# Upstream - Dan Heath Synced: [[2023_11_30]] 6:03 AM Last Highlighted: [[2020_07_07]]  ## Highlights [[2020_06_30]] (Location 1778) [[favorite]] > A similar strategy was used by the Permanente Medical Group in Northern California. In 2008, Alan Whippy, the medical director of quality and safety, was pushing hospital leaders to reduce preventable errors and infections, a major cause of patient death. She challenged those leaders to do detailed case studies of the last 50 patients who had died at each of their hospitals. To their astonishment, about a third of those deaths were due to sepsis, a problem that was barely on their radar at that time. By 2011, those leaders had reduced mortality for patients with sepsis by 60%. By getting close to the problem, they found leverage points to prevent unnecessary patient deaths. The postmortem for a problem can be the preamble to a solution. [[2020_07_01]] (Location 1826) > A necessary part of finding a viable leverage point is to consider costs and benefits. We’ll always want the biggest bang for our buck. But I want to draw a sharp line between “bang for the buck,” which is critical, and another, more pernicious idea. One of the most baffling and destructive ideas about preventive efforts is that they must save us money. Discussions of upstream interventions always seem to circle back to ROI: Will a dollar invested today yield us more in the long run? If we provide housing to the homeless, will it pay for itself in the form of fewer social service needs? If we provide air conditioners to asthmatic kids, will the units pay for themselves via fewer ER visits? These aren’t irrelevant questions—but they aren’t necessary ones, either. Nothing else in health care, other than prevention, is viewed through this lens of saving money. Your neighbor with the heroic all-bacon diet—when he finally ends up needing heart bypass surgery, there’s literally no one who is going to ask whether he “deserves” the surgery or whether the surgery is going to save the system money in the long haul. When he needs the procedure, he’ll get it. But when we start talking about preventing children from going hungry, suddenly the work has to pay for itself. This is madness. The reason to house the homeless or prevent disease or feed the hungry is not because of the financial returns but because of the moral returns. Let’s not sabotage upstream efforts by subjecting them to a test we never impose on downstream interventions. [[2020_07_01]] (Location 1947) [[favorite]] > In late 2010, Roli Saxena was hired to run the customer success group for LinkedIn’s flagship product for recruiters. (“Customer success” is like an upstream version of “customer service”—the mission is to keep customers happy with the products/services they’ve bought.) [[2020_07_01]] (Location 2103) > As we design early-warning systems, we should keep these questions in mind: Will the warning give us enough time to act effectively? (If not, why bother?) What rate of false positives can we expect? Our comfort with that level of false positives may, in turn, hinge on the relative cost of handling false positives versus the possibility of missing a real problem. [[2020_07_07]] (Location 2611) > One business created a feedback loop for meetings. The owners of Summit CPA Group, a 40-person accounting group founded in Fort Wayne, Indiana, made a decision in 2013 to let everyone work remotely. It was a popular decision, but it had consequences. Because they didn’t encounter each other in person anymore, their online meetings became their primary means of contact. At first, the meetings were problematic in familiar ways. “What happens is you get certain people that will talk forever and dominate the entire conversation,” said Jody Grunden, the cofounder of Summit. “You’ve got certain people that won’t say a word, and then you got people in between.” Worse, the people who dominated the conversation tended to be the complainers and the critics. The firm actually started losing CPAs because they found the interactions so negative. So the firm made some changes. They had a facilitator run the meetings, using a new structured agenda that included a segment in which every participant shared something positive from the previous week. It sounds a bit corny, and at first some people tried to pass their turn, but pretty soon it became the norm. The bright-spots focus changed the tone and, better yet, provided a venue for learning: They started sharing advice on everything from handling tough clients to making reports simpler. Beyond the structured agenda, though, they added a feedback loop. At the end of every meeting, every attendee verbally scored the meeting from 1 to 5. Outliers were asked quickly what had made the meeting unusually helpful or unhelpful. When people complained about something—a discussion going on too long, a problem not being resolved—those issues got addressed. As a result, the meetings steadily got better, because now they had a closed loop. The virtual meetings at this accounting firm now consistently score 4.9 out of 5.0. (Whereas Ben Affleck’s movie The Accountant scored 3.65 out of 5.0 on IMDb. He needed a feedback loop, apparently.) We [[2020_07_07]] (Location 2647) > Here’s where we reach our first surprise: While paper bags and reusable bags are far better than plastic ones from the perspective of keeping waterways clean, they are worse in other ways. They require far more energy to produce and ship than do plastic bags, which means they increase carbon emissions. A UK Environment Agency study calculated the “per use” effects of different bags on climate change and concluded that you’d need to use a paper bag 3 times and a cotton reusable bag 131 times to be on par with plastic bags. Not to mention that manufacturing paper and reusable bags causes more air and water pollution than plastic, and they are much harder to recycle. So now we’re forced to grapple with part/whole confusion: If protecting waterways and marine life, specifically, is our goal, then a plastic bag ban is a great idea. But if making the whole environment better is the goal, then it’s less clear. There are competing effects to consider. Another twist is that we’ve got to be very careful how we design the ban. In 2014, Chicago passed a law banning stores from offering thin, single-use plastic bags at checkout. So what did the stores do? They offered thicker plastic bags at checkout. The retailers’ supposed rationale was that customers could reuse these plastic bags, but of course most didn’t. That’s the cobra effect again: Trying to rid the environment of plastic led to more plastic.