Upstream Thinking . . . How to avoid harm?

“As you think about a system, spend part of your time from a vantage point that lets you see the whole system, not just the problem that may have drawn you to focus on the system to begin with.”

 ~ Donella Meadows in Upstream

This year’s Blueprint Bulletin theme is around Upstream Thinking for Systems Improvement

  • The first Blueprint Bulletin began our series where the primary focus was around the three forces that push us downstream:  1) problem blindness, 2) lack of ownership, and 3) tunneling. 
  • The second Blueprint Bulletin focused on the first of Dan Heath’s seven questions for upstream leaders, How to unite the right people?  
  • The third Blueprint Bulletin supported our thinking and understanding around How to change the system?  
  • The fourth Blueprint Bulletin continued with Heath’s third question, Where to find a point of leverage?  
  • The fifth Blueprint Bulletin focused on How to get early warning of the problem?  
  • The last edition focused on the fifth question, How to know you’re succeeding? and, 
  • This edition focuses on Heath’s sixth question, How to avoid harm? 

What might be meant by how to avoid harm?  Have you ever experienced unintended or unanticipated consequences?  For example, you mean to do something good for someone and, in the long run, ended up hurting someone/something else unintentionally?  How might you have known?  Afterall, your crystal ball works 24/7/365, right?  Unfortunately, that’s not the case.  Sometimes, we unintentionally “do harm” to others.  Dan Heath, in his book, Upstream, suggests that we need to anticipate the future, look beyond the immediate, close feedback loops, and be warned about failing to test and having overconfidence.

Heath shares a story where a young man was walking through Central Park when he was struck by a falling oak tree branch causing brain injuries and paralysis.  When the Comptroller of New York City started analyzing the claims paid by the city to settle lawsuits, he discovered a large number of settlements resulting from falling branches.  After he further investigated, he discovered that, in previous years, the pruning budget had been cut to save money.  It turns out that the city hadn’t saved money at all . . . the money that was saved on maintenance was paid out in far greater amounts in lawsuits.  How might upstream thinking have supported NYC in preventing physical and financial harm?

Unfortunately, downstream actions often lead to fixing the urgent, the here and now, where reacting to present problems seems to provide immediate solutions.  Upstream efforts are about intentionally anticipating the unknowns and using data to guide decisions.  When planning for interventions (for example, cutting the pruning budget), Heath suggests, “we’ve got to look outside the lines of our own work.  Zoom out and pan from side to side.  Are we intervening at the right level of the system?  And what are the second-order effects of our efforts:  If we try to eliminate X, what will fill the void?  If we invest more time and energy in a particular problem, what will receive less focus as a result, and how might that inattention affect the system as a whole?” (Heath, 2020, p. 176)

From day-to-day decisions to long-term planning, how might you avoid doing harm?  How might anticipating unintentional consequences and using feedback loops be used to guide decisions? The Blueprint Connections, Leader’s Corner, and Teacher’s Corner sections will be utilized to confirm your thinking and give you some additional food-for-thought and potential actions.

Blueprint Connections

“ . . . we don’t succeed by foreseeing the future accurately.  We succeed by ensuring that we’ll have the feedback we need to navigate.”

~ Dan Heath

The above quote references feedback . . . when you think of feedback, what comes to mind?  Did you think about improvement cycles? If you did, you understand that feedback is an important component of the recursive/iterative cycle.  Remember that the purpose of an improvement cycle (input, process, output, feedback ~ IPOF model) is to implement practices and to put systems in place to improve student outcomes. 

Based on data, you first begin with your district/school focus or goal and determine what input will be needed to accomplish that goal.  Your input can be an implementation plan/strategy/guide, a vision . . . in other words, the input directs the thinking within an improvement cycle. The process describes the actions, denoted by role, that must be taken for the input to be effective. The process also addresses the interconnection between different components of the system. Output is what you get after you apply the input-aligned actions identified within the process.  And, feedback, based on data, compares the actual results to the desired results, in other words, what is happening or not happening.  Feedback is a critical component as it supports teams in adjusting their input and/or process(es) to meet the desired output.

As you complete each iteration of your improvement cycle, consider these prompts to guide your thinking around feedback.

  • What outcomes or results have you seen so far?  How might these outcomes influence your actions for the next cycle?
  • What feedback came out of any initial data reviews and discussion?
  • How was this communicated to those who need to change their actions?
  • Are you going to run a second iteration of this data?  If so, will any questions or datasets change?
  • How long will your next cycle need to be to gather and report data?
  • Is the feedback leading to changes in practice?
  • How frequently should you monitor and review these cycles to be able to effectively improve practice?

You might be wondering . . . what do improvement cycles and feedback have to do with being an upstream organization?  According to the National Implementation Research Network (NIRN), “improvement cycles support the purposeful process of change.” (NIRN, n.d.)  Notice the use of the word purposeful . . . upstream organizations are purposeful in their planning and using cycles of improvement to change over time.  Purposeful feedback will help achieve your desired outcomes!

The Leader’s and Teacher’s Corner sections will support you with deeper thinking around how to avoid doing harm by looking beyond the immediate, closing feedback loops, remembering to “test”, as well as avoiding being overconfident.

Leader’s Corner

“You can practice shooting eight hours a day, but if your technique is wrong, then all you become is very good at shooting the wrong way.”

~ Michael Jordan

How might Michael Jordan have used feedback to improve his practice over time?  If you think about it, improvement cycles could be applied.  Michael is implementing a strategy.  Desired output is determined, processes are employed, and feedback is used to tweak the strategy (input) and/or the process.  Over time, Michael’s stats (desired output) improved.  

Please take a couple of minutes to watch The Upstream Solution (Prevent Child Abuse Arizona, 2016) video.  As you watch, reflect on:

  • What might have caused the shift from downstream to upstream thinking for the carpenter/village?
  • How did feedback inform the carpenter’s next steps?
  • How might improvement cycles be used to monitor the village’s desired output? 
  • How did the carpenter “avoid (or reduce) doing harm”?

Let’s apply this thinking to districts using the Blueprint framework.  Blueprint leaders also use improvement cycles where district and building teams use feedback to inform the recursive process.  Blueprint leaders who are upstream thinkers are proactively planning . . . they are considering ahead of time how to avoid doing harm by looking at information from outside the box . . . they determine how they will use feedback to inform decisions . . . they think about the long-term implications for decisions being made.  As you consider current or past strategies that you have implemented, how might improvement cycles have supported the implementation?  

Let’s see how the improvement cycles can help us in the work that MICIP asks us to do.  As a part of the MICIP process, the district will be creating goals around the whole child.  Research- and evidence-based strategies will be identified (input).  Interim targets (desired output) will be established, and activities (processes) will be determined.  How will you and your district and/or building teams use feedback to make adjustments to assure that your targets are met?  How might you be intentional about, when making decisions, to look beyond where you are as you plan?  In other words, how might data support you and your team in avoiding the proverbial branch from injuring passerbys?

Teacher’s Corner

“Make a habit of two things: to help; or at least to do no harm.”

~ Hippocrates

The Hippocratic Oath is one of the most widely known codes of ethics.  The theme of this oath is the idea that the individual is making a personal dedication to ethical and committed care. The oath is seen as an ideal for the practice of medicine with the guiding principle of putting the patient first.  Now let’s take this oath and apply it to the field of education.  Shouldn’t teachers make the same personal dedication to ethical and committed care of their students?  Shouldn’t teachers put students first?  Absolutely!  As an educator, the Hippocratic Oath serves as a reminder that you work with individual human beings and are in a position of influence with the potential for making a lasting impact on your students.  And therefore, it’s vital to cautiously approach your role toward each student.  Educational harm may not be the same as harm caused by a failed surgery or a treatment that has been misprescribed, however, what about the harm caused by not doing what is best for each student?

Education is about learning . . . learning even from the errors and failures we make.  Prompt and reliable feedback is needed for experimentation to succeed.  It is feedback that spurs improvement.  Heath addresses the concept of feedback numerous times throughout Chapter 10.  He recounts a conversation he had with Andy Hackbarth, a former RAND Corporation researcher, who also helped design measurement systems for Medicare and Medicaid.  Heath asked Hackbarth what advice he would give to people who were designing systems to make the world better.  Hackbarth replied, “The only way you’re going to know it’s wrong is by having these feedback mechanisms and these measurement systems in place.” (Heath, 2020, p. 180)

What are some of the feedback mechanisms and measurement systems that Blueprint districts have in place?  One that readily comes to mind is Teacher Collaborative Routines.  Each of the categories: Instructional Design and Delivery, Deepening Knowledge of Student Learning, and Collegial Reflective Practice, enable teachers to collaborate together and offer feedback around what is and what is not working with students.  One practice found within Deepening Knowledge of Student Learning is, Teachers collaborate to collect and analyze data using the district-selected protocol to monitor the learning of each student.  The feedback garnered from the analysis of data can help teachers prescribe the most effective course of action needed for each student.

John Hattie has long researched performance indicators and evaluation in education.  He wanted to understand which variables were the most important. Hattie set about calculating a score or “effect size” for each variable, according to its bearing on student learning. The average effect size was 0.4, a marker that represented a year’s growth per year of schooling for a student. Anything above 0.4 would have a greater positive effect on student learning. With an effect size of .70, feedback is almost double that of the average effect size.  Feedback is an effective instructional strategy that is applicable across disciplines and grades.

Within the category of Collegial Reflective Practice, one particular practice focuses on feedback and self-reflection.  The practice states, Teachers offer each other informal feedback on their instruction.  Teachers work together to build their capacity for success.  Feedback is crucial for both teachers and students.  

Just as a physician makes adjustments to their treatment of patients, a teacher makes adjustments based on feedback and self-reflection so that they are able to uphold the “do no harm” principle as an educator.  How might feedback and self-reflection support your own growth as an educator?  What might you need to be intentional about within yourself as you collaborate with your peers? 

Timely Topics

We currently offer 2 courses for on-demand learning. Anyone can access quality content, on their schedule, anytime of the day or night. On-Demand Learning offers flexibility, convenience, and courses that are easily accessible. No login required. 

  1. Educational Improvement Through Systems – This course will address a variety of ideas around systems and how they apply to the work you do in your classrooms, schools, and districts. This course is designed to help you learn about systems by looking at examples of systems from your daily life and your experiences in schools.  Approximately 5 hours to complete.   
  2. Changing Minds to Address Poverty in the Classroom – This course is based on the work of Eric Jensen who has conducted extensive research and authored numerous books on children living in poverty. His latest work focuses on how schools and teachers can impact and enrich the learning environment to increase the likelihood of success for students living in poverty.  Approximately 12 hours to complete.

2021 Virtual Summer Events – Registration is now open for BOTH of our Summer Events. To learn more and register, visit our Summer Events 2021 webpage!


“Get your model out there where it can be shot at.  Invite others to challenge your assumptions and add their own. . . . The thing to do, when you don’t know, is not to bluff and not to freeze, but to learn.  The way you learn is by experiment — or, as Buckminster Fuller put it, by trial and error, error, error.”

~ Donella Meadows in Upstream

Failing forward . . . isn’t that what we want our students to do?  Shouldn’t we expect the same from the adults who are being vulnerable by taking risks and changing the systems to meet the needs of our students? Thank you for being upstream leaders who anticipate the future, look beyond the immediate, close feedback loops, and heed warnings about failing to test and having overconfidence.

Hall, P. & Simeral A. (2015). Teach, reflect, learn: Building your capacity for success in the classroom. ASCD.

Hattie, J. (2009). Visible Learning. Routledge.

Heath, D. Upstream – How to Solve Problems Before They Happen. London, Transworld Publishers, 2020.

SISEP. (n.d.). Active Implementation Hub – Framework 5:  Improvement Cycles.  

Prevent Child Abuse Arizona. (2016, January 4). The Upstream Solution. [Video]. YouTube.

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