Bertrand Russell wrote at length about what it takes to be happy in his book The Conquest of Happiness. Aside from activities and dispositions to guard against Russell identified the primary driver for achieving happiness; he called it construction. In such an articulate way and in a single word Russell was describing the act of building anything in life, whether it is a physical object, an idea, raising a child or developing new knowledge. He postulated (I think rightly) that when people are engaged in activities of purpose with a result they can see, the act of engagement provides a source of joy. It does not mean the activity is not difficult, in fact, most frequently the more difficult the activity the more satisfying the feeling upon achieving the desired aim.
The Plan Do Study Act (PDSA) cycle offers a mechanism of engagement. It is an activity that when applied deliberately to purposeful outcomes in the workplace (or anywhere in life) can bring joy to the work. And it is hard. When working with teams who are new to the use of rapid cycle testing of ideas to produce intended improvement, or of rapid cycle investigation of their process/system to generate new knowledge, the hardest thing is explicating theory.
Individuals often feel they know what they. They feel things viscerally, and this represents a barrier to be overcome when someone like an Improvement Advisor challenges them with two questions: What do you believe about why things are the way they are? And, how do you know?
What do you believe about why things are the way that they are?
Because people live and work in an environment every day, this question can seem silly. For the nurse at the bedside or the physician in the theatre ‘why things are the way they are’ appears to be self-evident. It should be obvious. ‘Appears to be’ is the key phrase here. What is hard is shifting our mindset to never be comfortable with our understanding of the status quo. This puts the nurse/doctor/improver in a necessarily uncomfortable position in relationship to the work they do every day. The challenge being to continue working to identify what they believe about the causal system and remaining open to that knowledge being incorrect. It requires carefully and consistently cultivating a disposition that will work given their current level of understanding while trying to learn a better way. This second part requires method.
There is an axiom that you can’t change what you can’t see. This brings into sharp focus the second difficult question; how do you know? Despite our experiences there is a need to develop objective evidence about the causal system at work producing the outputs we see. ‘I know because I know’ or ‘everyone knows why we get the results we see’ become insufficient explanations for systems seeking continuous improvement always. When conversations begin and initial PDSA cycles are pursued it is very common for teams to discover they have different theories as to why things are the way they are and no way of measuring whether what they believe is true.
PDSA cycles offer the chance to explicate our theories, to formulate measures, to ask questions and pursue improvement in our system. For many teams though, this new style of thinking about their work is hard. It takes time, and frequently people say things like, “given the current demands we face to accomplish the work of care, we just don’t have the time to be so measured in our approach”. And they are right. Two things must happen.
Improvement Advisors need to work with teams to help them learn the skills of scaling down the questions they ask, the assumptions they want to investigate. At first, and perhaps always at the front line, PDSA cycles can be small. Question building (P) can take a few minutes, not an hour. Investigation (D) will be integrated into the work of the day, either as a short conversation or trying a normal activity or process in a different way. The reconciliation/production of new knowledge (S) will happen in real time for the person executing the test, and can happen rapidly through a huddle with the team. The next step (A) can similarly be accomplished quickly by understanding the direction of knowledge development being pursued. This last part is interesting because it means the leaders of improvement, the advisors, need a Meta perspective. While the team is a like a rally car driver looking at the road directly in front on them, the advisor is the navigator anticipating the turns ahead, predicting which questions to ask next and how new knowledge leads from one cycle to the next.
The experience of improvement can and should be an act of construction. Because it is difficult and because it is purposeful, the development of new knowledge about our systems and the improvement of their outcomes is a source of joy in work for the people who chose to pursue these aims. Over the long run, embedding the use of the Model for Improvement across a system can have the unintended positive consequence of raising the satisfaction of work, providing people across the system with a mechanism to be purposeful in creating an environment they understand and want to work in.
Next time…fundamental and reactive changes in the system…tinkering or transforming…
Improvement Science Consulting