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The Complexity Matters blog features the Thursday Complexity Post as well as other complexity inspired news items.

 

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The Best Story

Posted By Susan Doherty, Wednesday, September 24, 2014
Updated: Wednesday, September 24, 2014

In 2013, Plexus Institute received a $2.1 million grant from the Bill & Melinda Gates Foundation for a three year project in California’s Long Beach Unified School District (LBUSD) to discover, develop and promote methods that help K-12 educators continually improve so that their students achieve better outcomes. On September 17, 2014, Plexus Institute President, Jeff Cohn, joined a Healthcare PlexusCall to discuss Leading Change in a Complex World.

In the following audio clips Jeff describes one of the best stories to come out of the project so far and provides some background on the project and the model Plexus Institute is deploying in LBUSD. A transcript follows each clip.

The Best Story

Jeff: The best story that has come out of the work so far involves a music teacher. He is literally a department of one for the entire school so he has no peers from a subject matter standpoint to collaborate with. This team gave him an opportunity to interact that he was lacking so he loved that. The team landed on focusing on a particular aspect of this new common core curriculum that I don’t want to spend our time on but it’s a big focus of trying to help "transform public school education.” And one of the domains pertains to students use of academic vocabulary. Words that help their teachers and parents and peers recognize that they actually know what they’re’ talking about and have come to their conclusions in a thoughtful and meaningful way. This music teacher felt that this wasn’t particularly relevant to him, but the rest of the project and the opportunity to collaborate was so enticing that he would stay a part of the team as his teammates figured out ways to help their students learn how to use these vocabulary words productively.

Jeff: Then we’re moving into April. His big looming task is helping the band and orchestra prepare for the Spring concert and he’s still trying to figure out a way to integrate this academic vocabulary, push himself outside of his comfort zone, and he lands on an idea helped by some ideas that he had heard his peers on the improvement team come up with. So, one night he gives as an assignment listening to a recording of a recent rehearsal for the band and he also sends the kids home with a copy of his conductor’s score and asks them to write a short critique of what they hear. He also gives them a list of 10 academic vocabulary words and they’re assigned to use at least one of them in their critique. So the next day he got these extremely thoughtful perspectives from the kids on what they heard where they did find ways to integrate these words. And, maybe to his surprise, but also gratification, they incorporated their critique into how they did their remaining practices together and ultimately led to by far the best Spring concert that he’s ever been a part of. I think this, for all, was a great example of the sort of bottom-up emergent kind of learning that this sort of environment can foster.


The Project

Joelle: I know that Plexus has an on-going grant project in the field of education. Who is involved with that, Jeff, and what are you learning?

Jeff: This has been a really exciting project to be a part of. Through a grant from the Bill & Melinda Gates Foundation we’ve been working initially in two middle schools in inner city Long Beach, California. I know I had this vision of Long Beach as this vibrant coastal community, which I guess in some neighborhoods it is, but in the two schools where we’re working it’s a very underserved group of kids. 95% of the kids on subsidized meal plans and over half English second language. The goal of the project is to help teachers learn or re-learn how to continually improve. There’s data that was not collected by the Gates folks but which they’ve held up to the schools and to us that shows that most teachers after the first few years of their career plateau in terms of their effectiveness and plateau at a level that produces student outcomes less than what we would hope.

Jeff: So, how can, instead of the usual approaches in education of external experts coming in and telling schools what they should be doing differently, how might they be able to discover the improvement practices that exist within their own schools but which are hiding in plain sight of which they’re not aware. We’ve been working with teams of volunteer teachers that have been meeting before and after school with regularity. These are a diverse group teachers who initially kind of stayed isolated from each other, did not communicate across subject matter and/or grade barriers, but over the course of the first couple of months as they met and as we used Liberating Structures to design the time in which they were interacting and starting to engage in this challenge we noticed the pattern of interacting changing. Now you hear things like a math teacher asking an english teacher and a phys-ed teacher for help on a certain issue that is a challenge to him.

 

The Model

Joelle: What model are you using to shape this work?

Jeff: The [Bill & Melinda] Gates Foundation had come to us asking us for a proposal based on our previous Positive Deviance work. As we described our approach to Positive Deviance in a complex organizational setting they said, we hear you talking about PD, but we hear your talking about leadership, which we think is important in schools, and Liberating Structures, which we don’t know what they are but you seem to think they’re important, and something about networks and something about complexity, so it sounds to us like Positive Deviance plus plus. And, we wound up thoughtfully hearing what they were describing us saying and saying, yeah, actually our model of doing Positive Deviance work does include all those domains. This image that’s on the screenshare of the complexity lens and adaptive positive deviance at the center, that’s what we’re calling the whole Adaptive Positive Deviance, which is different than and greater than the sum of those individual components of a focus on leadership and Liberating Structures use and the complexity lens.

Tags:  cohn  education  music 

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It’s Not Unusual

Posted By Jeff Cohn, Wednesday, July 9, 2014
Updated: Friday, September 19, 2014

Jasper Palmer died last week. He was a patient transporter at Einstein Medical Center in Philadelphia for more than 20 years. Jasper and I became connected closely in 2005 when Einstein became a participant in the Positive Deviance/MRSA project, facilitated by Plexus Institute. The role of the patient transporter is to do just that: transport patients throughout the medical complex to wherever they need to go. When that patient is identified as harboring the "superbug" MRSA, preventing the bacteria from spreading during that transport is quite a challenge, one that even experts from the CDC hadn’t figured out. We recognized that working with the transporters and asking them how to transport MRSA-positive patients could uncover solutions and barriers of which we weren’t aware.

Jasper emerged as a leader when he pointed out a significant barrier to safe contact with these patients. MRSA-positive patients are placed in "contact isolation,” meaning that staff entering their rooms are required to put on gowns and gloves prior to entry. Jasper noted that trash cans were often overflowing with gowns that had been worn and disposed. This left the next person entering with a dilemma - does one do the right thing by wearing a gown, only to have no reasonable place to dispose it? Or does one avoid the disposal problem, take a risk, and perform the patient task without a gown? Not only did Jasper identify the challenge, he developed a solution that worked for him that could work for others. See him demonstrate his simple solution in the video.


Given a forum to share his concerns and solution, Jasper took it upon himself to help others learn this approach. He would stop physicians facing the disposal dilemma and tell them, "I think I have a method that could help.” He worked with his transport colleagues to develop safer methods of transporting patients, even those connected to ventilators and monitors. Not everyone adopted the Palmer Method. However, it garnered attention to the challenge and ultimately investments were made in different disposal apparatus that could accommodate the large volume of gowns being disposed much more effectively than the small, rigid trash cans in place before.

We wound up referring to Jasper as an "unusual suspect.” By this we meant he wasn't a typical infection prevention expert (i.e., physician, nurse, pharmacist). We learned that we needed to look beyond the usual suspect to those unusual ones, from which diverse perspectives and new innovations would emerge. Instead of asking, "whom do we need to involve?” we asked, "who doesn’t need to be involved?” and then tried to engage everyone else.

Upon learning of Jasper's death, I began to think about the concept of unusual suspects. On reflection, it strikes me as, while well intentioned, a bit demeaning and indicative of our fixation with hierarchy and position. Jasper had served his country in the military, was a family man, had worked at Einstein for many years, had lots of friends, and cared about patients. Why wouldn’t we think someone like him could be beneficial to our improvement efforts? Using this lens, who would qualify as someone unlikely to be a source of new behaviors and ideas, an unusual suspect? Someone wedded to the status quo? No, there are likely many benefits of the current state that deserve preservation. A skeptic? No, their contrary position can help expose blind spots. Maybe a good example is a content expert who is unwilling/unable to see any other perspectives. In the case of our MRSA work, those would typically be clinicians and the same people we initially thought would be our key contacts.

Jasper, I think you've taught us all a critical lesson. Anyone- no, everyone who cares about a challenge, who wants to be involved in any way, and who is willing to share collaboratively can be a useful contributor. In fact, we depend on the diverse perspectives of many to discover and create the solutions for our big challenges. Thank you, Jasper, for helping us to appreciate the wisdom that lies within our networks. Your legacy will live on through the work we and others you've touched carry forward.

Tags:  catching butterflies  cohn  healthcare  positive deviance  relationships 

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Collaboration - Emerging From Below

Posted By Jeff Cohn, Monday, February 17, 2014
Updated: Friday, September 19, 2014

The January issue of Health Affairs focuses on the benefits of "communication-and-resolution programs” (CRPs), designed to facilitate the communication between healthcare providers and patients and families following unforeseen outcomes, including errors. Intended to decrease the potentially adversarial nature of these conversations, the programs include formal training and support for those involved in the event. There is early evidence that investment in training like this can be associated with fewer malpractice suits and improved patient safety.

While there is emerging evidence to support CRPs, they’ll most likely be lengthy, expensive propositions. Work that Plexus is involved in currently suggests another way. STEP (Support Teaching Effectiveness Project) is bringing together educators who have volunteered from two middle schools in the Long Beach Unified School District to discover how they and some of their peers are able to continually improve their teaching effectiveness over the arc of their careers. Plexus is utilizing an Adaptive Positive Deviance (APD) framework to facilitate this work.

In an early meeting at Lindbergh Middle School, involved educators, realizing they were going to be discovering the pathway towards these positively deviant behaviors without external expertise, decided they would benefit from a dedicated space for collaborating and learning about effective teaching practices. They rapidly converted a vacant classroom into such a space, held an open house inviting all of their peers to engage in the discovery process, and began holding regular meetings there. Less than two weeks later, a group of educators who weren’t formally a part of this initiative were found sitting in the collaboration space, discussing how to better integrate student feedback of teacher performance into improved teaching.

People innately want to communicate and collaborate. Many organizations and their leaders have created incentives and barriers that inhibit relationships and foster a "me-first” attitude. The APD approach helps these interactions occur naturally, driven by curiosity, companionship, and purpose. Leaders should help people identify something that’s important to them, give them opportunities to be with and relate to each other frequently, and collaborative work will occur from the bottom-up. How much more effective and less expensive might an APD approach be than formal, designed from the top programs in pursuit of the same goal? If our organizational leadership creates the conditions, help the people working on the problem make sense of what’s going on, and then gets out of the way, this will allow collaboration and its consequences to emerge. The collaboration room in Lindbergh Middle School and what’s happening in it suggests those of us in leadership roles would be amazed at what can happen, driven by the collaborators themselves.

Tags:  catching butterflies  cohn  collaboration  education  healthcare 

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Finding our 15%

Posted By Jeff Cohn, Tuesday, September 24, 2013
Updated: Friday, September 19, 2014

Last week was the completion of the Jewish New Year period that ends with Yom Kippur, the Day of Atonement. One of the prayers recited on Yom Kippur describes the imagery of a process by which we are evaluated based on our behaviors over the past year and judgment is made regarding our worthiness to continue in our lives. The prayer recites the litany of wrongs that we may have committed over the past year. It ends with a phrase, "but repentance, prayer, and good deeds can lessen the severity of the decree.”

I reflected about this for a while. I realized that there are many kinds of good deeds that one can perform. Many think about good deeds that are heroic gestures, like rescuing people from burning buildings and serving one’s country in the military. There are macro good deeds that require large, coordinated efforts, like Plexus’s MRSA/PD work in healthcare and Starfish work with Ori Brafman and the US Army. These initiatives took funding, infrastructure, and human resources in order to be successful. Then there are meta good deeds- initiatives that involve processes like team building, improving relationships within one’s work group, and cleaning up one’s neighborhood. Not all of us are in positions to take these initiatives on, since they are sometimes associated with hierarchy in organizational settings. They also typically require the involvement of others in order to be successful.

And then there are micro good deeds. These are the ones that we can accomplish entirely on our own. We need nobody else’s permission or approval. One of the Liberating Structures we use, 15% Solutions, is based on the premise (first characterized by W. Edwards Deming) that 85% of all organizational problems are due to our systems and outside of the control of the worker. 15% Solutions flips that on its head, saying that this means that there is 15% that is totally within our control. As Plexus friends Keith McCandless and Henri Lipmanowicz say on their excellent website, www.liberatingstructures.com, "Everyone can do somethingsmallimmediately that may make a BIG difference.” Things like smiling, saying hello, offering brief assistance to someone infirmed, paying a compliment- these are all micro good deeds that are totally within our discretion.

Our complex organizational structures are comprised of rich interconnections, many of which reflect relationships between individuals. In these complex environments non-linear dynamics rule, meaning that, as Keith and Henri say, small changescanhave a very large influence on outcomes. What would happen if the relationships within our organizations were being impacted by a steady infusion of micro good deeds? Think how we’d feel at the end of our day, along with how those we connect with would feel. Let’s all commit to finding our 15%, acting upon those opportunities, and making our networks a little (maybe a lot) happier.

Tags:  catching butterflies  cohn  liberating structures 

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Healthcare Reform - The Real Elephant in the Room

Posted By Jeff Cohn, Tuesday, July 9, 2013
Updated: Friday, September 19, 2014

Many of us recall from childhood the Indian tale, "The Blind Men and the Elephant.” In the story a number of blind men come upon an elephant. Having never encountered one before, each reaches out to feel the animal, looking to understand what an elephant is. Each grasps a different part and begins to describe it to his compatriots. One states, "The elephant is very much like a hose” after grabbing the trunk. Another says, "Nonsense, it’s like a sharp spear” while holding the tusk, and so on for each body part. As they shared their impressions they realized that they were all saying something different and this led to an argument. None could "see” that there was any merit to what the others were saying, so sure were they that their perspective was the correct one. And the storyteller concludes, "All of them were correct, and all of them were wrong.”

Complex systems embrace diversity. Think of the metaphor of a long mountain range like the Appalachians. Finding a solution to a problem can be thought of like climbing to the top of a peak. The particular mountain you’re on reflects how high anyone with your perspectives can go, with the idea that the higher the better. Novices can only make it part of the way to the top. Adding experts may give you a better chance to get to the top of the peak you’re on. Once you’re at the top of that peak, however, you can’t go any higher. What if you happen to notice that there are other mountains whose peaks are even higher than the one you’re on? They represent the value of other perspectives. The only way to get to the top of those mountains is to change your perspectives to theirs. Or, even better, join them to yours. If your solution represents the entire mountain range, you can be assured that you’ve got the highest peak in there somewhere. You’ll have to measure, experiment, and explore to figure out which is the best, and that may actually change over time as well. But the diversity of perspectives gives you the confidence that you will eventually find what works best for you. As author Arin N. Reeves puts it in her book The Next IQ, "many heads are inevitably better than one.”

I believe that the current debates about healthcare reform represent a modern version of the elephant fable. Various groups of stakeholders have banded together to come up with their "solution” to the problems the current US healthcare model has created. We spend too much, our outcomes are not good enough, and too many people are harmed. As solutions are presented, not only are the stakeholders convinced of their merit, they are also certain that counterproposals are wrong. Accountable Care Organizations. Bundled payments. Health information technology. Consumerism. Price transparency. Single payer. Keep the status quo. One can find groups of smart people advocating for all of these.

I think the problem is not that any of these proposals are right or wrong. I think the problem is that perspectives that are not diverse enough generate them. All of them, like the blind men in the fable, are "right”- from their perspectives what they are proposing makes total sense. However, the lack of diversity involved in reaching the solution means that there are huge blind spots that cannot be overcome. A group of brilliant people with similar perspectives, interpretations, heuristics, and predictive models cannot be as intelligent as a group made up of average folks with cognitive diversity. At least not for complex challenges. And I think there is at least one thing everyone who has a stake in this agrees on, and that is that healthcare and its reform is complex.

What we need is the collective wisdom to recognize that all of these perspectives are right, and all are limited. Wikipedia lists the moral of the fable as "due to extreme delusion produced on account of a partial viewpoint, the immature deny one aspect and try to establish another…it is impossible to properly understand an entity consisting of infinite properties without the method of modal description consisting of all viewpoints.” Diverse perspectives and multiple right answers, or choosing "the one best”- what do you prefer?

Tags:  catching butterflies  cohn  diversity  healthcare 

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Making “Best” Even Better

Posted By Jeff Cohn, Thursday, June 13, 2013
Updated: Friday, September 19, 2014

The dictionary defines bestas "of the highest quality, excellence, or standing.” From this comes best practices, which Wikipedia defines as "a method or technique that has consistently shown results superior to those achieved with other means.” The definition continues, "a ‘best’ practice can evolve to become better as improvements are discovered.” What happens to our drive for improvement when we hear a practice being referred to as best? I think there is a natural tendency to think only about the first part of the definition and assume that our work is done. Couple that withthe fact that many things referred to as best practices are developed elsewhere and "shared” with us for us to "adopt.” Often these decisions are made near or at the top of our organizational hierarchies, and the challenge becomes one of implementation: "do what worked for them and it should solve our problems too.”

I met a colleague this week that arrived at her current healthcare role via a pathway that brought her to Silicon Valley. She has been struck by the tendency for healthcare workers to look to their "superiors” for permission prior to trying something new. She stated that things were quite different in the IT world. People, recognizing situations in which improvements were needed, took the initiative to try to make changes and then inform their bosses about the results of those experiments. There was a culture of ongoing improvement that included and, in fact, relied on the idea that for many of our problems, we’re going to have to discover solutions that work for us.

I believe that our organizations and communities need a learning approach to improvement. We may learn that someone else’s best practice is exactly what we need, and then enthusiastically go about implementing it. We may find that we can improve that practice as "improvements are discovered” that the originators hadn’t found. Maybe those improvements are intimately intertwined in the relationships, processes, and culture of our particular organization/community. In that case the improvement works for us and won’t work for others. For this reason we may learn that what was a best practice for someone else actually isn’t useful for us, because the "superior results” were intimately intertwined with someone else’s relationships/processes/culture and are not transferable to ours. We may actually discover that there already exist superior results that work for us- our internal best practices, our positive deviants, whose practices our organization/community will embrace once they are able to discover them from their peers. And, finally, we may find that we have to create our own solutions through an iterative process of innovation, experimentation, and continuous learning.

There is a clear link with all of this and how leadership occurs. A focus on imported best practices is consistent with a traditional hierarchical leadership model, as "solutions” flow down into the organization from above, leaders providing both the vision of what needs to happen and how to do it. The learning approach requires what Plexus Institute Board member Mary Uhl-Bien, PhD calls complexity leadership. Formal leaders create the conditions for the emergent learning necessary so that those who own the work can make decisions most useful for them. They provide a general vision and acknowledge there is no clear path for getting there, enabling and supporting the multiple possible "hows” that may work in local contexts. For me, organizations embracing this approach to improvement have the potential to go beyond best practices and become truly best.

Tags:  catching butterflies  cohn  community  leadership  organizations  technology 

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The What and the How

Posted By Jeff Cohn, Wednesday, May 15, 2013
Updated: Friday, September 19, 2014

The Washington Post from April 28, 2013 carried an article by Ezra Klein, "If this was a pill, you’d do anything to get it.” The author describes the recent work of Health Quality Partners (HQP), based in Doylestown, PA, focusing on improving healthcare outcomes and reducing expenses for Medicare patients with at least one chronic illness and one hospitalization in the past year. HQP has been part of a series of demonstration projects that emerged from the 1997 Balanced Budget Act that evaluate methods that aim to "improve the quality of items and services provided to target individuals and reduce expenditures.” Of the 15 funded programs, four improved outcomes but not costs. The HQP program was the only one to improve both. The initiative’s primary intervention has been the use of a nurse to visit enrolled Medicare beneficiaries weekly or monthly, whether they are sick or well. The HQP initiative reduced hospitalizations by 33% and Medicare costs by 22%. And now CMS is planning to eliminate the funding for the program.

Mr. Klein decries this policy decision, which is based on the unwillingness (or inability) of CMS to make the program permanent or to expand it to other populations. CMS plans to "integrate lessons from this experience” into designs for new scalable projects. The article describes how CMS pays for some very expensive, technology-based interventions without much scrutiny on their supporting evidence, while overlooking the successes already achieved through low-cost, non-technical interventions in small initiatives like HQP. He wonders what additional benefits CMS might accrue if they "took the lessons of HQP and used them to seed 15 more programs.” The HQP program has not had much of a budget. What if there were real resources? Couldn’t we get even better clinical and financial benefits?

As I read this I thought about a phrase we’ve used often to describe the effectiveness of the PD approach in improving outcomes: "It’s not the what, it’s the how.” What really are the "lessons of HQP?” Some might look exclusively at the end product and say, "do more of that- send more nurses to elderly, chronically ill patients’ homes in my community at least once a month” and assume that will achieve the same benefits. Others (like me) might look at the path that led to the HQP end product for the lessons. Maybe there are simple rules that are scalable, things like:

· Lead with confidence, curiosity, and humility (HQP’s founder, Ken Coburn, is reportedly this type of adaptive leader)

· Forge strong relationships with the community, and have them as thought partners

· Employ trusted members of the community to build healing relationships with the people being followed

· Ask the people what they need and help them develop skills to play a role in meeting that need

We all seem to be looking for the "solution,” the "magic bullet” that will cure what ails us. But what if it’s the "how” that is really the solution- what if it’s doing important work together, learning and evolving, that really matters?

Tags:  adaptive  catching butterflies  cohn  community  relationships 

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Imposing Order on a Microbial World

Posted By Jeff Cohn, Tuesday, April 9, 2013
Updated: Friday, September 19, 2014

Last week our Plexus call had a dynamic discussion representing different lenses focusing on the concern of preventing infections in healthcare environments. Ecologist Jessica Green, a researcher at the University of Oregon, has studied the role of facility design, particularly sealed/mechanical ventilation versus a green system that imports air from outside the facility, on the microbial environment of the air in the facility. Jessica has found that mechanical ventilation is associated with a less diverse and more pathogenic population of bacteria colonizing the environment compared with more "natural” ventilation systems (open windows, for instance).

Clearly the interplay of microbes, sterility, immune function, and healthcare facility design and maintenance is an excellent example of complexity. Mary Uhl-Bien, researcher and Plexus Board member, states that the clearest characteristic of complexity is "rich interconnectedness.” Imagine the network of connections that link bacteria with patients, their immune systems, the healthcare facility itself, and everyone working in and passing through that facility. What a complex array of relationships and interdependencies!

Now superimpose on this complexity our desire and need to impose order; this could be by keeping portions of the environment sterile, as in operating rooms; or it could be more general, as in cleaning processes after patients depart for home, or how to design the ventilation system of units or the entire facility. These actions are necessary to protect the most fragile of patients from harm-- whether the fragility is caused by an immune system impaired from illness or treatment, or from breaches in our own barriers to infection because of the need for surgery. What struck me as I began to think of this complexity was the realization that our infection prevention actions have consequences, as all efforts to impose order on complex adaptive systems do. I’m not advocating discarding these practices, which clearly save lives and prevent harm. What I’m wondering, however, is how we can hold the complexity and need for order together in a wicked question way, to even further help those most fragile among us remain free from harm as they receive care. How can we maintain strict sterility and allow favorable microbial adaptation and emergence to minimize the risk of healthcare-acquired infections? As always, I'm interested in your reactions and ideas.

Tags:  catching butterflies  cohn  healthcare  infection 

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Relationship-Centered Living

Posted By Jeff Cohn, Tuesday, February 19, 2013
Updated: Friday, September 19, 2014

My mom, Natalie, died last week, following a short ending to a lengthy illness. As family and friends came together to remember her and her life, one of the dominant themes that emerged was how critical relationships were to my mom. Several vignettes were particularly impactful to me in describing how skilled she was in forging relationships and what tremendous value emerged from those connections.

My brother Rich recalled a day when he was 7 or 8 when he accompanied my mom on some routine errands. He observed that what, for some, would have been the onerous tasks of dealing with an ill-tempered postal worker or waiting in a lengthy line in the bank before cashing a check, for my mom were opportunities to meet new people which, hopefully, would lead to ongoing relationships. A cheerful observation of how the weather was beautiful was enough to distract the postal worker from his drudgery and engage him in a brief but meaningful interaction. Both he and my mom remembered that, and her next visit for stamps prompted a smile from him- a sign that they had a real relationship. The wait in the bank line turned into an opportunity to meet the people standing in front and behind her. When she demonstrated she was willing to share with them information about herself, like where she grew up, how long she had lived in the neighborhood, her invitation for them to do the same resulted in a mutually beneficial conversation, where information might emerge that could be the foundation of a future friendship.

While she was in the hospital in her final days, she continued to form new relationships with skill and grace. As new healthcare providers introduced themselves for the first time she asked if they could show her their identification badge. She explained, "By seeing your name in addition to hearing it I’ll be better able to greet you by name when you’re here next time.” This simple request meant that she was interested in truly connecting with them as individuals- not some generic nurse/resident/therapist, but as the person with a name and a story that they really were. The day before she died was Super Bowl Sunday. My dad and I stepped out for a few minutes to grab lunch. When we returned we learned from my mom that the attendant who had delivered her lunch tray (I forget his name, but she named him by name) was a 49ers fan. She shared with him that she was rooting for the Ravens and why (my nephew Dan attends University of Delaware where Joe Flacco, the Ravens quarterback had gone). They mutually agreed they’d continue the conversation the next day, discussing how their teams fared. Think of how easy it would have been for that brief encounter to have come and gone without any real information being shared. Instead, my mom ended her life just as she had lived it: extending herself to another in an effort to begin a relationship that would continue, evolve, and provide joy and meaning for both parties. Of all the lessons I learned from my mom, the value of relationship-based living is probably the most important.

Tags:  catching butterflies  cohn  relationships 

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Embracing the Middle

Posted By Jeff Cohn, Thursday, January 31, 2013
Updated: Friday, September 19, 2014

When I was caring for patients as an oncologist I often found myself advising patients and families to adopt the perspective of "hope for the best, plan for the worst.” Lately I’ve been thinking about that model for a number of reasons, including our recent discussions of the book "Resilience” as well as thinking about my own aging parents and those of my friends and colleagues. I have assumed that this sort of thinking and preparation helps people be resilient, as they are thinking about what sorts of problems they and their families might experience if things don’t go their way, and what structures and supports need to be in place for those scenarios. People involved in risk management and patient safety sometimes refer to this as a failure-mode analysis, as one thinks of the various ways a process, a technology, a working group could fail, and then what could be done to prevent those failures or, at least, mitigate/minimize the harm those "failures” inflict upon individuals and groups.

What I realize, however, with this sort of approach, is that we focus our attention on the polarities- the best case and the worst case. And what we might miss is the opportunity to appreciate all those times that are neither best nor worst, but reflect the uncertainties of daily life. Linear pathways comfort us, and imagining the line connecting us with our current state to our best-case future state fits that style of thinking. Similarly, we often probably imagine the connection between the present and the worst that could happen is a straight line as well, not thinking about all of the ups and downs that likely would occur along the way.

When we awaken on most days, however, we have no sense as to which of those poles is going to be the stronger attractor for us over the next 24 hours. How do we deal with that uncertainty? Some might focus most of their efforts towards forging their path in one or the other direction: taking steps to maximize their best chance for a good outcome (no matter how difficult) or forcing themselves to make plans for the worst. What about approaching each day embracing the uncertainties of what it will bring, not trying to predetermine what the attractors are going to be? And then, as the day unfolds, going with the flow, smiling at the surprises, appreciating the experiences, doing and learning as the situations dictate. Some might view this is giving up control. To me, it is making a choice to accept the complexity of the world we’re in instead of fighting back against all of that complexity. Might that help us apply the concept of Liberating Structures to our own lives- structured just enough that we have a good-enough plan, and enabling ourselves to be liberated enough to try and take advantage of whatever the day may bring?

Tags:  catching butterflies  cohn  liberating structures  uncertainty 

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