In 2014, the C-section rate in Brazil was 57%, the highest in the world. In the country's private health system, 84% of children were delivered by C-section. The system was designed to prefer C-sections. After educating doctors and patients, the upstream solution caused a 40% increase in natural childbirth. The move away from problem blindness is the shocking realisation that you've come to treat the abnormal as normal.

Example of problem blindness

<ul><li>Problem blindness. "This problem is inevitable." You can't fix a problem you can't see.</li><li>A lack of ownership. "It's not my problem to fix." People resist acting on a problem because they may feel it is not their place. When no one owns the problem, it probably won't get solved.</li><li>Tunnelling. "I can't solve the problem right now." Researchers found when people lack money, time or mental bandwidth, the little problems take preference over the big ones. When people juggle many issues, they give up trying to solve them and instead adopt tunnel vision.</li></ul>

Barriers that prevent upstream thinking

<ul><li>“Rising tides” test. What else might explain the short-term success other than our efforts?</li><li>Misalignment test. How can we find misalignment as early as possible? What alternative measures could provide potential replacements?</li><li>Lazy bureaucrat test. What would someone do to succeed on the measures with the least possible effort?</li><li>Defiling-the-mission test. If short-term success undermines your long-term mission, what was the cause?</li><li>Unintended consequences test. What if we succeed at our mission, but cause negative unintended consequences? What should we pay attention to?</li></ul>

Find reliable ways to measure success

Banning plastic bags in San Diego caused serious unintended consequences. The deadly 2017 hepatitis A outbreak in San Diego is attributed to the lack of plastic bags. Homeless people used the bags to dispose of their own waste. But when the bags became hard to come by, the alternatives were much less sanitary.

Unintended consequences example

Downstream actions are reactions to problems. These efforts are fast and tangible. Upstream actions attempt to prevent those problems from happening in the first place by systematically reducing the harm caused by those problems. These efforts are slower and broader. A sign of upstream work is that it uses systems thinking. Example: You can offer a homeless person a meal today, but to figure out how to reduce evictions so that people don't become homeless might take years.

Upstream thinking

When you spend years responding to problems, you can sometimes overlook the fact that you could be preventing them.

Measures can fool you in three ways:<ul><li>“A rising tide lifts all boats.” Your measure shows that you're succeeding, but you mistakenly attribute your success to your own work.</li><li>Your short-term measures don't align with your long-term mission.</li><li>Your short-term measures became the mission and undermined the real work.</li></ul>

Ghost victories

<ul><li>Expedia: 58% of customers who booked travel on Expedia placed a call afterwards for a copy of their itinerary. No one was responsible for ensuring that customers didn't need to call for support. It was identified as an upstream problem. Once changes were in place, the need for customers to call for help decreased to 15%.</li><li>Dutch Bicycle Company: VanMoof regularly received complaints that many of its bikes were damaged during shipping. They started printing images of flat-screen televisions on their shipping boxes, thinking couriers would be more careful. It resulted in 70 - 80% less damage.</li></ul>

Examples of upstream thinking

Organisations have a tendency for downstream thinking. To succeed, leaders should change the focus to upstream thinking.<ul><li>Identify problems early</li><li>Target leverage points in complex systems</li><li>Find reliable methods to measure success</li><li>Consider new ways of working together</li><li>Embed their successes into systems.</li></ul>Find new ways of working together:<ul><li>Hand the problem to the right people.</li><li>Give them enough notice of that problem.</li><li>Align their efforts toward preventing instances of the problem.</li></ul>

Upstream thinking in leadership

Wall Street Journal Bestseller New York Times bestselling author Dan Heath explores how to prevent problems before they happen, drawing on insights from hundreds of interviews with unconventional problem solvers. So often in life, we get stuck in a cycle of response. We put out fires. We deal with emergencies. We stay downstream, handling one problem after another, but we never make our way upstream to fix the systems that caused the problems. Cops chase robbers, doctors treat patients with chronic illnesses, and call-center reps address customer complaints. But many crimes, chronic illnesses, and customer complaints are preventable. So why do our efforts skew so heavily toward reaction rather than prevention? Upstream probes the psychological forces that push us downstream—including “problem blindness,” which can leave us oblivious to serious problems in our midst. And Heath introduces us to the thinkers who have overcome these obstacles and scored massive victories by switching to an upstream mindset. One online travel website prevented twenty million customer service calls every year by making some simple tweaks to its booking system. A major urban school district cut its dropout rate in half after it figured out that it could predict which students would drop out—as early as the ninth grade. A European nation almost eliminated teenage alcohol and drug abuse by deliberately changing the nation’s culture. And one EMS system accelerated the emergency-response time of its ambulances by using data to predict where 911 calls would emerge—and forward-deploying its ambulances to stand by in those areas. Upstream delivers practical solutions for preventing problems rather than reacting to them. How many problems in our lives and in society are we tolerating simply because we’ve forgotten that we can fix them?

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Leadership & Management

Wall Street Journal Bestseller New York Times bestselling author Dan Heath explores how to prevent problems before they happen, drawing on insights from hundreds of interviews with unconventional problem solvers. So often in life, we get stuck in a cycle of response. We put out fires. We deal with emergencies. We stay downstream, handling one problem after another, but we never make our way upstream to fix the systems that caused the problems. Cops chase robbers, doctors treat patients with chronic illnesses, and call-center reps address customer complaints. But many crimes, chronic illnesses, and customer complaints are preventable. So why do our efforts skew so heavily toward reaction rather than prevention? Upstream probes the psychological forces that push us downstream—including “problem blindness,” which can leave us oblivious to serious problems in our midst. And Heath introduces us to the thinkers who have overcome these obstacles and scored massive victories by switching to an upstream mindset. One online travel website prevented twenty million customer service calls every year by making some simple tweaks to its booking system. A major urban school district cut its dropout rate in half after it figured out that it could predict which students would drop out—as early as the ninth grade. A European nation almost eliminated teenage alcohol and drug abuse by deliberately changing the nation’s culture. And one EMS system accelerated the emergency-response time of its ambulances by using data to predict where 911 calls would emerge—and forward-deploying its ambulances to stand by in those areas. Upstream delivers practical solutions for preventing problems rather than reacting to them. How many problems in our lives and in society are we tolerating simply because we’ve forgotten that we can fix them?

Dan Heath is a Senior Fellow at Duke University's CASE center. Dan has an M.B.A. from Harvard Business School, and a B.A. from the Plan II Honors Program from the University of Texas at Austin.He co-wrote a book titled Switch: How to Change Things When Change Is Hard with his brother Chip Heath.

Ghost victories

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