval state of existence from which everything that has order was created. Similar concepts exist in all ancient mythologies.

The sudden appearance of order from chaos is the subject of much debate and current astronomical science refers to it as the Big Bang … which is the sense that this 500 year old image captures.  Except that it appears to have happened bout 13.5 thousand million years ago.

So it is surprising to learn that the Science of Chaos did not really get going until about 50 years ago – shortly after the digital computer was developed.


The timing is no co-incidence.  The theoretical roots of chaos had been known for much longer – since Isaac Newton formulated the concept of gravity. About 200 years ago it became the “Three-Body Problem”. The motion of the Earth, Moon and Sun is a three-body gravitational problem.

And in 1887, mathematicians Ernst Bruns and Henri Poincaré showed that there is no general analytical solution for the three-body problem given by algebraic expressions and integrals. The motion of three bodies is generally non-repeating, except in special cases. No simple equation describes it.

The implication of this is that the only way to solve this sort of problem is by grunt-work, empirically, with thousands of millions of small calculations.  And in 1887 the technology was not available to do this.


So when the high-speed transistorised digital computer appeared in the 1960’s it became possible to revisit this old niggle … and the nature of chaos became much better understood.  The modern legacy of this pioneering work is the surprising accuracy that we can now predict the weather – at least over the short term – using powerful digital computers running chaotic system simulation models. Weather is a chaotic flow system.

So given the knowledge that exists about the nature of flow in naturally chaotic systems … it is surprising that not much of this understanding has diffused into the design of man-made systems; such as healthcare.


It has probably not escaped most people’s attention that the NHS is suffering yet another “winter crisis” … despite the fact that the NHS budget has doubled over the last 15 years.

If we can predict the weather, but not control it, then why cannot we avoid the annual NHS crisis – which is a much simpler system that we can influence?


StElsewhere_Fail
The chart above shows the actual behaviour of a healthcare system – a medium sized hospital that we shall call St.Elsewhere’s®.  It could be called St.Anywhere’s.  The performance metric that is being plotted over time is the % of patients who arrive each day in the A&E department and who are there for more than 4 hours. The infamous 4-hour A&E target.  The time-span on the horizontal axis is just over 5 years – and the data has been segmented by financial year.

The behaviour of this system over time is not random.  It is chaotic.

There are repeating but non-identical cyclical patterns in the data … for example the first half of the year (April to September) is “better” than the second half. And this cyclical pattern appears to be changing as time passes.

The thin blue line is the arbitrary ‘target’.  And it does require a statistical expert to conclude that this system has never come close to achieving the ‘target’.  The system design is not capable of achieving it … so beating the system with a stick is not going to help. It amounts to the Basil Fawlty tactic of beating the broken-down car with a tree branch!

The system needs to be re-designed in order to achieve the requirement of consistently less than a 5% failure rate on the 4-hour A&E target. Exhortation is ineffective.

And this is not a local problem … it is a systemic one … BBC News


To re-design a system to achieve improved performance we first need to understand why the current design is not demonstrating the behaviour we want. Guessing is not design. It is guess-work. Generating a hypothesis is not design. It is guess-work too.

Design requires understanding.

A common misunderstanding is that the primary cause of deteriorating A&E performance is increasing demand. Reality does not support this rhetoric.

StElsewhere_DemandThis system behaviour chart (SBC) shows the A&E daily demand for the same period segmented by financial year. Over time there has indeed been an increase in the average demand, but that association does not prove causality.  If increasing demand caused performance failure we would expect to see matching cyclical patterns on both charts. But it is rather obvious that there is little relation between the two charts – the periods of highest demand do not correlate with the periods of highest failure. If anything there is a negative correlation – there is actually less demand in the second half of the financial year compared with the first.

So there must be more to it than just the average A&E demand.  Could there be a chicken-and-egg problem here? Higher breach rates leading to lower demand? Word gets round about a poor quality service!  What about the weather?  What about the effect of day-length? What about holidays? What about annual budgets?

What is uncomfortably obvious is that the chaotic behaviour has been going on for a long time. That is because it is an inherent part of the design.  We created it because we designed the NHS.


One surprising lesson that Chaos Theory teaches us is that chaos is predictable.  A system can be designed to behave chaotically … and rather easily too. It does not required a complicated design – a mechanically simple system can behave chaotically – a hinged pendulum for example.

So if we can deliberately design a system to behave chaotically then surely we can understand what design features are critical to delivering chaos and what are not. And with that insight might we then examine the design of man-made systems that we do not want to behave chaotically … such as our healthcare system?

And when we do that we discover something rather uncomfortable – that our healthcare system has been nearly perfectly designed to generate chaotic behaviour.  That may not have been the intention but it is the outcome.

So how did we get ourselves into this mess … and how do we get ourselves out of it?


To understand chaotic flow behaviour we need to consider two effects: the first is called a destabilising effect, the other is a stabilising effect.

The golden rule of chaos is that if the destabilising effect dominates then we get bumpy behaviour, if the stabilizing effect dominates then we get smooth flow.

So to eliminate the chaos all we need to do is to adjust the balance of these two effects … increase the stabilisers and reduce the destabilisers.

And because of the counter-intuitive nature of non-linear flow systems, only a small change in this balance can have a big effect: it can flip us from stable to chaotic, and it can also flip us back.

The trick is knowing how to tweak the design to create the flip.  Tweak at the wrong place or wrong time and nothing improves … as our chart above illustrates.

We need chaotic-flow-diagnostic and anti-chaotic-flow-design capability … and that is clearly lacking … because if it were present we would not be having this conversation.


And that capability exists … it is called Improvement Science. We just need to learn it.