Not healthy

Management failure

I think of so many digital projects I’ve worked on where after months and sometimes years of work, effort and progress, some newly appointed manager decided to change, to start from scratch again simply for the sake of changing, of showing that they were doing something. I have often seen a manager decide not to use a particular design or piece of research, even though their team might have spent months of effort on it, or not to fix a blatant flaw in usability that was coming up month after month, year after year. 

Waste. Countless digital initiatives stopped on a whim or a bout of ego. I know the phrase about not throwing good money after bad, but this wasn’t that sort of thinking. It was someone somewhere deciding that they didn’t need this thing anymore, or that on second thought this initiative was going to be too hard to push through, or that they didn’t feel like moving forward with the project. Or their boss walked into the room and said the project needed more “innovation,” “interactivity” or “wow” factor. 

In other words, it needed that special something app of bullshit that would make this boss look good when they presented it for 30 seconds in front of the board. Some bullshit video or bullshit carousel or some bullshit content droning on about how the organization was so excited and cared so much about making things simpler. (What can be less exciting than hearing that an organization is “excited”?)

In large organizations the crap-makers, the waste-producers, often rise to the top. It’s not simply the poor management. Many involved in digital—and I am very much thinking about myself here—rarely gave a second thought to the fact that a huge amount of energy was expended creating these designs and this content and this code, and we shouldn’t just throw it away or leave it there to rot. 

And it rots. The bad code rots the good code because it makes the good code harder to understand, and it makes it harder for the good code to work because it gets in the way and slows things down and corrodes. It’s a vital skill to get rid of things because they don’t work, to prune things, to remove the old code or content that once was fresh and now is stale. But that’s not what happens. 

We leave so much stuff in Zombieland—not quite dead but not alive either. In reality, nothing really gets thrown away. The designs that with a bit of extra refinement would work great are stored somewhere because we might need them again sometime, except we never will. We must change. We must decide what must be deleted, removed, thrown away, and delete it. We must make the effort to understand what can be reused and reuse it. These are vital skills that are currently lacking among digital professionals and management in general.

When technology systems don’t work, they don’t get ripped out and properly replaced. Instead, they get left there when the new one is bought until there’s multiple half-baked training systems, and multiple half-baked document management systems, and multiple this and multiple that, until it’s a giant big rotting mess of inefficiency, where most of the time and money has to be spent on maintaining the hulking monster that nobody fully understands because the people who wrote critical elements of the code left 10 years ago and didn’t leave proper notes on how the code worked, or if they did they left notes that are so cryptic and bewildering that dipping into the bowels of the monster feels like the mission of a bomb disposal expert. 

And here’s the thing: management doesn’t care. They never did. We wouldn’t have 90% crap if we didn’t have 90% crap management. Traditional management has failed. Digital is too much for it, beyond its realms of understanding. Traditional management has been bred to subcontract and outsource. “That’s an IT issue. Let’s give them the budget and they can deal with it.” For too long that was the management mantra: not my responsibility. 

In the teeming galaxy of massive, outrageous enterprise software mega-disasters, the Canadian government Phoenix payroll system is one small star. Like every single one of these disasters, it was supposed to save millions and millions when it was launched in 2015. There were great photo ops with ribbons being cut. Staff responsible were given awards. 

It immediately crashed and burned. Tens of thousands were left without being paid properly. It was a typical unmitigated enterprise software disaster, totally predictable. Anyone with quarter of a brain would have seen it coming light years away. Instead of saving the Canadian government millions, it is estimated Phoenix will cost Canadian taxpayers over $2 billion to fix. Yes, that is TWO BILLION. Waste. 

Why? The relentless focus was on buying and launching the thing, instead of creating an environment, supported by software, that made it easier to manage pay. We must stop focusing on having more things and on ribbon-cutting opportunities. We must focus on the outcome. We must focus on the use. 

On another level, these managers are technology groupies. They totally bought into the magical thinking that if they buy the “right” technology, it will solve everything, and that the biggest problem in the modern organization is—wait for it—people. People are the problem that technology “solves.” That’s why productivity sucks. You still need people who have the skills to make decisions about what data to keep and what data to get rid of, who have the skills to create and nurture an efficient collaborative environment, who can head off conflict before it develops, who can gently keep everyone on message and focused. 

We have bred a breed of managers who have little interest in making it easier for employees to do their jobs because at heart they’re people-firers. How can they care about people, how can they care about making things useful for employees, when business school has trained them to be the job killers and cost cutters? In the frigid minds of these “managers,” every new technology or innovation is judged through the cost-cutting, people-firing lens. To them, agile software design isn’t about making better, simpler software. Agile is instead another way to cut corners and save costs. 

In more than twenty years of working in multiple industries, and working for hundreds of organizations, I struggle to remember a single senior manager who genuinely cared about making things easier to find and easier to do on their intranet. The result? It’s so much harder for employees to find what they need to do their jobs, to understand what they need to do their jobs, to get the best quality information available to do their jobs. Thus, time leeches away, productivity leeches away. 

Management has been trained to focus on the new and the short-term, rather than the existing and the long-term. Go to the vast majority of websites and what do you see? A barrage of messages, offers, and deals for “potential” customers. Some of these deals are exclusively for “potential” customers; current customers need not apply. If they’re lucky, current customers will have a tiny login in the top-right corner of the page. Current customers are treated almost as badly as employees.

Why is this? Because it’s hard to stand out by caring for and supporting current customers. After all, these aren’t even “your” customers. Someone else got them. Managers are bred and trained on much harder stuff than that. It’s a war out there, according to management culture. You need to have a military marketing and advertising “campaign” where you “target,” “capture” and “win” more new customers. Once having “won” these customers, they’re yours. Why would you care about them? They’re the spoils of war, the bounty you receive after a successful campaign. They’re your prisoners, and that’s essentially how current customers are treated in a great many organizations. 

Too many managers

You would expect that with declining productivity and declining return on assets, management as a discipline would be under pressure. Quite the opposite. As organizational performance has rapidly declined, senior management pay has skyrocketed. “CEO compensation has grown 940% since 1978,” according to the Economic Policy Institute, while “typical worker compensation has risen only 12% during that time.” Failure and poor performance have never had much of an effect on senior management pay, it seems. When Boeing fired CEO Dennis Muilenburg in 2019 for the 737-Max fiasco, he walked away with over $60 million.

The story of the US healthcare system over the last 50 years tells us a lot about why digital and managers have failed to deliver on their many promises contained in their many emails and PowerPoints. Between 1975 and 2010, the number of practicing physicians in the US grew 150%, while the number of health administrators and managers grew by 3,200%, according to an Athena Health analysis. 

Not surprisingly, healthcare costs increased from “0.8 percent of the economy in 1970 to 3.1 percent by 2000 and 5.4 percent in 2017,” according to the US Committee for a Responsible Federal Budget. “Federal health spending has grown by 230 percent since 2000, while economy-wide prices have only risen 40 percent, and the economy has only grown by 90 percent.” With all this new technology and all this new management, the US healthcare system has become hugely inefficient.

“With less than 5% of the world’s population, the US now accounts for 40% of global health spending, almost twice as much per capita as the next highest-spending country,” Shannon, Joseph Colucci, and Thom Walsh wrote in 2013. Since 1980, the gap between life expectancy in the US and that in comparable countries has increased, according to analysis by the Kaiser Family Foundation.

Why?

US healthcare focuses on technology, on activities, and work for managers. It focuses on organizational inputs, not patient outcomes. According to Brownlee et al., the tests and treatments become ends in themselves. Patients are recommended to undergo particular treatments simply because “resources such as beds and technology are available.” 

This is profoundly stupid. This goes to the essence, the core of why digital has accelerated waste production. Digital is being used to create inputs in the form of treatments and tests. Digital is then being used to vomit up endless useless data on the useless treatment that the useless administrators use to create useless PowerPoints so that they can present in useless meetings, and then listen to other useless data from other useless administrators. Inputs, inputs, inputs. Keep them busy. 

If we measured patient outcomes, we would radically reduce waste and deliver much better products and services. Did they get better? How long did it take them to get better?

Why don’t we measure patient outcomes? 

Jobs for managers. The inputs demand a lot of useless management. The inputs create a lot of metrics and digital is absolutely fantastic at creating reams and reams of useless metrics data. The more you manage the inputs, the more you paralyze the system because you begin to manage the minutiae of nothingness. Your focus goes further and further away from what really matters. 

Is the patient getting better? Did the treatment work? 

Enter Buurtzorg

If you are a social care nurse who goes out into the community to help people, chances are a huge digitally based administrative system has grown up around you that is measuring everything you do. It can measure how many minutes you spend with each patient, how long it takes you to change a bandage, to wash someone, to take their temperature. I saw a documentary once that showed a nurse as she bent down to tie the shoelaces of an old person in her care. “Now, I am delivering Product 67,” she said to the cameras. Everything the nurse did was measured. 

Of course, the fact that there are lots of measurements means that there is lots of management. There will be dashboards and reports and lots of meetings; lots of management stuff. You’ll hear about how there’s been a 7% reduction in the bandage-changing time in the last quarter, and how shoelaces are now tied in an average of 30 seconds instead of 33. Lots of “management.” Lots of waste.

In 2008, a Dutch home-care organization called Buurtzorg was formed. They had four staff and a radical idea. Get rid of managers and instead empower the nurses. Stop all the silly measurement of inputs. Instead, measure what mattered. Buurtzorg asked the essential question: What is the most important thing to a patient? The answer: To live a healthy, independent life. Healthy, independent living became the key metric. 

All the other micro-metrics that measured the nurse were thrown away. The nurses were trusted again. When a nurse met a patient for the first time, they were encouraged to get to know them and to build up their social network by talking to friends, neighbors and family. That would never have happened in the old system, where talking to the children and neighbors would not have been possible because it couldn’t be directly mapped to an activity input such as changing a bandage. A nurse was only allowed X amount of time per visit. Talking to a neighbor would have been seen as a waste of time. 

Buurtzorg threw out the old model and focused on the outcome of independent living. Now, if a nurse noticed that someone’s laces were untied, they didn’t just mechanically bend down and tie them. They’d keep an eye on things and if it began to become a regular occurrence, they’d talk to the patient, trying to figure out why. Did the person need more exercise? Perhaps the nurse might try and organize for them to go swimming or do yoga or maybe do some physiotherapy. 

Buurtzorg charges more per hour for their nurses than competitors. Yet they have the lowest overall cost for care in the Netherlands, and their patients spend the least time in hospital. They have the highest patient satisfaction and the highest employee satisfaction. They have grown from four nurses in 2008 to 14,000 in 2019. And they have done it all by having hardly any managers. There are fewer than 100 at headquarters. It’s all about small, independent, empowered teams of 10–14 people who are constantly sharing best practice. 

Why does it work? Why is it better than the old system of having huge numbers of managers and administrators and measuring inputs? Because if you are allowed the freedom to think, if you are allowed to address why someone can’t tie their shoelaces, they are less likely to trip and have an accident. If you spend the time to build the social network around the person, then that network can be an ongoing support. If they need to go swimming, then you might know a neighbor who could bring them. 

This is a model that shows us that we can create a better environment for almost everybody; less wasteful, more productive, with more satisfaction for all. Just as digital fed the old environment of input, it can facilitate the new customer-outcome-focused environment too. Teams are at the heart of the Buurtzorg model and isolated teams quickly become ineffective ones. The teams try to meet face-to-face on a daily basis, but they also use technology to keep in touch, share best practice, learn, collaborate, evolve. 

Digital gives the tools of organization to small teams that were historically the domain of larger, hierarchical structures. In a complex environment, the team is increasingly showing that it is wiser, more adaptive, more productive than the individual and the traditional manager model. We must use digital to liberate the collective intelligence rather than to reinforce the old hierarchical structures. 

The world has changed. Organizations have not. The number one rule at Buurtzorg is that the nurse must spend the majority of their time with their patients. In the many organizations I have dealt with, digital has become a wall between the organization and its customers, patients, citizens. Traditional organizations have used digital to focus on the internal mechanics of the organization. Fewer and fewer employees have any contact with the people they are supposed to serve. How can that be good? 

Digital has in many ways eliminated geography. That doesn’t mean it has eliminated distance. Sometimes, employees are emailing or using Slack when they could get up off their chairs, walk over and have a face-to-face chat. Knowing your customers involves more than knowing their data. 

Digital must empower teams to get closer to their customers. Digital design should occur “with” the customer, not be done in some back room “for” them. The further away the producer gets from the consumer, the more waste will occur. The closer the producer to the consumer, the less waste and the better the work. 

As UX researcher, Cyd Harrell, has stated, “People are better at their jobs when they can see the effect their work has on other people.” When you have such great distance between producer and consumer, then it is so easy to create meaningless features and to focus your attention on meaningless work inputs. 

The customer keeps you honest and can help you design in a way that is frugal and purposeful, keeping you constantly focused on the outcome, and thus constantly focused on true value.

Key actions

Measure the outcome for the person using the product or service. What use is it to them? What is their experience? However, don’t forget the Earth Experience. What is the outcome for the Earth?

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