Waste

The ‘Spaghetti notes’ phenomenon

giantknave Brain Farts , , , , , ,

Most people I know like pasta. I don’t. I find it bland and boring (sorry Italy).

I find spaghetti particularly annoying. No matter how much I eat, the portion in my dish never seems to reduce. It gets all tangled on my fork, it dangles everywhere, and it makes a big mess.

Which is a nice segue to this post:

The more ‘functional’ (i.e. specialised/ compartmentalised) a service has been designed then…

…the more likely that a client must speak with lots of different people (‘a new person every time’)

and the more likely that the client’s needs are then broken up into ‘transactions’ and passed on (a.k.a ‘referred’) to lots of other people to work on…

…the more people ‘touch’ (i.e. work on) a client record…

…the more file notes are left on the client record…

…the harder it is for someone working on a client record to work out what is going on…

…the more likely that, during a client interaction, the person attempting to help can’t possibly read ‘all the notes’ and so only reads what is obvious to them in the time (that they feel1) they have available to them…

…the more likely that something important is missed from within the notes…

…the more likely that inappropriate/ incomplete actions are taken and, worse, serious errors are made…

…the more likely that a client needs more work done2 on their record (to deal with the resultant failure demands, to ‘undo’ the actions taken, and the knock-on effects)…

…the more likely that a ‘leaving good notes’ policy is rolled out (including ‘best practice note templates’ and ‘quality control’ by inspection of note taking)…

…the more time taken by everyone working on a client record to make detailed notes (and to ‘police’ this)…

…the more involved each note becomes…

…the even harder it is to work out what is going on (because there’s yet more notes and each one has become painful to read – even containing internal hieroglyphics to supposedly make an ‘easier to consume’ short-hand)…

…until we arrive at the ‘spaghetti notes phenomenon’ where it’s virtually impossible to know, let alone understand, what’s gone on when viewing a client record, and it would take days of effort from a dedicated and experienced worker to review all the notes and patch them together into a coherent whole…

…and if they do this, they will stand back and think “oh my @%&!, what a pile of waste it took to achieve a shite client experience.”

 

The final ‘nail in the coffin’: Someone helping a client can often look at the spaghetti before them in the client record and (rationally) arrive at the conclusion that it would be much easier to ignore all the notes and talk to the client as if they are starting all over again.

 

Reflection:

Focusing on making good notes is an example of single-loop learning (‘making a wrong thing righter’).

The real problem isn’t with the notes, it’s with the design of the system that means that so many people are working on the same client record, because it’s this that creates the spaghetti.

 

Clarification: I’m absolutely NOT against good notes – if I’d worked on a client file a month ago, I’d like to read my own note that effectively and efficiently reminds me where I left off. I’d also like any colleague to be able to read it and gain a similar understanding.

What I AM against is a system design that causes a ‘note making’ reinforcing feedback loop3.

 

Footnotes

1. A person helping a client could take a great deal of time to work through the notes – to make sure that they gain the necessary understanding – but does their working environment cause them to think that this time isn’t available to them?

Do they feel like they’ve got to get through x number of tasks today and so time is of the essence?

2. And, of course, this ‘more work’ needs yet more notes adding to the client record.

In my experience, a ‘here’s what we did to undo an error’ file note is a convoluted thing to read (let alone write), and almost impossible to follow because ‘you had to be there’ to actually get it…which means that such file notes are often glossed over because it’s easier to do so…which leads us back around into the same torturous circle.

3. For those readers that may not understand what this means, a reinforcing loop is one in which the result of an action produces yet more of the same action, thus producing growth (or decline depending on which direction the action in question is leading).

Enough rope to hang ourselves

giantknave Brain Farts , , ,

NooseIf you pick up a shiny new thing, perhaps a tool or methodology but don’t have a true understanding of the underlying thinking….then you’ve probably just found yourself with enough rope to hang yourself.

Note: I don’t put myself above being at risk of suffering this condition 🙂

Take John Seddon’s failure demand concept, which is explained in this earlier ‘marbles’ post. Once you’ve (re)read it, you will see that the failure demand concept is REALLY easy to understand and potentially incredibly powerful. In fact, it causes ‘light bulb’ insight moments.

But wait, don’t rush off just yet. Why do we get the failure demand?

Oh, too late, someone’s rushed off…

John Seddon uses the example of a senior civil servant in the UK Government finding out about the failure demand concept and (using their existing command-and-control mentality):

  • a) mandating that local authorities will, from now on, collect and report (to central government) on failure demand using a standardised method; and then, once this was in place
  • b) setting targets to reduce it, likely putting in place ‘performance incentives’ for successful reduction…which then require the judging of people’s performance .

So, what do you think would happen?

Well…

  • Step a) causes under-reporting of failure demand. People start off very cautious and don’t like exposing it to a command-and-control hierarchy that jumps to blame and usually then goes on to dictate ‘solutions’;
  • Step b) causes the reporting of only the failure demand that they believe can be reduced or removed within their control….so that they can then show great success against the set target and gain the rewards on offer;
    • …which hides the most important cross-departmental failures;
    • …and means departments throw work over the fence to other silo’s (moving rather than removing the problems) and arguing between each other as to who is claiming what benefits;
    • …which leads to the ‘centre’ (policy dictators) to introduce controls and auditing of the results to catch ‘cheaters’ (which requires new work, requiring resource…which is waste)

Therefore the data collected is incomplete and distorted whilst the initiative looks really successful, paying out incentives for things that could easily be achieved anyway. Yet the system hasn’t changed, much of the failure demand remains hidden and much energy (and money) has been spent in wasteful activity.

Looking at this, what is the knowledge that was missing?

They didn’t stop and think to study why the failure demand was occurring. They jumped to use their existing management thinking in the hope of quickly ‘solving’ it.

A huge caveat: “To remove waste, you need to understand its causes”.

“Treating improvement as merely process improvement is folly; if the system conditions that caused the waste are not removed, any improvements will be marginal and unsustainable.” (John Seddon)

If they had studied their system, they would have seen the effects caused by:

If they understood their system, according to its purpose (from the customer’s point of view) and then designed it to allow the people within it to understand its capability (NO targets) and then collaborate across its components (No contingent rewards) to experiment with improvements….then they can successfully identify and remove failure demand…with no need for the waste of monitoring.

Moving on to waste:

Many organisations do the same ‘enough rope’ trick when it comes to waste.

They are taken through Taiichi Ohno’s 7 types of waste, with the 8th waste of untapped human potential added for good measure.

Each waste is explained, with examples, and some really good ‘class room’ understanding is achieved. Some of the more tricky waste concepts (like inspection and transport) take a bit of time to cement into place….but people ‘get it’.

…and so they are off, with their ‘waste spectacles’ donned, looking for waste.

But it goes awry when objectives (with targets) get set around waste reduction, and rewards are tied to achieving this. Management become waylaid with the categorising and reporting on the waste. They have now entered the same ‘existing management thinking’ game as is described above.

To be clear, Ohno didn’t want waste to be classified and reported, he wanted it to be removed. His reason for setting out 7 types was only to assist in spotting it….it is waste to spend your time categorising and reporting on waste!!

What you actually need to do is understand the root cause: why is the waste occurring…and this is far deeper than the process. It usually comes down to the current management thinking (which is rooted in management’s beliefs and behaviours).

Then, and only then, can you actually remove the waste.

Here’s a John Seddon quote that is worth taking some time to ponder:

“Fads and fashions usually erupt with a fanfare, enjoy a period of prominence, and then fade away to be supplanted by another. They are typically simple to understand, prescriptive and falsely encouraging – promising more than they can deliver. Most importantly, fads and fashions are always based on a plausible idea that fits with…management’s current theories and narratives – otherwise they wouldn’t take off.”

Don’t let failure demand and waste become ‘fads’ – they are not. They are very real things which drastically harm an organisation’s ability to meet its customer purpose…but we need to go deeper and understand the why, why, why.

Stating the obvious!

giantknave Brain Farts , , , , ,

Copy-of-dumb_blondeIt is really easy for any leader to say “I want…

  • Continuous Improvement;
  • Removal of waste;
  • Reduction in failure demand*.”

(* explained in my earlier marbles post here)

All are sensible, in fact obvious! But it’s a bit like a financial advisor telling you to ‘buy low and sell high’…what have you actually learned that you didn’t already know, and how does this help?

It’s much harder to understand the system conditions (structures, policies, procedures, measurement, IT), and underlying management thinking (beliefs and behaviours) that protect the status quo, create the waste and cause the failure demand….because you have to change your thinking!

“We cannot solve our problems with the same thinking we used when we created them.” (attributed to Einstein)

If you:

  • set numeric activity targets to make improvements…
  • …and offer rewards for their achievement…
  • …and rate (and rank) people’s performance against them…

…then you haven’t understood (or accepted) about systems, measurement and motivation.

To quote from John Seddon:

“Treating improvement as merely process improvements is folly; if the system conditions that caused the waste are not removed, any improvements will be marginal and unsustainable.“