Integrated Care Systems: Finding inspiration in unexpected places.

Hello Systems Thinkers,

This post recounts an email discussion a few of us had about an article Chris Ham of the the Kings Fund published last month on the subject of “Integrated Care Systems”, an NHS evolution of the concept of “Accountable Care Organisations”.  I shared an anonymised version of the email string with a friend in the systems/complexity community, who has an interest in the topic and he suggested I post it as a blog, so here it is.

The article in question can be found here:

https://www.kingsfund.org.uk/blog/2018/02/what-does-future-hold-integrated-care-systems

It’s a good article and our critique was not of the article or the author, but rather on the approach it describes and lessons we might learn from elsewhere.  As ever, the views expressed here are personal and not necessarily those of our employers, or any other organisations we’re involved with.

A conversation began

We were first made aware of the article when a group member shared it and said:

It’s getting hard to keep up with all the changes!”

Another group member quickly replied saying:

“It’s interesting that success in this setup, in the absence of aligned formal accountability, rests on organisations’ abilities to maintain a partnership approach. The level of maturity in the relationships between acute, community, commissioning, local authority etc will impact massively on Integrated Care System development.”

I agreed and jumped in with a reflection and comparison of a past experience working on the development of an altogether different type of mega-project:

Infections team spirit

“I completely agree.  I’m reminded of my experience on the Heathrow Terminal 5 (T5) construction project.  BAA moved heaven and earth to create an environment and contractual arrangements where trust between parties could flourish and as a result barriers to delivering evaporated.  I happened to meet a chap who is now senior position on the Hinckley C project a couple of months ago, who had also worked on T5. He described the T5 project has having a unique “infectious team spirit”.  And he was right. It was quite special and I still feel inspired by what was achieved by the project team; which included may different organisations

That didn’t come about by accident though.  There was enormous effort made to develop the supply chain to a place where that could occur, and then very specific and revolutionary approaches to contracting and pooling risk used.  A decade before construction even began, they realised they would need to take a new approach and set about creating an environment on other projects to start nurturing the new culture and approach and to develop the supply chain to a place where it could deliver T5.  Prior to that, there was no way the UK construction industry would have been able to deliver T5 on time and to budget.

A serious and deliberate approach

They really focussed on building the team.  It was all very deliberate.  I think a similarly deliberate and long term approach to developing the technical capability, environment and culture will also be needed to support the creation of sustainable “Integrated Care Systems”.  

The T5 approach wasn’t an Integrated Care System, but it was absolutely an Integrated project delivery system.  I think there are a lot of parallels.

Have a read of these articles.  They set out what an incredibly challenging project it was and the approaches to contracting BAA pioneered in order to deliver it.:

http://personalpages.manchester.ac.uk/staff/nuno.gil/Teaching%20case%20studies/BAA%20T5%20Agreement%20.pdf

https://www.nao.org.uk/defencevfm/wp-content/uploads/sites/16/2013/02/BAAPlcTerminal5.pdf

Back to Integrated Care Systems

Back to the article about Integrated Care Systems.  This paragraph stands out for me:

“Mutual accountability hinges on the existence of a high degree of trust and respect between organisations and their leaders. It also requires the establishment of governance arrangements that support collaboration while respecting the statutory responsibilities of these organisations. Integrated care systems have no basis in law and they depend on the willingness of the organisations involved to think and act as part of a wider system even when it may not be in their interests to do so.“

It describes perfectly what was achieved on T5.  Apart from the final sentence:

and they depend on the willingness of the organisations involved to think and act as part of a wider system even when it may not be in their interests to do so.“

I’m not sure how likely it is managers and organisations will act against their interests and without addressing this, they might struggle in the long term.  The reasons it might not be in an organisation’s interests to act as part of a wider enterprise are systemic.  Like they did on T5, the job at hand is to identify those systemic drivers of behaviour and address them. 

Chris Ham does identify this as a potential difficulty in the article where he says:

“……..workarounds are inherently unstable, even in the most favourable circumstances, and can only be sustained for so long.  Informal mechanisms such as memoranda of understanding and partnership boards to underpin decisions about the use of NHS resources have a part to play but may break down when difficult decisions arise. ” 

It’s not easy in public services

The point about the T5 project is that they deliberately created an environment, structure and contracts that meant all organisations were incentivised to pull together and do whatever it took to deliver the project.  That is why it worked. There was no fairy dust involved. 

It’s probably harder to do this in public services than it is in the private sector, where there is less political interference allowing for a longer term approach and accountability is more easily traced.  Accountability for the delivery of T5 lay firmly with the management of BAA and the company’s shareholders would hold them to account. 

But T5 is still a source of inspiration

Even so, we shouldn’t underestimate just how impressive an achievement it was for BAA to deliberately invest in and build up the capability of the UK construction industry to be able deliver a project as large and complex as T5.  It’s a great place to look for inspiration.”

Happy 10th Birthday!

And by happy coincidence, this month is actually the 10th anniversary of the opening of T5.

https://blog.heathrow.com/tag/terminal-5-10th-anniversary/

I will raise a glass to the project this weekend.  Join me.

Systems Thinkers Anonymous

Reflections on Systemigrams

Hello Systems Thinkers,

As promised last week, here is a post containing an blog comment and then email dialogue I had with STA friend and regular commenter Julian Johnson.  If you want to look him up, here is a link to Juian’s LinkedIn profile and here is a link to the website for his consultancy business, holistem.

The conversation is about what a “Systemigram” ought to be, and how that differs from an “Information Model”.  Julian has very kindly put together some slides showing how the canteen Systemigram we produced is actually an Information model, and another set of slides showing what a Systemigram might actually look like.  So, here are Julian’s slides showing how:

  1. The canteen set-up might be expressed as an Information Model – here
  2. The canteen situation might be expressed as a Systemigram – here

And here is the dialogue we’ve had.  It’s well worth reading. Thanks Julian.


Comment Julian left on STA blog week 27 on 3rd December 2016.  Here.

Tim, another great post from you, very interesting and thought provoking. A couple of (again I hope constructive) observations:

  1. On the nature of your systemigram: When I look at what you have above, this seems to be a less a systemigram (Boardman et al), and more a conventional information model (IM). So what is a conventional IM? Basically it identifies concepts in the domain of interest, and declarative relationships between them. It isn’t really about influence relationships, which is arguably the essence of a systemigram. In fact, if I take your diagram, and replace ellipses by rectangles, and arrows by (depending on notation) lines with a directed annotation label (UML class diag) or labelled ‘lollypop’ line (STEP modelling language), AND ellipse-in-ellipse by the appropriate supertype-subtype notation (open triangle notation in UML class diag), I’m about there. Its not that the diagram is wrong in any way, (in fact it appears very useful), it just (to me) seems to have moved from a systemigram underlying paradigm, to something else (IM paradigm).
  1. Pick your time comment: Cannot agree more. It often seems to higher up the organisation you go, the less attention span we find (rightly or wrongly), and the more things have to be reduced to primary colours. We’re talking seriously low end of ‘magic number 7 +/- 2’, if you know what I mean. However, in my experience, when getting something that can appear complicated / complex in a single diagram over, it is better not to through the whole diagram at the audience at step 1, and then explain all the elements, but more to build up the diagram on the blank paper / screen, so you end up with the whole picture, but you have brought an audience along, step by step. In fact, this is partly why some tools, like Insight Maker, have a storyboard capability…

Hope that helps…


Tim’s email response on 5th December 2016

Thanks Julian.

I do appreciate these comments!

I must admit that my head is now in my hands though (metaphorically).  I couldn’t quite get Rich Pictures, so I had a go a Systemigrams, and it turns out I’ve not “got” them either.

I wonder, reading your explanation, are Rich Pictures and a Systemigrams much the same thing, or rather serve a similar purpose form a similar perspective, but obviously produced with different media in a different environment?

Tim


Julian’s email response on 5th December 2016

Tim

“my head is now in my hands though”. Oh dear.

“I wonder, reading your explanation are Rich Pictures and Systemigrams much the same thing, or rather serve a similar purpose from a similar perspective, but are obviously produced with different media in a different environment?”

If I can interpret your question, there appear to be two parts to it:

  1.   That Rich Pictures and systemigrams are much the same thing, serving similar purposes and/or from a similar perspective;
  2.   They are produced with different media (notations) in different environments (tools).

First to respond to 2:

They could indeed be produced with the same tool, for instance, pen and paper / flipchart etc. (But so could any diagram regardless how ‘well formed’.) In terms of computer based tools, it would then start to depend how flexible the tool is. Basically both Rich Pictures and systemigrams could be said to be essentially node-and-link diagrams (essentially a visualisation of a ‘graph’, in maths of computer science speak). However, systemigrams appear to be stricter to the node-and-link paradigm, than Rich pictures, because they are essentially about one item (node, semantically a concept) being linked to one or more other items (nodes) via links (representing relationships). Systemigrams have another type of relationship, type-of, represented by the ellipsi inside another ellipse layout. Anyway, any computer based tool worth its weight that allows you to put diagrams together will have some awareness of the underlying ‘paradigm’. For instance, on a data flow tool, it would not allow you to connect a flow line directly to another flow line, only a flow line to a process bubble, or a process bubble to a flow line etc. We can see this when we use Systemitool, which only allows certain diagram constructs to be connected to certain others. I guess the nearest we can get to a rich picture tool is only something like powerpoint that generically has a large pallet of icons, symbols and various connector types, but is pretty free about where you put things.

As to 1:

Rich pictures and Systemigrams are similar to each other in that they are both pictorial views that a) help a group of people represent and communicate an understanding of a domain and b) are both used for early phases tackling complex / complicated or chaotic systems, often social technical, where ‘conventional’ systems development approaches tend to struggle. However, they differ (as representations) in that a) systemigrams are rather more constrained than rich pictures in the strict node-link metaphor above and b) rich pictures allow carte blanche in types of symbols, AND how they are placed. For instance, having a symbol representing a group of people labelled ‘project management’ and a second symbol representing a group of people labelled ‘engineering’ in some proximity on the diagram, and a drawing of a brick wall between them usefully communicates: these groups don’t talk. There is no explicit node-link construct, it is the simple placement that we see as a pattern.

My comment below: “…identifies concepts in the domain of interest, and declarative relationships between them. It isn’t really about influence relationships…” is the essence in a sense of difference between an IM view, and a systemigram view. This email is already too long, but if it helps [for your understanding], I’ll happy try find / create some examples to try to illustrate my expectation of the difference of typical IM and systemigram examples.

Regards,
Julian


Julian’s follow up Email on 12th December 2016

I’ve backed up from the week 27 canteen ‘systemigram’, given my observation that it appears closer to an information model than an systemigram, by building up an information model applicable to a canteen/ meals on wheels domain.

Attached is the result, which is basically a step by step build-up of a fledgling information model. I say fledgling as:

  •     I’ve not been explicit about capturing either requirements of what we are trying to achieve with such a model, nor with the use cases;
  •     I’ve not elaborated the nature of relationship ordinality (one-to-many, many-to-many etc)
  •     I’ve not elaborated many attributes that one would need to make the model ‘useful’.

However, you will see by the time you get the slide 8 which has the ‘full’ model (subject to caveats about AND any entity should have a definition) that the result is very similar (ignoring boxes rather than rectangles for concepts/entities, and straight versus arcs for relationships, and subtype representation is different) that there is much similarity; indeed I then hand marked with red ticks my paper copy of your systemigram, and may be 80% of items in your diagram are ticked (=covered).

In a separate response I’ll look at how my expectation on a systemigram would actually focus on how well (or poorly) a given canteen works (or doesn’t work) and it part why (or works or doesn’t work).

Hope this is of value to you… let me know!


Julian’s final email on 13th December 2016

Tim

Not hampered by tackling a real example, I’ve just tried to speculate a potential canteen and some of its issues. Attached is a slideset, where two of the slides are a prose explanation of some aspects that are ‘challenging’, and then the build-up of systemigram fragments. As you will see in the last slide, I came across some interesting issues, which probably means I need to (completely) read Boardman’s book properly, rather than just wing it. Anyway, I learned something by doing this anyway…

Hope it perhaps moves you a step closer to practical systemigrams, or at least, the distinction of systemigram to (say) information model?

Let me know if you go something (anything) out of this material…

Regards
Julian.

Julian Johnson, BSc, PhD, CSEP MINCOSE
Director, Chief Scientist, Holistem Ltd.
Julian.johnson@holistem.co.uk
+44 1254 209421
+44 797 442 8697

 

A Little Lull

Hello Fellows,

OK, so we were a little lazy this week.  We arrived at yesterday’s session with several of us feeling under the weather and most with our lunchtime sandwiches in hand.  Rather than dragging everyone down to business, we allowed some lunchtime conversation to flow, and flow and flow. It was a good conversation, largely focussed on systemic views of the health service both locally and nationally.  It was too sprawling and free flowing to make much of a blog post from though, so I won’t even try to do so.

So, we had a little bit of a lull in terms of both our sessions and this blog. Apologies if you came looking forward to your weekly update.

Don’t worry though, it’s only a sort of a lull.  In fact, there is lots of tip-top stuff going on and winging its way to the blog soon.  Our good friend and regular commenter/contributor Julian Johnson and I have exchanged a few emails recently.  He has been illuminating the similarities and differences between Rich Pictures and Systemigrams and how the Systemigram we produced of the canteen is actually more a standard “Information Model” than a true Systemigram.  We’ll work this up into a blog post.  It’ll be a good one.  Julian’s insights and contributions are always super helpful.

Secondly, I had a bit of an insight of my own this week when thinking about how one would put a strategy together for major service transformations.  I think I’ve come up with a practical approach for highly complex, uncertain and ambiguous environments (i.e. NHS at the moment), where top down reorganisations are the default, but often unhelpful, preference.  It combines the good stuff Jean Boulton has to say about a “complexity view” of strategy, Charles Lindblom had to say about “Muddling Through” and the “Last Responsible Moment” approach to making design decisions in large complex technical projects, such as  the Heathrow T5 build where I learned about it.  It may not be an original idea, but then again it just might be. It’ll take me a couple of weeks to develop and write up my thoughts, but I think it’s going to be an interesting and hopefully useful approach and I look forward to sounding you out.

Enjoy the weekend,

Tim

ASEC 2016

Hello Systems Thinkers,

A special guest….

The session yesterday was excellent.  We had a surprise special guest.  Well, a surprise in so much as it was arranged at the last minute.  The guest, was Matt, of the Royal Navy and MoD.  I’ve been talking to Matt about various opportunities and him attending a session for a little while, so when he got in touch yesterday morning to say he was available at the last minute, I of course jumped at the chance.

….and a trip to ASEC

I’ll write up a proper review of the session, including reflections from group members in the next week or so.  In the meantime, I thought I’d say a little bit about my trip to ASEC this week.  What on earth is ASEC I hear you say.  Well, it is the Annual Systems Engineering Conference which is organised by INCOSE UK.  It took place on Tuesday and Wednesday at the University of Warwick, and it was brilliant.

I’ve wanted to go to ASEC for a couple of years now, but haven’t been able to.  This year I got very lucky and was able to attend as a poster I submitted to the Academic Research Showcase was accepted.  I’ve become involved through STA in a pan European research project looking at different methods of innovation and how to both manage and teach them. The project is called the TACIT Knowledge Alliance.  Here is a photo of me standing next to the poster submitted.

TACIT poster
TACIT poster

And here is the poster itself:

TACIT poster
TACIT poster
So much good stuff

The event involved lots of talks and tutorials.  With several going on at any one time, choosing what to go to was not easy.  There were of course lots of opportunities to catch up with people I knew and also meet new people, including several good folk who are subscribed to this blog.  This was brilliant.  Spending 48 hours in the company of around 150 other people who were similarly into all things systems, was fantastic.  Really stimulating.

So, what were the highlights?  For me, I genuinely enjoyed every talk I heard, but I think the two standout sessions were the Service Systems Engineering Working Group session and also the Easy Approach to Requirements Syntax (EARS) tutorial.

The services working group

I was briefly a member of the Services Working Group earlier this year, but have had to step back from full involvement because of a lack of time.  It’s a shame, as it’s a fascinating and pertinent area, but it was great to catch up with where the group is at.  The group are looking at determining to what degree the regular INCOSE Systems Engineering (SE) approach (if there is such a thing) can be applied in the services domain.  We spent this session discussing the key differences between products and services and whether these matter when trying to use SE methods.  We worked on categorising services into various types based on different characteristics.

We only had an hour and a half, but the conversation and perspectives were fascinating.  In my view, services are all about the organisation that’s behind delivering them.  I think functional focussed approaches can be applied to the design of services, but I’m less sure about their applicability for the ongoing evolutionary development of them.  As we’re finding, our service design problems are often complex and wicked in nature.  I think Capability Engineering, and the approaches we’re learning about, which are better suited to dealing with socially complex situations are where we will also need to look. We’ll see.

EARS

Easy Approach to Requirements Syntax is a very neat way to write requirements.  It was created by Alistair Mavin. Who also ran the tutorial.  Alistair did a sterling job of teaching us this concise and robust way of writing requirements.  The word “easy”, refers to the difficulty of learning the method and language, rather than the actual job of defining requirements, which is never easy.

If you want to know more about EARS, here is a paper by Alistair I found on ResearchGate.  There are loads there, so have a look.

Easy Approach to Requirements Syntax

For me, a key insight I will take away from this session was something that Alistair said.  It was along the lines of:

“Customers don’t have requirements.  They have goals.  Systems have requirements.”

The example Alistair gave was of a car.for a fast car, a requirement might be that it can travel from 0 to 60 mph in under 6 seconds.  This would be a requirement of the car, a system.  It’s unlikely it would be a requirement of the customer though.  A customer goal might be to have a fast car that give a real thrill of speed when driven and impresses his/her mates.

The job of the Requirements Engineer is to take those poorly defined goals and turn them into technical requirements.  And if it turns out that producing a car that accelerates to 60mph in 5.8 seconds requires a larger and more expensive engine than a car that get to 60mph in 6.2 seconds, that requirement will need to be looked at and possible traded off to see if the customer goals can be achieved in a different way. Perhaps by adding some flashy chrome to the body work and tightening up the suspension.

What does this mean for us?

What does this mean for us in health services.  I’m not quite sure, so suggest we reflect on it and discuss.  It takes us back to the subject of patient outcomes.  How we determine what they are and then design systems that deliver them.  How do we determine outcomes, and then translate them into specific requirements for our systems?  This is a big question for us.

Back to normal

So, next week it’s back to normal. No ASEC, and no special guests.  We’ll get back down to Rich Pictures.  Please have a go at producing a new Rich Picture for the staff canteen.  Pick a stakeholder, or a perspective and have a go from that point of view.

In the meantime, enjoy the weekend.

Tim

Week 18 Part 2: Where in the world of Systems Thinking are we?

Let’s pause and think about thinking

We’ve charged head first into learning various tools and methods, but haven’t had much discussion about what Systems Thinking is and where the approaches we’re learning sit within the wider discipline.   We’re now on the verge of heading into learning about Soft Systems Methodology (SSM) and I thought it worth us taking an opportunity to catch our breath and talk about Systems Thinking more generally.

You’d think it’s all about System Dynamics

When you google “Systems Thinking”, the overwhelming majority of the top listings relate to the approach of System Dynamics and its proponents such as Peter Senge, Donella Meadows, the Waters Foundation and others.  System Dynamics is a valuable approach and is especially good for understanding relationships, causal effects and feedback loops between system elements.  

Another approach sitting high on the google rankings is John Seddon’s “Vanguard Systems Thinking”.  This is a kind of overhauled version of “Lean” specifically for service provision and has gained a lot of traction in the Public Sector here in the UK.  There is debate about whether it is genuinely a form of Systems Thinking or not.  Personally, I don’t intend to add to that debate, so will leave it there.  It is a good and useful approach in the right context, and the core concept of “failure demand” is particularly insightful.  Why not look it up.  Whether they are genuinely Systems Thinking approaches or not, these approaches have valuable uses and much can be gained from employing them.  

But there’s a problem.

Whilst they may dominate, these approaches only account for a very small part of what’s on offer in the world of Systems Thinking.  The problem comes when you tell people you’re into Systems Thinking, as they tend to think this is what you mean.  Well, it’s largely not what we mean.  Not to say there’s anything deficient about these approaches, it’s just that given our particular context, I don’t think they are the most useful for us right now.  

I hope we are going to be relatively agnostic in our approach and embrace the diversity of what is out there and become “mixed methods” practitioners.  There’s such a wealth of amazing stuff out there, with each approach having its strengths and weaknesses for any given context.  Here is an amazing map showing some of the incredible diversity and range of theories and approaches available to us:

http://www.scimaps.org/maps/map/map_of_complexity_sc_154/detail

Hard and Soft Approaches

System Dynamics, is from the “hard” school of approaches and is the dominant approach on the other side of the Atlantic.  Here in the UK, we use “hard” approaches extensively, where they are the more appropriate, but there has also been significant development in “soft” approaches. The term “soft system” is one coined by Peter Checkland when he created Soft Systems Methodology (SSM), but it has been extended to encompass the range of approaches created to help understand and intervene in complex situations involving humans, or “Human Activity Systems”, where “purposeful Activity” is being undertaken.

Are systems real?

One way “soft” approaches differ from their “hard” relatives is they don’t view systems as things that have their own objective existence. In this view, systems are not real things.  The operative word in Soft Systems Thinking is “thinking”.  It’s about using the various conceptual qualities of systems, such as boundary, purpose, structure and interrelationships to better understand messy real life situations.  There is a difference between thinking about systems and thinking in terms of systems.  Here is a quote from the Systems Engineering Book of Knowledge (SEBoK) describing this:

“The identification of a system and its boundary is ultimately the choice of the observer. This may be through observation and classification of sets of elements as systems, through an abstract conceptualisation of one or more possible boundaries and relationships in a given situation, or a mixture of both concrete and conceptual thinking. This underlines the fact that any particular identification of a system is a human construct used to help make better sense of a set of things and to share that understanding with others if needed.”
http://sebokwiki.org/wiki/What_is_a_System%3F

The System of Systems Methodologies

I am proposing we learn about SSM next.  I think it an appropriate method to support us in commissioning health services.  To give some perspective of where it sits in relation to other approaches, here is a very nice table called the System of Systems Methodologies (SoSM) created by Robert L. Flood and Michael C. Jackson.  It’s described and explored in their excellent book, Creative Problem Solving: Total Systems Intervention (I just checked and there are some second hand versions of this available for just £0.01 plus postage.  Why not treat yourself).  It also gives a good description of what Systems Thinking is and is not, as well as describing a variety of approaches and in what contexts it is most appropriate to use each.  I must admit I’ve copied this version of the table (to save me re-drafting it) from this rather good blog post about Critical Systems Thinking, another approach:
http://wulrich.com/bimonthly_november2012.htmlSystem of Systems Methodologies

For now, we’re in the Pluralist/Complex Zone

As commissioners, when we come to design new services, or intervene in existing ones, I think we’re very much in the pluralist/complex zone. Pluralist, because not all parties involved are directly under our control and will have different views, interests and motivations.  It is likely those interests are compatible though and an accommodation can be found, so ours in not a “coercive” environment.   It’s “Complex”, because as we’ve discussed previously, the problems we face in commissioning and intervening in services are “Wicked” in nature.

Having said that, if we find ourselves redesigning parts of our own or other organisations, we will likely shift to the left, a “Unitary” environment.  In that case, we would find a Cybernetic approach like the Viable Systems Model useful.  And if we find ourselves doing Lean, or Quality Improvement work within a single organisation we would drop into a less complex, simple/unitary environment and find an approach like System Dynamics useful.

The value is in matching approaches to contexts, not in the approaches themselves

To finish, I just want to make it clear that this System of Systems Methodologies is in no way a hierarchy.  I’ve observed some practitioners who tend to specialise in one approach, come to view their favoured approach as the “right” or “best” way to do Systems Thinking. I’ve also observed a kind of perception that there is more kudos and prestige in being involved in problems and approaches that are sited in the “Complex” domain.  I suppose it’s not helped by terminology such as “Simple”.  Perhaps we imagine that the less capable people deal with the “simple” problems, whilst we more impressive folk deal with the “complex” problems.  I think this is an unhelpful and wrong view.  As the SoSM shows, it’s about horses for courses, and selecting the most appropriate method for the problem you’re facing.  In our working lives, we’re likely to face organisational problems in all six of the zones.  Let’s just hope there aren’t too many in the Complex/Coercive space.

I’ve said we’re going to look at SSM next.  It seems to be the most appropriate approach for us, given our context, but I don’t want us to become attached to it, or personally identify ourselves with it.  I want us to be open to all approaches and to even get to the point where we are able to mix them.  We have to start somewhere though, and the best place for us to do that, seems to me to be with SSM.  Let’s see where it takes us.

Week 17 Part 2:  The relationship between Quality, Grade and Requirements….

…. and why being clear about each matters

This post is a catch up from week 17 where we had a spontaneous discussion about the relationship between quality and requirements and why improving the grade of a product or service will normally add cost, but improving quality will normally reduce cost.

The idea that increasing quality reduces costs seems counter-intuitive, but that is only because we’ve not understood what “quality” is, and importantly, how it is distinct to “grade”.  So here are some definitions of each from ISO9001, as defined by the International Standards Organisation (ISO):

Some definitions:

Requirement:  A need or expectation that is stated, generally implied or obligatory.

Quality:  The degree to which a set of inherent characteristics of an object fulfils requirements.

Grade:  The category or rank given to different requirements for an object having the same functional use.  For example, the class of airline ticket and category of hotel in a hotel brochure.

-Thanks to the International Standards Organisation (ISO) for the definitions. (https://www.iso.org/obp/ui/#iso:std:iso:9000:ed-4:v1:en)

And for clarity, “Object” is defined as:

An object is any entity that is either conceivable or perceivable. Objects can be real or imaginary and could be material or immaterial.  Examples include products, services, systems, organisations, people, practices, procedures, processes, plans, ideas, documents, records, methods, tools, machines, technologies, techniques, and resources.”  http://www.praxiom.com/iso-definition.htm#Object

Given that we are using ISO9001 definitions, I suppose it’s only right to explain a little about what it is.

“The ISO 9001 standard provides a framework of globally recognised principles of quality management, including: customer focus, leadership, involvement of people, process approach to management, continual improvement, factual approach to decision making and mutually beneficial supplier relationships. These are also known as the eight key principals of quality management.”  – http://certificationeurope.com/what-is-iso-9001/

These definitions of Quality and Grade are applied across the world in the discipline of Quality Management.  In manufacturing, services, agriculture and pretty much anything.  Some industries have specific variants on the base standard, for example I was involved in managing an AS/EN9100 Quality Management System (QMS) when  I worked in the aerospace design and advanced engineering  sector, but that standard is essentially ISO9001 with some industry specific variations.

ISO9001 isn’t perfect, but it’s pretty good

It’s not all good news with these standards.  They can be bureaucratic to administer and whilst that’s fine  for a stable organisation in a relatively stable market, for a more dynamic organisation  in unstable markets, it can be difficult, if not impossible to maintain all company procedures appropriately documented and audited, as certification  requires.

That was certainly my experience later when playing a leading role in transforming a construction company into a primarily logistics oriented one as a result of the highly unstable market conditions that existed post the 2008 financial crash; and the need for us to develop new services for new customers to stay in business.  The idea of  maintaining a fully compliant ISO 9001 QMS in that situation  is hard to square away. Similarly, it shouldn’t be allowed to constrain any positive change or transformation in an organisation.  It is not intended to, but through  it’s (inappropriate) application, that can be problem.

So, it’s not without it’s problems, but at it’s heart it is a sound approach. For our purposes, what I think is really useful and important is how it defines Quality and Grade. To reiterate the definitions above;

  • Quality is about the degree to which requirements are fulfilled.
  • Grade is about what the requirements actually are compared to the requirements for other products in the same category.
  • Quality is independent of Grade!
Do we mean grade rather than quality then?

People often confuse the two, or simply don’t know there is a distinction.   I’ve foud this to often be the case in healthcare. In a sense, that’s fair enough.  Industries can use whatever terminology they like to mean whatever they like.  However, if “quality” means “grade”, then what word is used to refer to “quality”, or rather, services that don’t fully satisfy requirements? I’m not aware there is one.  

In practice,  I think they’ve been merged into a single concept. And maybe that’s ok. After all,  we are offering a standard service to all.  A single grade I suppose.  The difficulty,  is that it’s not entirely clear that we’ve formally defined, recorded and agreed the requirements  or purpose of our services and systems.  We found it hard to do this for a GP practice if you cast your mind back, and we weren’t aware of a Requirements Document we could refer to.  How do we know if we are fulfilling requirements if we haven’t defined and documented them?  

Leaky windows

It’s not unusual to hear people in our and  other industries say “we can’t afford to provide a higher quality service.” or similar.  This might be a problem though.  If we understand quality to be about the degree to which requirements are satisfied, rather than what the requirements are, then we can see that ultimately we can’t afford not to increase quality.  Why is this?

If the basic requirement of a car is to get the driver from A to B in comfort, and there is an aspect of it, a leaking door seal perhaps, that prevents it from  doing that, then the car will be returned to the manufacturer to be repaired.  Or the problem may be picked up by “Quality Control” before it leaves the plant and repairs are made at that point. There are costs associated to this.  The costs of identifying the problem, and then fixing it.  These costs are specifically associated to poor quality.  You have to fulfil requirements.  There are no two ways about it. You have to.  And if you don’t, you will have to pay to correct the problem.

Providing it satisfies the requirements of a typical buyer, a brand new Dacia without a leaky window is actually a higher quality car than a brand new Rolls-Royce with a leaky window.  Presuming both sets of buyers have a requirement to arrive at their destination dry.  Of course, the Rolls-Royce is a far higher “grade” of car though. It will have all sorts of additional requirements on it the Dacia doesn’t, such as speed, comfort,  the degree to which it impresses your mates, etc. Quality and Grade are independent of one another.

Increase Quality to reduce cost

In health services, there will be a myriad of requirements on any service, but for the sake of argument, let’s assume a basic and fundamental requirement on all health services is to diagnose and cure, or treat as far as is medically possible (given  NICE sanction) a presented condition. Ultimately, this has to be fulfilled, or patients will unnecessarily die, or live with  unnecessary suffering.  They and their relatives will know this, and so they will keep presenting, or be passed around different parts of the health service until the requirement is satisfied (assuming it can be).

This is all the cost of low quality.  And worse than that, if the requirement isn’t fulfilled quickly, their health can worsen, and ultimately cost more to put right.  I have personal family experience of this, and sadly, I imagine many others do too.

So, increasing quality in a health service is about identifying and treating conditions as quickly and appropriately as we can, whilst treating people as individually and kindly as possible and it is not about “gold plating”. That would be “Grade”.   When we talk about “getting things right first time”, this is what we are talking about, Quality.

A tough job in public services

I don’t underestimate how difficult this is to do in public  services though. I think one particular challenge we have is defining the requirements and in turn  the grade of the service we should offer.  We all have individual personal expectations and requirements for all things that we buy and consume.  Ideally, all products and services would be produced for us individually.  This would not be economical though.  To get around this, companies will segment their customers into groups, generalise requirements for each of those groups and produce offerings for each and importantly, charge accordingly.

If we think about laptop computers, manufacturers will produce a wide variety of models, each aimed at a different category of customer.  The medium performance, but robust build quality for the person who needs it for work, the cheap and cheerful basic machine for the home user on a budget, the high performance machine  for those who work with graphics, and the good performance in a shiny, slim package, for the trendy person who wants to impress their mates.  Each of the options described will be priced differently to reflect it’s grade.

One difficulty we have in public services is that we need to offer a standardised service for all.  We can’t “charge accordingly”. It’s not possible to do this, and satisfy everyone’s requirements, and so there is a lot of compromise and accommodation going on along  the way and effort to try to provide services that more or less satisfy most people’s requirements. A kind of service for the “average” patient.  

For health services, the core functional requirement of making people better will be the same irrespective of grade, but there will be decisions made around waiting times, length of time it takes to treat, and other service elements like comfort of facilities, and where services are provided (hospital, GP practice, or at home) etc. i.e. Non-Functional System, Non-Functional Implementation and Non-Functional Performance Requirements.

It seems to me that all of this requires debate at national and local levels between patients, taxpayers, government, commissioners, providers, suppliers, lobbyists, activists and probably others too, to come  to an accommodation over what the grade of services should be. This is no mean feet! There are a lot of stakeholders to accommodate in  public services.  It’s a much bigger job than a manufacturer has when categorising customers and  defining their requirements.  

This does beg the question how one goes about defining the concept of “Value” in health services, but let’s leave that for another day.  There’s also the  question of the role “Outcomes” play in all of this. A central one. We should also need remember what Jean Boulton had to say about the things that really matter often can’t be easily measured quantitatively. How does that fit with this approach to Requirements and Quality.  Lots of swirling questions for us to keep in mind as we continue this journey.

Does it really matter?

Why does all of this matter to we Systems Thinkers.  Well, as we’re discovering, “Requirements” are a very close relation to a system’s “Purpose”.  So quality is about the degree to which something  is “fit for purpose”.  Before we can determine whether a product of service is fit for purpose, we need to have a clear understanding of exactly what it’s “purpose” is, and that is exactly what we have been doing in this group.  You may not have realised you  were learning  about “quality” as well as problem solving and design, but you are.

The momentum builds

Hello Systems Thinkers,

We’re going public

I’ve some good news to share.  Word of our efforts are spreading and I’ve been asked to give a talk about our excellent learning group at the upcoming Autumn Open Meeting of Systems and Cybernetics in Organisations (SCiO).

The event  is in  Manchester on the 17th October.  I’ve been to a couple of SCiO Open Days now and they are excellent.  They always have a set of talks covering a diverse set of systemic approaches to approaching organisation, management and leadership.  They are real melting pots and the questions, conversation and debate that follow on from talks are always rich and powerful learning experiences.  Here is a link to the event promo page. Take a look, as the other speakers look brilliant.  

http://www.scio.org.uk/node/7456

We’re part of a wider community

I’m thrilled and honoured the community view our efforts in STA to be worthy of a platform at this event.  I’ll try to capture the spirit of adventure we’re taking in our efforts to intrapreneurially improve our individual capabilities, joint capabilities and those of the organisations we work for. I mentioned in  a post a week or two ago that I’m genuinely proud and impressed with the way you group members have taken to and stuck with this and I will make sure that is communicated.  

We’re doing something special together

We’re beginning to gain  some real momentum, with spin off projects being set up by “sub-groups” now to look at specific topics. I’ve recently said in conversation to a couple of you that I think we’re doing something quite “special” here.  That’s not to say special in a sense that we deserve fame and glory.  I mean special in the sense that we’ve tapped into a ground-up approach to learning that’s genuinely working and there is a real sense of fun, productivity and for me at least, personal fulfillment in what we’re doing.  This self-directed approach isn’t the norm in our top-down “command and control” type hierarchical supraorganisations.

We’re not alone

Back to the talk, but also following on, I will be sharing the stage with a chap I know called Mike Haber.  Interestingly, he is also leading a Systems Thinking oriented learning group where he works.  The approach he, and his group are taking is different to ours, but at its heart is the same spirit of bottom up personal learning and development.  We’ll be doing a kind of compare and contrast of the two groups and why we’ve taken the approaches we have.  I hope we will draw out what others who may be interested in setting up their own  groups, and I hope others will, should think about and focus on.  Like I said above, I think there is something quite special about being in an active learning group and any advice and help we can offer to others so they might enjoy the experience, we will.  And on that subject if there are any readers of this blog out there who are thinking of setting  up their own learning group, please don’t be shy, just get in touch.

After a break, it’s time to tend the allotment

Good evening Systems Thinkers,

Big thank you to Gary Smith

Yesterday, we were extremely fortunate and privileged to have Gary Smith come to speak with us.

Gary is a seriously bright guy.  I already knew that, but what I hadn’t quite appreciated is just how deep a systems thinker he actually is and in particular, his incredible appreciation of systemic human interconnectedness.  Thank you Gary, I feel like I was missing something important that you’ve helped reconnect now. 

The session has given me a jolt and left me asking some questions about the direction we’re taking.  Perhaps we need to mix in more systems theory and philosophy and investigate the emotional and sensory apsects of being a good systems thinker, as well as plugging away with the practical tool kit we’ve been learning.  You thoughts are welcome.

I’ll write up a full reflection on the session and get it posted.  If you were there, and would like to add your own thoughts, please do note them down and let me have them.

Harmonised Requirements

Now, I know you’ve really missed having homework the past couple of weeks, so here is some for next week’s session.  I propose we revert back to our plan of do a show and tell of the two purpose Tree Diagrams we built.  To help us in our discussions about them, it would be good to improve our understanding of defining different types of Requirements.

I  realised my understanding of how to define and classify requirements isn’t up to scratch and that left us floundering a little when trying to do it, so if we can all read the linked document below and learn together, that will be great.  So, here’s the reading, the Harmonised Requirements Model:

http://www.burgehugheswalsh.co.uk/Uploaded/1/Documents/HRM-Tool-Box-V1.0.pdf

The Harmonised Requirements Model is quite a technical approach and there’s quite a bit of detail to digest and understand in this paper, so please do try to read it a couple of times, and not at the last moment.

Hard or Soft

This is an approach from the “hard” side of systems approaches and more commonly used in Systems Engineering of physical systems, rather than the “soft” approaches we are focussing on for use in systems involving human interaction, or Human Activity Systems as they’re known.

I think that is OK though.  It’s certainly OK to use this approach when you’re designing a stand alone service I think and the problem is relatively tame. That may or may not be the case with our allotment example. We can discuss that.

I also think this is a very helpful approach to help us gain a deeper understanding of requirements that relate to function, operation, performance etc.  It will give us a better understanding of how to describe systems and their purposes, before we get into the more comprehensive “soft” approaches.  This is should give us a good grounding.

So, enjoy your weekend and i look forward to seeing you next week.

Tim