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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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From the Front Lines: Kissing the Banana Trunk

Posted By Prucia Buscell, Thursday, October 16, 2014
In parts of Sierra Leone and much of West Africa, people have traditionally kept the bodies of loved ones in their homes for several days after death as mourners wash, caress, dress them and pray over them. Because the corpses of Ebola victims are highly contagious, the tradition has been a key vector in spread of the disease. Burial teams from the Red Cross and other organizations have been attacked trying to interfere with care of the dead. Some families have even hidden corpses to make sure proper rituals can be performed.

In a Psychology Today post, Steven Hayes, PhD, Foundation Professor of Clinical Psychology at the University of Nevada, writes that behavioral science is as important as medical science in discovering alternative rituals that honor both culture and safety.

Four years ago Beate Ebert, a German psychologist and others formed Commit and Act, a nonprofit in Sierra Leone devoted to bringing psychotherapy to people traumatized by a decade of civil war and violence. Hannah Bockarie, a social worker fluent in Krio, the local language, led workshops, evaluated through a partnering agreement with the University of Glasgow, to train indigenous counselors and health care workers. When Ebola hit, the organization was in a unique position to help. Hayes explains that Commit and Act, already known in the community, was able to educate people about Ebola and the practices needed to halt its spread. Bockarie also led local groups through therapeutic sessions that helped them come up with alternative burial customs that honored their values while allowing health care workers to safely dispose of bodies.

"A beautiful example one group came up with was substituting the corpse with a banana trunk," Hayes writes. "The body of the infected and now diseased person is burned. Relatives keep a banana trunk at home, and perform all the customary rituals on it, including kissing the banana trunk before burial. In the end the banana trunk is buried."

Hayes says he is awed and inspired by "a pathway forward" that could not have come from the outside, and that could not have been produced by military intervention nor dictated by foreign aid workers.

He explains that the evolutionary biologist David Sloan Wilson's Evolution Institute combined with Commit and Act to use Acceptance and Commitment Therapy (ACT) along with principles from the late economist Elinor Olstrom, who won a Nobel Prize in 2009 for works showing the skill of indigenous people in protecting common resources.

People who face a problem are the best poised to find ways to solve it. That's a key insight of Adaptive Positive Deviance. After the disclosure of the Ebola infection of a second nurse who worked at the Dallas hospital where a man died of the disease, health officials have aimed to promote caution without feeding panic. The second nurse flew on a commercial airline before she had symptoms and the CDC has asked all 132 passengers on her flight to self-monitor and call a CDC hotline. Some politicians propose a ban on travel to the U.S. from Western African countries. In Texas, a community college announced it was rejecting students from any country with confirmed cases of Ebola.

Officials don't know exactly how the two Texas nurses were infected, though multiple news reports have suggested infection control protocols in place at the hospital were insufficient for Ebola. National Nurses United, a nurses' union, said nurses at the hospital complained of confusion, frequently changing policies and protocols, inadequate protection from contamination and spotty training. Indeed the CDC has now recommended extra levels of protection for healthcare workers caring for Ebola patients, as well as detailed guidelines for the potentially hazardous process of removing contaminated protective gear. CDC Director Dr. Thomas R. Frieden has said the most important protection is for a site manager to oversee workers as they put on each piece of personal protective gear, and as they remove and properly dispose of each one. One hopes front line workers will be engaged in finding the best ways to adhere to new protocols.

When Plexus Institute led a multi-year initiative to stop MRSA infections, the protocols in use at the time differed from what is being recommended now for Ebola. But MRSA infection rates dropped dramatically when front line healthcare workers collaborated to developed methods that would achieve the most consistent adherence to the known protocols. The late Jasper Palmer, a patient transport worker at Einstein Medical Center in Philadelphia, devised a way to remove protective gear safely while also reducing the volume of contaminated trash. It became known as The Palmer Method. Watch here.

Tags:  buscell  complexity matters  culture  healthcare  MRSA 

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Community Health Vital for Healthy People

Posted By Prucia Buscell, Thursday, August 28, 2014

Leana Wen, MD, an emergency physician who has worked in inner city hospitals in St. Louis, Boston and Washington, D.C., writes in her blog about the painful experience of administering short term fixes to patients whose long term afflictions lie beyond her realm.

She describes a 19-year-old who has come to the emergency room three times with cuts and broken bones and gunshot wounds. An 8-year-old without an inhaler living among relatives in an overcrowded house with lots of smokers comes to the emergency room struggling to breathe. A 38-year-old single mother diagnosed with cervical cancer four years ago never got to see a doctor as she struggled with three part time jobs, the care of four children and inadequate insurance. By the time Dr. Wen saw her in the emergency room, her cancer had spread to her lungs and intestines.

"We in the ER provide a necessary service, but it's far from being sufficient," she writes in her blog The Doctor is Listening. "We need to recognize that health does not exist in a vacuum, that it is intimately tied to issues such as literacy, employment, transportation, crime and poverty. An MRI here, a prescription there, these are Band-Aids not lasting solutions. Our communities need innovative approaches to issues like homelessness, drug addiction, obesity and lack of mental health services." The route to good health, Dr. Wen says, is in the community. Dr. Wen is coauthor of the book When Doctors Don't Listen.

When he was still writing the Wonkblog for the Washington Post, Ezra Klein described an experiment in Oregon to rebuild the state's Medicaid program around community health rather than individual fee for service treatments. Klein tells a story Oregon Gov. John Kitzhaber loves to tell. Kitzhaber, a former emergency room physician himself, calls it an illustration of what's wrong with our healthcare system. A 90-year-old woman with well-managed congestive heart failure lives in an apartment without air conditioning. When her apartment gets too hot, the strain on her cardiovascular system causes heart failure. Medicare will pay for an ambulance and $50,000 to stabilize her, but not $200 for a window air conditioner.

The 90-year-old may be hypothetical, but the story illuminates a common paradox, and Oregon's experimental approach starts with creation of 16 Coordinated Care Organizations (CCOs) that are responsible for assessing the health of their communities. Kitzhaber has given the CCOs flexibility on how they can spend Medicaid money. They can buy that air conditioner. An NPR story describes a Medicaid purchase of a minivan for community health workers who can be available around the clock to pregnant women trying to stop substance abuse, and to help mothers get to doctors' appointments, school and jobs. What makes CCOs different from accountable care organizations, or managed care, is the community component. Once they assess needs, they have to come up with ways to address them. So money can be spent on care coordination and community health workers with the aim of preventing some expensive emergency care. Gov. Kitzhaber told Klein, "We're investing in health. It's just a paradigm shift."

With thanks to Annette Garner, who teaches in the nursing program at the Health & Science University, Portland, Oregon.

Tags:  buscell  complexity matters  health  healthcare  medicine 

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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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Researchers Tackle Orphan Genetic Disorders With Patient Powered, Crowd-Funded Science

Posted By Prucia Buscell, Monday, February 3, 2014

Dr. Jimmy Lin has never forgotten one little boy he saw when he began his medical training in pediatrics at Johns Hopkins. The child was 5, developmentally delayed and suffering from inexplicable bouts of agonizing pain. His parents had taken him to top doctors all over the country. Despite test after test, none of them could identify what was wrong. The image of the parents pushing their son's wheelchair down the hall as they walked away remains burned into his memory.

"It was heartbreaking," he recalled, wondering where that family would go next. Dr. Lin had been doing cancer research, and he still does, but he was haunted by families struggling with so many other diseases no one was working on. With all the extraordinary medical advances, resources and sophisticated technology available today, he thought, there has to be a way to help such families. That personal perspective and the recognition of a gaping unmet need led Dr. Lin, a physician, computational geneticist and former faculty member at Washington University in St. Louis, to found the Rare Genomics Institute. It's an unusual organization he hopes will be a catalyst for treatments and cures of rare diseases, and it may also inspire new business models in the life sciences.

Dr. Lin says there are 7,000 rare diseases afflicting some 30 million Americans and 250 million people world-wide, and many are genetically based. "The ultimate dream is that we'd like to see cures for all these diseases," he said in a phone conversation. "The intermediate dream is that we can have research projects created and study all these rare diseases so they are on a path to therapy or cure. We don't want to see loving parents trying to find cures no one is looking for."

The RGI team began with Dr. Lin's appeal to friends and friends of friends who were interested in genetic research and excited about seeing it have impact. "We posted the idea on Facebook, saying I've got this problem to solve," Dr. Lin said. "A lot of scientific researchers don't get to see the results of what they are working on, so this is very attractive to scientists. It appeals to their humanity. I myself have been amazed at how many people-from all over the world-have come aboard." See the RGI team here. Dr. Lin says all the RGI scientists are unpaid volunteers. The organization itself runs on less than $10,000 a year, he says, but produces nearly $1 million a year worth of research because so much of the work is pro bono. See news stories on RGI's work and the children helped here.

The cost of DNA sequencing has dropped dramatically, but is still beyond the means of most families. Dr. Lin spoke with his friend David Lam, who worked at Razoo, one of the largest social networking sites for philanthropy, and they came up with ideas to help patients crowdsource funding for their own genetic research. Volunteers at a consortium of 18 universities analyze RGI patients' DNA looking for abnormalities that potentially cause their disorders. As reported by TED, Dr. Lin tells the story of Maya, a 4-year-old with severe developmental delays. Within six hours of a posting on the RGI site, people from all over the country had contributed small amounts adding up to $3,500, the cost of sequencing Maya's genome and those of her parents. Researchers at Yale then discovered a previously unknown mutation in a gene active in fetal development, and it may be the first crowd-sourced genetic discovery. "People are still working on a treatment for Maya," he told Plexus. "There are only a handful of cases where there would be an immediate cure, and those are amazing. The normal process of discovery is to understand a gene, understand what it does, then figure out if there is a drug that can treat the problem it causes." That can take lifetimes, he adds, but discoveries about genes begins the processes that can lead to treatments.

"We see ourselves as jetpacks for parents," he said. "We make it a little easier for them to connect with the right doctors, to leverage resources." Crowdsourcing funds fosters the democratization of science, in his view, and RGI provides a platform where patient communities can fund research for any disease. Rare diseases are a long tail problem, Dr. Lin says, and that means a bottom up approach with patients and scientists making discoveries is the most workable.

Dr. Lin points out many diseases, such a muscular dystrophy have been identified as genetic, yet not all who have those diseases have the genes known to cause them. More needs to be learned about genes. "We're starting to see more and more that there's not a one to one match of disease to gene," he says. "Often you're dealing with a group of diseases, or many gene mutations. A disease can have a specific label, but many different causes-it may present as one disease but really be a different disease. We can help with that if we can see potentially there is another underlying cause."

Read a Salon story, and a story in Forbes. Other news coverage appears in Bloomberg Businessweek and TIME. Join a PlexusCall from 1-2 PM ET February 28 with Dr. Lin and Trish Silber, president of Aliniad Consulting Partners.

Tags:  buscell  complexity matters  healthcare  research 

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Health, Education, Poverty and New Jersey's "Apartheid Schools"

Posted By Prucia Buscell, Thursday, November 14, 2013
Good health and educational achievement are closely entwined, poverty erodes both, and researchers are discovering more about the connections. Ruth E. Perry, MD, who heads the Trenton Health Team, underscores an observation of Risa Lavizzo-Mourey, MD, CEO of the Robert Wood Johnson Foundation who says "Our Zip code may be more important to our health than our genetic code." Dr. Perry also cites reports on the overarching impact of health disparities and two recent studies that say nearly 100,000 minority New Jersey children live in isolated poverty and attend schools more segregated than any in the Deep South.

In a column for the Newark Star Ledger, Dr. Perry, a physician who comes from a family of educators, notes some of the research linking poverty, health and education. She quotes James Heckman, a University of Chicago professor and Nobel Laureate in Economics: "Children raised in disadvantaged environments are not only much less likely to succeed in school or society but are also much less likely to be healthy adults." In a New York Times Column Heckman writes that whether a person finishes college is largely the result of what has happened before kindergarten, and kids who lose the lottery at birth sometimes never get a chance to catch up. As an example of the value of counteracting early disadvantage, he describes the Carolina Abecedarian Project, in which a group of children received cognitive and social stimulation from infancy through age five while their parents got skills training. The children also got regular check ups and health care. Their progress was monitored at ages 12, 15, 21 and 30, Heckman writes, and the program showed lasting impact on IQ scores; in addition, those treated had higher educational attainment and more skilled employment than peers in control groups.

But most dramatic, Heckman writes, is the life-long health impact: 30 years later adults who were in the program now have lower blood pressure, less abdominal fat, and lower likelihood of metabolic syndrome and cardiovascular disease than untreated peers. Read his column here.

The Trenton Health Team (THT) is a partnership made up of the city’s two hospitals, a health clinic, the city of Trenton, the N.J. Department of Health and Human Services and many community organizations. THT recently completed a community health needs assessment that uncovered discouraging educational statistics. In Trenton’s six Zip codes, the high school graduation rate ranges from 53 percent to 74 percent, and college graduation rates range from a dismal 6 percent to 17 percent.

Segregation in New Jersey schools is analyzed in studies by Paul Trachtenberg at the Rutgers Institute on Education Law and Policy (IELP) and Gary Orfield of the Civil Rights Project at UCLA. The reports say nearly half of the black and Hispanic students in 2010-2011 were enrolled in schools where fewer than 10 percent of the students were white. The IELP report describes 191 N.J. schools in which one percent or fewer of the students are non-minority as "apartheid schools." Most of those are in Newark, Camden, Paterson and Jersey City. The report says 26 percent of black student and 13 percent of Latino students attend apartheid schools, and across the U.S. only Detroit and Chicago have more extreme school segregation. Trenton schools, where the poverty level is 70 percent and nearly 96 percent of the students are black and Hispanic, are among schools described as "intensely segregated." That's a category in which 90 percent of more of the enrollment is minority. Nearly 30 percent of Latino students and 22 percent of black students in N.J. attend intensely segregated schools. The landmark Brown v. Board of Education Supreme Court ruling of 1954 bans segregation by law, but not segregation by circumstance. The IELP report says while litigation has successfully brought more money to poor urban districts, "New Jersey's uniquely strong state law regarding racial balance in the schools has not been seriously implemented for the past 40 years." The report emphasizes half a century of research has documented diminished opportunities and less fortunate outcomes for kids in highly segregated schools where students come from impoverished families.

Dr. Perry says researchers from the University of Maryland and Johns Hopkins found more than 30 percent of direct medical costs of minority populations in the US results from health inequities-an amount that totaled $230 billion from 2003-2006. Indirect costs of those disparities, which include lost productivity, lost wages, absenteeism, and premature death over the same period, brings the total to $1.24 trillion. "Clearly," Dr. Perry writes, "reducing education and health disparities is in our best interest both for social and economic reasons." Read Dr. Perry's column here and the Rutgers IELP report here.

Tags:  buscell  complexity matters  culture  education  healthcare 

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Leading, Learning and Transformational Change

Posted By Prucia Buscell, Thursday, September 19, 2013

Eight years after Novant Health formed through the merger of two large regional hospitals in North Carolina, some executives realized, the organization still had multiple cultures, a wide variety of policies, strategic plans and information systems, and leadership development suffered as a result.

Presbyterian Healthcare in Charlotte and Carolina Medicorp in Winston-Salem merged in 1997, creating a system that now has 14 medical centers, 360 physician clinics, 158 outpatient clinics and 25,000 employees. In 2005, two of Novant's key leaders decided to begin a leadership program that would develop a pool of internal talent to fill the many new leadership roles they knew would be needed as the organization grew, and address cultural issues that could potentially undermine that anticipated growth.

Vic Cocowitch, a leadership and organizational consultant in healthcare, Stephen Orton PhD, who works for the North Carolina Institute for Public Health at the University of North Carolina, and the two Novant executives, Jacque Daniels, Chief Administrative Officer and Debbie Kiser, Vice President of Leaning and Development, describe their seven year program in a story in the OD Practitioner, the journal of the Organizational Development Network. Their article, "Reframing Leadership Development in Healthcare," explains that Leadership Novant was based on the beliefs that leadership is continuous learning, that the work environment in a healthcare system can be used as a great learning laboratory, and that managers and leaders need to learn through their own experiences.

Novant relies on interdisciplinary teams collaborating to improve patient safety, quality of care, and solve problems, the authors write, so Leadership Novant stressed teamwork throughout its curriculum in readings, assessments, simulations and social activities. A cohort program, of five three day sessions held at an off-site facility, included activities that helped participants deepen personal relationships and networks and think and act outside of their usual comfort zone. It emphasized three themes, which the article describes as follows:

The Use of Self is based on the idea that effective leadership depends on deep self-awareness and "an ability to intentionally manage and deploy self for desired organizational impact."

Team Leadership, which requires interdisciplinary collaboration, included such action learning projects as development of a health literacy program, analyzing post-acute care facilities and strategies, and developing a "cultural due diligence process" for potential mergers and acquisitions.

Systems Thinking and Change Leadership, which were reinforced throughout the program, were emphasized through learning content aligned with organizational needs. Case studies showed system wide change as it took place. As one example, leaders presented early plans for the inception of new health information technology in inpatient facilities and physician practices.

The authors write that a successful leadership program needs to be fully supported by the organization's CEO and entire executive team, and it needs to evolve continually so that critical and unexpected events are used as learning opportunities. An earlier article by Cocowitch and Orton about an organizational development approach to healthcare leadership and the program at Novant is available here.

Tags:  buscell  complexity matters  healthcare  leaders  leadership 

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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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Conversation, Engagement and Front-Line Ownership

Posted By Prucia Buscell, Thursday, April 18, 2013
Updated: Wednesday, April 17, 2013
Everyone can learn processes to generate and maintain organizational change. Organizational achievements can blossom when everyone is engaged. Safety culture in hospitals flourishes when front line staff members take ownership of safety issues.

Three articles by people affiliated with Plexus Institute examine how these ideas can benefit organizations and the people they serve.

Lisa Kimball's article, "Changing the Organization One Conversation at a Time," (pdf) describes processes that help facilitate productive large group meetings, intervene in whole systems, and maintain the enthusiasm that emerges from provocative discussions in newly formed relationships. Liberating Structures (LS), for instance, form a framework for designing processes that support high quality conversations. The structures are easy to learn and their use can promote creativity and engagement, not only at meetings but when people return to their daily routines. Lisa describes them as "Lego-like components that can be mixed and matched" for use anywhere people gather. The payoff, she said, comes when the use of these helpful processes becomes so widely distributed that it is the norm rather than the exception. Some useful LS processes include wicked questions, silence, and 15 percent solutions.

Questions are "wicked" when tension and paradox are embedded. There are no obvious solutions, and no right or wrong answers. Wicked questions expose assumptions and elicit new ideas. An example might be: How can we maintain top-down discipline needed for safety at the same time we level the playing field for bottom-up creativity? A brief silence creates a boundary between past activities and the present phase of a discussion, and it's a good reset technique if a discussion is veering off track. Peter Drucker suggested that most people control only about 15 percent of their work situations, and the other 85 percent is shaped by the existing structures, systems, events and culture in their environment. People who make the best use of their own 15 percent can create small changes that have outsized impact. Lisa's article appears in the Spring 2013 issue of the OD Practitioner, the Journal of the Organizational Development Network. Lisa has served as a Plexus Institute trustee and is its former president and CEO.

"More We than Me: Using Positive Deviance to Engage Everyone," (pdf) by Prucia Buscell, appears in the same issue. It describes how people from many departments and different disciplines at the Albert Einstein Healthcare Network in Philadelphia worked together using the Positive Deviance (PD) approach to drastically reducing the incidence of healthcare associated Methicillin Resistant Staphylococcus Aureus
(MRSA) infections. PD is based on the idea that in every community there are individuals or groups who solve problems better than colleagues who have access to the same resources. In healthcare, PD bridges the gap between what care-givers know and what they do. They know infection reduction protocols, but don't always follow them. At Einstein, all individuals in the healthcare environment-physicians, nurses, aides, therapists, housekeepers, and staff in all support services-engaged in the effort to prevent transmission of pathogens that might happen in their own work areas. People from different departments met and collaborated on ways to remove barriers to consistent adherence to known infection control practices. Asked if their achievements could be sustained, several healthcare workers emphatically said "yes." It would last, they insisted, because it was their own process. Prucia is communications director at Plexus Institute.

"Front-Line Ownership: Generating a Cure Mindset for Patient Safety" will appear online April 26th in Healthcare Papers: A New Model for the New Healthcare, Vol. 13, No. 1, 2013. While great advances have been achieved in the field of infection prevention and control, the authors of this article believe even greater progress has been hindered by power gradients, dysfunctional relationships, and lack of "safety mindfulness" in hospital and healthcare environments. One successful approach to these problems, they suggest, is front-line ownership, or FLO. Ownership involves having people who do the work develop ideas for design and implementation of solutions. The authors discuss the logic involved in safety, the need for inter-connectivity to amplify safety efforts, and the importance of context and social proof in developing a safety culture. The underpinnings of the FLO approach, they write, are Positive Deviance, and a complexity science analysis of complex adaptive systems and resilience. Their work also used social network mapping, Liberating Structures and insights from the field of organizational development. Their 18-month study at five Canadian hospitals provided evidence that FLO reduced the combined pathogenic organism rate at study sites and allowed different groups to attain best practices in ways that worked most successfully in their individual settings.

The authors are Brenda Zimmerman, Paige Reason, Liz Rykert, Leah Gitterman, Jennifer Christian and Michael Gardam. Liz is a former Plexus Institute trustee.

Tags:  buscell  complexity matters  engagement  healthcare  positive deviance 

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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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