Peel The Onion


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The solution can be very simple, but the analysis never is.

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  • Guidance on quality improvement is emphatic that we find and correct causes rather than symptoms. Variability and its causes (common and special) must be understood if we are to keep our processes moving smoothly.
    The Japanese say that asking “why” five times will lead you to the root cause. I think this probably works better in Japan than it does in the US. I have found that asking “why” tends to put people on the defensive and can shut down communication. Discovering causes can be messy and will take more than a brief conversation.
    Often, one person can’t answer the questions and talking with a number of people one at a time frequently results in missing critical perceptions that hold the key to the real causes. Find a cause always takes at least one meeting and make take two or, at most, three. Get someone from the process that is experiencing the pain and then get someone from the upstream process and the downstream process. With these three and a facilitator you will have about an 80% probability of find the cause in one meeting.
    Sometimes you will find as you begin to discuss the problem, that someone else needs to be there to provide the full 360 degree perspective that is needed. If that happens, don’t stop yet but back off slightly and begin to look for other missing perspectives so that when you schedule the second meeting, you will have everyone you need. The only reason to have a third meeting would be that you need an expert to help you determine the feasibility of your solution.
  • We have all come away from a visit to our physician with a prescription intended to treat one of our symptoms. In some cases, this is exactly what we expected. In other cases, treating a symptom while ignoring the cause makes our overall condition even worse. If we treat nausea and fail to discover the elevated WBC or tenderness in the lower right abdomen, we may wind up with a ruptured appendix. Don’t put yourself in the equivalent management position.
    Don’t settle on the treatment until you’re certain that you have devoted reasonable effort to the diagnosis. Sometimes you will find that there is some remediation (treatment) that may not go to the solution but will be part of any treatment path. You can feel safe in beginning this treatment before you finish your diagnosis. For example, establishing a standing meeting to talk about impending process changes will be helpful no matter what else you decide to do.
  • Best practices may be effective if you begin by accepting a best practices approach and resolve that you will adopt best practices as they are identified. While this sounds reasonable, in real life, there will always be someone who wants to do the best practice “except for” some costly piece. The bottom line is that organizations always want to pick and choose what they will accept as best practice.
    What this means is that the things we need to do must be accomplished with an awareness of best practice and a willingness to do what is needed. This is what MacGyver would do.
  • What do we have to work with? Usually not much at the beginning. It often amount to nothing more than a wish that we could do better.
  • It isn’t easy being MacGyver. If it were we would have so much hand-wringing and complaining.
    You say we’re going to blow up? Do we wait for management to show up and save us by giving us a big bundle of money to shield us from the explosion? We could do that and if we’re really fantastic at selling, we might get help in time.
    The funny thing about managers is that they hate emergencies. They like it when things go according to plan and stay on budget. That makes selling something based on urgency pretty tough. On the other hand, need and urgency seem to be closely associated in the manager’s mind so that budgeting for a need that has no urgency is also a hard sell.
    What’s really called for here is leadership, initiative, action. Once you have produced some value by helping the organization escape the explosion, you may well have some leverage to use in gaining resources for future efforts.
  • Do not think about the problem. Focus on the solution.
  • What relationships can you call upon? What communities are you active in? What do you have to offer?
  • Considering what CAN be done before what SHOULD be done is known as the path of least resistance. This path may lead from the frying pan directly into the fire.
  • Here’s where to begin your resource inventory. What do I have that I can use to build community and credibility?
    Community improves communication and vice versa. As we understand our inter-dependence we understand each other better. The improved understanding leads to improved communication. Credibility is awarded within the community on the basis of value to the community.
  • A community is a group of people who understand that they depend upon one another.
  • This is an extremely useful way to think about the group(s) you are working with.
  • Form a mental picture.
  • Leadership and management can be within the boxes but governance defines the inter-relationships among the boxes.
  • Understanding your communities is a never ending job. Just when you think everything is under control, your organization restructures or a key person leaves or a new role (box) is created.
  • Everyone needs to know everything (to the limits of their ability to comprehend). Answer all questions fully and completely until there are no more questions. “I’ll find out and get back to you” is a good answer—as long as you follow up. There is no reason to withhold information and you will lose credibility if you do withhold anything.
  • Communication methods and effectiveness depends on the Community. Both the roles themselves and the individuals currently in those roles will affect what and how we communicate.
  • Communication requires the active participation of two people, but are the one who must take the initiative. This is leadership. Create, create. New relationships. New community.
  • You need it. You have to give it. No one is going to cut you a break but you’ll have to hand out credibility like campaign buttons. Everyone gets the benefit of the doubt because you don’t have all the information. How much credibility you give to an individual may change over time. Match your expectations to the credibility level. Accountability is necessary to increase credibility. No accountability—no credibility.
  • Sometimes we award credibility too easily while at other times we fail to award credibility where we should. It is always worth reflecting on who we trust and why. Do I have credibility with others? Who has credibility with me? Trust is a huge part of credibility but so is competence. What is credibility based on within your community?
  • Relationships take time to become fully formed. You will need to create your own relationships so it’s good to avoid buying into someone else’s relationship with a third party. It is also wise to avoid trying to push your relationships onto someone else. When two people talk about a third, they are creating or attempting to create a shared relationship.
    It’s one thing to say, “We should bring this to Bob like this because he a new in his role and is feeling a little overwhelmed.” It is quite another thing to say something like, “Bob is not competent and we need to find a way to go around him.”
    It is good to remember that everyone is doing as he/she believes is best given the information communicated to them within their community. It is also good to remember that Bob may have access to information that you are unaware of.
  • When things aren’t going the way you hoped, this diagram will help you decide where to focus. You’ll come back here often. Remember, one size does not fit all. Each of these issues may be active within your community at any given point in time. If there are five people you may well have five different issues.
  • The differences in these roles is very significant because it follows that their goals are different.
    The goal of leadership is to change the course of the organization based on information about the marketplace
    The goal of Management is to produce specific results in a manner that optimizes the ratio of Revenues to Costs for the organization in accordance with its current direction.
    The goal of Governance is to create a recognition of inter-dependence, shared goals and the need for cooperation that will produce stability and consistency.
    Different goals means different methods. It will pay off handsomely to ask in any situation whether the particular solution that is called for requires leadership or management or governance .
  • There is an old saying to the effect that, “To the man with only a hammer, the world is filled with nails.”
    This is the reason for consultants. We lose perspective when we work within the same four walls every day. We begin to believe that all communities are like our community. When this happens, leadership becomes impossible without a guide.
  • Peel The Onion

    1. 1. Peel The Onion Diagnosing and Treating Organizational Conditions WhiteLake Data Management
    2. 2. Onions and Organizations • How many layers are there in your problem? – Your organization? • What are their names? • How thick (or thin) or they? • What’s at the center? • Which are important?
    3. 3. Everyday Scenario • People are unhappy with each other – Why do they keep doing this! – Not again! – Why can’t they get it right! • Verifying information is the job description for many of our employees BUT – The system won’t allow that. – That’s just the way it is.
    4. 4. Root Causes • Roots are far more extensive than we may think • Roots have branches – There is almost never a single cause – The several causes may be far apart – One or more of the causes may lie in another organization
    5. 5. Lessons from Medicine (Ideal) • Diagnose (Dx): Pt is cooperative and forthcoming concerning Complaints, Symptoms, Signs • We do a thorough exam and get appropriate imaging and laboratory input • We Prescribe Treatment (Rx/Tx) for the cause if possible and the complaint(s) if appropriate • Patient is responsible for following through with treatment
    6. 6. Best Practices Say We Need • Executive Management Blessing, Support, Involvement • Mid-Level Management Buy-in, Support, Involvement • Supervisory Staff Buy-in, Involvement, Enthusiasm • General Staff ([non]Exempt, educated, skilled…) Buy-in, Involvement, Enthusiasm
    7. 7. What Do We Have? • A Goal or Objective (sometimes a Vision) • A Timetable • Need for compelling Status Reports • A Budget for Consulting, Tools, Training • A lot of questions • Confusion, Resistance, Active Rebellion
    8. 8. 9 Necessity is the Mother… • Remember Angus MacGyver? – He didn’t waste time worrying about what he didn’t have (or he would have been blown up many times) – He started with the resources available • We’re all in MacGyver situations – Few of us act like MacGyver – We spend our time looking for “best practice” escapes – We invest in technological weaponry to defeat the problems – We focus on the problem—not the solution
    9. 9. Take a Deep Breath • Think like MacGyver – What is the result I want? • Can I break it down? • Will a partial result suffice? – What do I have to work with (resources)? • How can these be combined to create leverage? • Act like MacGyver – Put pieces together – Create
    10. 10. What’s in Your Pocket? • How can these resources be applied? • NOT to the problem • To the SOLUTION?
    11. 11. Recognizing the Solution • What would satisfy everyone? • Are there some whose satisfaction is most important? • If the complete solution is out of reach, what critical pieces will maximize satisfaction and establish a foundation to build on? • First ask, “What should I do?” • THEN ask, “What can I do?”
    12. 12. 1313 The 3 Cs…Center of the Onion • Community (Relationship) • Communication • Credibility Understanding these is useful in any context, but essential in organizational disorders
    13. 13. Community
    14. 14. Community • A group of people who – Live/Work together – Have one or more well-defined roles which are acknowledged as necessary and are usually defined by their job description(s) – Rely on others to perform in their respective role(s) • Benefit accrues to all (through cooperation) • Intuitive and Effective 15
    15. 15. 16 The Role Box • As in “thinking outside the“ • What are the boundaries of your box? • How much time do you spend outside it? • Why is this important? – Community demands an understanding of more than “my” box – Communication is at the boundaries – Credibility is built on respect for boundaries
    16. 16. 17 Stepping Out Of “My Box” Modeler Reception Governance is outside all the boxes. Architect Administrator Manager Nursing Clinician Administrator Technology Business
    17. 17. 18 You’re Never Done (History of Boxes) • Some boxes haven’t changed in centuries • Some are new since yesterday • Many are evolving because of – Relationship with other evolving boxes – Evolving/improving methods and tools – Improvement in theoretical foundation • Change happens whether we notice or not
    18. 18. Communication
    19. 19. 20 Communication Society cannot share a common communication system so long as it is split into warring factions. Bertolt Brecht Communication is the key, and it's one thing I had to learn―to talk to the actors. I was so involved with the visual and technical aspects that I would forget about the actors. Steve Buscemi
    20. 20. 21 Communications Secrets • Visit other boxes – Get invited – Ask for help – Always knock before entering • Bring gifts! – Remember Welcome Wagon – Find points of need – Offer help
    21. 21. Credibility It’s about TRUST and CONFIDENCE.
    22. 22. 23 Credibility Consultants have credibility because they are not dumb enough to work at your company. Scott Adams All credibility, all good conscience, all evidence of truth come only from the senses. Friedrich Nietsche
    23. 23. Credibility is Relationship • Desirable relationships such as Trust, Respect, Confidence, require time and consistency. • If you’re in a hurry Fear, Aversion, Distrust, Disrespect can happen very quickly. • Remember the Goal – C-C-C 24
    24. 24. Incentives Vision Skills Action PlanResourcesX XXX Incentives X Vision Skills Action PlanResources XXX VisionXIncentives Skills Action PlanResources XXX SkillsIncentives Vision Action PlanResourcesX XXX ResourcesXIncentives Vision Skills Action PlanX XX Action PlanXIncentives Vision Skills ResourcesX XX Successful Change Experiencing a problem? Here’s where to look. Gradual or No Change Confusion Anxiety Frustration False Starts Adapted from C. Lwanga Yonke: Information and Data Quality Conference, San Antonio. 2008
    25. 25. Postscript • Leadership – Produces CHANGE • Management – Produces EFFECTIVENESS • Governance – Produces CONSISTENCY 30
    26. 26. 32 Appropriateness • Tools and Methods must be appropriate to the community in which they will be applied. – The box I’m in – The box(es) I’m responsible for – The boxes I share boundaries with • No tools nor methods are universal • The problems are NOT technical • The tools/methods for dealing with them are NOT technical
    27. 27. Contact Michael P. Meier