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The Newtown Tragedy – Our National Response and Problem Solving

by Mark Graban on December 17, 2012 · 30 comments

bob 150x150 The Newtown Tragedy   Our National Response and Problem Solving leanAs are many people across the United States and around the world, I’m saddened by the violence that claimed so many lives Friday in Newtown, Connecticut at Sandy Hook Elementary School. The mass shootings that plague our country are incredibly upsetting. My friend Bob Emiliani created the graphic that’s shown at left, that represents our collective mourning.

As with many situations, it’s easier to identify that we have a problem. What’s less easy is figuring out solutions that will really prevent future violence. Complex problems rarely have simple solutions, right?

Can we have any sort of national solving effort along the lines of “Lean thinking” or the “A3″ problem solving methodology or will we just have knee jerk solutions proposed?

People blame the murder, they blame the parents, they blame the guns. They blame the shutdown of mental health facilities, they blame the media and movies and video games.

People propose all sorts of solutions – get rid of guns, ban the importation of bullets, reinstate restrictions on assault weapons… it all seems so reactive, so emotional… jumping to solutions is not good problem solving. People scream “do something!” — but what?

Doing nothing (as has occurred after recent mass killings) and expecting the problem to go away is not good problem solving.

As I’ve learned from the Toyota people I’ve worked with, good problem solving includes the following questions:

  • Do we have a problem? Yes.
  • Do we know the root cause? There are many causes… do we address the many contributing causes? Is there a single “root cause” that can be addressed?
  • Have we proven cause and effect between the root cause and what occurs?
  • Do we test the proposed countermeasures to see if they are actually effective?

Can we ask our leaders, at state and national levels, to be thoughtful and rigorous in their attempts to solve our societal ills and make things reasonably safe without trampling the rights of all law-biding citizens? What do we do about mental health treatment?

Can we expect good problem solving from government and elected leaders? Or just a bunch of talk about things that might just sound good? What do we do? There’s likely no single, easy answer.

My thoughts and prayers are with those who are grieving and mourning in Connecticut and all whose lives have been touched by this sort of violence.


Mark Graban 2011 Smaller The Newtown Tragedy   Our National Response and Problem Solving leanAbout LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as the new Executive Guide to Healthcare Kaizen. Mark is also the VP of Innovation and Improvement Services for KaiNexus.


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{ 30 comments… read them below or add one }

1 Mark Graban
Twitter:
December 17, 2012 at 8:07 am

A comment on LinkedIn illustrates jumping to fanciful technology solutions… I’ll push back again and ask “do we really understand the problem?

The linkedin comment:

How about developing technology where every single owned gun (especially handgun) has a computer chip in it. Upon walking through a TSA-style detector, the chip would automatically trigger and deactivate the firing mechanism.

Yes, there are ways around this – but at least many of these weapons wouldn’t have the opportunity to work indoors. Older guns? Who knows if they could be retrofitted – but at least all new guns and their gun-owners would be mandated to use such a chip.

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2 Dean Bliss December 17, 2012 at 9:17 am

The key to me is to think deeply, as Toyota teaches us, and to not come up with a knee-jerk reaction that would, at best, be ineffective, or at worst, could complicate the situation. I don’t know the answer, but I fear those who think they do without sufficient study and thought.

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3 Mark Graban
Twitter:
December 17, 2012 at 9:19 am

Amen to that, Dean.

For better or for worse, our political and legislative system tends to move very slowly…

I think the past will view the “Patriot Act” as a knee-jerk reaction to 9/11… our government doesn’t have a good record on knee-jerk reactions and moving swiftly.

You cite Toyota, we could even go back to Deming and his teachings about understanding a system and following a PDSA improvement cycle. Government rarely goes back to Study or Adjust after Doing something.
Mark Graban recently posted..Lean Healthcare Animation from British ColumbiaMy Profile

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4 Tim December 27, 2012 at 2:40 pm

Mark,
Government rarely goes back to study and adjust because our political system doesn\’t support it. In fact, our system encourages knee-jerk reactions. We rotate elected officials like laundry every few years at election time. The collective leadership of our government is in continual flux with new people bearing the latest great ideas arriving on Capitol Hill all the time. We vote for those we think can make a positive change and then vote them out again before they\’ve had time to see any of their efforts become fruitful. What business could survive with so many drastic changes in organizational values happening so quickly? Successful business leaders know you have to dedicate to a vision, mission, and goals that require a long-term focus. Our problems will persist and get worse as long as our government leaders are flip-flopped when they don\’t produce immediate results.

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5 Mark Graban
Twitter:
December 27, 2012 at 3:05 pm

Tim – data seems to suggest that House and Senate tenure are almost at all-time highs… see this chart:

LINK

Congress Tenure

I agree we need long-term focus and that, generally speaking, us voters get the government we deserve (based on our actions in the voting booth), but I’m not sure the data really supports the idea that there’s “continual flux.”

When there is flux, we have a revolving door between government and lobbyist roles… maybe that’s one reason things don’t change, policy-wise?

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6 Mark Graban
Twitter:
December 17, 2012 at 10:15 am

Another science fiction suggestion from LinkedIn:

Maybe all guns cud have a face recognition or some intelligence built in. If there is a small child in front, it should not fire.

That might be a countermeasure for 2113 not 2013…

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7 Mark Graban
Twitter:
December 17, 2012 at 1:43 pm

I’ve seen other problem solving defects in the public and media discussion:

1) Confirmation bias — I believe everything is the fault of Republicans or guns or liberals and so this catastrophe is clearly the fault of the thing or group I already don’t like

2) Can’t prove cause and effect of public policy… the great recession would have been even worse if we hadn’t passed the stimulus, etc.

3) We try huge blanket one-size-fits all solutions (at a national level) instead of at the state or county level. What works in New York City won’t work the same way in rural Arkansas. We don’t tend to start with small pilots and then spread what works… there is supposed to be a “laboratory of democracy” in our 50 states, not a federal monolith.

There was a case in Michigan in the 1920s where a crackpot killed 38 kids and some adults by dynamiting an elementary school. China recently had a school rampage with many killed injured by stabbings. It’s not just guns. Norway had that madman shooter… I thought Norway had banned guns, basically??

Maybe we just have to accept that humans can be violent creatures and we should not have unrealistic expectations of people peacefully co-existing if there were magically no guns.

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8 Paul December 18, 2012 at 3:17 am

Mark,
Maybe we just have to accept that humans can be violent creatures and we should not have unrealistic expectations of people peacefully co-existing if there were magically no guns.

Here you have hit the nail squarely on the head. Humans will be violent creatures until they learn how to be peaceful within themselves. Because all violence is, at base, a projection of the inner wars going on inside the not-peaceful psyche of each individual, I have little hope that anything short of a psychic revolution is going to matter. Look at all the great teachers in our past: Buddha, Lao-Tzu, the writers of the Upanishads and Gandhi’s bible, the Bhagavad-gita; not to mention Jesus, the ultimate exemplar of the Conscious mind utterly tuned to the Spirit of God which is unbounded Love. (I’m not meaning the above comment in the religious sense at all, unconscious human beings responding to their view of religion are responsible for massive amounts of violence in the world, past and present). They have clearly shown the way but we do not follow it. We cannot, because we are do not understand that we are Unconscious.

So, I’m not holding my breath for anything useful to actually happen. Meanwhile, absent the above revolution, there should be half-dozen or so school people rigorously trained in the use of firearms and have them with them at all times. No more “gun free zones” which are simply soft-target invitations to mass slaughter.

Further, individual citizens should also step up and get that kind of training so they can stop idiots like we have witnessed lately right where they stand. It does happen, but the media don’t report those incidents because they don’t ‘bleed’. Nobody died in a horrific shooting because the shooter was staring down the barrel of another weapon and quit. They are cowards for the most part, preying on unarmed civilians. Suppose the principal and school psychologist had been armed with pistols (will trained, accurate shooters)? I’m betting the shooter would never have gotten to the classrooms to do the slaughter.

Paul

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9 David Chambers December 17, 2012 at 2:10 pm

Like so many of you, I watched the news unfold in horror. My daughter covers the news for one of the big three news stations in Seattle and called us in tears, not knowing how she could go on covering this story for the days to come…

I think some of this thinking – using the “A3″ problem solving is well intentioned and offers some merit. I have listened to many debates but have this to bring to the conversation. I have far too much personal experience with violence from my past. (And so I contend, these issues differ from rational problem solving because they deeply affect our emotions as well as our thoughts – I know they do mine.) I was in Vietnam and in combat for about a year and I was also behind enemy lines for most of that time, which meant violence was extreme.

Yet when one looks at the event that occurred in Newton, there are a few very clear facts that emerge. People who wish to inflict extreme violence NEED assault rifles to do their terrible deeds on a grand scale. Assault rifles are no good for hunting, but they are immensely good at killing people. And they are good for killing a lot of people. On the same weekend, a man in China attacked a school but only had a knife. The damage from that event is not even remotely on the same scale as Newton. Not only should we have a ban on these weapons in this (and every country), we should round up those assault weapons in our communities and take them out of our neighborhoods PERMANENTLY! This has nothing to do with the right to bear arms. We regulate weapons already, for example, we can’t legally own hand grenades or other incendiary devices. Thus, hunting rifles are one thing, assault rifles are on a completely different level of weaponry. This is a root cause issue and needs to be addressed now. I would also recommend aggressively registering and tracking use of all concealed weapons. These are also far more likely to be used for evil purposes than hunting rifles or shotguns.

I am not saying that hunting rifles and shotguns don’t also represent a potential threat, but the scale of that threat is very different and these weapons can be used for legitimate reasons beyond law enforcement or military purposes.

Some people have argued that we should have more weapons and have them in places like schools. This is absolute lunacy. Anyone who has ever been in a real firefight knows that as soon as the bullets start flying, all bets are off and it is far more likely that the “good guys” will actually contribute to the carnage rather than stop it.

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10 Mark Graban
Twitter:
December 17, 2012 at 2:26 pm

David – thanks for your comments. I think the American people could actually find reasonable consensus in some middle-ground positions… but, our polarized political environment seems to have us flailing about from one extreme position to another.

You’re right that people aren’t allowed to own tanks and missiles, etc.

Those who harbor the fantasy that the 2nd amendment would allow people to fight a tyrannical government and its modern military (and there are many here in Texas who hold that view) are kidding themselves, anyway. This isn’t colonial times where revolutionaries and the tyrannical British all had the same weapons…

I’m all for middle ground, reasonable solutions that can be tested or put in place based on evidence and rational discussion. I think we can rationally problem solve as a society rather than make emotional decisions… this isn’t the heat of battle… let’s fix this and fix it well, I say.
Mark Graban recently posted..Lean Healthcare Animation from British ColumbiaMy Profile

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11 Karen Martin
Twitter:
December 17, 2012 at 7:05 pm

Good post, Mark, though it’s most unfortunate that an occasion arose necessitating it.

We have a lot more to learn about this case, but clearly there are multiple root causes (I count 5 so far) and, as you and several of the commenters have said, it’s vital that get solid data, eliminate bias, reflect deeply, and THEN define, test and execute the multitude of countermeasures that a complex problem such as this demands. Speed matters but not at the expense of deep understanding of the current state.
Karen Martin recently posted..Metrics-Based Process Mapping: What, When & HowMy Profile

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12 Mark Graban
Twitter:
December 17, 2012 at 7:12 pm

Thanks for commenting, Karen.

I agree with you and I’d also suggest we should look at countermeasures from the past… what really was the effect of the 1994 assault weapons ban that expired in 2004 and is now being re-proposed?

Here’s the wikipedia page on the impact of the prior ban

Some say positive impact, some say it didn’t have an impact on crime, and some say the law wasn’t in place long enough to really gauge the impact… and so it goes.

System kaizen is way more difficult than point kaizen, as this shows…

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13 Karen Martin
Twitter:
December 17, 2012 at 7:14 pm

Yes, history is valuable and we often forget to learn from it. Also, politics needs to stay out of this type of problem-solving, which I have little confidence can be achieved in the U.S. (or anywhere?).
Karen Martin recently posted..Metrics-Based Process Mapping: What, When & HowMy Profile

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14 Mark Graban
Twitter:
December 17, 2012 at 7:20 pm

As soon as the political analysis or the media turns to how one party or the other can capitalize on this, I think any real problem solving is a lost cause. I’m cynical and afraid we’ll get, at best, feel-good measures that poll well but don’t lead to anything we could consider improvement.

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15 Karen Martin
Twitter:
December 17, 2012 at 8:33 pm

I hope you’re wrong, but that’s my concern as well. Outstanding organizations sure wouldn’t let politics interfere with results, but governments fall far short of my definition.

This is a great example of where simple root cause analysis tools like 5 why’s don’t do the trick. Been teaching this a lot this year – novices try to apply tools in every situation vs. selecting relevant tools based on need.
Karen Martin recently posted..Metrics-Based Process Mapping: What, When & HowMy Profile

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16 Mark Graban
Twitter:
December 17, 2012 at 8:44 pm

Yeah, this situation requires quite a fishbone diagram to list and categorize all of the contributing causes. Definitely not a simple 5 whys that would work here…

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17 Salvador Sanchez December 17, 2012 at 8:32 pm

Mark, Thank you for raising the question. I guess the question I have is who takes this A3 on? The President? The congress? The local law enforcement in Newton? As parents my wife and I are taking this on for our family, I believe it starts at home but I do agree as part of living in this society we have to be put our differences aside and work on solving this problem. Just imagine if law enforcement, gun makers, law makers, medical practitioners. etc. could come together and put together this A3, what would it look like? That would be something.

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18 Liz Guthridge
Twitter:
December 18, 2012 at 1:29 am

Thanks for raising this topic, Mark. And I appreciate everyone’s thoughtful, measured comments. In terms of learning from history, how about studying MADD, Mothers Against Drunk Driving? This grass roots organization initially was successful in calling attention to the dangers of drunk driving and encouraging legislation. If parents in the community (maybe PUGS: Parents United for Gun Safety) tackled the issues in an A3 in addition to experts (law enforcement, government officials, health care providers, etc.), we may get somewhere.

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19 Paul December 18, 2012 at 3:26 am

Liz: Like PUGS!! Is that original or did you see it someplace? Would like to use with attribution, if needed.

Paul

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20 Liz Guthridge
Twitter:
December 18, 2012 at 12:46 pm

PUGS (Parents United for Gun Safety) is original. After considering several other phrases, I landed on PUGS for these three reasons: 1) Parents, not just moms, need to be involved (And even non-traditional parents like me [step-children and dog] can relate.); 2) We should focus on the positive–gun safety–to be more inclusive; and 3) Dogs set a good example with their behavior. Why bite when a growl will do?

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21 Mark Graban
Twitter:
December 18, 2012 at 7:32 am

Another fanciful suggestion from LinkedIn – why do people fixate so much on technology?

I feel that as soon as a person like this is discovered in the Campus – there must be a mechanism to localize or contain the threat with immediate effect. This could be self locking doors that make the kids secure within their Class rooms preventing the entry of the threat inside. The threat could be confined to only corridors and all enclosed spaces like Class Rooms, Gym, Library etc., may be secured from the threat. However every action has a consequence and the criminal may still shoot indiscriminately and kill people trapped in non-secure areas

Mark Graban recently posted..“Kaizen is all around our shop” — Toyota San Antonio VideoMy Profile

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22 Mark Graban
Twitter:
December 18, 2012 at 9:04 am

A thought-provoking comment from LinkedIn about the practical planning that schools should be doing – and maybe they aren’t do it (or they aren’t communicating well with parents):

As I write this my six year old sits in a class room in a public school. Maybe for that reason I’m a little more than motivated to take action and not think in the abstract. I have been going back and forth with the Superintendent of the Royal Oak School system via email and so far have had phrases like “best practices” and other catch phrases offered up but I’ve yet to receive the actual detail on what those practices are. I have ask so very simple questions. 1. Have our teachers been trained for a “shooter on premises” scenario? 2. Have they had gunfire demonstrated in their school setting so they’ll know what it is if they ever have the misfortune to hear it. (read the stories almost everyone mistakes the sound at first and loses precious seconds and only survive due to dumb luck) 3. Have we standards for our doors and windows. 4. Has anyone ever had a discussion about armed guards, “school marshals” being placed at our schools? I’ve yet to receive any answers to these questions and I’m very frustrated. I’ve had enough of abstract thinking and head in the sand mentality! I’m requesting a meeting next.

Good problem solving would involve multiple countermeasures at different levels — what’s the mitigation strategy if we can’t completely prevent mass shooters?

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23 Joe Barnes December 19, 2012 at 8:48 pm

I think we are all grasping at reactive straws. Does anyone who is old enough (over 65) not remember when times were much, much better? The one thing that stands out to me is the attempt to remove God and the morals that He teaches from public life beginning in the mid 60′s. Because we, as a nation, no longer has a moral compass we can expect more porn, video game that teach the joy of killing and lack of respect for human life. Until we wake up an realize what we have become and take steps to reduce the causes these horrors will continue.

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24 Paul December 20, 2012 at 12:02 am

Joe: You certainly have a piece of the puzzle (I\’m 75) and I would add that the primacy of the individual over the needs of society is another enabler of our current cultural decline. PC is just another example of being unable to call something as it is. Do you remember the umbrage when a BLACK school administrator in DC called his budget \”niggardly\”? Perfectly good word describing how he saw it but he was hounded and pilloried unmercifully.

However, I do not want to go back to those supposed halcyon days of the 1950\’s. They were very repressive of most different thinking and especially of what women were allowed to do. What we have to figure out is how to have individual freedom AND individual responsibility to respect and support the collective needs of society. Just one for instance: We can no longer forcibly commit people who are mentally ill to institutions where they might get treatments and a drug regimen that would help them. I\’m willing to be a considerable sum of money that the mother of the Newtown shooter tried to get help for her son for many years and got little or none. That event is the price we pay for not being willing to step up and support, with our taxes, institutions to help these kinds of people. All imho.

Paul

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25 Mark Graban
Twitter:
December 21, 2012 at 2:50 pm

I think this is terrible problem solving from the NRA… they have defined the problem as “shootings in schools” as opposed to “too many mass shootings.” Putting armed guards at schools just means, I’d think, that gunmen would choose softer targets like churches, schools, movie theaters, etc.

NY Times Link

Further emphasizing the failed NRA thinking, Columbine High School actually had an armed guard that awful day in 1999… didn’t stop anything.

LINK

Mark Graban recently posted..My Human Error with my KeurigMy Profile

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26 Liz Guthridge
Twitter:
December 22, 2012 at 12:56 am

Agree with you, Mark! And where are we going to find–or train–competent people in becoming armed guards for schools? And has the NRA thought about the psychological impact on children of all ages being surrounded by guards with guns at school?

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27 Mark Graban
Twitter:
December 22, 2012 at 8:52 am

The NRA just proposed a solution for hospital acquired infections and lack of compliance with hand hygiene:

armed guards in front of each hospital room…

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28 Paul December 22, 2012 at 11:34 pm

C\’mon, Mark, I know you don\’t like guns and the NRA (I\”m not a member, either), but that comment on HAI\’s is over the top. My wife has been working diligently, and successfully, to help hospitals reduce their incidence of MRSA, specifically. One has had an 84% drop and is holding. The real problem is not only carriers-not-sick that come to visit, but also physicians who refuse to follow protocols. Got nothing to do with the NRA.

The suggestion by NRA is beyond stupid. But so are many of the other things being bruited about. I think we all need to take a deep breath and step back from castigating others and stop offering solutions because we know absolutely nothing useful, imho.

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29 Mark Graban
Twitter:
December 23, 2012 at 8:52 am

Paul – My comment was in jest. It was meant to make fun of the poor problem solving exhibited by the NRA — that their solution to any complex problem might be armed guards.

You’re right that HAIs are complex problems that require a lot of teamwork and a lot of real world approaches, not castigation or simple solutions that sound good. The same applies to violence and mass shootings – it’s a complex problem.

Regular blog readers know I never blame nurses or other individuals for hospital problems – these are complex situations with many contributing causes and root causes.

I know your wife and many others are working hard on the HAI issue and I admire that. 84% reduction is impressive. The sad thing is that so many hospitals have NOT made that type of improvement.

I worry when the government or others propose simple solutions like fining or punishing people for infections, etc. — what other dysfunctions or unintended effects are caused by the simplistic solution?

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30 David Bueford December 27, 2012 at 10:01 pm

I can remember when war was a serious endeavor. Not something entered into lightly because we all had vested interested due to the draft. Any of our kids could be called to sacrificed for the nation. That really engaged and polarized the masses (parents) for change. Few care much anymore because no one other than volunteers and their families are asked to sacrifice.

I see the same dynamics working today …

More and more are made to sacrifice because of gun violence. No longer just a across the tracks problem. One way or another knee jerk or not, change is coming, parents won\’t allow the continued slaughter of their children.

When the dynamic changes from them to us … real change begins.
David Bueford recently posted..Tribal Knowledge in Lean ManufacturingMy Profile

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