M2: Handout for Davis Balestracci’s “Data Sanity” Minicourse

Overall Rationale for Minicourse [See also quotes on pp. 24-26]

I just want to make sure you realize what you’re getting into with this minicourse. Its concepts will challenge you and push many of you way out of your comfort zones. Regardless of your improvement experience, I’m willing to bet that this will be a totally new way of looking at – and approaching – organizational improvement – an approach that may even go counter to a lot of what you will hear at this year’s Forum. If this thought intrigues you and excites you and if you can stay open to a radically new “belief system” about improvement – i.e., “built-in to DNA” vs. “bolt-on to current culture” – keep reading. I daresay that you will become effective beyond your wildest dreams and finally get the respect for your role that you deserve.

Table of Contents

Part 1: Rationale and Scope Overall rationale framing today’s Minicourse pp. 2-3 A “reference” from Dr. Donald Berwick p. 4 Framing the day and its content p. 5 [live links] BRIEF Articles by Davis on seminar content pp. 6-7 [live links] “Big Picture” roadmaps of today’s seminar p. 8 Five KEY concepts of the day pp. 9-10

Parts 2 and 3: Transforming from Data INsanity to Data Sanity Key example: Important display and calculation p. 11 “Déjà vu” Scenarios for Minicourse Dialogue pp. 12-17

o Mid-year Progress Report: Complaints p. 12o The end-of-year performance report: Are we green? p. 13o Everyday work?

The every-two-week budget meeting p. 14 “I’m going to cut your overtime budget.” p. 15 “We need to improve our patient satisfaction scores!” p. 16

Seven Everyday Statistical Traps p. 17

Part 4: “Those Darn Humans” Major Points Key Skill: QBQ! p. 17 Auditing your culture regarding ‘improvement’ p. 18 Applying QBQ! to your everyday work behavior p. 19 Feedback/Perception, ‘Homework,” and B2 Mantras for Success p. 20 John Dew’s seven true root causes (?) – Are you “perfectly designed?” p. 21 Create cultural “Will” and “Belief” by your “Wherewithal” p. 22 Go back, observe, and be honest: What’s being “telegraphed” (B1)? p. 23

Key quotes shaping rationale of Minicourse pp. 24-26Post-seminar highly recommended readings, references and “nuggets” and

Davis and Paige’s contact information p. 27 [live links]

Davis Balestracci and Paige Hector M2 Data Sanity 1

Overall Rationale for Today’s Approach: Excerpts from Introduction to Data SanityAs so many of us have painfully discovered, true progress can seem virtually glacial. The time has

come for people in improvement roles to be far more pro-active in working cooperatively in true partnership with boards, executive management, and physician leadership in addition to staff. “Data Sanity” is both a catalyst and conduit to do this. It demonstrates a new way of thinking via a common organizational language based in process and understanding variation to motivate more productive daily conversations…for everyone. Most of you will find this suggested innovative roadmap quite challenging; but the rewards awaiting you are many.

DATA INSANITY CONTINUES UNABATEDThe rampant waste caused by poor everyday organizational use of data continues. Many high level

executives have no idea of the vast potential that exists to have their organizations take “a quantum leap to unprecedented results” through the common language alluded to in the last section. I call it “data sanity” – new, more productive conversations in reaction to the everyday use of data and the resulting meetings and actions.

In executives’ defense, given their experiences with business school statistics courses and the statistics taught by the consulting groups many hire, I must say this lack of awareness truly isn’t their fault! It’s time for people routinely working in improvement to own this, stop the excuses, stop training that is nothing short of legalized torture, stop tolerating the executive attitude of “give me the 10-minute overview,” and do something (else) about changing their perceptions of improvement and, especially, statistics.

To be fair, many people in improvement have had the exact same experiences with statistics in required courses, on-line belt training, and project facilitation training. They are naively passing on the only experience they know. All of this is the wrong focus – and the wrong material. Implicit in these is an approach that is “bolt-on” to the current ways of doing work.

Regardlesss, as the minicourse will demonstrate: Whether or not people understand statistics, they are already using statistics.

According to Mark Graham Brown, proper organizational use of data has the potential to reduce senior management meeting time by 50 percent and eliminate one hour of a middle manager’s time every day poring over useless operational data reports (60% of which are waste) – Time that can then be spent on organizational transformation and generating more time for your front-line to do what it likes best – patient care.

IT COULDN’T BE SIMPLER: “PLOT THE DOTS” AND WATCH THE CONVERSATIONS CHANGEStatistical training needs major surgery. It should no longer teach people statistics, but instead

teach them how to solve their problems…and make lasting improvements by thinking critically.

Data Sanity is an intriguing alternative that can be hardwired or “built-in” to your current culture. All it requires of participants are the abilities to: (1) plot data in its naturally occurring time order, (2) count to eight, (3) subtract two numbers (this “advanced” technique could involve some borrowing), (4) sort a list of numbers, (5) use simple multiplication and addition, and, most important, (6) think critically, which is missing in most training.

It is time for boards, executives, and middle management (and improvement professionals!) to discover the unknown and untapped power of some basic tools that will cause a profound change in conversations…and results. One must learn how to stop boring these powerful people to death and, instead, become willing allies in getting them desired results beyond their wildest dreams.

Leaders can no longer continue to abdicate their responsibility for learning basic methods for routinely understanding and dealing with variation. And it’s also time for promotions to reflect a person’s willingness to use them routinely, be successful with them, and teach them to their direct reports.

Davis Balestracci and Paige Hector M2 Data Sanity 2

THERE IS NO “MAGIC BULLET”Be careful: Books and consultants continue to try their best to seduce you with (ultimately

disappointing) easy answers, templates, and fancy Japanese words. I promise you realistic, practical answers that may not initially seem easy, but will address deep causes, get your desired results and hold these gains…if you have the wherewithal to learn and apply a new “belief system” to your daily work..

At this moment, a technique called “rapid cycle PDSA”(Plan-Do-Study-Act) is ubiquitously being touted as the “cure all” – and it might be…if used in conjunction with good critical thinking skills. If any of you have tried it and are frustrated, you have good reason – and it’s called “human variation.” It’s also time to take a realistic view of the “bolt-on” teams using rapid cycle PDSA and their inevitable problems that we’ve all experienced, both as members and facilitators.

My respected colleague Ron Snee cites six common mistakes continue to be made despite what has been learned in the last 30 years:

Failing to design improvement approaches that require the active involvement of top management

Focusing on training rather than improvement

Failing to use top talent to conduct improvement initiatives

Failing to build the supporting infrastructure, including personnel skilled in improvement and management systems to guide improvement

Failing to work on the right projects—those that deliver significant bottom-line results

Failing to plan for sustaining the improvements at the beginning of the initiative

I remain more convinced than ever that any solid improvement theory comes from the late W. Edwards Deming’s teachings. The basic tools and statistical theory underlying them have barely changed since his death in 1993. If anything, I have made their applications even simpler.

I agree with Snee’s observations on the six mistakes above. My goal is to help you create organizational cultures where the words “quality” and “statistical” are dropped as adjectives from programs because they are “givens.” [And, by the way, YOU are the “top talent” to which Snee alludes!]

Improvement methods may come and go, but the need to improve performance and the bottom line never goes out of style.

MY FINAL CHALLENGE: ARE YOU READY TO SAY “ENOUGH!” TO YOUR STATUS QUO?The time is now to:

manifest more effective executive engagement (and development), use everyday “data sanity” as a philosophy and conduit for organizational

transformation, utilize data more deliberately and efficiently in improvement, and create an everyday culture of improvement through leadership where key results can be

hardwired and built-in to cultural DNA.If you have read this far and are still intrigued and interested, then welcome, my newfound

companion and colleague, to a transformational journey. I hope you will respond to and learn from the many challenges that await.

[Note: Data Sanity is used as a text in the Mayo Clinic improvement curriculum (scroll to 9:00 in the following): https://www.youtube.com/watch?v=f-FbIA3ezBw&app=desktop ]

Davis Balestracci and Paige Hector M2 Data Sanity 3

Excerpt from FOREWORD to Davis Balestracci’s Data Sanity: a quantum leap to unprecedented results

Donald M. Berwick, MD, MPP

When I first encountered modern quality theory, I thought it was simple: A pinch of new statistical devices, a dash of participative management, a teaspoon of processes-mindedness, and, voila: breakthrough. I was wrong, but good fortune gave me mentors with the patience to let me learn step-by-step. Otherwise, I might have run away, daunted, from what has since become a life-long learning task.

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To guide us properly through this immense landscape – the vast technical terrain of each of the elements of Profound Knowledge, the adaptation of technique to the world of executive behavior and organizational leadership, the linkages among all of that, and the translation of theory into recommendations one can act on – requires either a large faculty or a rare polymath. Davis Balestracci is the latter: a polymath.

I have known Davis for almost two decades, and have seen time and again the reach of his intellect and imagination. One manifestation is his almost unparalleled mastery of the writings and literature of quality improvement. He can cite more authors with more authority and inclusiveness in the fields of improvement than perhaps any other writer of the last few decades except Joseph Juran, himself. He by no means stops at the usual boundaries. He explores ideas in eastern philosophy, poetry, and history, and brings back to us lessons, insights, and pregnant quotation over and over again. My email “inbox” has a folder called, “Davis,” in which I have learned over the years to store his messages with clever, unexpected references and stories that later on, often years later, will become relevant to my own learning or projects.

In this book, Davis packs together his decades of study and experience in a form accessible to readers at almost any level of maturation. So wide is his reach and so clear are his interpretations, that, in offering this resource, he can save learners a great deal of the time and energy they would need to devote on their own to knitting together the lessons from dozens of scholars on dozens of topics. For the novice, no single book on improvement offers a more complete and accessible summary. For the intermediate, no other source is more likely to resolve areas of chronic confusion, such as in statistics or the psychology of motivation. For the master, no overview will have a longer shelf-life in offering great examples, pithy vignettes, or linkages among topics to draw upon for both personal learning and resources for teaching others.

And, for anyone interested in the wide, wide field of improvement and its related sciences, no other book offers more discipline and wit wrapped into a single, enjoyable package.

Davis Balestracci and Paige Hector M2 Data Sanity 4

Part 1: Framing the day and its content

In a nutshell, the three articles below frame the minicourse (important): “Has the Pareto Principle Come Home to Roost”:

http://www.qualitydigest.com/inside/twitter-ed/pareto-principle-coming-home-roost.html

“The Sobering Reality of Beginner’s Mind” [Why I teach this to MBA students]http://www.qualitydigest.com/inside/quality-insider-column/sobering-reality-beginner-s-mind.html

“Are You Becoming a ‘Qualicrat’?”http://www.qualitydigest.com/inside/twitter-ed/are-you-becoming-qualicrat.html

Bottom line: Could what happened below still happen today at your organization? If so, what’s truly changed? Addressing these types of issues is truly integrating improvement into organizational DNA:

Hacquebord, H. (1994). Health care from the perspective of a patient: Theories for improvement. Quality Management in Health Care, 2(2)2, 68-75. [live link directly below] Note: 20 years old!

https://www.qualitydigest.com/IQedit/Images/Articles_and_Columns/December_2011/Special_Health/Heero_back_surgery.pdf [actual article]

Back surgery experience insightfully observed entirely through the lens of improvement theory (specifically Deming). Addressing the issues in this article would be true “improvement as DNA”!

http://archive.aweber.com/davis_book/K.sWM/h/From_Davis_Balestracci_Be.htm [Davis’s comments]

Hard reality of projects and teams…and PDSA [Are you in denial?]: Activity is Not Necessarily Impact: FOCUS! [Work on “5-Star” projects]

http://archive.aweber.com/davis_book/EDHNT/h/From_Davis_Balestracci_.htm [Wisdom of Matthew E. May]

How about applying critical thinking to the process of using Rapid Cycle PDSA?http://archive.aweber.com/davis-newslettr/76Wtr/h/From_Davis_Balestracci_.htm

“Quality Turf wars”: http://www.qualitydigest.com/oct97/html/cover.html [from 1997: still true? (YES!)]]

Minicourse’s Design and FormatThere is “method to Balestracci’s madness” of not letting you follow along with a slide deck. It will be

explained in the minicourse when I talk a bit about adult learning.

[For people reading this who are not taking or did not take this minicourse and are intrigued by the approach: We recommend the Joiner or Balestracci references given on page 27 of this document – this is a totally different mindset from what many of you are used to, and it’s necessary for seeing beyond this material’s elegant – and deceptive – simplicity]

Participants: Take notes and ask us questions any time and at the break. We can continue the dialogue via e-mail or an occasional phone call. Paige and I won’t disappear after the Forum!

There will also be extensive dialogue during the minicourse that we will facilitate within the changed mindset.

Davis has done extensive publishing of many “one-pager” and “one-to-two pager” articles on key concepts. They are listed in this document on pages 6, 7 and 27 with “live” links directly to articles.

o I feel that follow-up reading using these BRIEF explanations of key concepts – written in the conversational style in which I teach – will be more valuable.

We are absolutely delighted to follow-up on any questions with you via e-mail:

Davis: davis@davisdatasanity.com. Paige: paigehector@gmail.com

phone: 207.899.0962 phone: 520.955.3387

Davis Balestracci www.davisdatasanity.com 5

BRIEF (easily read in 5 minutes) articles by Davis Balestracci that cover key concepts from this minicoursePart 1: Rationale – Davis’s reviewing some history of the IHI Annual Forum to motivate seminar design rationale:

http://www.qualitydigest.com/inside/health-care-article/isn-t-it-time-we-consider-overlooked-problems.html

http://www.qualitydigest.com/inside/health-care-column/evolving-beyond-platitudes-holistic-improvement.html

http://www.qualitydigest.com/inside/health-care-column/new-conversation-quality-management.html

Parts 2 and 3: Data INsanity and Data Sanity1-2 page “Statistical Corner” articles by Davis for Quality Digest covering main topics of today:

TQM, Six Sigma, Lean and…Data? [Trust me: they’re all the SAME!]http://www.qualitydigest.com/july06/departments/spc_guide.shtml

Dialogue between Davis and World Quality Leader [Why leaders must understand variation!]o People LOVE Rankings -- http://www.qualitydigest.com/sept06/departments/spc_guide.shtml

o I Now Understand Why Deming Was Such a Curmudgeon http://www.qualitydigest.com/oct06/departments/spc_guide.shtml

Why avoid commonly used bar graphs? – easy: most of them are worthless!http://www.qualitydigest.com/june06/departments/spc_guide.shtml

Sick of Boring Meetings that Waste Your Time? [Beware of trend lines and direct two-point comparisons]

http://www.qualitydigest.com/sept05/departments/spc_guide.shtml

A Common Cause Strategy for Count Data [Pareto matrix concept: uses data from article above]http://www.qualitydigest.com/oct05/departments/spc_guide.shtml

Statistical Stratification: Part 2 (p-charts)http://archive.aweber.com/davis-newslettr/7E07T/h/From_Davis_Balestracci_.htm

The Wisdom of David Kerridge: Statistics and reality--Part 1 [dealing with “clinical trial” mindset of physicians, which is NOT RELEVANT to real, everyday world]

http://www.qualitydigest.com/dec07/departments/spc_guide.shtml

The Wisdom of David Kerridge: Statistics and reality--Part 2 http://www.qualitydigest.com/jan08/departments/spc_guide.shtml

It’s Time to Ignore the Traffic Lights (Example shown in minicourse)http://www.qualitydigest.com/july05/departments/spc_guide.shtml

The first two common cause strategies:o http://www.qualitydigest.com/inside/quality-insider-article/wasting-time-vague-solutions-part-1.html

o http://www.qualitydigest.com/inside/quality-insider-column/wasting-time-vague-solutions-part-2.html

Are You Using SWAGs? [Important article: shows a common WRONG analysis that I suspect will be very common to determine “pay for performance”]

http://www.qualitydigest.com/jan06/departments/spc_guide.shtml

Think you Know Balanced Scorecards? Think again… [your “Homework” scenario]http://www.qualitydigest.com/sept07/departments/spc_guide.shtml

Root Cause Analysis? Be Careful! (contains a very insightful explanation from an American Society for Quality member):

http://archive.aweber.com/davis-newslettr/CFmRX/h/From_Davis_Balestracci_.htm

Davis Balestracci www.davisdatasanity.com 6

Part 4 – “Those Darn Humans!” Transitioning your role to get the respect you deserve

Cultural resistance / psychology – a practical, realistic approach:

**The BASIC behavior model (human and organizational) introduced in the minicourse: http://www.qualitydigest.com/inside/quality-insider-column/frustrated-glacial-improvement-progress.html

http://www.qualitydigest.com/inside/quality-insider-column/frustrated-glacial-improvement-progress-part-two.html

http://archive.aweber.com/davis-newslettr/OgmhH/h/From_Davis_Balestracci_.htm

A universal statement from good improvement practitioners: A transforming organization is going to need a culture of feedback and coaching – and LOTS of it.

The absolute best resource for the type of coaching needed is The Heart of Coaching by Thomas

Crane.

o Download the first three chapters FREE at: www.craneconsulting.com .

A new definition of “personal accountability” (for us as improvement professionals and for our cultures)

o John Miller ( www.qbq.com ): QBQ: the Question Behind the Question

[Can be read < 1 hour. I use it as pre-reading for retreats]

Content overview: http://www.youtube.com/watch?v=bdBwkOgww_Y

[Note: Davis and Paige have NO commercial interest with either Thomas Crane or John Miller]

Davis Balestracci www.davisdatasanity.com 7

“Big Picture” Roadmaps

[Figure from www.jimclemmer.com ]

Today: Skills and Needed Mindset to “Build-in” Improvement into Organizational DNAShort-term Roadmap1. Top management awareness and deep knowledge of what I teach you today

Learn and apply in everyday work: Process thinking

Eradicate blame

Problem-solving tools Statistical thinking & “plotting the dots”

2. Post IHI. Build a critical mass: 25-30% of executives / management demonstrating their commitment to improvement [Focus post-Forum efforts here to create this critical mass]

Beware one time “spray-and-pray” events to culture at large motivated by the logic that knowledge = changed behavior. [Stop ALL “spray-and-pray” type education.]

(Only) 20-30% of organization needs to be educated in improvement theory (Only) 10-20% of organization needs to be trained in basic tools for improvement (Only) 1-2% of organization needs to be trained in advanced tools (“belts?”)

Promotions based on demonstrating changed behaviors regarding improvement

Ultimate goal: ‘Improvement’ as a way of life [4-6 year journey?]. Use as a barometer: “Am I routinely observing…?”

Customer orientation * Adherence to best-known methods Continuous improvement * Use of best available tools Elimination of waste * Respect for people and their knowledge Prevention, not detection * Results-based feedback:

emotionally intelligent

Davis Balestracci www.davisdatasanity.com

Many organizations are trying to “bolt-on” a “built-in” culture without giving up control (i.e., “traditional management” tendencies) – it just won’t work.

See: When Transformation is Involved, “Just DO it!” WON’T do it! http://archive.aweber.com/davis_book/5PKtM/h/From_Davis_Balestracci_When.htm

8

Reduction of variation culture Statistical thinking and use of data

Davis Balestracci www.davisdatasanity.com 9

Five KEY Concepts of the day1. Improvement “Pyramid” 2. Key

Model for Human (AND

Organizational) Behavior

Most organizations are stuck here because they think “logic” will be enough: Engines need Fuel=======================================

3.Davis Balestracci www.davisdatasanity.com 10

EVERYTHING is a process

4.

4. Why “traditional” statistics courses don’t work in the real world A visual of why the statistics you are taught

in a “basic” academic course are many times NOT

APPLICABLE in the real world – NO concept of either

“process” or HUMAN variation.

Unfortunately, the computer will do anything

you want.

The more you know what is wrong with your

data (“human variation”) the more useful it becomes.

The following brief newsletter explains things

further and shows the example I did during the

seminar comparing three hospitals: http://archive.aweber.com/davis_book/52KHQ/h/From_Davis_Balestracci_Old.htm

5. Brian Joiner’s “Levels of Fix” [from Fourth Generation Management]

Push for “deep level” fixes:http://archive.aweber.com/davis_book/ADapE/h/

From_Davis_Balestracci_.htm

Davis Balestracci www.davisdatasanity.com

Unless your improvement process is

consciously based on this framework, you

will not be solving the “deeper” problems of

which no one is aware.

Focus on reducing the “four Cs” of

confusion, conflict, complexity, and chaos

and the “other C” – costs – will go down.

Focusing solely on costs will increase

confusion, conflict, complexity, and chaos –

AND costs!

11

Elegantly Simple Example: “After that downward trend, why did we go back up?”

Bacteraemias Sorted Order Moving Sorted[TIME order] Range Moving Range

10 2 * 0 7 3 ABS (7-10) = 3 1 3 3 ABS (3-7) = 4 210 5 7 2 10 6 0 3 8 6 2 312 7 4 3 8 7 4 4 6 8 2 4 MRmed: Avg. of 7 8 Median: 10

TH 1 4 9th and 10th = 4

13 9 [9 smaller, 9 larger] 6 6 [KEY to process variation] 6 9 7 6 9 10 3 7 3 10 6 710 10 7 7 2 10 8 7 9 12 7 712 12 3 8 5 13 ABS (5-12) = 7

Davis Balestracci www.davisdatasanity.com

MRmed = 4

MRmax = 4 x 3.865* ~ 15

Process common cause: 8 + (4 x 3.14*) ~ [0– 20]

* From theory: Always used with MRmed

(Actually, you didn’t.

Despite 150 root cause

analyses, nothing has

changed… over FIVE

years.)

10

7310

10

8

12

8

67

13

6

93102

9

12

5

0510152025303540

2001-02 2002-03 2003-04 2004-05 2005-06

MRSA Bacteraemia 2001-02 to 2005-06

Q4Q3Q2Q1

12

Déjà vu? Five Everyday Scenarios (Real situations and data)

Scenario #1: Mid-Year Progress Report on Complaints [Total number and % resolution <20 days]“Over the last three years or so, we’re averaging about 25 complaints a month and some months we even get twice that many. I don’t like these numbers, and we’ve committed to a very expensive ‘total patient satisfaction’ program. The graph below on the left was done by my analyst and it compares January through June 2013 versus January through June 2014.

“The other graph, on the right, shows our complaint resolution performance. The three-person department responsible for complaint resolution is supposed to get them resolved within 20 days – if they don’t, I expect a special report telling me why it wasn’t. They were obviously able to do it at one-hundred percent once, so I don’t understand why they can’t do it again!

“That said, as you can see, there are more complaints this year, and they’re resolving them at a lower rate! Given the higher number of complaints, I probably shouldn’t demand 100% all the time. So, what do you think of giving them a ‘stretch’ goal that ‘90% of complaints should be resolved within 20 days?’

“In addition to the goal, what else do you think we should do?”

YTD: 187 (2014) vs. 123 (same period 2013: + 50%) YTD: 73.8% (2014) vs. 75.5 (down slightly from 2013)

In your initial investigations, you overhear some front line people talking about how they’re so glad the recent construction project is over – patients were really cranky and always asking staff for directions. The signage was downright awful. Not only that, a lot of them took it out on staff about that closed parking lot!

You ask a colleague about it and they tell you that the construction took place the first four months of this year…

We should start by…?

Davis Balestracci www.davisdatasanity.com

Com

plai

nts

MonthYear

654321212121212121

40

30

20

10

0

Chart of Complaints vs Month, Year%

Com

plai

nts

Reso

lved

< 2

0 da

ys

MonthYear

654321212121212121

100

80

60

40

20

0

% Complaint Resolution vs Month, Year

13

Scenario #2 – Let’s put traffic lights and arbitrary goals to rest once and for all

We should start by…?

Davis Balestracci www.davisdatasanity.com 14

Scenario # 3: The “All-too-familiar” Budget Meeting [an MBA assignment by Davis to his students]The dreaded bi-weekly discussion of the budget is the next meeting in your busy day. Times are tight and “accountability” is in the air. Once again, conversational snippets of “It’s not my fault!”, “You have to understand that something happened that we didn’t plan for,” etc. (ad nauseum) permeate the air as well as the predictable promises to “get right on it” (Yawn!).

A manager previously on the “hot seat” for budget performance regarding her paid FTE time (See the recent string of 10 out of 11 periods being above budget?) showed how the last three two-week periods have been below budget. Cries of “Well done” fill the room, so she was asked to share how she did it.

This particular manager is progressive and a good friend of yours. She has always been one of the best at utilizing resources. After giving her helpful “suggestions” to the room, she sits down and you catch her eye. You give her that “ ‘Whom do you think you are kidding?’ look,” and she smiles and discreetly slides you the a sheet containing the data [shown during the minicourse].

This meeting is so “typical” and dreadfully boring, so you take her data and sketch individual run charts of both total FTE and the variance from budget. [This will be done during the seminar]

Why is she smiling?1) Is the “every two week meeting” a common cause or special cause strategy?

2) Do you see any potential special causes in these run charts? If so, do you have any possible theories for what caused them?

3) Regardless, how does she seem to be doing relative to budget?

4) To complete the picture and analysis, let’s take a look at the two control charts.a. What further insights have you gained?b. Given the current budget, if nothing changes, what is the expected range for any random

two-week interval?c. If nothing changes, what do you predict her end-of-year budget performance will be?d. Do you have any recommended actions?

5) Should the “every two week meeting” continue to be routinely scheduled? Can you suggest a better alternative?

6) How much time does your organization spend on budgeting?

Davis Balestracci www.davisdatasanity.com

Actual FTEBudget FTE

0 5 10 15 20 25

102

107

112

Pay Period

FTE

Plot of FTE Performance Vs. Budget

15

Scenario #4: The Overtime Data [another MBA assignment by Davis to his students]

The same VP who held the every-two-week budget meetings was hammering a friend of mine (a

wonderful nurse and great supervisor) about “too much overtime” and was threatening to cut her budget. She

said, “Davis, it’s driving me crazy. Can you please take a look at it?”

She had delivered to my office a pile of 42 operational reports that needed to be transported by a dolly

because they were so thick (“60% of published operational data is waste”). The number I needed was on the

next-to-last page of each report – FTE of overtime per pay period (2-week period). So, I reconstructed her

overtime utilization history:

We should start by…?

Davis Balestracci www.davisdatasanity.com 16

Scenario #5: “We need to improve our patient satisfaction scores!”

I was invited to speak about data sanity at an organization. The executives were nowhere to be seen

during any of my multiple presentations. The plethora of traffic light reports were driving the culture nuts and

they told me so during my presentations – and were relieved when I showed them the futility of “red…yellow…

green” and the data sane alternative of run and control charts. In fact, each group spontaneously broke into

laughter! Of course word got back to the execs – who promptly told the person who invited me to never have

me back.

Here is some (disguised) data from their Press-Ganey surveys. Each month, the execs got the results and marched around as a group planting a red, yellow, or green flag on each unit.Now THAT’S “leadership”…

My recent experience has shown me that cultures are getting very obsessed with their percentile ranks

and using them as arbitrary goals.

Are you using a similar process? How much might it be costing your organization? And is your current plan for using this data much different from this organization’s?

We should start by…?Period Dept. 1

Percentile Rank

Dept. 2 Percentile Rank

Dept. 3 Percentile Rank

Dept. 4 Percentile Rank

Jan-11 61 44 70 51Feb-11 72 15 65 68Mar-11 77 8 68 17Apr-11 68 6 66 65May-11 52 12 68 82Jun-11 60 11 74 52Jul-11 58 36 62 78Aug-11 57 12 66 64Sep-11 48 19 56 94Oct-11 60 23 72 46Nov-11 52 16 47 21Dec-11 48 64 54 78Jan-12 56 25 69 17Feb-12 71 25 60 66Mar-12 70 45 71 14Apr-12 67 28 70 77May-12 74 30 57 83Jun-12 94 27 82 59Jul-12 82 72 73 35Aug-12 80 72 67 84Sep-12 87 29 79 97Oct-12 99 32 72 71

Davis Balestracci www.davisdatasanity.com 17

Seven Everyday Statistical Traps1. Treating all observed variation in a time series data sequence as special cause

2. Treating things that “shouldn’t” happen as special cause

3. Fitting inappropriate “trend” lines to a time series data sequence.

What part of “NEVER!” don’t you understand?4. Unnecessary obsession with and incorrect application of the Normal distribution

How often did I mention it?

5. Choosing arbitrary cutoffs for “above” average and “below” average

The process WILL tell you

6. Improving processes through the use of arbitrary numerical goals and standards

Goal = “Fact of life”

Is it a “would be nice to achieve” target (arbitrary) or a “We don’t attain this, we don’t survive” target (fact-of-life)?

“Is the ‘gap’ from the goal common or special cause?”

7. Using “rolling” or “moving” average

Rolling invalidates many commonly used statistical techniques and displays

Fitting inappropriate “trend” lines to a time series data sequence.

Part 4: “Those Darn Humans!” Main pointsJohn Miller’s QBQ! – Powerful! [ABC model is on page 9]

Davis Balestracci www.davisdatasanity.com 18

Cultural Audit – Is your culture by design or default? “Bolt-on” or “built-in”?

What behaviors get in the way?

Applying QBQ! to your everyday behavior – ALL interactions create culture

Davis Balestracci www.davisdatasanity.com

Can you predict the result if this B1 continues to be tolerated?

◦ Is it R2? [Probably not!]

◦ How would it have to transform?

B2

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“How” do “I” “create needed B2” by doing these in an A2 way?

o Perhaps no bar graphs… trend lines… traffic lights. And…

o …A2: Getting better results that move “big dots”

• “How are my B1 beliefs about my role challenged by this process?”

Davis Balestracci www.davisdatasanity.com 20

Feedback / Perception, ‘Homework,” and B2 Mantras for Success

Davis Balestracci www.davisdatasanity.com 21

“If we are unhappy with the behavior of people on our team or in our organization, we need to take a closer look at the system and structure they're working in. If they behave like bureaucrats, they're likely working in a bureaucracy. If they're not customer focused, they're probably using systems and working in structure that wasn't designed to serve the servers and/or customers. If they're not innovative, they're likely working in a controlled and inflexible organization. If they resist change, they're probably not working in a learning organization that values growth and development. If they're not good team players, they're likely working in an organization designed for individual performance. Good performers, in a poorly designed structure, will take on the shape of the structure.” [Davis’s emphases] -- Jim Clemmer[ http://www.clemmergroup.com/organization-structure-limits-or-liberates-high-performance.php ]Davis Balestracci www.davisdatasanity.com

John Dew’s Seven True Root Causes(?)

• Placing budgetary considerations ahead of quality,o A1? Tolerating “Costs” vs. “the four Cs”

• Placing schedule considerations ahead of quality,o A1? Tolerating arbitrary goals and deadlines

• Placing political considerations ahead of quality, o A1? Tolerating manipulation for personal gain

• [A1? Tolerating] Management A1 resulting from (unintentional?) ignorance and/or arrogance

o Management C1:

“Give me the 5-minute overview.”

“All I need is ‘red…yellow…green’ ”

[Is this your Leadership B1: “I have nothing to learn”]

• [A1? Tolerating] Lack of fundamental knowledge, research or education,

o C1: Blind benchmarking and copying (alleged) solutions

o Vague problems/solutions/meetings/results

• [A1? Tolerating] a pervasive belief in entitlement (management, culture, and MD),

[Write me for Peter Block’s “Employee Manifesto” (It isn’t all about leadership)]

• [A1? Tolerating] C1 autocratic leadership behaviors, resulting in "endullment” rather than empowerment.

o Cultural B1? “Learned helplessness”

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Create cultural “Will” and B2 “Belief” by C2 / A2 and your “Wherewithal”

o A2: New conversations via plotting dots

o A2: Fewer “account for” meetings

o A2: “Process” vs. “Goal” focus

o A2: Promotions reflect exhibiting improvement behaviors, including…

o A2: …routine use of and management generating their own run & control charts

o A2: ZERO tolerance for blame (QBQ!)

o A2: ZERO tolerance for Dew’s 7 root causes

Your final QBQ! sIs your improvement culture by design (B2) or by default (B1)?

• “How” do “I” “design a B2 culture” that will get us R2 results?

• “What” do “I” need to “start doing,” “stop doing,” and “continue doing?”

• To do: “What” should “I” “put” on a ‘To stop’ immediately list?

[John Miller’s message (~11 minutes):

http://www.youtube.com/watch?v=bdBwkOgww_Y ]

Davis Balestracci www.davisdatasanity.com 23

Go back, observe, and be honest: What’s being “telegraphed” (B1)?

How many of these “Old BELIEFS” are you tolerating? Will they allow you to get the R2 results you and your organization want? Is there any sense of urgency about the “New BELIEFS”?

“Given”: when you go back to your office, your culture will greet you with, “Been to that IHI forum and have lots of good ideas, eh? We’re all ready to eat them for lunch!”

“I’m sorry. Your behavior is speaking so loudly that I can’t hear what you’re saying.”

Davis Balestracci www.davisdatasanity.com 24

Key Quotes Shaping Rationale of Minicourse:

When we are dealing with people, let us remember we are not dealing with creatures of logic. We are dealing

with creatures of emotion, creatures bustling with prejudices and motivated by pride and vanity.

— Dale Carnegie, personal effectiveness pioneer and author

===========================================================Being human and passionate about improvement, we have delusions of success and a bias for optimism. We take on more than we should, routinely exaggerating the benefits and discounting the costs. We exaggerate our abilities as well as the degree of control we have over events -- tending to take credit for success and blaming failure on external events. We over-scope, over-scale, and over-sell while, simultaneously, we under-estimate, under-resource, and under-plan.”

– Matthew E. May [See article on page 5: “Work on ‘5-star’ projects”]

Laminate the following and hand it out liberally: ZERO tolerance for blame!

==========================================

From Matthew E. May: Seven seemingly unshakable truths about projects A major project is never completed on time, within budget, or with the original team, and it never

does exactly what it was supposed to.

Projects progress quickly until they become 85% complete. Then they remain 85% complete forever - sort of like a home improvement project.

When things appear to be going well, you've overlooked something. When things can't get worse, they will.

Project teams hate weekly progress reports because they so vividly manifest the lack of progress.

A carelessly planned project will take three times longer to complete than expected. A carefully planned project will only take twice as long as expected.

The greater the project's technical complexity, the less you need a technician to manage it.

If you have too few people on a project, they can't solve the problems. If you have too many, they create more problems than they can solve.

Barriers: “Lack of…”Davis Balestracci www.davisdatasanity.com

Only about 15 percent of [problems] can be traced to someone who didn’t care or wasn’t

conscientious enough. But the last person to touch the process, pass the product, or deliver the

service may have been burned out by ceaseless [problem-solving]; overwhelmed with the volume of

work or problems; turned off by a “snoopervising” manager; out of touch with who his or her team’s

customers are and what they value; unrewarded and unrecognized for efforts to improve things;

poorly trained; given shoddy material, tools, or information to work with; not given feedback on when

and how products or services went wrong; measured (and rewarded or punished) by management

for results conflicting with his or her immediate customer’s needs; unsure of how to resolve issues

and jointly fix a process with other functions; trying to protect himself or herself or the team from

searches for the guilty; unaware of where to go for help. All this lies within the system, processes,

structure, or practices of the organization… --Jim Clemmer Firing on All Cylinders

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…top management support

…workers wanting to be empowered

…end to ‘command and control’

…leaders providing a good role model

…people being held accountable

…people being on board and aligned

…organizational patient focus

…a sense of urgency

…clear and common vision

…clear, enforced ground-rules for dialogue, consensus, teamwork, decisions and feedback

Peter Block:All of these points are true. It is just that they have become useless to talk about. They have become habitual

language and we have become anesthetized to their meaning and depth. These words, because of their

popularity, now belong to someone else, not to us. The phrases get used for persuasion and political

advantage, not for their capacity for human connection. They have become the party line and evoke

unconsciousness and keep us frozen in the comfort of routine.

==========================================================

My challenge to you for today: Are you ready to say “ENOUGH!”?Enough of attending meetings that lead to building a bridge to nowhere, enough of asking what I'm supposed

to ask rather than what needs to be asked, enough of praising people who are undeserving of praise, enough

of valuing form over substance, enough of accepting good when what is needed is outstanding, enough of

enabling people to act as victims when they need to take personal responsibility.

Inevitably, this kind of shift doesn't happen unless a substantial number of leaders put their collective foot down

and say “Enough!” in unison. - - Mariela Dabbah 

=============================================================

A HUGE Caution: “The modern world’s tech-giddy control and facilitation makes us stupid. Awareness

atrophies. Dumb gets dumber. Lists are everywhere — the five things you need to know about so-and-so; the

eight essential qualities of such-and-such; the 11 delights of somewhere or other. We demand shortcuts, as if

there are shortcuts to genuine experience. These lists are meaningless…When you are not told what to do you

begin to think what to do. You begin to see without distraction.” – Roger Cohen [NY Times 10/10/2013]

===================================================

Davis Balestracci www.davisdatasanity.com 26

Jim Clemmer: Why most training fails“Too often, companies rely on lectures ('spray and pray'), inspirational speeches or videos, discussion groups

and simulation exercises. While these methods may get high marks from participants, research (ignored by

many training professionals) shows they rarely change behavior on the job. Knowing isn't the same as doing;

good intentions are too easily crushed by old habits.  Theoretical or inspirational training approaches are where

the rubber meets the sky.” -- Jim Clemmer

============================================================

Jim Clemmer: The Behavior-shaping role of structures and systems “It's like the strange pumpkin I once saw at a county fair. It had been grown in a four-cornered Mason jar. The

jar had since been broken and removed. The remaining pumpkin was shaped exactly like a small Mason jar.

Beside it was a pumpkin from the same batch of seeds that was allowed to grow without constraints. It was

about five times bigger. Organization structures and systems have the same effect on the people in them. They

either limit or liberate their performance potential. Many organizations induce learned helplessness.”

-- Jim Clemmer [ www.jimclemmer.com ]

=========================================================

Any good quality management system is the sum of the decisions made within it…Each time we choose to

sacrifice the good of the system for one person, or allow an ineffective, outdated legacy practice to continue,

we take small steps toward lower and lower standards.

When we have a culture that puts quality and environmental attainment at a lower priority than feelings and

keeping the status quo, slowly we make the hundreds of decisions that eat away at total performance.

Over time, harmless little decisions can derail a quality management system. -- Jim Verzino

WHAT ARE YOU TOLERATING?============================================================

Davis Balestracci www.davisdatasanity.com 27

Highly Recommended Useful Follow-up References

Good basic material [Start here! – note that two outstanding articles are free (**)]

Balestracci, D (2015). Data Sanity: a quantum leap to unprecedented results. Englewood, CO:

Medical Group Management Association. [New edition, including e-edition, to be released in January

2015.

If you liked my lecture, you will like this. I “write like I talk.” I also address the “cultural” issues you will face as

you try to implement changes. [e-mail me for Chapter summaries – davis@davisdatasanity.com ]

Joiner, BL (1993). Fourth generation management: the new business consciousness. McGraw-Hill.

http://www.amazon.com/Fourth-Generation-Management-Brian-Joiner/dp/0071735860/ref=sr_1_2?

ie=UTF8&qid=1358526612&sr=8-2&keywords=brian+joiner+fourth

Outstanding overview of a sound everyday quality perspective with which to approach all work.

**Nolan, T and Provost, L (1990, May). Understanding variation. Quality Progress. Retrieved from

http://ww.apiweb.org/UnderstandingVariation.pdf [Direct link to a free .pdf copy of the article]

This article was seminal in my understanding of process thinking and common vs. special cause

**Neave, H. (n.d.). Understanding variation: The springboard for process improvement. Download free

from: http://www.routledge.com/economics/articles/understanding_variation1/ [Direct link, click: This article ]

Another brilliant introduction to understanding variation in an analytic context

Davis’s Quality Digest articles – cover all aspects of improvement, including culture. These are more like 2-pagers:

Link to the archive (many articles listed, with live links to individual articles): http://www.qualitydigest.com/read/content_by_author/11300

A useful newsletter by Davis

o Maybe you need to think about a better method for educating your culture?

http://archive.aweber.com/davis_book/5PKtM/h/From_Davis_Balestracci_When.htm

Davis Balestracci: Paige Hector e-mail: davis@davisdatasanity.com e-mail: paigehector@gmail.com

phone: 207.899.0962 phone: 520.955.3387

web site: www.davisdatasanity.com web site: www.paigeahead.com

Davis Balestracci www.davisdatasanity.com 28