Upstream: How to Solve Problems Before They Happen by Dan Heath

Section 3 – Seven Questions for Upstream Leaders

5. How Will You Unite the Right People?

  • The main idea here is to form a team composed of people from every agency that would be involved with a problem and to give the team time and resources to come up with solutions. Dan includes several examples of where this has worked. The first is the multifaceted team that tackled teen drug and alcohol use in Iceland. It may seem simplistic, but this team tackled the problem by finding other things like sports for the kids to spend time on.
  • Next we have a team that tackled the problem of spousal abuse and homicide in Newburyport, Massachusetts. This is the rare place where police officers and domestic violence advocates work closely together. They came up with a way to identify women at risk and had the police do a lot of drive-bys of the women’s homes. They also made sure the men in the penal system didn’t leave without their GPS bracelets installed.
  • Finally we have the story of the homeless fight in Rockford, Illinois. Instead of only giving housing to people who had given up drugs, gotten treatment for mental health, and taken vocational training, they gave housing to the most vulnerable. They also went from a yearly census to a real-time database so they knew where everyone one was. From seven agencies working on homeless issues, they went to a single point of entry.

6. How Will You Change the System?

  • To change the system is to change the rules that govern us or our culture. A well-designed system is the best upstream invention. The 80% decline in deaths per mile for automobiles since 1967 is an example of an upstream system change. It involved efforts to reduce drunk driver, requiring seat belts, airbags, and better braking technology among other things.
  • Sometimes system change can be simple. To prevent people from throwing away plastic trays, fast-food restaurants used garbage cans with smaller holes. To reduce the damage of bicycles in shipping, one company printed images of flat-screen TVs on their boxes. The idea is to prevent wounds as well as bandage them. You also need to empower people to fight for their interests so they can win policy victories to change the system. Laws are just a set of rules based on the input of people with power.

7. Where Can You Find a Point of Leverage?

  • When it comes to preventing problems in complex systems, finding the right lever and fulcrum is what you need. Systems have great power and permanence, (think inertia or status quo) which is why change is difficult. The first example involves trying to stem youth violence in Chicago where impulsive young guys with alcohol and guns equal a dead body. A program that helped featured using cognitive behavior therapy on groups of young men in the target demographic.
  • The second comes from the health care system where doctors are only paid for treatments they provide to people who are already sick. Some organizations are trying to change this by encouraging doctors to get to know the whole patient and to see what they can do to prevent problems. Every problem has its own array of factors that increase risk or protect against it, and each of those factors can be a leverage point. Sometimes it makes sense to spend a lot of money or time on a small part of a population.

8. How Will You Get Early Warning of the Problem?

  • Early warning systems are only useful it they give you time to act and if your action is beneficial. They act like smoke detectors. Examples include the people at LinkedIn who used customer inactivity during the first month as a warning and reached out to these people to cut their leave rate. The folks in the Chicago Public Schools used off-track freshman data as a warning.
  • Some problems follow patterns. One ambulance company pre-deploys their fleet so that they are more likely to be near places like nursing homes. When one ambulance goes on a call the others shift their positions to cover the hole. Elevators connected to the Cloud can let repair people fix problems before they result in people stuck in an elevator. Too many false positives can be a problem. In South Korea, the health care system started testing for thyroid cancer and the positive rate went way up resulting in lots of surgery. Unfortunately, thyroid cancer is one that is very unlikely to spread or cause death, so most of the surgeries only caused harm.
  • A final example deals with the aftermath of the Sandy Hook Elementary School shooting in 2012. In an effort to prevent further school shootings, an organization called Sandy Hook Promise studied the warning signs that were missed in school shootings and taught students what to look for. They also set up an anonymous “See Something, Say Something” hotline. See the video they made here.
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