M15 “Bolt-on” to “Built-in” Improvement as Cultural …app.ihi.org/FacultyDocuments/Events/Event-2206/Presentation-7461/...Davis Balestracci 1 1 “Bolt-on” to “Built-in”

Davis Balestracci www.davisdatasanity.com 1

www.davisdatasanity.com 1

“Bolt-on” to “Built-in”

Improvement as Cultural DNA – Part 2

Davis Balestracci

www.davisdatasanity.com

e-mail:

[email protected]

Jim EastonFormer NHS National Director for Quality, Improvement, Productivity and Prevention (UK)

e-mail:

24th Annual IHI ForumDecember 10, 2012

M15


This Afternoon’s Roadmap 13:00-14:25: Hardwiring the organizational DNA

– Deeper understanding and use of ABC model: “Those darn humans!” [Slides 3-13]

– The role of the Exec team [Slides 14-18]

– Exposing cultural handcuffs (Audit) [Slides 19-37]

– Heart based coaching [Slides 38-43]

– Takeaway #3: Separating Facts from Feelings [Slides 46-52]

~14:25: “Data Sanity” as a time liberator [Slides 54-81]

[Break ~14:45] Extensive summary and dialogue (last hour)

[Slides 82-98]



Human behavior: Once again, as “Simple” as “ABC”

Activating events Filter through…

Beliefs Triggering…

(observable, describable) Consequential Behaviors

Leading to…

(observable, describable) Results(Relationship and/or work result)


One more Pyramid Level: ITS BASE

7. Quality of individuals’ mind-sets– Unique personal values and “baggage”

every individual brings to work – The base of the pyramid

– Interacts with Level 6 [Culture]

Individual Mindsets



Base of Pyramid (B1): An Individual’s1000’s of beliefs = “Belief

system”

Belief “window”:

The “dirty” windshield (B1) through which we perceive the world…

…and filter our information

Unique beliefs develop to meet needs of survival, giving and receiving love, feeling important, and having variety


To liveTo be viable To be strong To be in control To be safe

To survive: To love and be loved:

To have good relationships To have friends To be admired To be trusted To be helpful To be part of a group or team

To feel important:To be valued To be a leader To play an important role To make a difference To be successful To have meaning in one’s life

To have variety:To be challenged To have excitement To be growing in competence To be innovative To interact with others To be learning new things



Belief: “If…then…”

“IF someone believed [B1] and they were put in this situation, THEN you can probably expect [C1]”

Patterns of behavior (C1) can also be read to intuit beliefs (B1)


“Groups” Have Belief Windows

Doctors Nurses Middle managers Executives Administrative staff Clinical staff Cafeteria, maintenance… Finance

– What do these groups above “believe” about each other?

– What do YOU “believe” about the groups above?[Think of mental meeting preparations]

--These “beliefs” create your organizational culture!

“We have all the truth”

“NIH”

“We are entitled to do whatever we want”



Patterns (C1)…

…expose beliefs, which allows

prediction of future behaviors…

…and results…

…including your own

[DB’s experience with middle managers]


DB’s Lesson: New B2

B1: “Quality improvement is misunderstood and not respected.”

B2: “If I’m not getting the results I want, I have a bad belief somewhere.”



Perceived threat = Strong reaction

Given: ALL energy has been temporarily diverted to getting the perceived need met (Individual or group)– Further logic will not be persuasive– Trying to get need met and make you

go away• “Short term win”• Long term “destruction” for

organization


Questions about this model?

Learn anything about yourself?

Does organizational “resistance” to QI “trigger” you? How?

Care to process any of your “strong reactions” to what we’ve presented?



Personal feedback processes

Relationships

Perceptions and Feelings:CULTURE

THOSEDARNHUMANS

FEELS LIKE THIS!


Organizations also have “Needs”

To Survive

To be Respected

To have a Market niche

Innovation



Executive Team

“Culture” results from– Executive team’s “beliefs” trying to

meet these needs, which interact with…

– Its collective (and individual) “beliefs” about leadership/power

Culture at large will (unintentionally) mirror their behaviors


From Rodney: Are Any of these Your Cultural C1?

Ambiguity is not discussed, Inconsistencies are not discussed, Ambiguity and inconsistencies are

not discussable, The undiscussibility of ambiguity

and inconsistencies is undiscussible.



Personal feedback processes(Feedback on their behaviors?)

Relationships through which information flows(How often are you in contact?)

Perceptions and Feelings influencing

relationships: CULTURE (Execs’ signals about ‘improvement’)

The “quality” of YOUR relationship w/ Execs?


Back to Jim: Your team as an improvement team

Walk the talk or you are DEAD in the water!

Jim Clemmer: Organizations march to the same beat as the management teams leading them. All too often, senior managers don't recognize their own values being reflected back to them.



Back to Jim’s emphasis on alignment: CLEARLY defined R2

“Anchor” through which to view your role and give needed personal “feedback” to change beliefs…

Reminder: “CLEARLY”Keep them free of “excess baggage”!


Or…

“Those darn humans!” WILL continue to produce R1!

Is the sharing of these R2 results just an A1 experience? (“Here we go again!”)

“But this time, we mean it!” (A1 ?)



“Those darn humans!”

If You are confused, THEY are confused

If YOU are clear, THEY will act confused

– Interpret R2 through B1 and “tweak” R1

– “Stated” reason (Why they can’t) vs. “Real” reason

– No consequences (A1)? “STONEWALL!”


Auditing Culture: Patterns of current behavior (C1) “telegraph” beliefs

What do budgets, schedules, and meeting agendas “telegraph?”

What meeting behaviors are “expected” and tolerated?

What determines promotions, hirings, firings (or “bureaucratic shuffling”)?



How are poor performers and “jerks” dealt with?

Studer: In transforming, it is INEVITABLE that you will “hit the wall,” i.e.,

The gap between good performers and poor performers WILL become intolerable

The culture is watching…

YOUR chance for an A2 to create B2


Keeping it “real”:

“We should focus on studying the systems we use to manage an organization and the beliefs and behaviors that shape these management systems, but we should not drift into attempts to answer questions about humanity’s place in the universe.”

--John Dew



A2: Overcome Seven “Root Causes”

Placing budgetary considerations ahead of quality,

– A1? Tolerating “Costs” vs. “the four Cs”

Placing schedule considerations ahead of quality,

– A1? Tolerating arbitrary goals & deadlines

Placing political considerations ahead of quality,

– A1? Tolerating manipulation for personal gain



[A1? Tolerating] Management A1 resulting from arrogance

– Management C1: “Give me the 5-minute overview.”

– [Management B1: “I have nothing to learn”]

[A1? Tolerating] Lack of fundamental knowledge, research or education,

– C1: Blind benchmarking and copying (alleged) solutions

– Vague problems/solutions/results




[A1? Tolerating] a pervasive belief in entitlement (management, culture, and MD),

– Write me for Peter Block’s “Employee Manifesto”

[A1? Tolerating] C1 autocratic leadership behaviors, resulting in "endullment” rather than empowerment.

– Cultural B1? “Learned helplessness”


Creating B2 for R2

1. Identify the current C1 behavior patterns (work, organizational, and cultural) perceived as barriers to C2 and R2



What is Being Implicitly Tolerated?

Observedundesirable

ACTIONS

Make all management report “rosy” Don’t tell your peers what you really

think of their ideas Don’t speak up think in a meeting Wait until you can solve a problem

before telling your boss about it Blame someone else when something

goes wrong Anyone who speaks up is labeled a

“troublemaker” by management and is evaluated as “not a team player.”

Healthily assertive individuals rarely last longer than two years in this department


Creating B2 for R2

1. Identify the current A1 behavior patterns (work, organizational, and cultural) perceived as barriers to A2 and R2

2. Identify possible beliefs driving these A1 behaviors [What “Needs” might be threatened?]



B1—Old culture…old results

Old BELIEF

Honest communication is a career limiting move

(Driving need: “Survival”)


Creating B2 for R21. Identify the current A1 behavior patterns (work,

organizational, and cultural) perceived as barriers to A2 and R2

2. Identify possible beliefs driving these A1 behaviors [What “Needs” might be threatened?]

3. Predict future actions/behavior – and results – based on these beliefs [Motivates the need to change]



“IF…then…”

Can you predict:

“If [B1] continues, then we will get [Result]”

– Is it R2? [Probably not!]


4. *Identify alternative beliefs [This is where cultural “healing” starts]



Transformed B2—New culture for new results

New BELIEF

The way you get ahead is by being open and saying what you think.

C2: Individuals balancing needs to respect the business

Exec B2: “The customer is more important than my power.”

Middle mgr B2: “The customer is more important than my advancement.”


4. *Identify alternative beliefs [This is where cultural “healing” starts]

5. Predict future actions/behaviors based on the new beliefs. Will they attain R2?

“If we believe that [B2], then everyone would…” [next page]



Coachable C2NewACTIONS

…share appropriate bad news proactively …offer peers straightforward feedback

related to business results and their personal success

…facilitate open dialogue in meetings …let people know early when there is a

problem …ask, “What else can I do?” when things

go wrong …run meetings as energized vehicles for

teamwork and communication …engage someone delivering bad news

in healthy dialogue

Would these attain R2?


4. *Identify alternative beliefs [This is where cultural “healing” starts]5. Predict future actions/behaviors based on the new beliefs.

Will they attain R2?

6. Peer coach in the moment every day to the behaviors generated in (5)

Thomas Crane: The Heart of Coachingwww.craneconsulting.com –Download first three chapters free



Cultural Handcuffs Lurk

“Name” them (Observe patterns)Unlocking cultural handcuffs takes:

– Group effort (A2)– Interdepartmental effort (A2)– Formal management effort (A2)…

• …and reinforcement (A2)• …and preventing even a WHIFF of A1!

• Seeking and giving feedback (A2) – LOTS of it


“Given” B2: Feedback

B2: “Every individual is responsible to deal with his/her

behaviors interfering with organizational success and

will coach and be open to non-judgmental coaching-in-the-moment”



Back to Cultural leadership transformation mantra #4

“Help me understand…”

Sometimes with the preface, “I have a problem.”

Describe behavior objectively and non-judgmentally (mirror), then…

“Help me understand so that we can both respect the needs of the business.”


A2: New feedback

“The behavior you just exhibited at the meeting will help neither the organization’s success [R2] nor your personal success [Value]. Help me understand what was going on [i.e., the strong reaction]so we can move forward.”

NO judgment



This Model…

…allows you to be appropriatelyaggressive about behavior…

…without attacking the human being!


Time out…

Is “lack of trust” a cultural handcuff?

Let’s use the model to address it with a powerful takeaway:“Separating Facts from Feelings”



Takeaway #3: Separating Facts from Feelings – Steps 1-2

1. Acknowledge the presence of strong feelings. (“Help me understand”) Understand the past – How did things get to

this point?

2. Clarify individual feelings and needs. What expectations have not been met? What disappointments have we

experienced? What mistrusts have developed over time?

EACH side uninterrupted Except: Clarifying questions only


As you listen to or facilitate Feedback…

Remember: It is a perception being shared, NOT a truth being declared

If you are one of the participating parties: “How are my behaviors perceived?”



Separating Facts from Feelings – Step 3

3. Separate personal needs from business needs Insulate your hot button: It is in the

interval between the stimulus and response that the leader emerges

1. Is that a perception I want people to have?

2. If that perception continues, will I be effective and will we get R2 results?

3. If not, ‘how’ do ‘I’ ‘create’ a different perception (A2)… …resulting in B2 to drive C2?


Separating Facts from Feelings – Step 4

Step 4: Identify and respect the needs of the business (R2)

Changing a situation How many windows have to change? What is the only window over which you

have control?– Can you create A2 activating events

that might make them open (B2) to choosing to change past behaviors (C2)?



5. Be willing to change based on what you learn. (A2 to create B2)

– “ ‘How’ do ‘I’ ‘create an activating event’

(A2) to replace a fearful belief (B1) with a

belief (B2) that will drive behaviors (C2)

contributing to the desired result (R2)?”

Mantra #5: “I must learn to swallow my ego 10 times before breakfast and another dozen

more times before lunch.”


6. Believe that a win-win solution is possible: for you, for others, and for the organization, (B2)

7. Be truthful and compassionate in the process and its follow-up (A2). Set expectations (A2) and seek feedback

(A2) on your perceived “support” Peer coach to R2 results (A2):

Depersonalizing and focus Seek feedback on progress (A2) and act

on it (A2)



The “I can’t trust them!” to “I can trust them” B2 Dance

“We have both committed to changing the situation.” (B2)

“My behavior will demonstrate that I am indeed committed to changing the situation.” (C2)

“I will be open to letting their behavior change my belief window about them.” (B2)


Breakthrough in Behavior?

“I will seek feedback on my behavior.” (A2)

“I will give feedback on their behavior.” (A2)

“All feedback will focus on specificexhibited behaviors in context of…(A2)– A barrier to organizational success (R2)– Genuine concern for personal success.”



Questions and/or Comments

“A BIG ‘Aha’ I’ve had is…”

“A concept I’m REALLY struggling with at the moment is…”

“I’m just about with you, but could you please clarify…”


Where is the time (“priority”) for Improvement going to come? –

DATA SANITY!

Statistics?!

B1?



A NEW Way of “Thinking” About Data (B2)

My overall goals– Challenge your CURRENT (B1) thinking…– Create awareness of “data” as “waste” (B2)

MY B2: “Data sanity” is THE “catalyst” to embedding “improvement” into organizational the DNA.


Board Member #1: “I don’t like that recent upturn. Find out what happened!”

Déjà vu? -- “WAG”



Board Member #2: “But what’s the overall trend?

You tell me…

“SWAG”


“Account for your quarterly results!”“Upward Trend” (?)

“Downturn” (?)

“Rebound” (?)

“Setback” (?)

“Turnaround” (?)

“Downward Trend” (?)

This month…

vs. last month…

vs. 12 months ago

3 Months of Quarterly results…

This quarter…

vs. last quarter…

vs. same quarter last year



Statistical definition of “trend”

Special Cause – A sequence of SIX successive increases or decreases [< 20 data points: Use FIVE]

Usually indicates a process “in transition”

This rule is to be used only with a table of data without any context of variation for interpretation.


Tampering: An Insidious, Destructive Force

Tampering: Treating common cause as special cause

Deming: “The losses caused by tampering are incalculable.”



Profound truth: Given two numbers…

SomethingImportant

Yesterday Today

…one will be larger!


In an everyday world: Does it look like this…?

…or this?

Context of variation



Human tendency: ALL Variation is Special

Time comparisons, undesirable “events,” performance comparisons

– Even if things “shouldn’t” happen, you might be “perfectly designed” to have them happen

– Specific events (“Never”)

– “Given a set of numbers, 10% will be the top 10%”

Variance: ANY difference from a goal


Transition to More “Advanced” Skills From “Human Variation” (Ouija board):

– Colors, Faces, Drawing circles, Trend lines, Traffic lights, Variance-to-goal reports

To “Theory”:– Counting up to “8”– Subtracting two numbers– Sorting a list of numbers

– Asking better questions!

– “Plotting the dots!”– Reacting appropriately to variation– New conversations = New results



Bread-and-butter tool: Run Chart

A time ordered data plot with the MEDIAN as a reference


Special Cause: A consecutive sequence of 8 or more points on one

side of the median (Theory)

Indicates a probable shift somewhere during this time period



GOAL: Go from 50% to 75% compliance

% Compliance6/97 44.44 %

41.6750.00

9/97 50.0052.7858.33

12/97 33.3341.6750.00

3/98 69.4469.4466.67

6/98 66.6769.4472.22

9/98 66.6766.6763.89

12/98 69.4455.5650.00

3/99 69.44

Sorted33.3341.6741.6744.4450.0050.0050.0050.0052.7855.5658.3363.8966.6766.6766.6766.6769.4469.4469.4469.4469.4472.22

Note: DIFFERENT questions!


What would you do now? - Plot the dots!

Have they improved?



“We made a difference!”—Reduced NICU Infections

Really?

“We worked SO hard and did 149 RCAs!”


“Red…Yellow…Green…” RUBBISH!

Getting Better Results• Improve the process (Recommended)• Distort the process (Frightened people are VERY clever!)• Distort the numbers



Do you do “% Compliance?”

IF you do the math…


The Math Is So Simple, It Would ASTOUND You!

Week-to-week EXPECTED variation: <= 3.5%

93.2%

87.9%

90.6%

93.6%



Common Traps with Percents

Traffic light trap: Don’t treat every deviation from the goal as a special cause

“Shouldn’t”: Don’t treat every non-compliance as a special cause

– A non-compliance on a green day / month could very well be the same as a non-compliance on a red day / month

– Explaining something “after the fact” does NOT mean it’s a special cause


Goals a la Dilbert Boss:

– Our goal this year is ZERO disabling injuries.

– Last year our goal was 25 disabling injuries; however, in retrospect, that was a mistake…

–

What are you “perfectly designed” to get vis-à-vis the goal?– Difference: common or special

cause?– “It only has to average…”



This…?


…or this?



(Remember?) This…


…or this?



“But our execs LIKE red…yellow…green!”


Alarm Signals Connected Now?

Senior management meeting time with data– 50% is WASTE

Daily managerial review of unimportant performance data– 1 hour a day is waste

Daily pounds of published performance reports [“Backup” data]– 60% is waste

Time that could be devoted to improving everyday work – integrating “quality”

into the DNA



Data Sanity SPECIFICALLY for Execs

Chapter 2 – What EXECS need to know…the “20% of statistics that will solve 80% of their problems.”

Use it to create DIALOGUE with them and SOLVE THEIR PROBLEMS…especially “silly meetings.”

STOP BORING THEM!


New results require new “beliefs”

A2 help to CREATE B2 [This seminar?!]

Organizational AND Human behavior

1 = Present2 = Future (Desired)

Remember: It ALL goes back to this

Activating events

Beliefs

Consequential

Behaviors

Results



Crane: The “Results” Cycle Beliefs

– What I hold to be true about people, power, relationships, work, etc.,

– …determine my… Behavior,

– How I act and interact with others,– …which influences…

The Quality of My Relationships,– The degree of openness, trust, and rapport,– …which affects the…

Results,– The outcomes I create,– …which reinforce my…Beliefs…


Bears repeating: Goes beyond describing A2

How do YOU create experiences to motivate the beliefsto drive the right actions that will achieve desired organizational results? AND…

• How do YOU stop recreating experiences (or perceptions of E1) that reinforce old beliefs that drive unwanted actionsand produce undesired results?

•Have we done this?•What B1 of yours have been challenged?

•Do they need to change to B2?

•What A2 will you create then you go back?



B2: Conscious Business

If a pattern or problem repeats itself, we look for the source of the pattern in ourselves.

We commit to learning instead of defensiveness in toxic interactions.

We become skilled at thanking people and the universe for giving us feedback.

We make conscious commitments and hold scrupulously to those commitments.

We seek feedback on how we’re doing on these four skills.

AND…


“We will insulate our hot buttons and…

…think of it all as entertainment!”Leadership mantra #6

“It’s in the interval between

the stimulus and response

that the leader emerges.”



B2: Commit to Excellence

“In such a culture, employees manage their

own morale. Employees are in charge of their

own happiness. You can’t do it for them. You

can create an atmosphere for the person to

make good choices, but you can’t make them

happy.” –Hardwiring Excellence p. 56

– ALWAYS connect results back to purpose, worthwhile work, and making a difference

It’s all about “hardwiring”!


Thursday morning…

LEADER perception

FRONT-LINE reality

Somebody’s mad!



Need some B2? What A2 will create them?




Joiner: “I’ve found that I can take any five problems from anywhere in a company, and if I push deeper and

deeper, I find that they all stem from the same core issues.”

Lack of a clear direction Barriers between departments Management by rewards and

punishments based on goals Reliance on inspection and rework rather

than prevention Failure to understand that suppliers are

part of the system (including internal customers)


Thursday morning…

Confusion…conflict…complexity…and chaos

B1 → B2 ?YOUR B2 to deal with

this?

What will your behaviortelegraph 6 months from now?



Mantras “New results = New Beliefs” “ZERO tolerance for blame.” “No whining…to go (gently) unchallenged” “Those darn humans…God bless ‘em!” “That’s the ‘stated reason’ – What’s the real

reason?” “How do I change?” “Help me understand…” “Allow 10% ‘jerk time’.” [Mine behind closed doors]

“Think of it all as entertainment…” “Learn to swallow my ego 10 times before

breakfast…” “Lack of time = Lack of priority”


E-mail me ANY time!

[email protected]

www.davisdatasanity.com– Archive of published articles– Bi-weekly e-newsletter sign-up– Click on “the brain” icon

Data Sanity is in bookstore



Most importantly…

Never believe totally in anybody else’s B.S.

Never believe totally in your own B.S.


Short term Roadmap to EMBED Improvement into DNA

1. Top management awareness and education…via A2 events Learn and apply in everyday work:

• Process thinking• Problem-solving tools• Statistical thinking & “plotting the dots”• Apply to “vital 20%” of organizational data /

issues

– Create an A2: Solve a MAJOR problem



2. Post IHI: Build a critical mass…via A2

KEY: 25-30% of management demonstrating their commitment to improvement (to create cultural B2)• A2: “New conversations” via

“plotting the dots”• A2: Fewer “account for” meetings• A2: “Process” vs. “Goal” focus• A2: Promotions reflect behaviors

committed to improvement


2. Post IHI: Build a critical mass…via A2 A2: STOP the “training mills” via “A1

logic” that knowledge = changed behavioro (Only) 20-30% of organization needs to be

educated in improvement theoryo (Only) 10-20% of organization needs to be

trained in basic tools for improvemento (Only) 1-2% of organization needs to be trained

in advanced tools (“belts?”) A2: Teach via “solving problems”

o Universal language (100%): Process, variation, common/special cause, “count to 8” “Are we ‘perfectly designed’?” “Is this a common or special cause?”