1. culture clash

2. 2 how we think ▲ Fast: ▲ Enumerative ▲ Heuristics ▲ Surface ▲ Slow: ▲ Analytic ▲ Understanding ▲ Under the surface Hard wired to operate here. Science /C.I. operates here

3. 3 thinking about things Political / Enumerative Scientific / Analytic describe populationfocus / inferenceanalyze process staticframe of referencedynamic fastmode of thinkingslow theory over datatruthdata over theory command and control management modelleadership

4. 4 enumerative / analytic thinking

5. 5 cultural dimension

6. 6 Organizational Expression CharacteristicProfessional Management Practicing Management Management Model/Thinking Hierarchical Command and Control Systems Thinking and Leadership EthosDogmatic, ideological, rules, control Pragmatic, scientific, experiments, learning LocationExecutive Suite, 42th floor of head office Gemba, the heart and soul of the operation Information processing / understanding Enumerative, descriptive/inspection Analytic, explanatory/predictive Primary activityReading reports and writing directions Running the business and providing leadership hierarchy and positionsorganizational modelsystems and processes

7. 7 Systems Thinking: Complexity & Variation

8. 8 the challenge: improvement & innovation ▲ The boss and the business are hardwired against change (despite endless talk to the contrary). ▲ Further, they are hardwired against analysis and evidence-based arguments (despite endless claims to the contrary). ▲ Make improvements. Just don’t change anything.

9. PRACTICAL TOOLS TO CHALLENGE THE STATUS QUO THINKING 1. Kahneman’s Human Psychology 2. Systems Map 3. Capacity/Little’s Law 4. Control Chart/Performance Measurement 5. Taguchi Nominal Targets

10. 10 1. Kahneman Heuristics Heuristics ▲ Representativeness ▲ Anchoring & Adjustment ▲ Availability Strategies ▲ Metaphors, Comparative Similes, Stories ▲ Accurate Baselining, Detailing the Variation, Models. ▲ Broaden the Search Field, Provide Context, Use Models Enough doubt must be raised to convince people to give up their evolutionary tendencies and expend energy in thinking slow about the problem and solution.

11. 11 2. Systems Diagram Source: revised from Vanguard Consulting Group, with permission

12. 12 3. Understand Capacity/Little’s Law ▲ Capacity is dynamic concept ▲ Metaphor spirit, let’s talk about pipes ▲ Little’s Law: TH = WIP / CT

13. 13 3. Understand Capacity: Process Dynamics

14. 14 3. Understanding Capacity: Variation & Congestion

15. 15 3. Understanding Capacity: Variation & Congestion UU Term Processing time in hours (t e ) Wait Time in hours (CT q ) Total Cycle Time in hours 70%2.332.45.68.0 80%4.02.49.612.0 90%9.02.421.624.0 95%19.02.445.648.0 100%infinite2.4infinite

16. 16 4. Performance Measurement What gets measured gets done. --Current Management Insight If you cant measure it, you can’t manage it. --Current Management Wisdom Measure the meaningless and misinterpret what is measured. --Current Management Practice

17. 17 4. AHS Performance Dashboard YTD Target compared to Actual This Qtr. compared to previous Qtr. YTD compared to YTD last year

18. 18 4. Executive Trends... any two data points

19. 19 4. Hospital Scorecard Performance Rank LOS Comparison to System Average Target Comparison to Target Hospital 113.03  2.5 Hospital 233.07  2.5 Hospital 343.12  2.5 Hospital 423.03  2.5 Hospital 553.15  2.5 Overall System Average3.082.5 Legend:  Better than expected  Within +/- 5%  Worse than expected 

20. 20 4. PM Hospital ANOVA Minitab Output: No significant differences among the 5 hospitals

21. 21 4. PM: No Difference? Run and Control charts are the only ways of communicating any performance metric.

22. 22 5. Taguchi / Nominal Targets

23. 23 5. Performance Targets Where did this come from? Nominal is the place to be.

24. 24 5. Taguchi Nominal ▲ Provides the cost at any target distance from nominal. ▲ EL(x) = k(s 2 + barx 2 ) smaller is better ▲ k is a constant = cost (scrap) /(x scrap -T) 2

25. 25 5. Emergency Service ▲ k = cost (scrap) /(x scrap -T) 2 =.007 ▲ cost (scrap) = 1 life ▲ X scrap = 20 minutes ▲ T = 8 minutes ▲ EL (x) =.007 (s 2 + barx 2 ) = 0.28 ▲ s = 2 ▲ Bar x = 6

26. 26 5. Taguchi Implications This target builds in a 28% death rate arising from slow ambulance response rates.

27. CONCLUSIONS  Understand that you are coming from a whole different perspective.  People are hardwired to reject your approach and your reasoning  To shift people from Fast to Slow, use facts to address their operating heuristics  Many Lean, Lean Six Sigma, Continuous Improvement tools are designed to do just that.