Bright Spots, Best Practices, and Playlists

Seeking Solutions: Best Practices, Bright Spots, and Playlists

The cases below describe practices and results reported when the book was written.

The massive scale of Walmart—its $444 billion revenue in 2012 amounts to $64 for every person on earth—inspires a complicated mixture of emotions: awe, fear, admiration, and loathing. It’s easy to forget, though, that Walmart began as a pipsqueak, a small business in Bentonville, Arkansas. Though the founder of Walmart, Sam Walton, became a global Goliath, he started as a small businessman.

In 1954, years before Walmart, Walton was running a variety store in Bentonville. Walton constantly scoured other stores for good ideas. So when he got wind that some Ben Franklin variety stores in Minnesota had created a new approach to the checkout line, he resolved to see it firsthand. He hopped on a bus and made the 600-mile journey to Pipestone, Minnesota.

When he finally arrived—imagine taking a 12-hour bus ride to do a bit of industry benchmarking—he was impressed by what he discovered. In the stores, all customers were funneled through a central checkout line at the front of the store. This was a departure from the industry norm of departmental checkout. In most stores, including Walton’s own, customers shopping for kitchen supplies would pay at the kitchen counter, and if they also needed soap, they’d pay separately at the toiletries counter.

The centralized model had several key advantages, Walton realized. It required fewer checkout clerks, which reduced payroll. It reduced the handling of cash, which minimized errors and theft. It ensured that customers would only have to pay one time.

Convinced Franklin’s process was superior, Walton quickly implemented the idea in his stores. The book describes the same model as standard practice at Walmart and most other big-box retailers.

Throughout Walton’s career, he kept his eyes out for good ideas. He once said that “most everything I’ve done I’ve copied from someone else.” In the early days of discount store chains, he crisscrossed the country in search of insights, visiting discounters ranging from Spartan and Mammoth Mart in the Northeast to FedMart in California. Through conversations with one of FedMart’s leaders, Walton clarified his thinking on distribution, which would eventually become a defining strength of Walmart. And he admired the merchandise mix and displays in Kmart, founded in Garden City, Michigan, by S. S. Kresge. “I’ll bet I’ve been in more Kmarts than anybody,” Walton said.

Again and again in his career, Walton found clever solutions by asking himself, “Who else is struggling with a similar problem, and what can I learn from them?”

To Break Out Of a Narrow Frame

We need options, and one of the most basic ways to generate new options is to find someone else who’s solved your problem. If you’re not sure how to cope with a relative who has an alcohol problem, talk to someone else who has endured a similar situation (that’s why groups like Al-Anon exist). If you’re unfamiliar with the grant-application process for a particular foundation, talk to someone who has previously navigated the process.

Sam Walton made a habit of sniffing around his competitors’ stores, looking for ideas that were better than his. His style of eager competitive analysis later became conventional wisdom for many executives. They’ve long since learned to “benchmark” competitors and absorb industry “best practices.” While these habits are useful, they are rarely transformative. Good ideas are often adopted quickly. When all retailers adopt centralized checkout as a “best practice,” it’s no longer a competitive advantage for anyone.

In other cases, practices that work for one organization may be incompatible with another, like an organ transplant that is rejected. (Imagine if McDonald’s, inspired by movie theaters, started trying to hawk $12 Cokes.) That’s why we shouldn’t forget, when hunting for new options, to look inside our own organizations. Sometimes the people who have solved our problems are our own colleagues. That’s what the leaders of Kaiser Permanente discovered. The book describes it as an HMO with almost 9 million members, among the largest in the country.

In early 2008, Alan Whippy (her first name is pronounced uh-LANN), the medical director of quality and safety at the Permanente Medical Group in northern California, was staring at a set of data that astonished her. To continue pushing their hospitals to get better, Whippy and her team had asked the leaders of the 21 Kaiser Permanente hospitals in Northern California to do detailed case studies of the last 50 patients who had died at each of their hospitals. One problem their hospitals had addressed aggressively—heart attacks—accounted for 3.5% of the deaths. But almost 10 times as many deaths came from another cause that was barely on the radar screen at Kaiser Permanente or most of the other hospitals they knew: sepsis.

Dr. Whippy explained sepsis with an analogy: “If you have an infection on your skin, it gets inflamed—red and hot and swollen. The infection itself doesn’t turn the skin red, that’s the body reacting to the infection.” Sepsis involves a damaging response to an infection; the infection need not originate in the bloodstream. The body’s inflammatory reaction spreads to the whole body, even to parts far away from the infection—a case of pneumonia, for instance, can trigger kidney failure or even brain damage.

What Dr. Whippy and her team realized was that physicians were paying careful attention to the infections, like pneumonia, but they weren’t aggressively treating the associated sepsis, which was often the true cause of a patient’s death.

Freeze there. Whippy had a problem on her hands: She needed options for improving Kaiser Permanente’s treatment of sepsis. Where could she find those options?

She located one critical connection within Kaiser: Dr. Diane Craig, a physician at Kaiser Permanente Santa Clara. Craig and her colleagues had spent several years working on sepsis and had already shown some reduction in their hospital’s sepsis death rate. They were frustrated that progress was not quicker, though—especially since the “recipe” for managing sepsis was known. In 2002, a provocative article had appeared in the New England Journal of Medicine showing that patients were substantially less likely to die from sepsis if they received quick and intensive treatment shortly after they were diagnosed.

It was easier said than done, however. As Craig knew from personal experience, the quick and intensive treatment was difficult to implement for two reasons. First, sepsis is hard to detect. A patient might look fine in the morning but plunge into crisis by lunchtime, and by then it is often more difficult to correct the cascade of internal damage. Second, the protocol recommended by the article for treating sepsis—which involves administering large quantities of antibiotics and fluids to the patient—carries its own risks.

As Craig said, “It takes a while for people to get comfortable saying, ‘This patient looks good but I’m going to put a large central IV catheter in their neck and put them in the ICU and pump them full of liters and liters of fluids. And we’ll do all this even though they look perfectly fine at the moment.’ ” Craig and her colleagues judged that the research justified the intervention in their protocol. But it was difficult for doctors, with their “Do no harm” ethos, to move as quickly and forcefully as the research said they should.

Craig and Whippy realized that, to fight sepsis, they had to overcome these two problems by making sepsis easier to detect and by demonstrating to staff the risk of inaction.

With Whippy’s support, Craig and her team began to incubate new approaches to the problem at Santa Clara. One idea was simple but powerful: Whenever physicians ordered a blood culture—a sign they were worried about a blood-borne infection—a test for lactic acid was automatically added to their orders. (Lactic acid is a critical indicator of sepsis.) This allowed them to detect sepsis well before it began to influence the patient’s vital signs.

Other changes were intended to make the Santa Clara staff more aware of sepsis. Posters and pocket cards were printed up that highlighted the symptoms of sepsis. A grid on the printed materials showed the mortality risk for different patient circumstances. “People could see that this patient, right in front of me, even though they look good—they have a 20% chance of mortality. It was very powerful,” said Craig.

If the doctors and nurses spotted the symptoms of sepsis, they were asked to call a “sepsis alert,” equivalent in urgency to the “code blue” called when someone is experiencing a cardiac arrest. The sepsis alert summoned a team that could assess the patient and, if appropriate, begin the intensive sepsis protocol.

These innovative solutions began to work. Sepsis deaths began to decline. Whippy, who’d been following the work, knew that the Santa Clara team was assembling a package of cultural interventions that she could spread to other hospitals. Meanwhile, other hospitals, which had been pursuing their own solutions, added other critical pieces of the puzzle, like a “pressure bag” that fit around an IV like a balloon, ensuring that sepsis patients would receive fluids quickly enough.

Within a matter of months, under Whippy’s direction, the sepsis protocol was being actively implemented in other hospitals. By summer 2012, Kaiser Permanente Northern California, composed of 21 hospitals serving 3.3 million people, had driven down risk-adjusted mortality from sepsis to 28% below the national average.

To illustrate the potential scale, the authors imagine all hospitals reaching Kaiser Permanente’s reported rate, 28% below the national average. They compare the implied annual lives saved with all male prostate-cancer and female breast-cancer deaths combined. That is a counterfactual comparison, rather than a demonstrated result of transferring the program.

Finding Internal Bright Spots

The leaders of Kaiser make it a priority to study their own internal “bright spots”—the most positive points in a distribution of data. For the treatment of sepsis, for instance, Dr. Craig’s team represented a bright spot, because of its lower death rate.

Bright spots can be much more mundane, though. If you’re trying to stick to a new exercise regimen, then your bright spots might be the four times last month that you made it to the gym. If you take the time to study and understand your bright spots—how exactly did you manage to get yourself to the gym on those four days?—then you can often discover unexpected solutions. Maybe you’d notice that three of the four occasions were during lunch, which tends to be the least complicated time for you. So you might make a point to avoid scheduling things at lunchtime, keeping that time free for future workouts.

Bright spots have a practical advantage: they come from your own setting. You still need to understand what made the success possible and whether those conditions can be reproduced.

Both bright spots and best practices, then, act as sources of inspiration. If you’ve got a dilemma and you need new options, you can look for new ideas externally, like Sam Walton, or internally, like Kaiser’s leaders. Notice that in both situations the process is reactive: Your dilemma sparks the search. But there’s a lot to be gained by taking the results of your search and recording them for future use—to turn a reactive search into a proactive set of guidelines.

To see what we mean, imagine a manager who has a talented and ambitious employee, one who’s eager to advance and earn more responsibility. Unfortunately, there’s no obvious way the manager can honor the employee’s ambition—no clear promotion path, no easy way to boost compensation. How do you avoid dampening the person’s enthusiasm or, worse, losing them altogether?

The search for options might lead the manager to search first for best practices. In a world with thousands of other organizations, someone has surely faced this problem before. Next, she might look for bright spots within her own organization, interviewing a couple of longtime managers to fish for their insights.

What if she took things a step further and actually encoded what she learned so that the next manager in a similar situation—whether a month or a year down the line—could consult her ready-made list of suggestions? Her list might include thoughts like these: Is there a way you can delegate some of your own higher-level work to the employee? Can you carve out a project that they can lead? Try to find ways to ensure that the employee is recognized publicly for their work.

By encoding the advice, she’d be creating a kind of “playlist” of managerial greatest hits: questions to ask, principles to consult, ideas to consider.

This playlist idea turns a reactive search—Who has solved my problem?—into a proactive step: We’ve already found the people who have solved this problem, and here’s what they said.

Dion Hughes and Mark Johnson have used this playlist technique, to considerable success, in the advertising industry. They founded a firm, Persuasion Arts & Sciences, that acts as a relief pitcher for advertising agencies that have hit a creative roadblock. Hughes and Johnson often come in at the last minute to offer fresh ideas just before an important pitch.

Both men had worked previously in top-tier ad agencies. Johnson had been part of the team that developed the “ultimate driving machine” positioning for BMW, and Hughes had won awards for the “how to speak Australian” campaign for Foster’s beer. (Sample billboard: A picture of a dagger is captioned, “Australian for dental floss.” Next to it, a bottle of Foster’s is captioned, “Australian for beer.”)

Dion Hughes said, “We knew that creative people tend to be precious about their ideas and find the ones that they’re passionate about and then invest a lot of emotion into them. And they spend most of their time diving deep into one or two ideas and not a lot of time spreading their wings. So we thought, well, why don’t we do the opposite?” So when Hughes and Johnson are called in by creative directors, they try to send them a dozen possible directions within a week. (Notice the multitracking.)

To generate that volume of ideas, they come back to the same playlist of questions again and again. For example, they might ask, What kind of iconography within the brand is useful and what could we build around it? For a UPS project it might be the shield logo or the classic brown UPS driver uniform or the familiar, boxy shape of the delivery truck. Other questions in the playlist include:

• Is there a key color for the brand? • What is the enemy of this product? • What would the brand be like if it was the market share leader? • What if it was an upstart? • Can you personify the product?

In 2008, Persuasion Arts & Sciences was approached by a small mom-and-pop brand, Diana’s Bananas, which sold only one product: frozen chocolate-covered bananas. Diana’s had been founded by a Chicago woman who had subsequently passed away, leaving her husband with, as Hughes said, “a tiny little company and a tiny little factory with one shift of workers.”

Hughes and Johnson, moved by the story, agreed to do a small project for Diana’s. The owner had $80,000 to spend, and they had to gently tell him that his budget wouldn’t support a major TV ad campaign. In brainstorming campaign ideas, the duo knew they needed to overcome two problems: First, few shoppers came to the grocery store with “frozen bananas” on their grocery lists, and, worse, impulse buys were unlikely, since Diana’s lacked the budget to pay for good placement in the freezers. The packages tended to be stranded on one of the bottom shelves.

These problems got them thinking: These bananas are mostly for kids, and we could count on them to beg their parents to buy them, but the kids don’t know the product exists. So we’ve got to lead them to the right place. But how?

As they worked through the playlist, they paused on one question: What kind of iconography within the brand is useful and what could we build around it? One character on the packaging was a baby monkey in diapers. They started thinking about the monkey and the bananas, and they thought, Hmm, what if the monkey were eating bananas and leaving the peels behind, like a bread-crumb trail?

Excited by the idea, they designed a series of decals—bright yellow banana peels—that could be stuck to the floor of the grocery store, creating a trail that led right to the freezer where Diana’s was stocked. Kids immediately caught on to the game, following the trail like a treasure hunt.

After the trails had been installed in a chain of grocery stores, Hughes and Johnson called to see how the campaign was doing. The owner said, “We have had to put on a second and third shift to keep up with demand.” The trail of banana peels had worked like a charm.

The book describes Hughes and Johnson’s biggest success at the time as a project for a client that they aren’t allowed to name, a Fortune 100 company that had put its ad agency on notice. The agency was told that if it didn’t come up with fresher material, the nine-figure account would be moving elsewhere. So the agency, in a panic, summoned a group of around 40 creatives to an airport hotel outside a major industrial city. Hughes and Johnson joined the group, which was sequestered in secrecy, like the jury on a high-profile murder case. Even the locals from the ad agency weren’t allowed to go home during the days of the briefing.

“We are looking around the room,” said Hughes, “thinking, ‘There are a lot of talented people in this room. How can we win?’ ” Knowing that the other agencies would take a few days to generate one or two carefully curated ideas, Hughes and Johnson went back to their playlist of questions. They thought they could win with speed and quantity.

They resolved to meet with the creative director the very next morning. “We won’t have any TV commercials to view or print ads to give out,” Hughes said. “We will just say, ‘Here are the big fat areas for this brief to go in.’ We will put an idea on each of those squares so that we own that square. So that when finally his other creative teams come to him a week later, he’ll look at their work and go, ‘Sorry, I already got something like that from Dion and Mark.’ ”

The plan succeeded. In the end, the ad agency presented six “finalist” ideas to the client. Four of the six were created by Hughes and Johnson, as was the eventual winner. The playlist had triumphed.

Working Through a Playlist

There’s a brute-force aspect to the strategy used by Hughes and Johnson. They force themselves to consider prescribed questions, one at a time, to generate new options. A “canned” list of stimuli seems to spark fresh insights. What’s particularly surprising is that this brute-force approach can work in advertising, a domain that prizes creativity and novelty. The case suggests a way to test the approach in other settings.

Could you create your own playlist to help your colleagues discover options? Think about some of the common types of decisions that have been made historically in your organization. For example, one unpleasant but common type of decision is how to make budget cuts. What if the wisest minds in your organization had come up with a list of ready-made questions and issues that could help direct the budget cutter?

• Is it possible the budget can be cut by delaying planned expenditures rather than by paring existing expenditures? • Have you exhausted other potential sources of income that might relieve the need for cutting? • Resist the urge to cut everything by a fixed amount. Think about ways to be more strategic with cuts. • Could you cut deeper than you need to in order to free up funds to invest in exciting new opportunities?

As with the Hughes and Johnson playlist, this would allow a manager to sort quickly through potential options. Let’s say a county government official is struggling with the need to cut her library budget by 10%. Initially, the official might have considered two options: cutting hours by 10% across the board or closing one library branch entirely. The playlist helps her see a broader spectrum:

• Is it possible the budget can be cut by delaying planned expenditures rather than by paring existing expenditures? I can delay a few IT hires. That will help a little but not a lot. • Have you exhausted other potential sources of income that might relieve the need for cutting? Not much promise here—we certainly can’t raise taxes in this climate. We can try to attract corporate sponsors, but those efforts wouldn’t pay off until next year. • Resist the urge to cut everything by a fixed amount. Think about ways to be more strategic with cuts. It might be wise to be strategic about the hours we restrict. For instance, with the library near the college, we could leave the evening hours intact but move the opening time later. In the neighborhood that’s full of retirees, we could open at the same time but close earlier. • Could you cut deeper than you need to in order to free up funds to invest in exciting new opportunities? This might make a lot of sense. If we closed our least utilized branch and cut back hours, that would free up $2 million that we could invest in our online tools, which would allow everyone in the community to benefit 24-7.

Organizations that repeatedly face similar decisions may find playlists useful. The questions need to remain relevant, and the list should leave room for options its creators did not anticipate. A checklist is useful for situations where you need to replicate the same behaviors every time. It’s prescriptive; it stops people from making an error. On the other hand, a playlist is useful for situations where you need a stimulus, a way of producing new ideas. It’s generative; it stops people from overlooking an option. (Don’t forget to shine your spotlight over here …)

Playlists also encourage us to consider several options and shift between prevention and promotion mindsets. Note that in the budget-cutting example above, the last sentence is an explicit prod to shift to the promotion mindset: “Could you … free up funds to invest in exciting new opportunities?” That’s a useful stimulus, because most decision makers struggling with budget cuts are likely to be trapped in the prevention mindset (concerned with preventing harm).

A playlist will not cover every novel decision. Use it as a starting point: ask which past experience applies, which assumptions have changed, and what options the existing questions may leave out.