Failure to recognise failure
Failure is an experience common to all human beings, its a fundamental part of our existence. Sometimes things go well and we experience success and sometimes the opposite occurs and we experience failure. If we are honest most of us probably don’t enjoy failure. Some of us might have developed the ability to learn from our failures so that failure is not an end in itself, but rather a means to end, helping us to continually learn and improve as we journey through life.
But what if we fail to learn from failure? Or even worse, we aren’t aware of failure at all? What if we just blundered on thinking that it was the norm?
Flicking switches and changing bulbs
The following is an imperfect analogy but it might help to emphasise the point. Imagine for a moment if every time you flicked a light switch in your house the bulb blew. As a result your daily routine involved walking to the cupboard to fetch a new bulb, fumbling around to find the right one, walking back to the room, standing on a chair and fitting the new bulb. Imagine if you just accepted this as your “normal work”? What a waste of time! What a waste of money!
After talking to a friend one day you suddenly become aware that this situation can be improved. She tells you how she has put a spare bulb in each room and has managed to save 8 minutes per bulb change per day. Wow! What an impressive improvement. You now set about improving and discover that by using a low energy bulb instead of an incandescent bulb it only blows every eighth flick of the switch, saving not only time but also money. A little later you discover that if you rotate the rooms you use during the hours of darkness you can generate further time and cost savings – brilliant! And so it goes on.
Clearly this is a ridiculous story. None of us would ever tolerate such inefficiency, such waste, such failure and poor quality. Its clear that a huge amount of effort is being wastefully directed to improve bits of a fundamentally flawed lighting system, using what amounts to a series of workarounds and streamlining the “fire fighting”. This situation occurred because you failed to recognise failure, and even when you did, you failed to look at the system as a whole. You focused on managing components for functional efficiency instead of looking at end to end flow.
But there is another critical factor that helped you to rapidly recognise the silliness of this story and spot where to make improvements?
We all know and understand that the purpose of a lighting system in this context is to light a room. This understanding of core purpose and context gives us knowledge that helps us in two main ways:
- properly understand what is real work that generates value
- more accurately diagnose the probable location of the fault and deal with the root cause of the failure, instead of wasting resources “improving” our workarounds.
Once we have this knowledge we become aware that much of what we previously thought was “normal work” (i.e. changing the bulb every time we flicked the switch) was actually work to compensate for failure. Because we lost sight of (or never knew?) purpose we were blind to this fundamental truth. In our scenario we can imagine how a whole system of measures and methods could be developed that were of no real use.
This type of activity has been described as “failure demand” and you can read more about it here: www.wellbeing.vanguard-method.com. This type of demand is created by the failure of a service to deliver on its core purpose. Failure to get it right for the customer, and to get it right first time.
What is the purpose of the health and care system?
In the story above the system was not wired to achieve its purpose of lighting the room. This generated significant extra demand on resources, in fact most of the activity was failure demand. But what would this look like in the context of health and care services? What is the purpose of the health and care system? Is it “wired” to achieve its purpose? Do we have a lot of failure demand in the health and care system? To begin to answer these questions we need to start by identifying and understanding purpose.
The purpose of our health and care system should be to provide high quality service to the people it serves. This means we need to find out what really matters to the people who use the service. We then need to convert these “things that really matter” into simple measures in our system to be used where the work is done (at the frontline). Once we have done this we will have a better understanding of how we are doing and where we have opportunities to improve. This is the real work.
As time goes on and the relationship develops, we learn more about what provides value and the things that cause variation in the quality of the service. Why did Mrs Jones have a very good experience, but Mr Smith had a poor experience? Understanding the causes of this kind of variation enables us to continually improve and innovate. This is designing and improving against true demand rather than failure demand. When we organise our work in this way, with the people who use services, its described as collaborative customisation, or to use another word in vogue – coproduction.
But this is also where service organisations need to turn the conventional improvement wisdom on its head! Its not about reducing variation in the conventional sense (usually achieved by standardising). If we think about care planning for example, standardisation would be counterproductive for the service user because it would reduce the system’s ability to flex around what really matters to them. In this context our aim should be to design a system that reliably identifies and responds to what really matters to each individual. When we design services built around this aim we are on the road to a truly person-centred health and care system.
How are we doing?
Do we have a health and care system that has a clearly defined purpose? Do we understand what really matters to those people we serve? Does our system value and respond to the natural variety that occurs in human beings? I’ll leave you to ponder these questions.
Lets imagine that the core purpose of our health and care system is to “support people to stay well and lead as good a life as they can defined by their own terms” (this might not be a perfect but you get the idea). Once we’ve established this as our purpose it becomes easier to identify what is real work – those things that generate real value for the people who use services. It also helps us to clearly identify failure demand – the catch-up work we have to do because we aren’t giving people what they want and need.
I’ve recently had the privilege of working with some frontline teams in a hospital setting supporting them to develop and test ways to reliably find out what really matters to the people who use their service. They are then using this information to collaboratively develop care plans focused on the things that the person identified as important. We have helped them to develop a few simple measures related to this purpose that build knowledge about what works well and what needs to be improved. The work is embryonic, but its been encouraging to see the enthusiasm of the frontline teams to work in this way, and also to hear the stories from people using the service who have had their needs met efficiently and effectively.
Contrast this “what matters to me?” approach to frontline work with one that is driven by top-down targets and standards. In most cases the latter distorts measurement, creates a de-facto purpose (i.e. meet the target) and stifles innovation making genuine improvement very very difficult to achieve. This unintended consequences of this approach have been widely described in a variety sources (you can read more by following up on the references below).
When measures are derived from purpose as defined by the user of the service (e.g. I want to live as good a life as I can as defined by me) things start to look different. These person-centred measures can then be used where the work is actually done – at the frontline by those who do the work. This in turn builds knowledge and creates the freedom and space to improve and innovate
An enormous opportunity
Having a clearly defined purpose and making sure we maintain its primacy over measures and method helps us to understand the nature and causes of demand. This is absolutely critical to our ambition to develop a health and care system centred on people. If we want to change the system we have to change the way we think. Designing against true demand (not failure demand) from the bottom up with a strong focus on the things that really matter, represents the single most important opportunity to transform our health and care system.
Is our system wired to support me to live as good a life as I can as defined by me? There’s certainly some movement in that direction but there is no time for complacency – there is still much work to be done! The question we need to keep asking is: “are we just flicking the switches and changing the bulbs or are we re-wiring the house?”
- Miller and Grant (2013) Letting go: breathing new life into organisations. Argyll Publishing
- Deming (1986) Out of the Crisis. Deming MIT Press Ed edition (2000)
- Seddon (2003) Freedom from command and control: a better way to make work work. Vanguard Consulting Ltd
- Caulkin (2006) Forget about targets and decide what really matters The Guardian (2006)http://www.theguardian.com/business/2006/may/21/theobserver.observerbusiness4
- Guilfoyle (2012) On Target? Public sector performance management: recurrent themes, consequences and questions. Policing (2012) 6 (3): 250-260. Oxford Journals
- Bevans; Hood (2006) What’s measured is what matters: targets and gaming in the English public healthcare system: Public Administration Vol. 84, No. 3, 2006 (517–538)
- Ghobadian; Viney; Redwood (2009) Explaining the unintended consequences of public sector reform. Management Decision 47 (10); 1514-1535
Shaun Maher is an Improvement Advisor with the Person Centred Health and Care Collaborative at Healthcare Improvement Scotland