I love this cartoon! It so clearly articulates what I consider to be one of the most virulent barriers to transforming organisations. This disease seems to have taken hold in many industries, but disconcertingly over the years, I’ve spotted some of the symptoms glistening across the sweaty brow of Healthcare.
Having invented the concept of a national health system, we’ve been doing it for quite a while. There are a few simple things left to put right, but that’s mostly because they are forgotten, as opposed to missing. I’m not opposed to simple things, in fact, much of the simple work or basic care as it’s sometimes called, is the main reason we exist. The art of medicine is to distract the patient, while nature cures the disease – he says twisting Voltaire into the age of Twitter. I don’t use the word simple or basic, I prefer to think of these things as essential work, a phrase I was reminded of recently.
I once heard a neurosurgeon dressing down a manager “if there’s nobody there to wipe the poorly bottom, then the brain surgery is not happening”. He was making a serious point and didn’t call the care basic, he called it #essential … I like that.— ComplexWales (@ComplexWales) March 30, 2019
But we have a problem with these essential things. The true power, impact and importance of the essential work, is too easy to underestimate and undervalue. Spending more time with patients, keeping the place clean and making sure people are safe, warm and well fed – and I don’t just mean in Hospital. Enabling staff to take breaks and having dedicated time together for training and reflection. Regularly taking a really good set of observations and not just pulse and respiration but also mood, tone, how they engage in conversation and promoting participation. Each time, finding out a little more about the person and their aspirations, because no matter how big and clever you are, being unwell makes you feel vulnerable. Capturing feedback from patients and staff continuously and really using it to understand the organisation, understand what needs to change and probably more importantly, understand what and who needs to be deeply valued and protected. I could go on and I expect these things translate to many businesses.
Trouble is, if you try and put that stuff in a business case for more resources or just to prioritise against other pressures on time, the essentials don’t translate well. The top of the pyramid will always say that these things are important and then spend most of their time talking about the 0.05% of the budget that needs a strategy.
It’s a kind of Bikeshedding often called the law of triviality, where you don’t talk enough about the stuff that really matters. Very important Board Members rarely understand the far more important but technical matters of their organisation, so they tend to let it wash over them in important meetings and try desperately not to look stupid, by not saying much. Then, next up on the agenda is the new Bikeshed for which everyone has an opinion about what matters. The skeptic may even suggest the bikeshed is put there deliberately so that the old duffers feel like they are actually contributing. Then there’s the essential work in Healthcare, albeit simple to the front line staff, it is just as alien to the old duffers who can’t understand it’s impact or why it matters, so they don’t talk about it – A kind of Anti-Matters. The unconscious effect of Anti-Matters, is that if you accept that these essential things are the business – the thing that matters most – then you also have to accept that they are bloody easy to do, so why aren’t we doing them?
“We can’t accept that running the organisation is this easy, or we are going to look stupid” they say, “quick, find me something important to invest in, something visionary and Shiny”.@complexwales
This is a particularly difficult problem for public health, when competing for resources against some of the more well known and sexier specialties. Our health system is a mature and complex web of interacting people and places and purposes and as such, to act in it successfully, you have to understand the nuances of why the system works, not just fiddle about with how it works. Although the essential things are in themselves very ordinary, they interact at a granular level to create a dynamic living system. It means that although some things are foreseeable their effect is less predictable and the causal chains from input to impact are non-linear. A small input in one place can have a massive impact and counterintuitively, a big input in another place does nothing at all. There are literally hundreds of really good books and articles on the subject but unfortunately, even more arseholes obsessed with crappy logic diagrams.
The technical term is a Complex Adaptive System. Although there is an explicit science to learn how these living systems behave, the principles and theories are completely complementary to the science of medicine, because that too is all about nurturing living systems. As a result, those immersed in the essential business of healthcare, gain deep insight and experience over many years, to understand implicitly, how to act in such systems. Empiricism at its best, perhaps and again I suspect that this pattern of learning translates to many businesses.
Just to prove my point, this now infamous network diagram, describes the influences at play over just one subject that will potentially have a catastrophic effect on health and healthcare – Obesity. Ironically, to a certain cadre of Lightweight Leaderist, this complexity and subsequent requirement for experiential depth, is bloody inconvenient. It creates a visceral and almost allergic condition in them, I call Inconvenientis (in-con-VEEN-ee-entis).
Don’t get me wrong, over the years I’ve worked for a large number of completely brilliant people who’ve ended up in charge. Each one furnished with the same basic apprenticeship – having dodged the regular redisorganisations – they spent a long time in the same place, getting to know everyone everywhere and understanding what is really connected to who and why. Nevertheless, there are others and John Ronson’s lovely book The Psychopath Test, suggests that at least 1:4 of them atop any big institution, have a peculiarly different outlook on life and other people. You know the sort, good at interviews and crap at jobs.
These Lightweights live in the world of Work-As-Imagined rather than Work-As-Done. They imagine that doing good work is about filling in standardised action plans, predicting everything in advance and making pompous assumptions about other people. They typically spend their time usurping other people’s work to promote themselves and motivating the masses with a load of verbiage that nobody will ever read, after it’s impeccably filed. They lack an appreciation for the grit required to do real work and insist that everyone follows the management equivalent of painting by numbers on tissue paper.
And herein comes forth the Shiny! A suitably simple offer with a Shiny explanation, pitchable in two Shiny minutes in a lift, dressed up on Shiny slides with Shiny words lifted from the latest Shiny strategy, typed into Shiny boxes connected with Shiny arrows and sold with the fervor of the Lone Ranger crashing through a Shiny window, astride a Shiny steed with pistols full of Shiny Silver Bullets. Shiny and simple to explain and fundamentally wrong.
And we’re nicely back to that cartoon. Doing things that are simple but wrong, is the symptom of a terminal case of Inconvenientis. Real work with real substance and real insight into the nuances of quality and experience is not generalisable. Yes, there are some commonalities but the work is all about adapting, situationalising and absorbing the complexity, the diversity, the heritage and the uniqueness that makes it meaningful, to those who commit themselves and their entire careers, to one small but essential corner of the world. People don’t resist change but they will quickly form a Staff Militia: to repel a Lightweight astride a Shiny, trying to change them.
Transformation is to become something new, in such a way that you can never go back. You cannot transform work, service and people if you don’t understand what makes those things what and who they are. The history, the individual delights and the shared dilemmas, the battles lost, the wars won and the scars earned. No Shiny can do that.
Healthcare as an industry is mostly biological not mechanical, the motivation is intrinsic not material and the fulfilling outcomes are immersive and individual, not imagined and impersonal. Healthcare systems and services are fundamentally complex and therefore, to influence them successfully, the methods must be compatible with that fundamental nature. Follow Dave Snowden or watch a few minutes of his presentations on YouTube and you’ll soon get a sense of the state of the art.
Obvious individual things, the essentials as I put it, are really valuable, but treating everything as if it were Obvious, no matter what the context within which those practices are applied, is dangerous. Just as an aside, put two experts in a room and they’ll come up with at least three equally good ways to do anything. That’s the complicated space, where old school, bloody good design will thrive.
In short, the right answers can be difficult to understand and can be equally difficult to articulate in a classroom or on a business case. The right thing to do sometimes – in fact often in terms of the essential work – does not have a logical linear root. The right thing is often felt, deeply experienced, lived with, reflected on, learned over a lifetime and doesn’t come in a convenient box or a perfectly predictable percentage.
To the Lightweights and Psychopaths, this requirement for insight and experiential depth is incredibly inconvenient. They’d much rather have something Shiny that they can read in two minutes; Shiny enough to fit on a single supplier justification; Sufficiently simple and Shiny to be delivered instantly; and with a Shiny benefits realisation so full of lightweight platitudes as to be virtually indistinguishable from their own personal Shininess.
Slowly but surely over the past few years, various businesses seem to have been distracted by the Lightweights, away from the essential work and appear to be drifting inadvertently towards a terminal case of Inconvenientis, one Shiny at a time.
Sorry for this but the analogy I introduced earlier – the management equivalent of painting by numbers – needs a nice visual hook to keep it alive in your mind and this brown one is going to stick.
Personally, whenever I see a Shiny, it reminds me of my 3 year old little nephew excitedly explaining to me how to colour inside the lines. He’s lovely and he’s not entirely wrong, so you just have to sit there patiently and offer occasional nods of positive reinforcement.
What the Lightweights don’t know is that we are really just biding our time, waiting for the right moment to clean up the mess, waiting for the next Organisational Goldilocks Zone. Perhaps I should explain that last phrase!