I want to thank Dave for kindly inviting me to be the guest blogger for Cognitive-Edge this past week. I will end my blog series with a topic he is also researching: Improving management of chronic illnesses in today’s society. Five years ago I became involved in researching how people with diabetes can be better supported with their diabetes (self-)management by the professional healthcare community. While this is based on research in progress, I do want to present two points: 1) Healthcare professionals are still, by and large, stuck in a conventional expert normative paradigm of treatment, “tell and explain” and ignoring a naturalistic approach — discovering the context in which the patient operates to collaboratively tailor effective solutions. 2) Ironically through default of the healthcare community, patients are leading the way in exploring innovative approaches to managing diabetes as chronic illness.

The Problem

Diabetes is a chronic illness that, if not well managed, can lead to devastating complications. These include, blindness, heart attack, kidney failure, amputation of limbs, depression and premature death. There are now around 246 million people affected by diabetes worldwide and the total cost of treating and preventing diabetes in 2007 amounted to $232 billion. And the problem is only growing, and quickly. You can find an excellent overview of facts at the International Diabetes Federation website with more detailed explanations of what this disease is as well. I will not go into the details of the disease itself.

There is no cure for diabetes, only management of the condition on a spectrum from excellent to poor. At its core, diabetes requires the management of blood sugars within as close to normal levels as possible. That is a ‘round the clock, 24/7 regimen involving diet, exercise, administering medicine, testing blood sugars and managing stress levels — all by the patient. If the patient manages diabetes well, the risk of diabetic complications mentioned earlier can be reduced and possibly prevented and the patient can live a relatively normal healthy (long) life. Management requires on the part of the patient knowledge about the disease, an ability to interpret data about how the body is responding to the variables: food, exercise, medicine and emotional changes, and all in real time. This 24/7 regimen is emotionally exhausting, which in turn influences one’s sustained ability to manage one’s blood sugars. So in addition to having a good grasp of the science of diabetes a patient must also have enough emotional skills and stamina to manage the emotional impact. One could go so far as to suggest that to manage diabetes well, you have to be a medical doctor with degrees in diabetes, the emotional side of diabetes, nutrition and exercise physiology.

Antonovsky’s Theory of Sense of Coherence

So what will it take for a patient to succeed? This question can in part be posed for any chronic illness, like Parkinson’s, multiple sclerosis, Crohn’s Disease, although what’s unique to diabetes is that the patient is responsible to a much larger degree to administer his or her own care based on constant assessments, decisions and real-time actions. To answer the question posed I would like to use Aaron Antonovsky’s theory of Sense of Coherence (SOC). When he researched how people under adverse circumstances managed to succeed, he found three key components: Comprehensibility, Manageability and Meaningfulness.

Comprehensibility in our case means that the patient understands what is going on. For example, if one eats simple carbohydrates (like white bread or cake), blood sugars will rise fast, but if one eats complex carbohydrates like beans or dense grain breads blood sugars will rise slowly. Manageability means that the patient perceives he can influence the circumstances. For example, if one chooses to eat two cups of pasta to keep blood sugars in target range one needs to inject 4 units of insulin. Meaningfulness refers to “why is it really worth it for the patient to learn all this stuff and manage diabetes 24/7?” Here many patients temporarily lose sight of the goal, the reward of doing all the work. If you prod however, they uncover their very personal reason why they want to ensure their health: to see their grandchildren grow up, to travel in retirement with their partner, to start a second career.

These dimensions refer to the “why, what, how and when” something needs to be done in order to manage diabetes. The answers to these questions depend on the unique and very individual contexts – e.g. work, family, neighborhood, culture – within which the patient lives because remember, so many aspects of managing the disease are affected by these contexts, and, the patient must self-manage diabetes. Since the medical doctor does not come home with a diabetes patient, the patient is largely his or her own healthcare provider!

The Complex Challenge

So, the challenge that has stood in front of the healthcare community for decades is how to motivate and mobilize the patient to understand, design, manage, maintain and continuously improve their own systems of self-management. Consider too, no two days are exactly alike, even when they are, the body will not necessarily respond identically, and diabetes is a progressive condition and changes over time as does one’s physiology. It is truly a complex environment. To help make patients successful, this requires a clinical approach based on discovery, dialogue, an inquiry-based coaching style and creating a partnership between provider and patient so that the expert approach can be applied appropriately – i.e. after the context has been discovered.

Unfortunately, today’s healthcare system is designed to provide services through the expert medical paradigm of “diagnose-cut-cure” and “tell & explain.” This paradigm is controlled by the medical expert and often devoid of any unique patient context. It is ill-equipped – forgive the pun – to deal with the true function of the health care provider regarding diabetes, to empower the patient to provide the necessary management to prevent diabetic complications. In-fact, the current paradigm causes what would be considered insanity to an objective observer. The health care system as currently designed provides financial incentives to experts to deal with the consequences of poor management — the complications of diabetes. Surgeons now amputate limbs and insurance companies pay for it. However, there is no significant amount of money allocated for education, and there are no incentives to run a system of inquiry-based coaching and support that can prevent these complications. Nor is there any respect for such an approach. Dialogue and inquiry-based coaching skills are not taught at medical school. In fact, most medical students receive one to two days total education about diabetes in all their years of schooling. Again, the goal is making quick diagnoses, and due to managed healthcare, seeing as many patients as possible in an hour. Under the current expert paradigm the patient who fails to manage his or her diabetes is quickly and simply classified as non-compliant as a certified diabetes educator explained to me last night during dinner.

The Research

In the research my network is conducting around improving patient performance with diabetes management we began by interviewing people with diabetes from all walks-of-life. Some manage their diabetes well, others poorly, some have lost both legs, others have little or no complications. Using explorative questions as much as possible we asked them to tell us their story. To date we have gathered more than 100 stories. Many respondents e-mailed or called days afterwards to tell us how helpful it was to them to share their story. Testimony to the power of descriptive self-awareness and not a surprise if you are a member of Cognitive-Edge!

We are also learning that many people, sometimes despite horrifying complications, are happy. Many are proud of how they manage diabetes and have feelings of a “sense of accomplishment for a job well done.” Frequently those interviewed pointed out that the disease is giving them a new sense of appreciation for life, valuable friendships through support groups, discovering their own strength and courage, humility in the face of worse conditions and so forth. Some share that they are now highly motivated to eat healthy and exercise regularly and they feel good about that.

In addition to the understanding that living with diabetes can give one something positive, another emerging insight is the potential power of patients using their own positive emotions to help themselves manage their diabetes. Contrast this with the current healthcare system that focuses almost exclusively on negative emotions. Medical professionals try to motivate patients through fear around complications and guilt around poor management. A quick trip to the bookstore will show that many medical experts write about how to cope with depression and diabetes or with diabetes burn-out. Again the negative emotions seem to be central to the medical community and leveraging the power of positive emotions to manage your diabetes is ignored! But there is a glimmer of hope in an emerging trend in chronic illness which I will touch on shortly.

Patients leading the way

That brings us to where we started regarding patients leading the way with innovative approaches. Examples abound. The Patient Mentor Institute in the U.S., funded by a grant from the pharmaceutical, Sanofi-aventis, trains people with diabetes who have proven to be successful at managing their diabetes deliver informative and motivating programs to fellow patients sharing their personal story. The program has rapidly grown over the past 4 years. Today it has more than 60 patient presenters – called champions – operating nationwide. Another example is the Divabetic organization that attracts women to fun events and then educates them about diabetes through certified diabetes educators. Novo Nordisk is sponsoring this grass roots movement that is growing fast. An enormous amount of diabetes blogs, like DiabetesMine and community diabetes health web sites like Tu Diabetes, have sprung up where patients share information, experiences and feelings and educate and support each other. A UK based website has made 50 oral stories from people living with diabetes accessible. And, Amazon has one book now listed that coaches patients to better management through the use of positive emotions titled, The ABCs Of Loving Yourself With Diabetes. Three other books I can cite that reveal this emerging trend in chronic illness are The Five Gifts of Illness about Crohn’s disease, Blindsided about multiple sclerosis and Strong at the Broken Places that features living with various chronic diseases.

The need for the Cynefin Framework

The current health care system is stuck in conventional expert and normative thinking and patients are taking it upon themselves to push through to a more effective and emotionally satisfying approach. Bill Polonsky, a noted psychologist and founder of the Behavioral Diabetes Institute in San Diego told me peer coaching is the next major advance in diabetes care and most likely also in other chronic diseases. We are seeing that emerging trend of patient experts leading the way instinctively sharing their stories and coaching each other. In the network’s research we are designing a coaching methodology that is consistent with the naturalistic and descriptive self awareness approach. One aspect of it will be to begin with the patient’s own storytelling so that the various patient specific contexts can be discovered.

We aspire to offer this approach to the medical community as we believe that unless they are willing to adopt a more patient-centered approach using naturalistic methods, chronic illnesses will bankrupt our societies.

Central to this approach is an ability to switch perspectives from complex to complicated to simple and we are therefore not suggesting that the expert paradigm is not valid. We are suggesting that experts need to extend their intervention and behavioral repertoire so that they can make an informed choice as to when to use an expert “Tell & Explain” approach and when to use a collaborative inquiry based coaching approach based on patient engagement.

Some awareness in the medical community is apparent. Consider for example Kaiser Permanent’s four habits model of clinician-patient communication that is based on spending more time in inquiry with patients before any diagnosis is made. This is an improvement in the face of Jerome Groopman’s findings in his bestselling book “How Doctors Think,” that doctors typically interrupt their patients within the first 18 seconds of a consultation. Patient and author Michael Weiss and co-author Martha Funnell, a certified diabetes educator, advocate a patient empowerment approach using inquiry based coaching techniques in their book “The little Diabetes Book you Need to Read.”

The time has never been more ripe for use of the Cynefin framework advocated at this website to research and design a promising way forward for our healthcare systems to deal with chronic illnesses.

In yesterday’s Wall Street Journal I read two articles that at first glance seemed unrelated to each other. The first article is about China’s role in manufacturing raw heparin, a key ingredient in blood-thinning medicine that because of suspected impurities may be responsible for allergic reactions with 350 patients and the death of four. The second article discussed the fact that the U.S Department of Agriculture claimed that some 50 million pounds, roughly one-third of the 143 million pounds of California beef that was recalled last week, went to schools and that 20 million pounds of those 50 had already been eaten.

I am going to suggest that both cases have something in common. Bureaucrats and executives alike, believe that quality control systems and detailed knowledge about supply chains can guarantee quality. And that addressing these two aspects will make the problem go away. They are, of course, dead wrong.

The reality is that it is not the quality control system or a lack of knowledge that caused the failure. Rather, it is the design of these complex systems that is the root cause for the problems. The design has, for example, not taken into account that highly centralized systems cannot secure the quality of output through centrally determined rules, regulations, quality checks and inspections.

Let’s look at the beef system first. In 2007 there were 21 beef recalls in the U.S. for E. coli problems involving some 21.7 million pounds of meat. It was one of the worst years on record for beef safety. The recalls involved meat that had already reached the stores and consumers. In other words, the government was too late in each case.

Cows in the U.S. are now slaughtered in a few centralized slaughterhouses where 300 or more cows are processed every hour. All you need are one or two sick cows going through the same grinder and you have huge potential for contamination that goes into a distribution system that covers much of the U.S. In “Safe Food: Bacteria, Biotechnology, and Bioterrorism,” author Marion Nestle presented an interesting fact. I quote from The Economist: “A single lot of hamburger meat at one processing plant was determined recently to contain parts from 443 different cows.” This presents a fantastic opportunity for cross-contamination. Because cows are fed corn – for reasons that have to do with government subsidies – which is not what their biological system is made for, many cows become sick. The recent video from the Humane Society (warning, the images are quite graphic) exposed how these sick cows are still entering the food chain, against all rules and regulations. No inspection or regulatory system is set up to stop this. There are too many incentives to push all cows, sick and healthy, through the system. Everything is based on efficiency, economies of scale, more is better and faster throughput and distribution is what creates more profit. Consequently, preventing and tracking contaminated beef is almost impossible and by the way, responsible for some 2 million foodborne illnesses each year in the U.S. alone. So we have a system that is set up for failure.

The heparin case is different in that more than half of the world’s heparin comes from China. Heparin is produced through an intricate process from pig’s intestines before it reaches an IV bag in a hospital and is used world-wide by patients who have surgery and or need dialysis. The supply chain is poorly documented and recently 350 allergic reactions among patients in the U.S. were recorded and the FDA is currently investigating the deaths of 4 patients that may have been caused by heparin manufactured in China. The heparin involved was sold by Baxter International Inc. who said that “it selects suppliers that have proven quality track records.” One of Baxter’s main suppliers is Scientific Protein Laboratories whose president claims he can’t trace its supplies from China “in as much detail as it can from the U.S.” Investigations in heparin-producing-factories in China show “widely varying standards of regulatory oversight.” And anyone who reads the articles – and sees the online photos in the Wall Street Journal – will learn that the factories themselves have varying standards in everything from hygiene, administration, equipment to the level of training of workers. A global supply chain like this one for heparin is so complex that any suggestion that rules, regulations and inspection systems can guarantee quality are by definition false.

So here we have two core supply chains that impact societies we live in: one is food, the other is medicine. If we cannot trust quality systems for food and medicine what should we do? The answer lies not in beefing up – forgive the pun – inspection and control, but in dissolving the problems through redesigning the systems. The systems that currently produce the products are the same systems that enable the problems. Bill McKibben presents the idea of “Deep Economy” that involves self-organizing local communities where, for example, cities and local farmers manage quality of the food supply together because they are mutually dependent on each other. Feedback cycles would be immediate and possible foodborne illnesses – should they occur – would be limited to regions or cities rather than a whole country. In such communities we could also go back to having cows eating grass which is actually compatible with their stomachs! For such a community to work you would need small (local) slaughterhouses which the current government inspection system makes practically impossible. For interesting and original research on this topic I recommend Michael Pollan’s book “the Omnivore’s Dilemma.”

As for heparin the solution might involve an investment program from pharmaceutical companies in Chinese suppliers involving capital for appropriate facilities and on-the-job training. In essence, going local with investments and technology transfer. It might even lead to temporary partial ownership and therefore the creation of a radically different system than we have today. Quality is built-in rather than controlled through inspection.

The moral of these two stories for me is two-fold. First, government bureaucrats, politicians and business executives mistakenly believe that you can eradicate problems described here through punishment, legislation, better quality inspection, more rules and regulation and that the current system is not the leading cause of these problems. They need to be educated! Second, don’t eat beef and avoid surgery and dialysis.

Recently I started doing some work with a major hospital and in preparing my first intervention I reviewed some of the earlier work I did in the health care industry, which included working with executives from the Alexandra Hospital in Singapore. To update myself I also explored their website and found out that they are using a publicly accessible webcam for their Emergency Services waiting room. Why would you want to do that?

Before I explain that, I should tell you that Alexandra’s management team, under leadership of Mr. Teng Lit Liak, was always serious about continues improvement. They had done some amazing things including analyzing and improving the flow of patients from the moment they leave their house for a same-day procedure to arriving at the hospital and going back home again. This was in 2002. When I visited Mr. Liak 2 years ago, he was still at it with his management team, now using insights from Toyota, very carefully translating them with his people into possible applications that would help improve the patient’s experience at Alexandra Hospital.

Apparently one of the ideas that emerged was putting up a web-cam in the emergency room that would provide every 5 minutes an update on the average waiting time for patients and the absolute number of patients waiting to see a doctor. The hypothesis is that people who have a minor injury and would like to be treated in a hospital would first check the waiting time on the internet before they would go to Alexandra hospital. Based on what they see on the webcam they might make a more informed decision, e.g., go to Alexandra Hospital, or go to another hospital or clinic. This idea is based on the so called “Hejunka” principle derived from the Toyota Production System. “Hejunka” means to level or make smooth and in the emergency room context could potentially lead to better management of the relative unpredictable peaks and surges that occur. Possible advantages might include that patients are served more timely and a better match of people resources (number of doctors and nurses to patients).

The whole idea is based on a self-organizing patient flow, i.e. the patient making decisions based on one extra piece of information that could influence the actual demand of patients at Alexandra hospital.

The question is, will it work? It was decided to just try it. In October 2005, the average waiting time was 1 hour and 43 minutes and in October 2006, a month after implementing this system, the waiting time for 95% of the patients had fallen to 1 hour and 12 minutes. The implementation team agreed that it was not clear that the webcam contributed to this result, in other words the cause-and-effect relationship was not apparent, but they decided to continue the use of it and of course the real benefits will come when other hospitals also adopt a similar system. The decision making process for the patient then becomes easier.

Guess what, to date Alexandra hospital offers you links to four other hospitals who have a similar system. With the usual publicity in newspapers and other media, the emerging system is beginning to do its work.

I think this is a classic example where cause-and-effect relationships are unclear, the adoption by other hospitals was unpredictable and a new system of patients making more informed decisions about where to go is emerging. The outcome is unpredictable. You are dealing with a complex system with so many actors that your best bet is to send in a probe. In this case the cost was minimal, some S$ 400 for a webcam! Call it a probe or an experiment, do some careful sensing and move forward. Simple and Complex!

With the US economy getting worse every day, many executives have started to cut their budgets. Cost reduction for many companies is now number one on the priority list. As logical as it may seem, this is a great mistake. Why? In yesterday’s contribution I pointed out that any improvement must be focused on what you want. Therefore, if the economy goes south and you want to improve your business results, you must be focused on what you want. What top management should want and be focused on is to increase the value for its stakeholders. This is markedly different from focusing employees on cost reduction.

The basic question any management team must contemplate is why does the company exist? Why do customers buy from them (and not from others)? When would they buy even more from them? What customers are we not serving and could we profitably serve? Why do banks give them credit and why do shareholders buy their stock? Etc..

All answers to these questions are related to the value proposition the company presents to its stakeholders. Therefore, any management team must ask its employees to stay focused on the key question: How do we increase value for our stakeholders, rather than ask its employees how we can reduce cost.

As I explained in my previous contribution, the solution domain is much larger if you focus on what you want. A company does not exist to lower its cost. Hence focusing employees on reducing cost, means you are directing their energy to the wrong objective. Often, asking employees to focus on cost reduction leads to the wrong decisions. For an example, see also my contribution in my second blog.

Mind you, cost reduction is not excluded from the solution domains employees will come up with if you ask them the value improvement question. But cost reduction becomes an outcome as a result of asking the right question, rather than an input because you ask the wrong question.

Ask employees about how to improve value and they will come up with many solutions, for example those that are related to improving profitable sales, a refinancing of a loan, using video Skype conferencing rather than a business trip, improving procedures with suppliers that could lead to less problems and therefore less cost etc..

I was reminded of all this when I saw a segment on TV last week when at the morning news, two so-called experts advised employees what to do now the economy was worsening. All suggestions were focused on the individual. For example, now is not a good time to ask your boss for a salary raise, get your resume in order, start looking around for other possible jobs. Not one suggestion was related to helping the company you work for do better. Not one expert suggested that now was a good time to brainstorm with colleagues how you could improve revenue generation, work smarter etc. and bring these ideas to your boss – thereby also impressing your boss with useful ideas and how good you are as an employee. Perhaps I should not have been so surprised. After all, the US is a hyper individualistic society. But it does underscore my main point: if top managers don’t ask their employees the right question they are certainly nog going to come up with the right kinds of answers.

Do executives really want cost reduction? No! They need value improvement.

Another sin I often see in companies, is that executives focus improvements on what they don’t want, rather than what they do want. There are two reasons why this is wrong. First, if you eliminate what you don’t want, you don’t necessarily get what you do want. Second, by focusing on what you don’t want, your solution space is much smaller compared to when you focus on what you do want.

Many companies that are engaged in formal improvement initiatives like lean six sigma or operational excellence, are focused on elimination of defects and waste. Their executives mistakenly believe that if they remove defects and waste they improve the performance of their company. Not true. A case in point is Motorola who tried to apply six sigma to improving customer satisfaction by focusing on reducing defects in the late 1980s. While they succeeded in improving their manufacturing through six sigma, a much more ordered and stable environment than the market place for products – they failed when they tried to apply six sigma to improving customer satisfaction. Their assumption was that as long as you would reduce defects (“something we don’t want”) it would improve customer satisfaction. However, no matter how hard they tried, their own customer research proved them wrong. We can explain their failure using the Cynefin framework.

The environment of the customer is a complex environment. It is dynamic because customer preferences are always changing, competitors are introducing new products and customer satisfaction is always relative towards what others are doing in the industry – something over which you have no control – unless you have a monopoly. So Motorola introduced pagers or mobile phones that with technically superior mean-time-between-failures, but customers bought products from competitors because they had a much more attractive design or a more attractive feature set.

In my story about the company with the safety issue, they were measuring the lost-time-injury rate. The focus is therefore on what they did not want. The assumption is that measuring and reviewing this performance indicator will create more safe behaviors. This assumption is false. What does happen in many companies – and in fact did happen in the company I discussed – is that employees did not want to be responsible for reporting an injury and increase the lost-time-injury rate. So accidents happened but went unreported and this reduced the lost-time-injury rate. However, because the injuries were not reported, they also were not analyzed and the safety environment did not improve – and improvement of the safety environment is what they wanted!

All of this goes back to the basic axiom that Russel Ackoff presents: “Improvement must be focused on what you want, and not on what you don’t want! This can be easily proven,” he says. And this example draws on one of his lectures. “What are the chances if you switch on the TV that you get a program you like?” Ackoff figured out it is about 1 percent. “So if you switch the TV on and you have a program you don’t like – a defect – you can get rid of it by switching to another station. What is the chance you get a program you like? Again, it is only 1 percent. Focusing on what you don’t want and eliminating it, does not necessarily give you what you do want!”

So if you want to improve, you need to focus on what you do want. The second reason why this is sensible is that your solution space is much bigger than when you focus on what you don’t want. To go back to Russell Ackoff’s TV example, if what you want is to have an evening of good entertainment, you could get a subscription to Netflix and play a DVD or download a movie from Apple iTunes or decide to go to a concert etc.. If you want to improve safety in your company, you could focus on creating a safety culture and review how this culture is evolving. Using the Cynefin framework and recognizing that a culture is a complex system, you might decide to get an impression of the current culture, for example, through the use of narratives. You would dialogue with workers on what their ideas are to make improvements – because they are after all the actors who create and re-create the safety culture etc. and together with them design interventions.

The solution space quickly explodes if you begin to formulate and focus on what you truly want. Almost by definition you will find that the solution domain is a complex domain with many possibilities and nonlinearity rather than a complicated or more structured domain which is the world of the defect. Therefore, a much more facilitative and dialogic intervention is necessary. Hence, the use of interactive tools such as designed by Cognitive-Edge that open up the communication are necessary.

My provocation is that if executives agree that improvement initiatives must be focused on what they want, they must also be willing to adopt the complexity paradigm. From this follows that they should be willing to engage in a much more facilitative leadership style and that they need to become comfortable with facilitative tools and approaches.

In many of the companies where I am involved as an advisor or consultant, managing improvement is an inherent part of running the business. A common mistake executives make while trying to manage improvement is that they localize their improvement focus and don’t connect their improvement efforts to the organization as a whole. The net effect of such an approach is that it lowers the performance of the organization as a whole.

Examples abound. Recently I came across a manager in a service organization who had received a cost reduction target for his department. He removed a return envelop from a standard mailing that another department is responsible for that goes to clients when they close on a contract. We are talking an annual volume here in the tens of thousands so a significant cost saving – or so he thought. However, the net effect was that many customers did not return a required form (which is why the return envelop was usually enclosed) that led to a downstream department getting into compliance problems. In the end thousands of customers needed to be called and some mailings needed to be redone. It cost the company more than it saved in out-of-pocket expenses without taking into account the employee and customer dissatisfaction that was caused as well. In another company the sales and marketing department decided to drop the price of a particular product to get more market share. This led to more sales and more sales bonuses, but they had failed to talk to the operations department who could not handle the extra volume. This led to all sorts of delivery problems, lower customer satisfaction for the organization and reputational damage in the market place. And to go back to the company that tried to order safety as if it was food on a menu in my previous contribution, the pressure on people to sell and produce more, sometimes led to postponement of preventive maintenance which in turn would lead to the breakdown of equipment which led to potentially unsafe situations and costly operational delays in serving the customer.

My approach to deal with these type of problems is to not only visualize the systemic nature of these problems with the managers involved – often I ask them to do this – but to also share with them the notion that an organization is a social system where the whole cannot be divided into independent parts. To show this I do a simple exercise where I ask the managers to choose an end-to-end process and to calculate the rolled-throughput-yield of the process. This demonstrates mathematically that, as Russel Ackoff so eloquently articulates, “an organization is as good as the product of its interactions.” From this follows that leadership must have a high priority focus on the interaction of the parts of an organization and that any local (departmental or functional) improvement will have a consequence for the whole of the organization. Local improvement must therefore be put into the context of the whole of the organization,

I find that the works of both Russel Ackoff and Peter Checkland help me in coaching my clients to a better understanding of these very basic organizational axioms. I particularly recommend Ackoff’s Idealized Design and Checkland’s “Systems Thinking, System Practice” and “Soft Systems Methodology in Action.” I believe that the Idealized Design concept from Ackoff and the soft systems methods from Checkland are useful for opening up the discussion in complex organizational contexts and are therefore consistent with the toolset that Cognitive-Edge is developing.

I would like to share with you an interesting case I worked on that involved influencing the safety culture in an industrial company. For reasons of confidentiality I cannot mention the name of the company. The case is, I believe, a good illustration of how approaching the issue of safety through the complexity paradigm can lead to a rich set of consequences that, in the eyes of top management, was unexpectedly highly successful.

I was engaged by the company to provide leadership courses for their junior and senior managers. About a month before one of the leadership courses, I was asked to meet with the HR director at the company’s head quarters. I was told that the company had experienced quite a few industrial accidents that involved fatalities. The trend was disturbing and despite repeated ‘requests’ from top management, an onslaught of powerpoint presentations by safety officers and top management, not to mention intranet publications about the need for safe behaviors, the safety record was barely improving. I was told that something was wrong with the safety culture and it was imperative that I spent a morning on this subject in the course. “Please design a session so that our employees understand the importance of safety.”

I realized immediately that the executives with all good intentions had turned safety into a two-dimensional rational issue. When I visited the Corporate Safety Director, he proudly showed me several dozen colorful slides with all sorts of graphics, charts, statistical data and bullet points of safe behaviors that would help reduce the lost time injury rate and fatalities. And of course he would be a guest speaker in the course, so he could impart his insights.

What to do? I decided that I needed to give safety a human face. I asked if I could have two managers who had dealt with an industrial accident under their watch in which an employee had died. I was pleasantly surprised when HR quickly arranged introductions. I asked if they were willing to tell their story about what it was like to have to deal with an industrial accident. They agreed, not only to tell their story, but also to not use any powerpoint.

On the morning of the safety session in the leadership course, I arrived early in the room and moved all the chairs of the participants in front of the tables so that they were seated in a circle. Both managers told their story. One of them used two slides after all, but to my relief they were photos. One photo of the name badge with a photo of the employee who had died and one slide with a photo of the accident scene. The other manager told his story and then showed a video of the funeral. Both stories were authentically shared. The managers showed emotions when they relived their ordeal. Their personal lessons flowed naturally from their stories and their appeal to the participants to not become a manager who has to go to a partner of an employee and tell that their partner will never come home again was impactful. After an intense 90 minutes we adjourned for coffee. I will never forget how tangible the emotions were in the room. Some of the participants had tears in their eyes. Conversations were muted.

The Corporate Safety Director had attended the session from the beginning. I had asked him to present after the coffee break and to limit his slide presentation as much as possible. The HR manager had already told me that this was a futile request. However, we both were in for a surprise. The Safety Director approached me somewhat nervously in the coffee break and he told me that after what had transpired – he was referring to the emotions in the air – he felt he could not do his presentation anymore. I suggested that a few slides would be fine, after all, we all needed a bit of distance from these two cases so we could put it in perspective. And perhaps he could ask questions and even create a dialogue.

After a longer than usual coffee break, the Corporate Safety Director entered the circle. To the amazement of the HR manager, only 12 slides were used, but over and above that, it became a highly interactive session. The HR manager claimed he had never seen that before with this executive. Various participants spontaneously offered their help to the Corporate Safety Director. They felt that the storytelling had been so powerful that they wanted to help the Director with capturing more company stories on safety and find a way to use these to raise awareness for better safety behaviors. The Safety Director readily agreed and appointments were made.

Fast Forward 18 months. At a board meeting the lights go out and a 20 minute video is shown consisting of interviews with people from around the world working for this company who had been involved in industrial accidents. It is the first time that board members see the video – and some had tears in their eyes when the lights went on. A group of participants in that leadership course had received a budget and had captured true stories of safety at the company. In a careful orchestrated process this video found its way to each of the company’s sites where discussion sessions were organized.

Safety had been given a human face. It was no longer just a chart on a piece of paper or on a colorful slide. Instead, it was something that had come alive.

Did the safety record improve? Yes it did, but I cannot claim that this was due to this video and that single intervention in the leadership course. Too many others things were done as well. However, no one disputes in the company the importance of that session that caused an unpredictable sequence of events that had markedly influenced the safety culture of the company.

For me this story shows what you can achieve if you switch perspectives from an ordered world to an unordered world, from a deliberate tell & explain style of leadership to a much more facilitative and interactive style of leadership. No one could predict what would happen as a result of that session.

What are your stories on Safety Management? And by the way, I promise my next contribution will be shorter!