So often in life, we get stuck in a cycle of reaction. We tackle the most urgent tasks. We deal with emergencies. We put out fires.
We intuitively know we’d be better off if we figured out a way to be more proactive rather than reactive, thereby preventing fires from starting in the first place, but we can’t seem to switch our approach.
My guest today explores why that is and what we can do to start solving the problems of business, life, and society before they become problems.
His name is Dan Heath and today we talk about his latest book, Upstream: The Quest to Solve Problems Before They Happen. We begin our conversation discussing the issues that keep us from nipping problems in the bud, including problem blindness, lack of ownership, and “tunneling.” Along the way Dan shares insights into how to overcome those roadblocks. We then shift gears and explore how to find the best upstream solutions to problems, which requires getting as close as possible to the problem, while also being able to survey the system it’s embedded in from a bird’s eye view. Dan explains the principles at play with plenty of real-life examples of how these tactics were used to effectively tackle big, seemingly intractable social problems.
Lots of great insights that you can apply to solving problems in your personal life, business, and community.
If reading this in an email, click the title of the post to listen to the show.
- Why are we more drawn to the reactive moments of life?
- Why it actually feels nice to solve downstream problems
- What is “problem blindness”?
- How to stop tunneling on specific problems
- The recurring conflicts that couples run into and solving those problems upstream
- Why we adapt to problems rather than solve them
- Taking ownership for problems that aren’t “yours”
- Bringing groups together to solve large-scale problems
- How do you change systems and bureaucracies?
- Getting close to problems
- Measuring success with solving problems that don’t happen
- How data can lead us astray
- Understanding the ripple effects of our interventions
- Selling your ideas about solving problems upstream
Resources/People/Articles Mentioned in Podcast
- Made to Stick
- How to Improve Your Work and Life With Systems
- Peak Performance: Elevate Your Game and Avoid Burnout
- The Power of Checklists
- You Need a Reset Day
- A City Solves Veteran Homelessness
- How to Keep Your Head (and Even Thrive) in a Bureaucracy
- Becoming a Man
Connect With Dan
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Read the Transcript
Brett McKay: Brett McKay here and welcome to another edition of The Art of Manliness podcast. So often in life we get stuck in a cycle of reaction. Tackle the most urgent task, we deal with the emergencies, we put out fires. We intuitively know we’d be better off if we figured out a way to be more proactive rather than reactive, thereby preventing fires from starting in the first place but we can’t seem to switch our approach. My guest today explores why that is and what we can do to start solving the problems of business, life, and society before they become problems. His name is Dan Heath, today we talk about his latest book, Upstream: The Quest to Solve Problems Before They Happen. We begin our conversation discussing the issues that keep us from nipping problems in the bud, including problem blindness, lack of ownership, and tunneling. Along the way Dan shares insights to how to overcome these roadblocks. We then shift gears and explore how to find the best upstream solutions to problems which requires getting as close as possible to the problem while also being able to survey the system it’s embedded in from a bird’s-eye view. Dan explains the principles at play with plenty of real-life examples of how these tactics were used to effectively tackle big seemingly intractable social problems. Lots of great insights that you can apply to solving problems in your personal life, business, and community. After the show’s over, check out our show notes at aom.is/upstream.
Alright, Dan Heath welcome to the show.
Dan Heath: Hey, thanks, Brett, glad to be here.
Brett McKay: So, I’ve been following your work for a long time since Made to Stick and you’ve got a new book out, Upstream: The Quest to Solve Problems Before They Happen. I’m curious, how is this book a continuation of the work you’ve done with your brother Chip on your other books?
Dan Heath: Well, this one was a slow burn, to be honest. The first time I opened a file called Upstream notes was 2009. So this has been in the back of my brain for over a decade. And there were two things that happened right about the same time that got me interested in this topic. The first was, I heard a parable somewhere, I can’t even remember where, but the parable goes like this: You and a friend are having a picnic on the side of a river. And just as you’ve kinda laid out to your picnic blanket, you’re ready to get started, you hear a scream. You look behind you, there’s a child in the river apparently drowning, splashing around, and so you and your friend just instinctively jump in, grab the kid, bring him to shore, and just as your adrenaline from the save starts to die down a bit, you hear another scream. You look back, there’s a little girl in the river drowning. So back in you go, you fish her out and no sooner have you brought her to shore that you look back, there are two more kids drowning in the river and you begin this kind of revolving door of rescue in and out. And just as you’re starting to get really fatigued from this work, you notice your friend is wading over to the shore and steps out as if to leave you alone and you say, “Hey, where are you going? I can’t do this by myself. There’s all these kids drowning.” And your friend says, “I’m going upstream to tackle the guy who’s throwing all these kids in the river.”
And that story really stuck with me. And then it feels like maybe a month later, I was having a conversation with an assistant police chief in a Canadian city, and he told me a story that just resonated with that parable. And what he told me was a kind of thought experiment where he said imagine you got two police officers and one of them goes downtown in the morning to an intersection that is kind of notoriously chaotic. And just by stationing herself there visibly, she gets the drivers to be a bit more cautious, to be more careful, and her presence deters accidents from happening. And then the second officer goes to a different part of downtown where there’s a prohibited right-turn sign and she hides around the corner and waits for people to break that rule and then she nabs them and gives them a ticket. And his question was which of these officers is doing more for public safety? And he said, indisputably, it’s the first that’s preventing accidents from happening. But he says, guess who gets promoted in the department? Guess who gets rewarded? Guess who gets praised? It’s the second officer because she comes back with a stack full of tickets, that’s the evidence of her work.
And something about those two things together just got me thinking in-depth about this issue of why are we so often drawn to reactive elements of life, like the cop who’s reacting to people who make this illegal turn, when it theoretically, at least, would be desirable to do a better job preventing problems, going upstream and tackling the guy who’s throwing the kids in the river rather than perpetually saving the kids downstream. So that was the birth of this
Brett McKay: Well, as you said it’s fun… I mean, it’s not fun, but it is kind of fun to react to problems ’cause you feel important, you feel like you’re doing something as opposed to thinking about well, how can we make this thing not happen at all?
Dan Heath: Yeah, I mean, there’s a kind of heroism that comes from downstream response. I mean, in some of the obvious ways, a firefighter putting out flames or a lifeguard jumping in to save someone who’s drowning, there’s a genuine heroism there. We even have forms of it in white-collar jobs, the person who stays up all night to meet the critical deadline and gets a lot of praise around the office. And I suspect we all know some people who almost seem to live for those moments. In fact, I’ve gotten some emails from some people who said they suspect that their colleagues almost want the flames to break out so they can be the firefighter. And I think while certainly we should be glad there are people around to save the day, my point of view is the need for heroics is usually pretty good evidence that there’s a systems problem, right? It’s great that the lifeguard saves the kids in the YMCA pool. But if things have been properly configured, if you didn’t have kids in the pool who were weak swimmers, if the lifeguard chair had been put exactly where it’s supposed to be so there are no blind spots for the lifeguard, if the lifeguard had been taught better scanning techniques, maybe there never would have been a drowning incident in the first place. And so that riff on heroism like is a hero the person who saves the day or is a hero the person who keeps the day from needing to be saved? That really got in my head.
Brett McKay: So let’s talk about… So I think we all agree, we’d rather prevent the problems than you have to deal with them when they do happen. But as you start off in the book, you just talk about how it’s really hard to first, solve downstream problems because oftentimes we can’t even see that the problem exists. And you call this problem blindness. And in your research, you say there’s a lot of things going on psychologically, sociologically that causes this problem blindness. What’s going on there
Dan Heath: Yeah, problem blindness says, oftentimes, we can’t see the problems around us or even if we can see them, we code them as if they’re just inevitable. Let me give you an example, there was a guy named Marcus Elliot, who was a medical doctor that was interested in sports. And back in 1999, he was hired by the Patriots, the football team, to join their staff. They’d been plagued by hamstring injuries, especially from some of their skilled players, a lot of wide receivers out. They’d had 22 major hamstring injuries the season before and it was just really wreaking havoc with their performance. So, Marcus Elliot comes in. And the mental model at that time, in pro sports, especially football was, “Look, this is the dangerous game, it’s a violent game, people are gonna get hurt. That’s just the way it is, of course.” But Marcus Elliot had a very different philosophy. His point of view was, most of the injuries that happen in pro football are actually the result of subpar training, inadequate training.
And so he started this brand new regime at the Patriots where before it was like a one-size-fits all program. It’s like people that were in radically different positions. Nose tackle and wide receiver were getting, generically speaking, the same kind of training. They’re trying to get stronger, they’re lifting weights. And so, Marcus Elliot starts doing this individualized training where first he assesses them on a variety of things, and he’s looking, in particular, for muscle imbalances because what often creates an injury is when, for instance, your right hamstring is significantly stronger than you’re left and that can show up in ways that end in injury. And so he starts doing these kind of one-off training programs to make sure there was balance among muscle groups, that they were preparing for the kinds of skilled maneuvers they’d be doing during the game and the proof was in the pudding, the season after he had begun his regimen, there were three hamstring injuries versus 22. And so all of a sudden, Marcus Elliot is making believers out of people.
It’s like the attitude before, “Well, injuries are just part of the game, they always will be here. It’s a violent game, of course, that happens.” That’s problem blindness. That means, we may be aware, certainly, we’re aware when athletes get hurt, but we just assume, “There’s nothing we can do about that.” And it takes in these situations, someone like Marcus Elliot, to come along and say, “Hey, wait a minute. What we’re coding as inevitable, what we’re coding as natural is neither. We can do something about this, we can fix that problem and that’s how we overcome problem blindness.
Brett McKay: But how was he able to see that there was a problem? What was it about Marcus that made him different?
Dan Heath: I think with people like Marcus what happens is they have an understanding of the problem that’s deeper than most people. Keep in mind, he’s a medical doctor. It’s not often you find medical doctors and end up as trainers on pro teams. And so when I’m talking to him on the phone, he no longer works with the Patriots, he has his own sports training outfit, and he does this just incredibly obsessive analysis of pro athletes. I would almost describe it like an MRI for the way pro athletes move. They’ll train multiple cameras and all of these diagnostics on NBA athletes and watch how they pivot and jump and land. And some of the stuff he was telling me, I literally could not even understand, I just don’t have enough knowledge of physiology, but he can get down to the granular detail of look at the way you landed after that rebound and look at the tension that’s running across your knee. And based on our diagnostics, people who have the kind of tension that you’re experiencing right now, almost always have a knee injury within the next season or two. And so when you’re that close to a problem, you start spotting leverage points, you start spotting opportunities for change. And I think that’s what allows them to see that there’s hope.
Brett McKay: In other words, you say that keeps people from actually working on these upstream, solving these problems upstream is that there’s a lack of ownership, that there’s no one held accountable for solving those problems. Why is that?
Dan Heath: A lot of times it has to do with silos that develop in organizations. I’m sure everybody that works in business knows exactly what I’m talking about. Here’s an example from Expedia, the online travel site. So back in 2012, this guy named Ryan O’Neill, who worked in the customer experience unit, he was looking at some data and he discovered something that kinda blew his mind. And that was at that time, for every 100 people who booked a flight or a hotel or a car on Expedia, 58 of them end up calling the call center for support. 58 out of 100. Now, the whole point of an online travel site is presumably self-service. And yet the… Not the vast majority, but the majority of customers using the site ended up needing intervention. So he’s like, “What? What in the world is going on here?” So he starts digging into the data figuring out why are customers calling us. The number one reason customers were calling was to get a copy of their itinerary.
20 million calls were logged in 2012 alone for people trying to get a copy of their itinerary. And so this is one of those forehead-slapping moments where you’re like, “How could this have happened? Why was there not an alarm going off when we logged our eight millionth call for a copy of the itinerary?” And so the CEO at that time worked with Ryan O’Neill to create a war room where they started analyzing this question and figuring out, “Hey, we need to change things, we need to start asking a different question, how do we keep people from needing to call us?” And the fixes were the easiest thing in the world, right?
I mean, you give customers tools to get their own itinerary, you change the way you send out the emails, so they don’t end up in spam filters and on, and on, and on. The solution was not the hard part. What made this hard was that Expedia was organized in a way where it was in everyone’s interest to ignore or neglect this problem. So you think about the silos, there’s a marketing team whose job it is to try to attract people to come to Expedia instead of one of the other travel sites, they get measured on numbers of people coming. And then you’ve got a product team whose job it is to make the site so easy to use that you’re just constantly pushing people toward a transaction. And so they’re measured on can we get transactions closed? And then you’ve got a web team that’s measured on uptime and speed, and then you’ve got the customer call center and they’re measured on what? How quickly can I get somebody off the phone? And how satisfied are they with the resolution? So all those goals make kind of superficial sense when you hear them, but then you realize something, it’s literally no one’s job to stop a customer from needing to call, nobody.
It’s even worse than that. No one would even get a gold star if that happened. It’s not on anybody’s scoreboard. And so this is the thing that happens in organizations where because we’re constantly pushing for efficiencies and specialization, because we wanna wring more productivity out of the process, we start missing what might be major, major problems because they just transcend the gaps between silos. And once Expedia caught on to that, and once they decided to push their way upstream, it turned out the solutions were actually very, very simple and those 20 million calls just vanished.
Brett McKay: So another barrier is what you call Tunneling, what do you mean by that?
Dan Heath: There’s a great research study by this woman named Anita Tucker, who for her dissertation at Harvard, she followed nurses around for hundreds of hours, just shadowed them to see what their life was like. And what she found was they’re solving problems constantly. They go to get a towel for a patient, there’s no more towels, so they have to figure out where to get a towel. They ask for some medication from the pharmacy and they get the wrong medicine or the wrong dose or the pharmacy is out or some equipment breaks. Anita Tucker talks about this one day that a woman was trying to discharge a mother who just had birth. And in the discharge process, they realized the baby doesn’t have the security anklet that goes around its ankle to… They’re intended to keep children from being abducted and so when it’s missing, it’s a big deal. They hunt around for it, it turns up in the baby’s bassinet, so, great.
They can get the mother checked out. Then three hours later, the same exact thing happens with a different baby. Again, missing an anklet. This time they do a frantic search, can’t find it. So they had to create another way to check the mother out and honor security and so that was that. And so this portrait that Anita Tucker is painting is nurses are responsive, they are improvisational, they’re resourceful, they don’t go running to the boss everytime something goes wrong, they can kind of own things and work around problems. And when you think about it like that, it’s pretty inspirational. It’s a great portrait. But then from another perspective, you look at the situation and you go, “This is the description of a system that will never improve. A system that never learns,” right? Because if you are constantly working around problems and you’re never solving those problems at the systems level, why are we running out of towels? Why are these anklets slipping off babies ankles?
You’re dooming yourself to solving those problems forever. Now, to be clear, this is not a nurse thing. I’m not picking on nurses. I think Anita Tucker could have shadowed probably any profession and found exactly the same thing. And the phenomenon she discovered, I think, is well described by some psychologists who wrote a book called Scarcity and they call this tunneling. And they say that tunneling happens when we have a scarcity of time or resources to combat the problems we’re facing. And when we have that scarcity, it’s almost like we give up thinking that we can solve all the problems on our plate. And we may even give up trying to prioritize them and it just becomes this experience where we feel like we’re in a tunnel. Just conjure up that mental image. And in a tunnel, all you’re thinking about is, “God, how do I get forward? There’s something blocking my way, I wanna get it behind me as quick as possible. I just have to keep moving, those nurses.”
“Okay, I’m out of towels. I don’t have time to do root cause analysis on why there’s no towels. I got 10 patients clamoring for my attention. What am I gonna do? I gotta go steal a towel from the unit down the floor.” And that makes sense and that’s familiar behavior and I suspect all of us can empathize with tunneling, but we just have to realize that it’s a trap, that if we’re stuck in the tunnel, we stop asking the really important questions like are we even going the right way? Are we headed to the destination? Might there be an entirely different tunnel that would get us there faster or better? So this is one of the key traps that I think keeps us downstream tunneling.
Brett McKay: Well, I think you talk about this in the book. One problem that we spend a lot of time, money, and resources trying to solve downstream is poverty and poverty is often caused by tunneling. And people who are in poverty, they have scarcity of time, resources, bandwidth. And so they’re just trying to put out all the fires, they don’t take the time, they don’t have the ability to take the time out and think, “Okay, what can I do to not have these problems in the first place?”
Dan Heath: Exactly right. If you look at something like payday loans which, of course, we all know are just notoriously expensive and the APRs can be hundreds of percentage points a year and it can be a real trap, but from the perspective of tunneling it makes sense. If you’ve got more problems than you can handle, if you’ve got a sick kid and you’re working two jobs and you’re already on thin ice and you can’t afford to miss any more days, and child care isn’t easy for you, and your nutrition isn’t easy, and then your car breaks down and it’s like to keep your life in order, doesn’t it make sense that you would just walk down the street to the payday loan place and get enough money to fix your car so you can get to work that day and not get fired? It’s like we come from outside with this attitude of kind of pristine financial advice thinking, “Oh, well, that’s not wise to make a decision where you have an APR that’s so high.” But if you’re in the tunnel, it looks like a solution. And I think that’s why to make some of these upstream solutions possible, we first have to find ways to escape the tunnel.
Brett McKay: Yeah, you gotta provide some slack in your life.
Dan Heath: Exactly, and I think it’s easy to say in the case of poverty, I don’t think I have the answers. I wish someone did to figure out how do we get more slack in the system. In organizations I think it’s slightly more practical, though still difficult. Like in that nurse situation, the way I portrayed it, it seemed like, “Well, they’re gonna be stuck in the tunnel forever.” But I think there are surprisingly easy ways to at least provide an escape, a temporary escape. There’s a bunch of health systems that have adopted what are called safety huddles where every day, usually in the morning, they have an all-hands meeting. It might be very quick, 15, 20 minutes where they talk about safety near misses from the day before, things that went wrong or almost went wrong, maybe the wrong medication almost delivered to a patient caught at the last second. And they talk about, “Hey, how do we keep those kinds of things from happening in the future?” And that’s systems thinking and they look at the day ahead of them, they say, “Is there anything really different or complex that’s gonna be happening today that we should watch out for?”
And what I love about that is that’s a kind of structured way to get out of the tunnel. That would have been the perfect opportunity for that nurse dealing with the missing security anklets on babies to say, “Hey, this weird thing happened yesterday twice with the anklets. They’re falling off, and I swear we’re putting them on tight, we need to figure out what’s going on here, we need to deputize someone to take this over.” And so even a temporary escape from the tunnel, I think can be really powerful.
Brett McKay: One thing I’ve done personally in my life, my wife and I have done is whenever… I’m sure we all had those experiences, where we’re just getting overwhelmed, everything’s kind of piling up because you got sick, kids got sick, stuff happened at work and you’re just like, “I can’t get this done.” So we have these things called a reset day where we just take a day off during the workweek. So the kids are at school, we plow through all those things that have been building up and then we also take time to figure out how can we prevent this from happening again? And we do it… It’s just you do it when you feel like you need it. But I’ve found that to be a way to provide slack and it pays off. Taking that day off pays off dividends down the road.
Dan Heath: I love that idea and it’s the perfect illustration of how slack can be the antidote to tunneling. I’ve been fascinated by… In researching this book, probably we’re gonna talk a lot about big social issues, but I’ve also been fascinated about how upstream thinking can make a difference in our personal lives. Like I talked to this guy who… All couples have these recurring things that they bicker about. You left the toilet seat up again and that sort of thing. So his thing with his wife was the hallway light. And he was always going in and out, usually to take the dog out, and so he’d flip on the hallway light and he come back in and he’d forget to turn it off and that just irritated his wife, so it became this little thing that they bickered about. And one day all of a sudden he realizes, “This thing we’ve been fighting about, that’s like a recurring irritant in our relationship, I can solve this, I can make this go away forever.” And so he files for divorce. I’m totally kidding, he didn’t file for divorce. It was a much simpler fix. He went to Home Depot and he bought what’s called a light timer, which is just like a different plate that goes over your light switch. And you can press a button that says five minutes, the light will turn on for five minutes and then it’ll auto turn itself off.
And I just love stories like that because how many places in our life have we just learned to adapt to something? We’ve adapted to a problem, we’ve just come to accept that well, we’re forever gonna be bickering about that one thing. When I mean, for God’s sake, it took one trip to Home Depot and a $10 light plate and now this irritant has disappeared from this couple’s existence forever. That’s upstream thinking.
Brett McKay: That actually inspired me. So one of the irritants we have in our family is with iPads. So we have iPad tablets for each of our kids and the problem is charging them. They’re always running out, it’s like 1%, and we only have one cable. And we’d always plug it in the computer and they’d always bicker about who gets it. And I was like… It was almost every other night and so I decided to buy a hub for USB chargers and I put it in there, they’re gonna be able to plug in their iPads at night, both of them, and not gonna have an issue anymore. And I’m looking forward to it.
Dan Heath: I love that. I love it. And then you’re kicking yourself like ‘Why didn’t I do this three years ago?” My favorite example… I love this one ’cause it’s just so wonderfully trivial. So this woman was talking about… She got transferred to a different department at work and she had to move desks. And her desk was right by one of those heavy doors that goes into a stairwell and everytime that door was open from somebody coming up the stairs, it had this just horrible squeak and it just drove her crazy. And so she puts up with this for two days, and then on the third day she brings in a can of WD-40 and just lubes up the hinges, the squeak disappears, and people on the floor treat her like she is a miracle worker. They are astonished that she solved this problem that they’d probably been living with for months or for years. And that’s what I mean about our capacity to adapt to situations can almost be a curse. Because we come to just accept that certain problems are part of our world that really don’t need to be
Brett McKay: Well, three things happened there. So she saw a problem, she took ownership of the problem when she didn’t have to. She had to volunteer for it, it wasn’t assigned to her, and then she got out of the tunnel, she did something about it.
Dan Heath: Exactly right. And your ownership point is the one that I really wanna call out because this is a very, very strange thing about upstream versus downstream problem-solving. So with downstream problems you can almost always pinpoint when something goes wrong whose job is it to fix? A house catches on fire, of course, it’s gonna be the fire department that’s gonna fix that, or at the YMCA pool someone’s thrashing, it’s gonna be the lifeguards job to fix that. But when you flip it around and you say whose job is it to prevent fires from happening? All of a sudden, the ownership gets very diffused. Well, the homeowners have some responsibility and the builders have some, and the people who write building codes have some, and the fire department in the sense of education has some… And all of a sudden when a problem doesn’t have an owner, the chances are it’s not gonna get fixed. And so this leads to a very odd conclusion, which is even though downstream activity is obligated and almost mandatory like, of course, if there’s a problem we’re gonna fix it. Upstream activity, even though the stakes can be enormous is often voluntary.It’s often chosen rather than demanded. So upstream activity starts when somebody somewhere says, “I didn’t create this problem, but damned if I’m not gonna be the one who fixes it.” And sometimes that’s in trivial things like being the person who brings in the WD-40 to work, sometimes it can be huge things like telling some stories in the book about homelessness and substance abuse and others where it was a group of people who voluntarily put on their shoulders the burden of solving that problem.
Brett McKay: Well, this leads nicely to my next question. So we talked about the barriers of solving problems upstream. Once you do that you’ve looked at… You have seven questions that people should ask themselves as they’re trying to fine-tune what the problem is and working on the solution for that problem. And the first question you found that’s useful is how do you unite the right people? ‘Cause as you just said, upstream problems, the responsibility is diffused. It might be a whole bunch of different people who are responsible that can solve that problem. So how do you find those people who can actually help solve the problem before it happens?
Dan Heath: This was one theme that I noticed again and again in very different looking kinds of problems is that people learn to do what I call surrounding the problem. So I’ll give you an example from… There’s a city called Rockford in Illinois, it’s actually the second biggest city behind Chicago, and they had a problem as do many cities. This is kind of a former factory town that had gone into hard times after the great recession. And so they had a homelessness problem there, and the mayor was a gentleman named Larry Morrissey. He was in his third term, he’d been working on homelessness for nine years and by his own account, he said they’d made no progress and maybe even the problem had gotten worse. So he’d become a bit jaded about the issue of homelessness. And around that time, one of his colleagues challenges him to take what was called the Mayor’s Challenge, which was an initiative sponsored by the federal government to encourage communities to try to end veteran homelessness in their cities. And so Morrissey is kind of skeptical. He’s like, “What’s gonna change? We’ve been doing this for nine years, we’ve gotten nowhere.”
He agrees reluctantly to take this challenge. And about 10 months later Rockford becomes the first city in the United States to eliminate the problem of veteran homelessness. And so you just look at kind of the bookends of that story and you go, “What in the world happened in 10 months that didn’t happen in nine years?” And it has to do with, basically, two things. They changed a bunch of their strategic and systems work which we can unpack later. But to me, I think the fundamental thing that they did was they changed the way they collaborated. So the first thing they did was… Back to that example of whose job is it to keep fires from happening? The question here is whose job is it to keep homeless people from being on the streets? And you could make a case for about a dozen different parties, the VA has part of the ownership, and the police department, the healthcare system, the homeless shelter, social services. And so it’s one of these situations back to the Expedia example where things are heavily siloed, there’s lots of gaps between organizations. So in Rockford, they start getting together, meeting as a group with all those constituents I just described and others, they meet around the same table.And so that’s part one of the story is you got the right group of people together, people with all the different facets of the problem. And then the second thing is you changed how those parties collaborated. So one thing that had plagued homelessness up to that point is that they lacked useful data, the federal government requires cities to do what’s called a point in time census where you kinda go out one night every year and you do your best to count all the homeless people, and then you wait until the next year and you do another one. And they realize that’s just totally inadequate for trying to manage a problem in real time. And so what they created on their own, back to that notion of upstream work being voluntary, they created a by name list of every person in the community who’s homeless. Literally, I saw it. It’s a Google doc. And you go down and you’re like, “Well, there’s Steve and there’s Michael and there’s David,” and for every person, there’s a description of what their situation is and how’s their health and roughly how old they are and who’s talking to them.
And so these meetings among the different organizations who are surrounding homelessness, their meetings would be conducted name by name. Instead of talking theoretically about, “Hey, what can we do about this horrible systemic problem of homelessness?” No, no, it was Steve. “Okay, who’s seen Steve in the last week? Where is he? Well, he still got his tent set up under the bridge, but he’s been coming into the homeless shelter a bunch to eat lunch. We wanna let Steve know that we have housing for him, when he’s ready to move in, we’re ready to get him off the street. So who’s gonna talk to Steve this week?” And it became practical, it became human, it became tangible and it was also easy to score victories because you start saying, “Hey, last week Steve was on the street, this week Steve is in supported housing.” And Larry Morrissey, the mayor said that that kind of approach was transformative, that these meetings they would have used to be bitch sessions, he said and now, it was like they had a goal, they had a tangible mission.
And so that’s how you can spin your wheels for nine years on homelessness and accomplish nothing. And then in 10 months, you can become the first city on record to end veteran homelessness. And I think that’s such a powerful illustration of how we may have more power than we’re even aware of, that just by changing the way we collaborate and who collaborates and how we measure our progress, we can make a big difference in problems that we might have thought intractable.
Brett McKay: So the next question you ask or you think is useful to ask when you’re trying to solve these problems upstream is how to change the system. And that’s a big question because systems like that can be hard to change. They’re embedded in bureaucracy, they’re calcified with tradition, so it can seem like it’s impossible to change the system. So I think that… Can that question lead people to be like, “Well, there’s nothing we can do ’cause there’s a problem blindness. It’s how it always is.” So what does that look like in action when people ask how to change the system?
Dan Heath: Yeah, changing the system can be a very big deal for the reasons that you said. Systems can be big, they can be bureaucratic, they can be slow to change, but I think the saving grace is that small changes in big systems yield big changes, so that’s what they were fighting for. One of my favorite stories in the book is about this guy named Darshak Sanghavi, who is working in the healthcare system in the federal government. And his job is to look for prevention programs that deserve the support of Medicare and Medicaid that could receive funding from those two. And so, he’s scanning and he comes across this program called the Diabetes Prevention Program, the DPP which is a well-known program in healthcare. It’s been proven again and again to stop some people that are at risk of developing diabetes from developing it, so that’s a big deal because diabetes is a chronic disease, it’s very expensive to treat, it causes a lot of harm for the individual.
And so to get Medicare and Medicaid funding for DPP, Sanghavi has to establish two things: Number one, that this program makes a difference in people’s health. And so check, there’s a ton of evidence for that. Second thing he has to prove is that the program will save the government money. Well, it seems like there’s a slam dunk case there, too, because if you can stop someone from developing a chronic disease, chronic diseases cost a ton to treat, surely you stand to save a bundle. So Sanghavi puts his evidence together, he thinks this is gonna be my first real widespread victory in this role. He takes it to the government actuaries, who are the people who can certify it as a cost-saving program. It’s the last step before expansion and the actuaries say, “No, we can’t certify this as cost-saving and the reason is that this DPP program is extending people’s lives, and when you extend people’s lives, their healthcare costs more.”
So just sit with that logic for a second and think about that. That is not a sick joke I’m making, that was the actual official logic of the federal government which is, of course, the biggest payer in our healthcare system. And so Sanghavi is just sitting there just stunned like really the success of this program is gonna be the force that brings it down? And so he and his boss, a guy named Patrick Conway, write an appeal to the chief actuary. And then this is my favorite part of the story, this is in late 2015 and just three days before Christmas, something remarkable happens. One of the actuaries that reports to the chief actuary is a guy that’s on the cusp of retirement, sends this memo. And in the memo he makes this impassioned case that this ruling is just wrong, it’s morally wrong. And in the memo he envisions what would happen if the media got wind of this and the kind of headlines that they would write.
Medicare saves, seniors die and the press storm that would come out of this. But fundamentally, the case he’s making is that we should not penalize programs that help people live longer, that that is an abuse of what actuaries stand for. And he says, actuaries have a special responsibility because while doctors at their worst might only harm a few people, actuaries at their worst could harm millions. And he says calculators should play a role in determining how much we should reimburse hospitals and doctors, but calculators should not play a role in determining how long people should be allowed to live. You can almost hear the trumpets playing in the background with this memo and justice prevails in this situation. The chief actuary reverses the decision, DPP gets funded. There is now a change in a federal register somewhere that says a prevention program’s ability to extend lives cannot be held against it in computing its costs.
And so back to this idea of systems change, that’s what systems change looks like. I mean it’s boring on the merits. If I showed you the wording of that legal clause in an actuarial guide book somewhere, you would yawn. It’s not satisfying like a rescue is or a gun fight or a life-saving expedition. But boy does it matter. That one little tweak to the federal rule book is going to save or extend thousands of lives. There are people that will never develop diabetes who otherwise would have in a world where that one little cluster of sentences hadn’t been changed. And so that’s why systems change is worth fighting for even though it can be quite difficult because it can make all the difference upstream.
Brett McKay: Right, and it was a small change, it was difficult to get through. And I think the next question you think is useful to ask is what’s the leverage point? In this situation, it was a small change, this was the leverage point. This was the point where change could happen. And so the question, what’s the leverage point, can help you find out what’s one thing you can change in the system that will have all these cascading effects downstream?
Dan Heath: Yeah, that’s the thing is when you’re dealing with some big problem, it can be paralyzing. Where do you start? If you got interested in hunger in your community, my God, where would you… What would you do in the first week? And I think the best advice that I’ve gotten from the people that I’ve studied is get closer to the problem, to immerse yourself in it. If there’s any people listening who are kinda operations gurus at Lean or Six Sigma, you know this phrase, Go to the gemba, get close to where the work is happening so you can observe the problem. And I’ll give you an example from a really big issue in Chicago. There have been recurring crime waves in Chicago and during one of those, some academics that formed what’s called the University of Chicago Crime Lab, which is this… It’s almost like a bridge between academia and police and government practice. They were trying to find evidence-based ways to reduce crime. And at this time there had been just an absolute wave of youth homicide, so lots and lots of young men were being killed and the lore at that time was it’s gang activity. It’s gangs, they’re fighting, struggling over turf, people are getting killed.
Well these academics said, “We don’t know much about gang activity, but we do know how to study problems.” And so what they did was they went to the medical examiner’s office and they asked to examine the records and reports for the last 200 young men who had been killed. And they went through those reports and what they found is a very different picture. Yes, there were some deaths related to gang violence, but what they found was it more commonly was a situation like this and this is essentially a streamlined version of a real case that a couple of groups of young men got into an argument on the street and one of the groups was arguing that a guy from the other group had stolen one of their bikes. And it started as an argument and it escalated and one of the guys started to walk away and the other group took offense to that, found it disrespectful and shot the guy in the back.
And so what you found when you got close to the problem was what’s happening is that the kind of dumb arguments that teenage boys all over the world get into were escalating to gun violence. And so Harold Pollack was one of the academics involved and he was studying these reports. He said, “At University of Chicago we have to have equations, and so our equation after reading all these reports was young guys plus impulsivity plus alcohol plus guns equals a dead body.” And so when you think about that, just think about that, let’s zoom out of this situation to think about what they’re doing. They go without bias to just study and look close at what happened in these situations that went awry. And then they come out with this kind of equation which admittedly it’s simplified, but what it says is those are all independent leverage points. You could try to intervene to reduce access to alcohol, you could try to intervene to reduce access to guns, you could try to combat impulsivity somehow. Those are all independent ways to try to get some progress on this problem. And in this case, they chose the leverage point of impulsivity and we can talk more about the solution they ended up funding if you like. But I think the important thing for our perspective is their instinct to get closer to the problem was what unlocked the potential leverage points that could be used to find a solution.
Brett McKay: Well, yeah, we can talk about it. ‘Cause I thought it was really interesting, they decided to do the impulsivity thing and basically they… One guy developed this afterschool program for boys where they learned how to control their emotions.
Dan Heath: It’s a fascinating program. It’s called Becoming a Man. BAM is what they call it for short. And it was invented by this guy named Tony D who had kind of a rough upbringing but found himself as a young adult, discovered that he loved psychology and that he wanted to help men, young men, grow up with male mentors and to teach them how to be a man and how to live with integrity. And so he figures out this program which is just utterly unique. It’s like, imagine 10 or 12, 16-year-old boys in high school who are brought together and they put their chairs in a circle and they start these sessions with a check-in which is just sort of like what’s on your mind? How are you feeling today? How are you feeling psychologically, physically, spiritually?
And at first, as you can well imagine, these kids, it’s like crickets. No 16-year-old boy is just gonna make themselves vulnerable in a situation like that. And so for the first session or two, Tony D has to basically claw it out of them, “Will you at least tell me whether you’re mad, sad or glad today?” But eventually they come to trust each other, and they come to open up. And what Tony D does with them is like a combination of a support group and tough love and male mentorship, but there’s also an important part of the program that’s about self-control. And it’s about Tony D contrasts warrior energy with savage energy, and it’s fundamentally about anger is a natural state, I mean, especially for a teenage male. Anger’s gonna happen but it’s a question of how do you use anger? Do you let it be a destructive force or a constructive one? Can you be the person, when that argument breaks out in the street about the stolen bicycle, can you be the one that takes three seconds to just reflect, “How badly could this go and is that what I want? Do I wanna live with the consequences of escalating this?”
And so Tony D had created this program called BAM, this kind of fascinating program. And when the crime lab people found out about it they said, “Aha. What if what Tony D is doing is operating on this leverage point of impulsivity?” In other words what if his program is teaching people to rethink the instinct to escalate, to get violent? And so they end up funding the BAM program, and they do a randomized controlled trial to test whether it really works. And the results come back and they kind of astonish everyone. It takes almost a year for them to finish crunching the data, and they’ve had to get the police department involved ’cause they’re trying to cross reference arrest rates and so forth.
And they have this unveiling and Harold Pollack, the guy I mentioned earlier, who had examined the medical examiner reports, he tells the people involved, “Among the students who participated in this BAM program, arrests were down 28% versus the control group, and violent crime arrests were almost cut in half.” And everybody’s jaws dropped. And Pollack said it was one of the greatest moments of his entire career. And that’s the kind of thing that can happen with a problem that is as seemingly complex and unsolvable as a crime wave in Chicago. They took it apart, they got close to it, they found a potential leverage point, they found a program that would act on that leverage point, and in this case, it worked.
Brett McKay: And in this case they were able to measure success. But one tricky thing about solving problems upstream is sometimes it can be hard to measure. How do you measure a problem that didn’t occur? I mean, you’d say, “Well, it could have been worse.” It’s like, “Well, could it have been worse? I don’t know.” ‘Cause you had nothing to judge it against.
Dan Heath: Exactly right. And if you go back to at the very beginning, I was talking about the two police officers, and one of them stayed in the busy intersection and kept accidents from happening. You ask yourself, “How do you prove,” as you said, “when something doesn’t happen?” That morning, the police officer’s presence stopped a guy who was commuting to his job downtown. He would have been killed in an accident that morning had it not been for her presence, but he’ll never know. And she’ll never know. And so the only thing that you can rely on in a situation like that is data. You keep logs of the accidents that happen before and after you positioned a police officer there, and if you do your proper statistical analysis and the number of accidents go down, maybe you can attribute that to your work. That’s what upstream success looks like. It’s like numbers moving on a page. It’s not as tangible, and it’s not as satisfying as fishing a kid out of the river.
But then, having said that that the data is the scoreboard for this kind of work, it also opens up a whole can of worms. Think about it this way: Imagine that, in whatever town or city you live in, the chief starts touting that crime has gone down 20% over the past few years, and that, on the surface, is a huge victory. Everybody should be happy about that. And that’s an example of measuring upstream progress with data. Crime did not happen. Okay, so hurray. But then you start having to poke at that data in different ways. For instance, what if you found out that the crime had gone down by 20% everywhere in the US? Now how would you feel about the police chief’s genius and approaches. What if you found out that the crime was down 30% nationally and 20% locally? Now how would you feel about the intervention, success or failure? What if you found out that the chief had been so vigorous and aggressive about enforcing a reduction in crime that you discovered that officers at the street level were kinda burying crimes? Like looking the other way in certain situations or doing what’s called downgrading where very serious crimes like rape are often scaled down to something like sexual assault because nobody wants to have a rape number show up on their record.
And so, all of a sudden, what looked like just plain and simple statistical proof that you’d done a good thing, we have a lot of questions like, “Could you have actually made things worse even as the numbers suggested you were making things better?” And so that’s a theme in the book is, number one, we’re almost lost if we don’t have some kind of data to use to orient us and to guide us. So data is essental, but data is also just a minefield of potential problems that we have to be aware of and we have to constantly be trying to root out.
Brett McKay: Well, the last question I wanna talk about is when you start messing with systems. Systems are complex, so you can make one change one place and you can see the change you want and maybe it has the desired effect, but then it causes a problem somewhere else. So how do you ensure the changes you make isn’t gonna actually cause more problems for you?
Dan Heath: This is another one of those cautionary themes in the book, is because we’re intervening in systems, we’ve gotta be very, very clear on what the ripple effects of our intervention are. Here’s an example from New York City, so about 10 years ago, there was a young Google engineer, a young man, he was just walking through Central Park and this freak accident happens. He was struck by a falling branch from an oak tree and it caused brain injuries and paralysis. It was just a horrible thing, total fluke injury. Except that a bit later, the controller of New York City, a guy named Scott Stringer, he starts analyzing the claims that the city is paying out like this engineer’s lawsuit eventually got settled for $11.5 million. And what Scott Stringer realizes is there’s actually a whole rash of settlements coming from falling branches and he’s like, “What the hell is going on here?”
And he keeps investigating and finds out that a couple of years earlier the city’s pruning budget had been cut in an effort to save money. And so one of his assistants, David Saltonstall said, “Whatever money we thought we were saving on the pruning side, we were paying out and then some on the lawsuit side.” And so they start studying the city’s claims and they start finding these examples of… There’s one playground in Brooklyn that was responsible for multiple lawsuits like five different kids had broken their leg on this playground, sued the city because a swing had been hung a little bit too low.
And that’s an example of what we’re talking about where, depending on how you frame the situation, yes, the Park’s Department saved some money by cutting the pruning budget. That looked good for them for that piece of the system. But if you zoom out and look at the system as a whole, that was a bad decision. It cost the system as a whole money because it, number one, costs more payouts in terms of lawsuits, leaving aside the obvious human misery that came from the falling branches. And I think a good caution is there’s this systems thinker named Donella Meadows who I quote a lot in the book and she said, “When you’re thinking about a system you’ve gotta figure out a way that lets you see the system as a whole, not just the part that might have drawn your attention to begin with.” And I think that’s a great caution is a lot of times we’re coming into problems with some angle.
There’s some part of the income statement in a business or some part of our scoreboard that we’re operating against that’s kind of provoked us to action, but we gotta be careful. What are the parts that are linked up to that and might making problem ‘A’better actually make other problems worse in a way that brings down the system as a whole?
Brett McKay: And this is where having the right people like multiple different groups involved can help solve that, ’cause you can see how this could affect different parts of the system.
Dan Heath: That’s a really good point, yeah, exactly. So the Park’s Department is making this budget decision unilaterally but if they’d really thought through, and if they’d brought in some colleagues from other places maybe they could have discovered that in advance, maybe they didn’t have to learn this the hard way.
Brett McKay: So let’s say someone’s listening to this and they’re part of an organization, it could be their business, non-profit, church, whatever, and there’s a lot of downstream problems and they’re like, “I’m gonna make the sell, we’re gonna start solving these problems upstream.” Any advice on how to make that sell ’cause it could be a hard sell to take time off to solve these problems that you might not… It might take a while to solve the problems. How do you think you can make the sell?
Dan Heath: Yeah, it can be tough. This was not intentional, but there’s kind of two meanings of the word upstream, upstream in the sense of preventing problems and then there’s the sense of upstream as in swimming upstream. And I think it’s no accident that the word means those two things. It’s hard to break out of this pattern, and I think maybe your best strategy is to do two things. One we’ve already talked about, which is to get close to the problem and really be able to describe it up close to look at those medical examiner reports or to get up close to the factory lines and look at where errors are happening. And then the second part that we haven’t talked about is find a way to show what you’ve discovered. Because I think showing is, as our eighth grade English teacher always told us, showing is a lot better than telling.
nd I’ll give you an example. I was working with DuPont years ago and one of the managers told me the story that they were trying to get one of their factories to take waste more seriously. Any factory these days, after 50 years of quality improvement is gonna be pretty good just from the get-go. And so we’re talking about round off air type waste, probably 1 to 5% or something, but still is a problem we’re tackling. But if you’re somebody who works on the front line of a factory like how do you get excited about going from 3% waste to half-a-percent or something? And so there wasn’t a lot of motivation around this move to reduce waste.
And so the manager is trying to figure out how do I get people to want to do something different? And he realized that he had to stop talking about it at the process level and he’s had to be able to help them visualize the harm. And so one day they show up to work and they’re expecting to get on the factory line and instead he kind of ushers them all into a van and drives them to the landfill that they used, and there was one particular section of the landfill that was kind of DuPont’s area. And he brought them out there, and he showed them just this vast expanse of trash and waste. And you know when you see something like that, it hits you at a visceral level, not an intellectual level. Just the horror of how much stuff you’ve just dumped onto the earth because of your work. And he said, “What you’re seeing right now is the reason why I want us to start taking waste more seriously.”
And he said, “All of a sudden it made a night and day difference that people started getting with the program, they started helping him iterate the processes.” And I love that story because I think it’s a good inspiration for the rest of us that as we get closer to the problem, as we turn up those leverage points we don’t wanna talk about those things, we don’t wanna intellectualize about them. We wanna show people what we found, we wanna show people that medical examiner written report about the two groups of kids that ended up in a gun fight over an argument over bikes because those are the things that are gonna motivate action when other people can see what we see.
Brett McKay: Well, Dan, this has been a great conversation. Where can people go to learn more about the book and your work?
Dan Heath: If you’re interested in more about the book, just go to upstreambook.com and it will have all the details you could ever want.
Brett McKay: Fantastic. Well, Dan Heath, thanks for your time. It’s been a pleasure.
Dan Heath: Thank you, enjoyed it.
Brett McKay: My guest today was Dan Heath. He’s the author of the book, Upstream: The Quest to Solve Problems Before they Happen. It’s available on Amazon.com and book stores everywhere. You can find out more information about his book at his website, upstreambook.com. Also check out our show notes at aom.is/upstream where you can find links to resources where we delve deeper into this topic.
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