“Every system is perfectly designed to achieve the desired results.” — Attributed to Paul Batalden
And heather The inspiration for his latest book, , comes from a single parable that the sociologist Irving Zola.
“You and a friend are having a picnic by the river. You have just laid out your picnic blanket and are preparing for a feast when you suddenly hear a scream coming from the direction of the river. You look back and see a child thrashing around and apparently drowning.”
Instinctively, you and your friend jump into the water and swim out to rescue the kid. But after you’ve got safely brought the kid back to shore and your heart rate is just returning to normal, you hear one other child calling for help.
“So, back in,” Heath said. “You fish the child out. As soon as you do that, you hear two screams. Now there are two children in the river. And so this kind of revolving door of rescue begins.”
Just as exhaustion sets in, Heath says, you notice your friend swimming back to shore, emerging from the water and running upstream.
“You say, ‘Hey, where are you going? I can’t do all this work by myself.’ And your friend says, ‘I’m going upstream and confronting the guy who’s throwing all these kids in the river.'”
The story resonated with Heath since it reflects an issue all of us face in every aspect of our lives, within the financial world and beyond: he calls it the “reaction trap.”
“We’re always chasing emergencies, we’re always busy putting out fires,” he said. “We respond after the bad thing has happened. And we so rarely take the time and provide the resources we need to get to the root of these problems.”
But to take an upstream approach, we must first understand what keeps us on this reactive, downstream attitude. What makes one picnicker within the parable keep jumping into the water while the opposite tackles the issue on the source? Heath identified three foremost obstacles and described how we will recognize and overcome them.
1. Blindness
“You can’t fix a problem if you can’t see it.”
Some problems are so pervasive and deep-rooted that they develop into a part of the environment or are considered inevitable – the value of doing business.
Heath gave the instance of hamstring injuries within the National Football League (NFL). When 11 players on each side of the football collide at full speed, some are certain to suffer hamstring injuries.
The New England Patriots had 22 such injuries in a single season. That was too many to stay competitive. They needed a brand new perspective and a fresh approach, in order that they hired Marcus Elliott, MDto evaluate the issue.
Elliott saw things otherwise. These ailments weren’t “inevitable,” but the results of poor training and muscle imbalance. In hindsight, it was obvious. Linemen weighing 300 kilos went through similar offseason training programs as wiry wide receivers. That had to vary.
But Elliott went further. Not only did different positions require different protocols, but each individual player needed a novel, personal approach. “Some people have quadriceps that are so strong that they actually interfere with the functioning of the system,” Heath said. “Other wide receivers have one quad muscle that’s a little stronger than the other, and that creates an imbalance.”
When Elliott tried to implement his latest system, he was met with great skepticism. His approach ran counter to football orthodoxy. But within the season after Elliott’s changes were implemented, the Patriots’ variety of hamstring injuries dropped from 22 to a few.
“It was clear that we should try it,” said Heath. “And that convinced many people.”
2. Tunnel construction
“In a tunnel, assuming you don’t want to go backwards, there is only one direction: you just have to go forward.”
When we spend all day caring for injured football players or fishing a college of drowning children out of a river, it’s hard to step back and take a systems view. Heath calls this tunneling, a term he borrowed from the psychology textbook.
“In the tunnel, there is no comprehensive macro vision, you just have to keep charging forward,” he said. “There is no question of strategy. There are no forks in the road.”
And once we’re in that tunnel, it’s hard to get out. One problem leads to a different and one other, and we spend all our time desperately putting out fires. “At the end of the day,” Heath said, “you ask yourself, ‘Did I do anything to actually advance my work, or was I just chasing problems all day?'”
We are so focused on moving forward that our first response to an obstacle just isn’t to handle or solve it, but to take a detour.
“It takes so much of our energy, so much of our bandwidth, just to deal with the problems, just to get around them,” he said, “that we’re robbing ourselves of the very resources that would have been needed to prevent these problems in the future.”
This practically guarantees that the issue will keep occurring.
3. Lack of ownership
“Who pays for what doesn’t happen?”
We all know what to do if our house burns down: call the fireplace department.
“It’s amazing how often ownership is crystal clear in an emergency, isn’t it?” Heath noted.
However, the reply is just a little less clear once we ask: “Who is responsible for ensuring that our home does not catch fire?”
As residents of the home, we come first. But we will not be alone. Who made the constructing codes? Who selected the constructing materials? And our neighbors and neighborhoods also play a task.
The more complex and diffuse an issue becomes, the less likely it’s that there will probably be a transparent allocation of responsibility, Heath said.
“If no one is aware of a problem,” he said, “it’s unlikely to get solved.”
And that brings us back to the response trap:
“There’s an emergency, and then we respond to it, and then we become inert,” Heath said. “We stop acting until the next emergency occurs, and then this cycle repeats.”
And this cycle is commonly fueled by the economy. Where there’s an emergency, there’s economic activity and financial reward.
“Someone breaks their hip and has surgery. The surgeon gets paid, the hospital gets paid,” Heath said. “But who gets paid to prevent a hip fracture?”
Break the cycle: “Maintain, maintain, maintain”
“Upstream thinking requires us to look at how organizations work from a new perspective.”
To return to the opening quote: Systems are designed for efficiency and when systems deliver consistent results, whether good or bad, Heath argues, we treat those systems as if delivering those results were their primary purpose.
“How do we get a big job done?” he asked. “We break it down into parts. And then we measure the success of each of those parts. Often, when we optimize one part, we neglect the whole.”
If our job is to tug kids out of a river or treat hamstring injuries, we’ll find ways to enhance our performance. But we is not going to get to the basis of the issue.
The response trap exacerbates such a downstream pondering.
“When we design for response efficiency,” he noted, “we often actually slow down the process of eliminating the problems we are responding to.”
In the river story, Heath explained, there are only two places: downstream, where we keep saving children from drowning, and upstream, where our friend eliminates the explanation for the issue once and for all.
“We should go beyond that,” he said. “It’s actually much simpler and more practical to think of downstream and upstream as a spectrum, an almost endless spectrum.”
To explain, he pointed to the YMCA as a real-life parallel to Zola’s parable. Millions of kids swim in YMCAs yearly. Emergencies are inevitable. But the YMCA didn’t take an upstream or downstream approach; they took an allstream approach. They moved the lifeguard chairs around to eliminate blind spots. They developed a system of coloured wristbands to point a toddler’s swimming ability. And they got to the basis of the issue.
“The YMCA is the nation’s leading provider of swim lessons,” Heath said, “which, when you think about it, is a pretty good way to completely prevent accidents downstream.”
And this approach hits the core of upstream pondering.
“Any problem that is immediate and important enough to prevent almost requires multiple layers of defense,” he said. “The fundamental trap really has nothing to do with how far upstream you go. The trap is that in the real world, we spend 95% of our time down here, responding to problems.”
We must abandon this downstream mindset, says Heath.
“We need a generation of upstream heroes,” he said, “people who don’t rush to help immediately, but make sure the situation doesn’t need to be rescued.”
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