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Root Cause

February 22, 2015

“A root cause is an initiating cause of a causal chain which leads to an outcome or effect of interest. Commonly, root cause is used to describe the depth in the causal chain where an intervention could reasonably be implemented to change performance and prevent an undesirable outcome. …The term root cause has been used in professional journals as early as 1905. Paradies would define a root cause as follows: “The most basic cause that can reasonably be identified that management has control to fix and, when fixed, will prevent the problem’s recurrence.”

Root Cause is well known to Lean Practitioners. Lean is a management system that focuses on a dual pronged philosophy of “Respect for People” and “Continuous Improvement.” By delegating improvement activity to lean trained production workers, you delegate continuous improvement, and respect their talents to achieve improvement. They improve by a relentless search for the Root Cause.

Today, I read that the U.S. Dietary Guidelines Advisory Committee has changed a number of its warnings. Cholesterol and coffee consumption are tops on the list. They have recognized that dietary cholesterol is consumed in such small amounts that it has no effect on serum cholesterol in the blood and body. Coffee consumption has some significant benefits and the Committee actually says that some consumers should consider increasing coffee consumption. In Root Cause analytical terms, cholesterol consumption and coffee drinking have been eliminated as the Root Cause for bad results.

The Committee also took a tentative step towards recognizing something that I have been advocating for some time—that diet affects mental health. In an article published by the Huffington Post, this statement captured the hope contained in the new guidelines.

“For instance, the report mentions that the American Psychiatric Association classifies omega-3 fatty acid supplements (normally found in seafood) as ‘complementary therapy’ for major depressive disorder. And some studies show that a diet high in vegetables, fruits, nuts, legumes and seafood are linked to a reduced risk of Alzheimer’s disease and dementia.

In the past 4 months, I submitted abstracts to 2 different conferences to discuss the impact of nutrition on violence, and had both rejected. I have also advocated for mega vitamin therapies for a variety of mental health issues, including Omega 3 for reducing violence and ADD/ADHD behaviors, B Vitamins for a variety of addiction, inflammation and cognition issues and other vitamins and minerals for reducing the inflammation caused by stress.

Information published takes years to filter through to the general populations, and you will still find many who continue to deny current information based on their past education. This new set of guidelines holds many implications for health in Indian Country, and I hope we pay attention to it. Poor nutrition is the Root Cause of many behaviors that we treat with therapies that might not be necessary. Let’s start a conversation around this topic: the nutritional root cause of many behavioral issues.

Using Lean Government to Improve Foster Care

February 8, 2015

A colleague of mine had a brilliant thought: how can we apply the principles of Lean Government to foster care. I did the research, and it confirmed my already deep conviction that any process can benefit from the application of Lean Thinking.

I was a foster kid once The Washington State family services took my four sisters and me away from my mother when I was 10 years old. The police picked me up at school and took me to the Seattle Youth Detention Center. I ended up staying there for months while a suitable placement was found. I spent months in foster care before they were able to reunite us with our mother. It was a hugely traumatizing event. My one safe place at that time was the school library. I felt comfortable there. I never really felt comfortable again for a long time.

A foster care system has concrete processes in place. Takt Time is the number of opportunities encountered by the system. And when I say opportunities, it is a negative, but only a descriptor for how many children we will process in the course of a period of time. Once a child is in state custody, they encounter a lot of processes, none of which are likely coordinated very well. But if we know how many children enter the system, we have a start.

The second step is to identify the process the child goes through when in foster care. I am sure there is intake. You need information and an initial placement. There are investigations and interviews to conduct. Services occur and are scheduled. If we discuss it, we can develop a visual map of the process steps each child goes through. The visual map will originally be chaotic and random appearing. But it is still a process capable of viewing.

Services and other interactions with a child can be viewed a “pull” systems. If a child has a toothache while in custody, they need to see a dentist. That’s a pull system. A psychological evaluation, medical appointment, and school conferences are all “pull” systems. If the child needs the service, it is pulled only when or if needed. The amount of time a child is in the foster care system is called cycle time. Cycle time just describes the amount of time it takes us to provide services to a child. Lead time is the total amount of time they are with us, and value adding time is the time spent benefitting the child.

There are typical types of objections made by staff engaged in any system, and my assumption is that foster care is no different. However, Lean Thinking is all about increasing the value of our services to the children we serve. If we eliminate wasteful steps, does that benefit the child? Yes, it does. The state of Iowa reported this result for an intake process: “Child Protective Intake. Increase ease and efficiency for staff and timeliness of response for customers. Reduced Child Protective Intake cycle time by 63% and delays by 91% for a total reduction of lead time by 79%.” Now that is a real benefit for the child. In a Child Welfare Adoption system, they reported that “Delays reduced by 32%; Steps reduced by 8%. Identifying and implementing efficiencies across workers was a key outcome in the new process.”

Lean Thinking provides real and tangible benefits to children, while reducing the cost of providing those benefits.

Denver Human Services examined their certification and recruitment processes for foster care and came up with a strategy to reduce the certification process by over 50% and the numbers of families certified increased by 25%. This benefits children who are impacted by not having enough certified families.

This report comes from a non-profit organization in Florida:

“As a result of the team’s effort:

  • Average licensing time dropped from 200 days to below 100 days.
  • Changes to the licensing process resulted in bringing in new foster families and expanded capacity of existing homes.
  • As of March 2014, they had 79 new foster beds, exceeding their internal goal of 75 beds.
  • With cost savings, Kids Central could serve an additional 505 families annually.
  • Through moving 50% of youth from facility-based care to foster home, they would save approximately $900,000 per year.”

This is a solid and tangible demonstration of improvements that benefit children. And considerable savings accrue in cost avoidance.

The State of Alaska needs to start having the conversations that lead to an implementation of this type of benefit for our children. Can we afford to wait? Not if we care about our kids.

Kaizen (Red Ocean) vs. Kaikaku (Blue Ocean)

January 30, 2015

My thinking about ACE’s is informed by a systems approach I learned while adopting and implementing a management concept called “Lean Thinking.” There are 2 essential elements to Lean Thinking: Respect for People and Continuous Improvement. As I analyze how knowledge about ACE’s moves into the public consciousness, it is gratifying to see the discussion of potential solutions. However, one lesson I learned many years ago was not to jump to solutions before you understand the facts. I am not saying study everything to death. We assess the current level of factual knowledge available to us, and we act on that knowledge with appropriate experimental solutions. We discuss how to improve a system in an event called Kaizen. In business settings, Kaizen is a one week improvement event where many participants in the process being analyzed identify relevant facts, map out the current state, propose countermeasures to the problems/defects they identify, put together a project plan to test the countermeasures, review the progress regularly, and if the countermeasures are successful, add them to the most effective way you have identified to do the work. It uses the PDCA Cycle as a scientific method for problem identification, research, systems analysis, solution proposal and testing. It truly works for improving already existing systems.

Kaikaku is a different process. Years ago, I studied the concept of Blue Ocean Strategy. The concept discusses how you identify a place in the market that is not occupied (or Red Ocean). When you find Blue Ocean, you generally have the market to yourself. Kaikaku is the Lean process of finding Blue Ocean. It introduces radical change, and that can be difficult. However, when you compete in the Red Ocean, you face constant pressure from competitors. When you find Blue Ocean, you have great freedom to access the market and great benefit.

I worked in health care delivery in rural Alaska for 10 years. Kaizen is not applied in Alaska Tribal health care. We spend about a billion dollars annually for health care for Alaska Natives. I estimate that we could recapture about $300 million in value from our current systems with an effective Lean transformation. Imagine what that could do for Alaska Native health care. I am not sure how much additional revenue could be captured, but I suspect it’s considerable. Many Alaska Natives do not use their Tribal Health care systems because they do not address their needs—either because of lack of capacity or long wait times.

Recognition of ACE’s and development of a new response system for health care is Blue Ocean. Kaikaku is the process I used to envision a different system of care that promotes healing instead of profit. The Red Ocean that we are engaged in is interesting. Consultants, researchers and funding agencies are all focused on problem identification and are seeking new and innovative approaches. But they do not have the foundational, systemic facts that are required for new solutions. Nor are there many minds open to new solutions and new ideas. It is basic human nature to resist change and innovation. We have to change that, and Acesconnection is a wonderful tool for sharing ideas and thoughts on how to change.

I wanted to share my though process because what I see on Acesconnection are many wonderful people going through the fact collection stage. Solutions are being proposed, but they are based on Red Ocean. That space is already occupied, and we need to find the Blue Ocean. Funding agencies need to think about Blue Ocean. I had a chance to think about this when the National Institute of Mental Health put out a Request for Information on how to address the issue of suicide prevention in Indian Country. NIMH is mining the Red Ocean and seeking Blue Ocean. I fear they don’t have a mindset that allows them to see it.

I responded to the RFI. My basic approach states that the facts implicate Developmental Trauma (ACE’s) in the development of suicidal thoughts and actions. If we approach identification of developmental trauma causation and its effect on all behaviors and health issue, we have a factual basis on identification of an at risk population. The countermeasures will have to be individually developed, but the earlier we can identify someone who has risk markers for development of suicide, the earlier we can intervene. And our intervention will not only help to reduce suicide, it will help to reduce many other risks that we currently address through what I refer to as “Silo’s.” Addressing developmental trauma should help address many issues.

I now this might sound like a strange post. But we have been addressing many developmental trauma based issues for decades and developed a deep Red Ocean. I hope there are enough people who understand this concept and can start the movement to identify new practices. If you have made it this far, thank you for reading.

Reforming Education Using Lean Thinking

January 25, 2015

Being trained in the management system inspired by Toyota, referred to as Lean Thinking, has guided my approach to addressing Adverse Childhood Experiences, or developmental trauma. I thought I would take a Lean Thinking approach to addressing education reform. Here is what I came up with.

The problem statement I developed is fairly broad. It says that our education system is expensive, managed almost exclusive using a top down command and control system, does not flow, and produces a high percentage of defective work, as measured by the rate of dropouts and poor performance on academic testing.

A Root Cause analysis is also broad, and complicated by my inability to utilize a Kaizen to map out the process. So I am relying on my experience as a parent to ask the 5 Whys that we use in Kaizen.

My 5 Why’s led me to 3 possible inputs that produce the defects. They include 1) developmental trauma (Adverse Childhood Experiences); 2) nutrition deficits; and 3) academic proficiency. There are likely others, but the Lean Thinking process takes you to your level of current expertise, and mine I acknowledge is not very high.

Our only measurement system currently in place for education is through grading and assessment testing. Once a student is placed into a specific grade, they flow with that grade—not according to achievement and present ability. Classes do not flow either. All students progress at the same rate. Training is conducted by batch. The class is the batch, both as to grade and subject.

No assessments are conducted for developmental trauma impediments to learning. No nutritional deficits are considered when looking at achievement levels. Research into each topic on the influence they exert on education levels would lead one to conclude that we should consider the impact of trauma and nutrition on learning. In fact, teaching may be a lesser input considering the impact trauma and nutrition might have in helping remove a student from the classroom. Trauma affects social, emotional and behavioral development. Any of these domains can affect the ability of a student to learn.

So what are possible solutions? I believe assessment for trauma and nutrition should be included in how we assess students for determining their class selection. When either impacts the student’s ability to learn, we should train the student on both the impact of trauma or nutrition on their performance and do all we can to develop a strategy for improvement and assist their improvement efforts. We can also provide supplemental nutrition and healing assistance for trauma.

We can also help education flow better by discontinuing the batch teaching and arrange for flow training. If we have standard work for learning, we can train to the standard work and allow the students to move at a pace of their own choosing. If they are advancing fairly rapidly in one area, they should be allowed to move to lessons at the pace of their advancement. We should also consider the benefits of practice and allow more time for students to repeat the material until master.

I am sure that there is so much more that can be done. I would like to encourage a progressive school district to try this and see if we can benefit all of our students. By using a comprehensive problem solving tool like Kaizen, with a team that includes students, parents, teachers and administrators, perhaps we can revolutionize education.


January 15, 2015

Dr. Anton Antonovsky, an Israeli social scientist, coined the phrase that forms the title of this blog and described it in 1979.[i] The concept is brilliant, and what surprises me is that after 6 intense years of ACE’s informed work, I had not heard of it before today. Just to let you know that this is common in my work. As a non-formally trained (no Ph.D.) scientist basically self-teaching, I come across new concepts and theories on a regular basis. I know have another avenue of inquiry I need to go down. And I believe it’s an important one. I have already been down this path, and it’s a fundamental principle in my Restoration to Health Initiative (RtH)—combining medical, behavioral health and nutrition screening in a health care system to identify victims of developmental trauma.

I haven’t really explained the “Systems” approach I used to develop RtH. As a new Executive for a non-profit in Alaska in 2003, I was shocked by the dysfunction in our work processes. After a short conversation with a business executive who had adopted a system of management based on how Toyota managed, I was introduced to “Lean Thinking (Lean).” Lean has 2 essential principals—Respect for People and Continuous Improvement. After immersing myself in both the cultural development of Lean and learning the skills of continuous improvement, the non-profit improved considerably. I blogged about my experiences learning and implementing Lean at the non profit so you can read about it there if you have any interest.[ii]

When I became aware of ACE’s, I had been trained to think systemically and I applied that thinking to my research into trauma. At a 2010 event for our tribal members, I had put together the original concept of medical and behavioral health in one entity. We had developed a number of A 3’s[iii] addressing issues that had to be solved before merging the services. I left before we could accomplish the tasks set out in the A 3’s and I don’t believe that work has continued.

Salutogenesis describes a systems approach to health. Most babies are born “defect free.” If their upbringing follows a biologically predictable pattern, without interference by Adverse Childhood Experience, they have fewer medical and behavioral issues. That is a fundamental insight I derived from the ACE Study. As a child develops, Lean Thinking tells us that when defective parenting appears, we should intervene quickly, as a team, to address the issue and eliminate the defect. Through information (to parents about the consequences of ACE’s), teaching (of parenting skills), healing (for the negative behaviors implicated in transmission of ACE’s, such as alcoholism) and continuous improvement (for both parent and child), we achieve a health adult.

Dr. Antonovsky used his theory to study the concept of resilience. It’s a little more involved that my limited research can explain, but he observes that many people thrive despite having Adverse Experiences (including childhood derived) in their lives. I will tackle this explanation when I have more knowledge. Basically, there is a process that prepares some people to rebound from adversity. They don’t have negative health outcomes because their development process contains factors that help them cope. I believe this is what others refer to when they describe resiliency.

I want to add one more thought, also based on the concept of resiliency. It is my belief that some resilience can be attributed to the adoption of positive and neutral behaviors. I described this before in the context of successful childhood actors and singers. They do well until the praise stops, usually at age 18. Criticism sets in at the same time. As adults, they can access more coping materials: alcohol, drugs, sex and buying stuff (“retail therapy”). Lots of teens are praised for their skills and devote extraordinary amounts of time and effort to develop them. I believe for ACE’s kids, both the exercise and the praise help alleviate the feelings of stress, tension and anxiety. However, a meltdown (from the accumulated effects of substances and stress) leads to both physical and behavioral issues later in life.

It is appropriate to have trauma informed employees wherever kids spend time: schools, sporting events, juvenile justice systems and recreation centers, among others. Recognizing the infliction of ACE’s or the manifestation of ACE’s is critical to what I described in the systems approach as identification of a defect. We can then utilize a team approach to solving the problem.

I should add that the systems approach does not rely on blame or shame when fixing defects. And defects should not be used in a judgmental form. A defect is only a descriptor for occurrences that we know can lead to problems in the future.

[i] Antonovsky, A. “Health, Stress and Coping” San Francisco: Jossey-Bass Publishers, 1979


[iii] An A 3 describes an 11” x 17” document used by Toyota to write, on one page, all of the information required to improve a process.

Accepting and Advancing Change

January 12, 2015

I have tried to make sense of why there is significant resistance to new knowledge that has great potential for improving our lives. When I became aware of the ACE Study in 2008, it changed my worldview. As a child growing up with trauma, I could see the impact on my family and, as I began talking to others about trauma, many other families. I spent a considerable amount of time reading, researching and talking about ACE’s. I also began trying to convince others about the importance of understanding ACE’s and developing new approaches for responding to the new knowledge. This is a small part of what I have learned in my quest to understand resistance to change and how to advance new knowledge.

Dr. Anders K. Ericsson, a Professor at Florida State University, wrote in a 1993 scholarly article, “Many characteristics once believed to reflect innate talent are actually the result of intense practice extended for a minimum of 10 years.” [i] Dr. Ericsson,[ii] Malcolm Gladwell,[iii] and Matthew Syed,[iv] among others, have discussed this concept in the lives and achievement of many notable scientists, athletes and performers. Two significant parts of the concept of achievement discussed is “deliberate practice” and “purposeful effort.” We must take time to practice, and we must practice with a purpose. Every time we achieve, we need to increase the bar, to use a pole-vaulting analogy. Too many people believe that performance is because of talent, not practice, and choose not to put in the time and effort to learn and practice. They choose to live in the comfort of the knowledge they have because it is familiar and they are not challenged by it. There is very little opportunity for failure.

Dr. Carol Dweck[v] has identified another theory that makes a lot of sense to me. Individuals have either a fixed or a growth mindset. In a brilliant experiment, Dr. Dweck tested 2 groups of kids and for those with good grades on the test, told them either that they must be really smart, or they must work really hard. Those who were told that they must be really smart stopped, for the most part, accepting challenging work. Those told that they must work really hard continued to accept challenging work. A fear of failure stopped the “smart” group from accepting challenges and further achievement.

If we look at both theories working in concert, being told you are smart stops many from the deliberate practice and purposeful effort required for achieving. Being told that you are hard working encourages you to take on more difficult tasks, and fail enough times to train yourself to become proficient. As a pitching coach for baseball players, I have watched the joy of a “hard work” kid, making mistake after mistake, as they learn the skills required to become a successful pitcher. So many kids don’t meet with immediate success, are criticized, and don’t practice or make the mistakes required to become good. The best are those who accept new theories, try them and become proficient through their use. The same is true for developing new knowledge. You are going to fail, but the faster you move into acceptance and practice mode, the more proficient you are going to become.

When horses were brought to North America, American Indians who tamed and trained on use of horses gained a considerable economic advantage over those who did not. They were able to travel and hunt over a greater range, chase down game and haul big loads. They had a substantial competitive advantage over those who did not.

The numbers of people who don’t accept new knowledge and challenges are overwhelming. They have not developed skills necessary to thrive because of their “fixed mindset.” They are comfortable where they are. Resistance is substantial when it comes to accepting new knowledge. If we are doing well with the knowledge we have and use, we will do all we can to protect it. The excuses I encounter include: that’s not true opinions (based on old science and existing culture); we are different; we have already tried that; it’s not my idea so I am not interested; we need experts to help us; we can’t afford to fail; and we don’t have enough money. I am sure you can add more excuses.

The findings of the Adverse Childhood Experience Study have been available for about 20 years. Longer if you consider that some outliers were very aware of the impact of developmental trauma on behaviors long before ACES. Yet the American Academy of Pediatrics did not implement a Policy on developmental trauma until 2012. It takes a long time for new knowledge or understanding to permeate culture. Knowledge is not leading to a change in treatment requirements. This is not unusual. It’s the nature of the human brain. Dr. Abram Hoffer once postulated that we will not change until 50% of the general population, and 10% of the professional population, that uses the old knowledge accepts the new knowledge.

So we have a number of hurdles to overcome. First, we have to continue to disseminate good knowledge about the impact of ACE’s in our tribal communities. ACE’s Too High and ACE’s Connection help with this goal. When we reach a “tipping point,” knowledge will flood through our communities and become common knowledge, and become a part of our cultural knowledge. When people start looking for solutions, there will be many proposed solutions that are not based on solid science. The reason I write about knowledge, nutrition, trauma release exercise and other self directed healing methods like mindfulness and emotional freedom technique is because each has been acknowledge, in part, as a solution to healing from developmental trauma.

As we look for healing methods, we will also encounter entrenched ideas about healing. Advocates and those who earn their living from established methods will continue to push established methods, even if the science shows they are inefficient. We have to be prepared to meet the counter arguments that are being advanced, not in a hostile manner, but in a reasoned debate.

In the meantime, outlying theories of healing should continue development. They will, at some point in time, demonstrate success and more individuals will use them. We need to have “hard workers” who are willing to “practice deliberately” in new areas, make plenty of mistakes and through purposeful effort, advance our knowledge in this new and fruitful area. We cannot afford to have others treat it as a fad. The science demonstrates that developmental trauma is real, and there are emerging theories for addressing the issues caused by this trauma.

We need deep thinker and doers at this stage of preparing our Tribal Communities for healing. I hope all of you encourage deep thinking and doing. Don’t adopt ready excuses. Listen (or read) to the ideas proposed by others. Spend the time necessary to become proficient. We all benefit from realizing that we can make mistakes, learn from them, and advance the state of knowledge we have.

[i] Ericsson, K.A. “The Role of Deliberate Practice in the Acquisition of Expert Performance,” Psychological Review, 1993, Vol. 100. No. 3, 363-406

[ii] K. A. Ericsson, ed. Mahwah, The Road to Excellence: The Acquisition of Expert Performance in the Arts and Sciences, Sports, and Games, NJ: Erlbaum, 1996.

[iii] Gladwell, Malcolm. “Outliers: the story of success,” New York: Little, Brown and Co., 2008

[iv] Matthew Syed,Bounce: Mozart, Federer, Picasso, Beckham, and the science of success,” New York: Harper, 2010

[v] Dweck, Carol S., “Mindset: the new psychology of success,” New York: Random House, 2006

Explaining a Pathway to Behavioral Problems  

January 3, 2015

Problem solving requires looking for the root cause of the problem. It’s not always easy to identify a root cause. Behavioral issues and psychological problems have a root cause. But because there are so many variables (Inputs) into the development of issues and problems, they can be hard to accurately identify. I am going to attempt to explain my understanding of where the root cause of many behavioral and psychological issues start.

There are 3 interacting variables, although you could certainly identify more by breaking my three into further groups. I call them Trauma Derived, Nutrition Derived and Culturally Adopted.

“Trauma Derived” root cause describes developmental trauma. Called Adverse Childhood Experiences in a study of the same name, developmental trauma affects how a child adapts to an environment where its fight or flight (fear) response is continually activated. Developmental trauma leads to an increased stress response system, greater anxiety and inflammation. Developmental stress is causally linked to many negative behaviors, including anger/aggression, alcohol/drug abuse, promiscuity/teen pregnancy, dropping out of school, depression and suicide, among others.

“Nutrition Derived” root cause describes a pattern of nutrition that affects the physical function of the brain, organs and body. Obesity comes from a nutrition pattern of heavy sugar and processed carbohydrate consumption. Schizophrenia, depression, learning/cognition problems, heart disease, and cancer have been linked to nutrition deficits.

“Culturally Adopted” root causes come from peer pressure (religion, gangs, citizenship) on action and reaction to cultural situations. A culture of poverty can affect nutrition and health care, which compound other issues.

As a child grows towards maturity, the mix of Inputs varies and the child’s reactions differ from other children with a different mix of inputs. Outcomes vary as well, depending on the types of soothing and calming resources the child has access to. A heavily traumatized child might find that sugar is soothing and calming, ingests more and more sugar, and starts gaining excess weight as a result. The excess weight may lead to more teasing from peers and different treatment by adults. The child might be excluded from different activities, and fail to learn skills and develop talents that might be soothing and calming. The child’s addiction to sugar might be transferred to alcohol, which is simply a more refined sugar, and lead to the development of other negative behaviors. As a teenager, alcohol and drug use can put a teen into contact with the law, and additional labels are attached to the teen that make it more difficult to function.

In interplay of the three Inputs describes a system of inputs and outputs that vary widely and are not necessarily predictable. One child might use their aggressive behaviors to achieve in sports or business, while another might end up in jail.

In my next post, I want to talk about the difference between outcomes that appear to be positive, and how they may actually be detrimental in the long term, to the individual and to society.