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Better by Atul Gawande

better_011Better is a wonderful book which provides a fascinating take on improvement – a key topic for clients and consultants alike. Here are the key insights.

Better starts with the simple but profound question: “What does it take to be good at something in which failure is easy?” (despite having serious consequences such as killing people).

The book explores this question through a series of life or death medical scenarios. During these, doctors struggle with what appear to be intractable problems in which the lives of millions are at stake. Here are some of the scenarios and lessons learnt.

On Washing Hands

If you are a health worker there are no personal consequences to not washing hands. Yet 2 million Americans a year contract a disease while in hospital of whom 90,000 die of it. Most of this could be prevented if health workers were diligent and washed their hands 100% of the time. Alas, they only wash their hands 30% to 50% of the time which is not enough (you need close to 100%).

Here are some of the ways they solved it at one hospital:

  1. Used industrial engineering methods, i.e. working in teams to identify: a) what makes it difficult to comply with hand washing, b) improvements, c) positive deviants (i.e. people who are good at it) and asking them how they do it [aka internal benchmarking] and d) minimising other causes of infections (i.e. one stethoscope per patient).
  2. Making it easy to comply. They did this by introducing antiseptic hand gel dispensers in easy-to-reach places. This gel is more effective than soap and takes 20 seconds to apply vs hand washing which takes >1 minute.
  3. Creating a culture in which peer pressure makes it difficult to not wash hands. Colleagues openly criticise co-workers for not washing hands.
  4. Ensure that improvements are kept up and that this whole process becomes ‘business as usual’.

The author acknowledges how difficult it is to sustain this activity when hospital doctors typically see 20 patients an hour. Yet it has the potential to save millions of lives.

Casualties of War

Industrial engineering methods were used to radically reduce American battlefield casualties. Consider the following table:

us_war_casualties1

This big and surprisingly recent improvement was achieved by a systematic approach to improving operational methods. The key driver for innovation was the realisation that most lives were lost due to blood loss. Key improvements included:

  • Improved medical battlefield backpacks to stop bleeding early
  • Focused battlefield hospitals near the front line
  • Helicopter based medical units
  • Rapidly stopping blood loss and shipping the wounded to specialist hospitals to repair the serious damage

Stunning how such simple processes save so many lives and yet it took so long to figure out and implement. Tens if not hundreds of thousands of lives could have been saved if such thinking had been applied earlier.

Doing Right

The author examines a number of medical ethical dilemmas. Although well written and thought provoking, this section of the book is of less immediate practical use than the rest of the book.

However, in a world where fewer than 98% of management consultants have signed up to a professional code of conduct and ethics this is definitely thought provoking.

The Score

Measuring the correct performance indicators and acting on poor results can radically improve performance.

Up to the mid 1930s 1 in 150 women died in childbirth in the US. By 1950 this had dropped to 1 in 2,000 due to medical progress including the availability and use of antibiotics. Paradoxically, during the same period (1930 to 1950) the mortality of the newborn remained the same at 1 in 30.

In 1953 Dr Virginia Apgar published what has become known as the Apgar Score. This simple to apply measurement done 1 minute after birth and 5 minutes after birth (and repeated if required) is an objective assessment of the health of the newborn. It rapidly tells medical staff what if any actions to take if a baby is heading in the wrong direction.

Reassuringly, in the US today, fewer than 1 in 10,000 mothers and 1 in 500 babies die during childbirth.

Suggestions for Becoming Better at What You Do 

The author offers five suggestions for those who wish to get better at what they do:

  1. Ask an unscripted question. People are full of fascinating information and insight yet as professionals we won’t discover any of this unless we ask them. Normal professional conversations are unlikely to uncover this so invest a little time in discovering more about the people you are working with.
  2. Don’t complain. Focus on the interesting challenges of life rather than its problems. It can feel tough if you are a busy professional. However, if clients didn’t have difficult problems, we consultants would be out of a job! There are great ideas lurking in those challenges and you are just the person to discover them.
  3. Count something. It is often as easy to be diligent as to be sloppy. There is a lot of data around our professional activities and we are often too lazy to collect and analyse it. I take great interest in reviewing my participant feedback scores at the end of each course and constantly seek ways to improve them.
  4. Write something. This gives a greater sense of purpose to life and allows one to develop and challenge oneself. Choose an audience and get started. Blogging is easy to set up. Who knows, you could even find yourself making a contribution!
  5. Change. Become an explorer, an early adopter and continue to challenge yourself. This makes life more of an adventure and you will amaze yourelf!

Key Lessons

Unlike the world described in this book, failure in business or public services is seldom life or death. Yet the the practices described can have a profound impact on most measures of organisational performance, even shareholder value.

Although only fleetingly referred to, industrial engineering practices (we call them value methods in our programmes) have a major impact on performance improvement. First they provide a powerful toolkit to investigate and improve any aspect of performance. Second they lay the foundations for long term sustaining of performance improvement.

The ultimate challenge wherever we work is to develop an organisation culture to make this stick over the long term. Organisations that manage this become legends. Toyota does it, Southwest Airlines does it and so does Schlumberger in its Wireline Division (where I worked for several years).

At the end of the day there are limitless opportunities to improve the world around us. This insightful and readable book challenges us to do just this.

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