Process
Status Items Highlights Done See section below Claims None Questions None Output None
Highlights
Location 41
When you spend years responding to problems, you can sometimes overlook the fact that you could be preventing them.
Location 77
focus is both the strength and the weakness of organizations. The specialization inherent to organizations creates great efficiencies. But it also deters efforts to integrate in new, advantageous ways. In upstream ways.
Location 92
we tend to favor reaction: Because it’s more tangible. Downstream work is easier to see. Easier to measure. There is a maddening ambiguity about upstream efforts. One
Location 180
treating patients with serious diseases such as cancer or heart disease. That’s why Saudi princes fly to Houston or Boston to
Location 221
our noble efforts to make the world better
Location 331
Every system is perfectly designed to get the results it gets.
Location 362
problem blindness. You can’t solve a problem that you can’t see, or one that you perceive as a regrettable but inevitable condition of life. (Football is a tough game—of course, people are gonna get hurt
Location 534
The first force, problem blindness, means: I don’t see the problem. (Or, This problem is inevitable.) A lack of ownership, though, means that the parties who are capable of addressing a problem are saying, That’s not mine to fix.
Location 708
What if you told the story of your relationship problems as if you were the only one responsible? What if employers told the story of their employees’ health as if they were the only ones responsible? What if school districts told the story of high school dropouts as if they were the only ones responsible? Asking those questions might help us overcome indifference and complacency and see what’s possible: I choose to fix this problem, not because it’s demanded of me, but because I can, and because it’s worth fixing.
Location 788
how are her colleagues going to feel about someone who is always yammering on about “fixing processes” rather than simply grabbing more towels from another unit?
Location 796
The need for heroism is usually evidence of systems failure.
✏️ Feel like this can be a broader thing about heroism across the board. Having heroes around means there’s a gap somewhere and they’re filling it. It shouldn’t be a sustainable thing however. The ideal situation is to eventually not need the hero. 🔗 Location 796
Location 808
When your emphasis is always forward, forward, forward, you never stop to ask whether you’re going in the right direction.
Location 1039
husband, boyfriend, or ex. (If a woman is murdered, there’s a nearly 50% chance that the perpetrator fits one of those descriptions.)
Location 1112
A cross-functional group is presented with a goal: Help millions of our customers avoid the nuisance of calling us. That’s a valuable and challenging target. And then the group is basically locked in a room together, armed with regularly updated data to see if the number of calls is going up or down. The team members come up with theories and then they test them. They watch what works. That’s the “data for learning” part. They don’t need a boss standing over them, hollering out specific targets: “We need to cut four percent call volume by tomorrow!”
Location 1285
When we marvel at the inner-city kid who gets into Harvard, we’re marveling at the odds she defied. But what we don’t appreciate is that our celebration of her carries an implicit indictment of the environment we put her in. We forced you to climb Everest to get ahead in life—and you did it! Congratulations!
Location 1381
Success comes when the right things happen by default—not because of individual passion or heroism.
Location 1455
Their goal was to build an evidence base that policymakers could rely on to reduce crime—to bridge the gap between academic research and public policy. They were looking, in short, for leverage points. Ludwig was frustrated by the city’s lack of progress in combatting crime. Everyone had “answers.” The schools had answers, local nonprofits had answers, and policymakers had answers. The problem was that no one knew whose answers were right—or even if anyone’s answers were right. There was little evidence about what worked in preventing violence.
Location 1473
“My fundamental equation is a couple of young guys plus impulsivity, maybe plus alcohol, plus a gun, equals a dead body.” All of those are potential leverage points: moderating impulsivity or reducing alcohol consumption or restricting access to guns. The next question becomes: Can you identify an intervention that could plausibly accomplish one of those goals?
Location 1491
He started inviting young men to join small-group sessions with him. The lure? They could skip class once a week. In the early sessions, Tony D would lead icebreaker activities to get them laughing, to get them comfortable with each other. One was called The Fist. Students were paired up, and one member of each pair was given a ball. The other was told that he had 30 seconds to get the ball from his partner. Pandemonium ensued, with each pair wrestling for control of the ball. After the 30 seconds, the partners would switch roles and a second round of chaos would begin. Afterward, Tony D would point out that no one had thought to simply ask his partner for the ball. At first, the young men would scoff: “He wouldn’t have given it!” “He would have thought I was a punk!” But Tony D would ask, “How would you have reacted if your partner asked you nicely for the ball?” Many would admit something to the effect of “I probably would have given it. It’s just a stupid ball.” Tony D introduced a tradition called the “check-in” at the beginning of each session. He’d arrange the young men in a circle—there were usually 8 to 10 in each class—and ask each to reflect briefly on how he was doing that day: physically, emotionally, intellectually, and spiritually. At first, the young men were reluctant. Skeptical. Tony D would goad them for a one-word answer, at least: mad, sad, or glad. With time, they began to open up. They saw it was safe to share problems, to talk about their pain or their anger. By the end of the semester, it had become one of their favorite activities—the one time in the school day when they could lower their guards and just be themselves. As one young man said to researchers who were studying BAM, “I like how we can just sit down and just talk to each other… it’s calming.” Managing anger became a recurring theme in the sessions. You can let your anger overwhelm you so that you act like a “savage,” Tony D taught them, or you can channel it to become a “warrior.” Anger could be a destructive force or a constructive one, he stressed, and we’re free to choose.
Location 1512
They evolved into a fascinating hybrid, blending the confessional aspect of support groups with the tough love of male mentoring and elements of cognitive behavioral therapy (CBT), a technique that helps people learn to change their patterns of thought and, as a result, their behavior. Beyond that, it had to be fun. It had to be cool. What teenage male would voluntarily sign up for therapy or a “support group”?
Location 1579
Every problem will have its own array of factors that increase risk for or protect against it, and each of those factors is a potential leverage point.
Location 1600
One of the most baffling and destructive ideas about preventive efforts is that they must save us money. Discussions of upstream interventions always seem to circle back to ROI: Will a dollar invested today yield us more in the long run? If we provide housing to the homeless, will it pay for itself in the form of fewer social service needs? If we provide air conditioners to asthmatic kids, will the units pay for themselves via fewer ER visits? These aren’t irrelevant questions—but they aren’t necessary ones, either. Nothing else in health care, other than prevention, is viewed through this lens of saving money. Your neighbor with the heroic all-bacon diet—when he finally ends up needing heart bypass surgery, there’s literally no one who is going to ask whether he “deserves” the surgery or whether the surgery is going to save the system money in the long haul. When he needs the procedure, he’ll get it. But when we start talking about preventing children from going hungry, suddenly the work has to pay for itself. This is madness. The reason to house the homeless or prevent disease or feed the hungry is not because of the financial returns but because of the moral returns. Let’s not sabotage upstream efforts by subjecting them to a test we never impose on downstream interventions.
Location 2006
The question that the executive faced (Should I invest in Ford stock?) was difficult, but the answer to an easier and related question (Do I like Ford cars?) came readily to mind and determined his choice. This is the essence of intuitive heuristics: When faced with a difficult question, we often answer an easier one instead, usually without noticing the substitution.”
Location 2098
When people are rewarded for achieving a certain number, or punished for missing it, they will cheat. They will skew. They will skim. They will downgrade. In the mindless pursuit of “hitting the numbers,” people will do anything that’s legal without the slightest remorse—even if it grossly violates the spirit of the mission—and they will find ways to look more favorably upon what’s illegal.
Location 2254
we must experiment. “Remember, always, that everything you know, and everything everyone knows, is only a model,” said Donella Meadows, the systems thinker. “Get your model out there where it can be shot at. Invite others to challenge your assumptions and add their own.… The thing to do, when you don’t know, is not to bluff and not to freeze, but to learn. The way you learn is by experiment—or, as Buckminster Fuller put it, by trial and error, error, error.”
Location 2324
we can formulate some questions to guide a decision about whether or not to stage an upstream intervention. Has an intervention been tried before that’s similar to the one we’re contemplating (so that we can learn from its results and second-order effects)? Is our intervention “trial-able”—can we experiment in a small way first, so that the negative consequences would be limited if our ideas are wrong? Can we create closed feedback loops so that we can improve quickly? Is it easy to reverse or undo our intervention if it turns out we’ve unwittingly done harm?
Location 2549
Paying for upstream efforts ultimately boils down to three questions: Where are there costly problems? Who is in the best position to prevent those problems? And, how do you create incentives for them to do so?
Location 2576
“capitation,” a payment model used by health systems
Location 2790
Building a habit is one way to counteract this downstream bias. IT leaders, for instance, have learned that, when it comes to network security, the weakest links are often their colleagues. Phishing schemes—in
Location 2844
We have just been lucky.… Our civilization has a considerable ability to pick up balls, but no ability to put them back into the urn. We can invent but we cannot un-invent. Our strategy is to hope that there is no black ball.”
✏️ All of requires is a technology that causes mass destruction which can be placed in the hands of small, willing groups 🔗 Location 2844
Location 2894
first baby steps upstream to work collectively on the civilization-threatening problems we may face in the years ahead. The person in charge of these efforts was a NASA employee called the Planetary Protection Officer (originally the Planetary Quarantine Officer). The office still exists;
Location 2973
“Be impatient for action but patient for outcomes.”
Location 2995
Macro starts with micro.
✏️ Ambitious goals need close up experience. Tackle individuals or on town level vs populations or country level. 🔗 Location 2995
Location 3011
Favor scoreboards over pills.
Location 3025
In the Scoreboard Model, you get a group of people together who’ve agreed to take ownership of a problem, and you arm them with data to assess their progress.