Public Health, business, jobs, and profit

All of my theoretical models lead to the same conclusion - the field of "public health" cannot really do their job well until the needs and interests and realities of multi-human meta-organisms are included as well.

In English, that means that we ARE what we are PART OF, which is increasingly clear in public health studies of the impact of social connectivity on physical and mental health.

But it also means that the internal life of corporations, cultures, and nations, as well as the entity called "the public", are all very real systems that behave as if they were separate biological goal-seeking, energy-consuming, adaptive, reactive, self-protective organisms.

It also means that it just doesn't make any sense to evaluate the impact of different interventions in the health of people without, at the same time, evaluating the impact on jobs, employment, and the health of corporations and business and the business community.

The physical health of people in a community or nation is very directly influenced by the "health" of the community or national economy. If the economy or businesses crash, it will show up "under the skin" very rapidly.

The failure of many in public health to have a wholistic approach that includes BOTH people AND corporations reduces the credibility of public health. If there is one lesson "systems thinking" teaches, it is that the word "OR" is vastly over-used. We shouldn't be thinking that EITHER we can serve people OR the public - we need to lead the way in serving BOTH. And, similarly, we need to get corporations realizing that they can't survive if the workforce they draw on, and customer base they need in this country collapse. We need each other. We are each other, in some very real ways, and our respective "health" depends on each other in a feedback loop, either for better or worse.

Similarly, it makes no sense to me that "Republicans" should be fighting for the interests of "business" and "Democrats" for the interests of the "people" - because there is only one, multi-leveled complex life-form on this planet, which includes "cells", "people", "corporations", "cultures", and "nations."

We are all in the same lifeboat. At this point if the people all die off, so do the corporations. If the corporations all died off, so would almost all the people. Get over it.

If we're upset that corporate or national planners don't include "human factors" in their planning, we shoudn't also assume it's because they refuse to -- it is, in my experience, more that they are clueless as to how to do that.

If public health wants to change that equation and interaction, great, pick up that heavy burden and figure out how to include humans in the equations and not make them indescribably difficult to solve. If corporations can get better bottom-line performance by doing better planning including more of reality in the plans, they'll do it, but someone has to show them how that would work and make a convincing case that it does work.

That gets down to that messy problem of "profit." As the Ross School of Business here in Michigan says "Non-profit is a tax strategy, not a business strategy."

Or, as one sister from Trinity Health Care's catholic leadership put it, "No margin, no mission."

Health is intimately tied to growth and life which are intimately tied to "wealth."
That component sub-systems decay and die is a given; what's up for grabs is whether there's a balancing source of regeneration and growth, which requires that actions result, ultimately, in absorbing more energy than is spent in getting there.

In other words, in the larger accounting scheme of life, public health interventions have to "pay off" or they will simply "die off." This is a schitzohrenia that both clinical health and public health seem to have - the idea that making money is intrinsically bad or a dirty concept.

Yes, obsession with short-range, stupid strategies to make money at the expense of life, health, and stability are indeed stupid. On the other hand, there is no such thing as a long-range strategy of losing money each year.

The most important distinction is that wealth, and health, are not zero sum, and are based heavily on interactions across levels of the MAWBA beastie.

Health can, in fact, be created out of thin air.
Wealth can, in fact, be created out of thin air.
BOTH of these, health and wealth, cross-support each other.
Being "rich" and "dead" is not a winning strategy.
Some balance is required.

Public health has an opportunity to teach the principles of SUSTAINABLE GROWTH, which means sustainable rates of return on investment. Business owners hate that venture capital firms and stockholders expect them to operate to maximize profit this quarter, at over 27% a year annual rate, but to keep operating in the long run.
Those are incompatible goals. With the exception of discovering gold or the equivalent, healthy businesses probably grow at 10% or less, maybe as low as 2% per year. If public health would show CEO's how to keep stockholders from jumping ship if the companies invested more internally in people and showed such "small" profits, the CEO's would love public health. Everyone knows this is an absurd demand that's killing off healthy, stable business as "not up to par."

These problems cause each other. People are stressed out because the businesses they work for are stressed out. Businesses are stressed out because they don't know how to tap the healthy creative power of people at a sustainable rate. They are different views of the very same, multi-level, MAWBA problem.

If 30% of the humans died or were seriously put out of commission for 2 months by something like avian flu, at least 30% of the corporations would crash and burn as well, because they are riding very close to the line on being as short-staffed as they can be right now. The crash would cascade, as suppliers of key components failed. The interests of public health and "big business" align when it comes to stopping global pandemics.

This fact is maybe less visible because of the invisiblity of the details of the roles of people on "the bottom" in keeping corporations operating. My guess is, after the last round of layoffs, that more than half the large corporations in the US are vulnerable to crashing and burning if 30% of their Information Technology staff were to abruptly be incapacitated on the same day. All meta-life involves a constant battle between natural collapse and regenerative efforts, which may "look like" nothing is going on and all is "well." Remove those people who are holding everything together, and it will suddenly become apparent that maybe they were doing something after all.

Other areas of "infrastructure" are similar. We have huge reliance on armies of people doing low-visibility or invisible jobs, without which the wheels of commerce would cease turning in a cross-cascade, house-of-cards type collapse.

It is a mistake to think that pulling out the "safety net" has "worked." It hasn't been tested on a full-scale pandemic yet. The effect of having almost 50 million people in the US without health coverage will have the same effect as having a basement filled with gasoline-soaked rags would have on a small house fire. These are things you really do NOT want to give a running start on you.
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(This was originally published 11/21/06 on my weblog "might as well be alive" at http://mawba.blogspot.com)

Multilevel Architectures - Bane or Boom?

Marsden Bloise once described life as having a "curiously laminated quality."

Life on earth does have levels, and they have important mathematical consequences.

In fact, the multi-level model is one we find reasonably familiar and can live with. We structure our corporations and government to have layers and levels, with people one "one level" reporting to people on "a higher level."

Not only are there levels, there are gaps between the layers. It is almost like a quantum mechanical model, where there are legal levels and forbidden zones.

In the world of large-scale enterprise computing, there are officially levels (see the OSI model), where there is a hardware level, a messaging level, an application level, etc. The goal of each level is to function so well that it essentially becomes a perfectly flat, stable platform or metric on which the higher levels can be built. A perfect level "goes away" and "falls out" of the equations.

So, in the best world, when nothing is going wrong, an application such as Microsoft Word can say "save this file!" and, behold, it happens. The application doesn't need to concern itself about the details of what brand disk-drive is in the computer, or how may empty slots of what size are there, or how to chain them together and break up the document into chunks that size for storage and retrieval later.

Or, in business, workers and "the boss" or the next level of management up have a functioning gap between them. The boss doesn't really want to know the details of how something happens, and only wants a simplified, almost cartoon-level sketch, and mostly cares, yes or no, did that happen. The employees see all the details and prefer the boss not "micromanage". The employees have little idea what the boss does all day - so long as reasonable work tasks come down the pike in reasonable order, it's good. The boss has little idea of the complexity of many tasks, or the pains that have to be taken to accomplish them.

On the upside, this makes "management" even possible, because otherwise the world would rapidly become way too complex for anyone to ever comprehend, and the largest business would probably be something like 200 people.

And, if perfectly managed, lower level computer "infrastructure", like plumbing or electrical wiring, should be completely invisible. The thousand upgrades a day, putting in new hardware, swapping out old networks, installing new security patches, upgrading the database or operating system, should all be done "seamlessly" and at most result in a slight slowing down of normal response time.

One downside of this is that it is very easy for the upper levels to mistake the perception with reality. The classic problem in preventive maintenance is that, if perfectly done, all problems are seen coming in advance, headed off, and so "nothing ever breaks" -- and consequently upper management, at the next budget crunch, decides they can lay off the maintenance department because, who needs them, nothing ever breaks! So, they do, and only later discover what it was that the department did.

A second downside is that upper management is shielded from details by multiple layers of oversimplified sketches to the extent that they mistakenly believe that the tasks people at the front, or on the bottom, are actually easy to do, or even trivial. Consequently, it follows that the people doing them are really only one step above morons, and also that failure to do the tasks must be due to not only incompetence, but bad attitudes, because anyone can see the work is trivial.

Thus we have what I call "wicked-II" (wicked two) problems - where the tasks may be enormously difficult, but from above or outside they appear to be simple or trivial.

The immediate consequence of those misperceptions then are that management may decide, in its infinite wisdom, to undertake some new task, or "put in" a new computer system that, from their very limited depth model, should be "easy." First, they seriously lowball the associated work and costs. Then, they interpret reports of trouble from below as being obviously due to incompetence, laziness, or, worse enemy action that demands instant retaliation and disciplining or firing the idiots who resist. Management says "I don't want to hear about problems! Don't tell me you can't do that!" That directive appears to be successful, as complaints drop to zero, until the whole project finally crashes on the rocks the employees were trying to warn management about when they got fired. Management blames the employees for failing to do what they were told to do. And everyone loses.

This model of operation appears to be the norm, and enormously easy to slip into, even if management is trying hard not to. It is what "safety cultures" and "high reliability organizations" have to try to overcome in order to work.

So, we also expect to find, throughout history, a vague awareness of this type of problem and hard-won advice on some benchmarks to avoid falling into that same pitfall in the future - advice typically ignored as old wives tales, so the future generations end up rediscovering the world of hard knocks.

In some ways, this is like the brain-body dichotomy, where our conscious selves are able to think deep thoughts, like what movie to go to, and be generally unaware of all the hard work going on in the body below synthsizing enzymes, digesting food, managing pathogen invasions, etc. It is all too easy, not seeing those details, to take "the body" for granted and neglect or abuse it. And, as with management, complaints can be suppressed and we can continue on deep into fatigue and exhaustion because of higher goals, until some physiological system that was trying to warn us finally collapses. (Recall the old rule of thumb - the time to furl your mainsail is the first time it occurs to you that maybe you should furl your mainsail. Those who forget it as the wind picks up rediscover it after their mast snaps or the boat overturns.)

Similarly, "upper" levels of society are reminded in all religious literature to "remember the poor" and take care of the powerless "below" them. This advice is often neglected for short run gain and long-run disaster.

Similarly, "upper" structures, such as corporations, can easily forget that their existence depends on the lower level existence of a healthy workforce and community, and a stable ecology and climate. Again, industry can take actions for short term gain that undermine the workforce health or environmental stability, with long term catastrophic results. It's very easy to do, and very easy to suppress complaints.

Similarly, "upper" levels of the military, or civilian government, can suppress dissent and ride roughshod over the key needs and observations of their own staff, often without realizing they are doing it. The result is being surrounded by "yes men", being cut off from reality into a fantasy shell, and making terrible mistakes that end up being catastrophic.

The problems listed above are all the "same" problem mathematically. Interlevel communication and the tradeoff between "invisibility / detail hiding" and constant needs that have to be met remains an open problem.

(note: I originally posted this Nov 21, 2006 on my weblog mawba.blogspot.com,
where mawba = "M.ight A.s W.ell B.e A.live", and it got this comment:
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Frank said...

Wade:
A truly great analysis. Are you aware of Macintosh, Moffat, Atkinson's works on resilience and networks? They are going to the High Reliability Organizations conference in Deauville next may (http://www.hro2007.org/index.html ). I find Atkinson book in particular quite congruent with your analyses. There is a link on that page where you can download it: http://www.hro2007.org/speakers.html
Frank H. Wilson

5:42 AM

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Disaster Prepareness using Web-based tools

I put another paper online:
Web-tools as potential assistance to Public Health Preparedness and response tasks.

Abstract

Faced with the prospect of natural and man-made emergencies for public health, it is worthwhile to see whether any of the new software tools might help. The new "web-2" tools have changed in a surprising way - they are easier and more fun to use. These tools are often free of charge, require no installation, consume no disk-space, and require no IT-department support -- all of which meet constraints that public health workers have faced in the past. The focus of these new tools is on cost, agility, simplicity, ease-of-use, and collaborative work. This paper reviews what tools are available, and how they might fit into the set of public health tool-box. Finally, training issues and other barriers to adoption are assessed, with an eye to figuring out what University-based Disaster Preparedness centers might do to make this technology legitimate, more accessible, and better utilized.

There's also a discussion of rules-based "plan generators" instead of "plans" in the appendix.

My Comair 5191 crash analysis now available

Because "systems thinking" is a difficult concept to describe, I wrote and just posted a paper analyzing a commercial aircraft disaster - the crash of Comair 5191 - in Lexington Kentucky, August, 2006. This is a full-length (30 page) analysis with pictures and diagrams and source materials, aside from the cockpit voice recorder transcripts, which are linked below. The final NTSB findings on the case are not yet out, to my knowledge.

It's a little rough around the edges, but it starts with the basic astounded question of how two, fully trained pilots, not under pressure, could taxi to and attempt to take off from the wrong runway, resulting in the death of all on-board except the one who was flying the plane, who was pulled from the flaming wreckage by a first responder. The runway was a few hundred yards too short for the plane to have made it off the ground safely.

So, it goes from "How on earth could this have happened!?" to "Oh... There but for the grace of God go I." Only the new commercial pilots on the pilot chat blogs couldn't imagine how such a thing could ever happen to them. It brought to mind the old saying "There are bold pilots, and there are old pilots." In this case, however, the rest of the world conspired to set the stage.

As with "errors" in hospitals, it typically takes a whole team of people to align their actions in the wrong way (the "swiss cheese model"), for someone to buy the gun, someone to load the gun, someone to cock the hammer, someone to hand it to the poor last guy in the chain, and that guy to pull the trigger. For legal purposes, blame is assessed one way, a way this paper does not assess. For purposes of safety engineering, and seeing where interventions might help to avoid ever having this happen again, we need to look at a whole different set of factors that set the stage for this "accident".

Please contact me if you'd like to use this paper (or a newer, better version) for instructional material. Thanks!

( Note: I am a private pilot, but I'm not a member of the NTSB or any official agency, and this analysis is a personal analysis for instructional purposes in safety engineering, not intended for legal purposes. I have no relationship that I know of to anyone involved in this case. These are all real, living people and my reconstruction may be entirely wrong. The point is to honor those who died by learning everything we can from their deaths so this won't happen again.)

Prior Posts:
Comair 5191 - Confirmation Bias and Framing (1/20/07)
Cockpit voice recorder transcripts
Washington DC Crash of Air Florida was 25 years ago - remembered
(with links to BMJ, High-reliability engineering, TEM, etc.)

Powerpoint on why too much quality doesn't work

It seems to me that there can be such a thing as too many procedures, to the point where, as John Gall would say, the component that will fail is sthe one that you put in to make the system "fail-safe". That is, the thing that will kill you is the thing that you put in place to save you.

This may have been true of Comair Flight 5191, that crashed while attempting a mistaken takeoff from the wrong runway in Lexington, Kentucky last August.

Some pilots have wryly compared the pre-takeoff check list on a 727 to a "Michner novel", in terms of its length. In the case of Comair 5191, judging from the transcripts of the cockpit voice reocorder, the right-hand seat co-pilot apparently spent the entire taxi-time with head down, going though the checklist, while the left-hand seat pilot taxied the plane to the wrong runway, opened the throttles and told the copilot "you've got it."

We have some mixed signals on how to deal with this. In a perfect case, even a very "lightweight" solution is more than adequate. The picture illustrates a single sheet of typing paper rolled up and taped into that shape, holding up 3 books.

However, when it comes to checklists, or standard operating procedures (SOP's), sometimes there are simply too many. Cultures in the red-quadrant of the "competing values" diagram think that the problem is always too few procedures, and want to add more. They think the graph of reliability versus standardization goes up forever. In practice, the graph seems to be more hill-shaped, going up to a point, then somewhat down as more and more procedures start getting in the way, and finally result in catastrophic failure as the system crashes under the weight of it's own safety system. One can think, perhaps, of the "right number of laws" to have optimal regulation of an industry, and which of those two curves applies in whatever is your own case.

I put up a powerpoint slide presentation (no audio) considering this issue.
you can get it here, titled "spectacular.ppt".

Narrated capstone talk is now available

If anyone wants to hear and see my actual May 1st 2007 Capstone talk from Johns Hopkins, or get a copy of the PowerPoint slides without all my comments in the way, they're both available:

• Just slides, no audio (CapstoneSlides.ppt 1.5 meg -- a self-extracting archive that will ask first.)
• or
  
• Self-running slide show with audio (15 meg) that you need to download (WadesTalk.exe) and then manually double-click for it to uncompress a dozen files and then run the ppt viewer.
  

The manual step is to give you a chance to virus scan it or whatever you need to before running an executable file. Some firewalls may prevent you from downloading it at all, in which case email me and I'll point you to a zip file you can download and unzip manually to get around that problem. The self-extracting winzip archive doesn't require you to have "Winzip", and it includes a powerpoint viewer so you don't need to have PowerPoint either.

Wade

The Sixth Discipline of Learning Organizations - part B

Yesterday, in my post The Sixth Discipline of Learning Organizations, I reviewed a few of the lessons Peter Senge's book The Fifth Discipline teaches that we can learn from thinking in circles, not in lines.

There are other properties of loops that are critical, but as subtle as the difference between the behavior of a spinning bicycle wheel (a gyroscope) and a stationary one, or attempting to throw a plate or a playing card that is spinning rapidly versus one that is not spinning. At first glance you might say - it's just spinning, so what? But the behavior of trying to throw a plate and a "Frisbee" is quite different - the plate may go 20 feet and the Frisbee 100 yards.

Spinning rapidly in a circle matters. All feedback is not the same. The speed of feedback in a feedback loop also matters. The feedback rate matters ( loops per second or per day or per year).

But this morning I want to start looking at vertically oriented loops in hierarchically structured organizations - for which a triangle or pyramid shape is more helpful than a circle for discussion.
(Imagine the pyramid shown on the back of every US dollar bill.)

Say that the "boss" is the eye on the top of the pyramid, and that the boss's orders come down the right side, through the "chain of command" (which is actually a branching tree shape.)

At the bottom of the organizational pyramid, where it actually touches the reality and "ground truth", employees attempt to carry out those orders, and imagine that activity moving us from right to left across the bottom of the pyramid. Finally, status reports ("mission accomplished!") move back up the chain of command being consolidated at each level all the way back to the boss at the top. So, we have a vertically oriented loop, or cycle, because now new orders come down the chain and that loop pattern repeats.

So far, so good.

In a static, simple world, if all employees except one named "Joe" report success, and Joe keeps reporting failure, the classic model would say that the action management needs to take is to replace Joe. The model says all employees are interchangeable machine parts and if a part fails to do its job, the part is broken and should be replaced. This is a simplified version of McGreggor's "Theory X" of management, very popular in the machine age, from 1850 - 1950.
Another implicit assumption is that the boss completely understands the tasks to be performed, and is the resident expert. If people don't "perform" it must be because they are "lazy" and what is needed is a "bigger whip." Employees are told to "jump" and they don't need to understand why or agree -- they just need to ask "yes sir, how high sir?"

That model worked for early industrial models, such as workers in textile mills, or slaves picking cotton.

But, in a dynamic, complex world, that model breaks down and doesn't work. Actions and responses that worked yesterday suddenly no longer work. The "cheese has moved." The organization has to learn new responses to the same old inputs. The response of the outside world to an action is no longer predictable, and has to be judged based on rapid-feedback and a quick poke to see what happens and learning from that. We move into McGreggor's "Theory Y" of management where the expertise is now on the bottom of the pyramid, where front-line
troops are as likely to reply "What bridge? The bridge is gone!" as "OK, yes we crossed the bridge." Now an ever-changing set of facts or dots of information have to be aggregated upwards and "reporting" has to change into continuous "sense-making" of shifting patterns and images of the battlefield truth.

Again, this model is not that strange. It's the basic model we use when we have to move a bit of food from the table to our mouth on a very windy day - we move the hand a little, see where it is now, move it a little move, see where it is now, etc., in a very rapid sequence that automatically adjusts for the wind. If we don't adjust for the wind, the hand and food will miss the mouth on the downwind side. We don't "compute" wind velocity and use Newton's laws to figure out what to do - we just do it and watch while it's happening. It's no big deal. It's the basic "cybernetic loop" of tiny intent, tiny action, tiny perception, and repeat the loop rapidly over and over. It's a loop we can use to cross an unfamiliar room in the dark. Move slowly, stay alert and aware, and adjust as you run into things. It works. It doesn't require quantitative analysis or calculus or a computer or a PhD in robotics. It just requires using a very basic action and sensory loop over and over.

And, like any feedback loop, causality disappears in the normal sense. Motion alters perception and perception alters motion and the two become one, in a very real sense, a single motion-perception action and a loop as an actor.

Again, no big deal. So why is this important?

The big deal is that our society is in the middle of adjusting to this change from "Theory X", and a stable, static world with expertise at the top to "Theory Y" with a very dynamic, unknown world and the expertise at the bottom. In fact, because of the property of loops, there really is no longer much of a "top" and "bottom" in the classical Theory Y sense of the terms.

Just as the level of the water could be seen to control the hand on the faucet, the staff at the bottom of the chain of command can be seen to be controlling the General at the top of the pyramid -- and both those models are wrong, because it's actually the shape of the feedback loop that now has taken on a life of its own, on a whole different scale, and is controlling both of them.

Senge's point, and mine, is that most of the organizational problems we see around us are because we haven't managed to get that much right. In some health care organizations, an extreme case of the expertise being on the "bottom" of the pyramid, the top management still thinks in "Theory X" terms and tries to see itself as the expert in everything and "gives orders" to move in a certain way. The body reports back "No -- what bridge?" and the boss sees this as stubbornness, stupidity, or hostility and things just get worse from there.

Arguably one of the best "learning organizations" around is the US Army. I've mentioned many times before role of Doctrine in FM22-100, the US Army Leadership Field Manual. The pyramid model I just described is the theoretical basis for the doctrine, and every field action is supposed to be followed with a "lessons learned" session. News, particularly surprising news about a misfit between upper management's concept of where the battle or bridge should be and what actual boots on the ground see in front of them, is supposed to be free to travel upwards. Management, as it were, is supposed to listen to the staff and learn what's actually going on, not what management imagined yesterday was going on. It's not insubordination to say "Sir, What Bridge Sir?"

By simple trial and error experience, repeated millions of times, the Army has finally figured out what works and what doesn't and come to some conclusions that are startling to the Theory X old guard, but not at all surprising to the Theory Y thinkers. For one thing, listening has to go upwards, at every level. It's as important that superior officers listen to junior officers as vice versa. If new conditions at the bottom don't result in a new picture of what's going on at the top, the whole pyramid will simply drive off a cliff or otherwise carry out actions that bear no resemblance to reality.

And, because the picture of reality is not perceived directly, but has to come up the chain of command and be re-filtered and consolidated at a dozen different levels, that process has to be incredibly accurate, frank, honest, and unbiased. Even a 10% "adjustment" in facts, repeated over and over at each level of consolidation, can result in a reported "reality" at the top that is 180-degrees out of whack.

In a profound sense, the key word is integrity, and not just integrity when the going is easy, but integrity when the going is tough - not because of enemy action but because of "friendly fire from above". That kind of integrity is also part of the other key word in the doctrine - character.

If the information flows freely and rapidly and can spin up to a high rate of rotation, as with a bicycle wheel or gyroscope, this whole design pattern becomes very stable, agile, nimble, and capable of navigating the most bizarre terrain as events unfold in surprising and unexpected ways. BUT, if there are pockets of resistance to the flow of information, such as cover-ups, that model breaks down. Or, if there are superiors who think "superior" means they know everything and they don't need to learn from their men, the model breaks down. So, another few important words are honesty and humility.

See US Army Leadership Field Manual FM22-100
and What relates Public Health and the US Army?
and the whole posting from my Capstone slide 7 Theories are Changing which has twenty more references to the literature on high-reliability organizations in nuclear power plants and chemical plants and aircraft cockpits and hospital intensive care units, and what makes them actually work in practice. It just keeps coming back to the same thing and the same model that's right in front of us be we haven't finished mastering.

And, again we have a place where our religious heritage has been observing what makes society work for thousands of years and has more wisdom to offer on this than scientists, although the science is beginning to catch up at last. Our religions have been stressing virtues - integrity, honesty, compassion, humility, etc. - for centuries but we haven't really been listening or haven't thought that "mattered any more in the modern age." Actually, the basic cybernetic model is ageless, and true at any size and scale. It's going to be something we have in common with aliens from other worlds when we meet. It's a universal truth every bit as solid as other physical "laws" we rely on.

These are truths that are seen by Hindus, by Muslims, by Christians, by Jews, by atheists, and by learning organizations like the US Army. They can serve as a basis for unity among even such diverse groups and cultures. They can link science and religion without either side having to admit they were wrong about something and lose face.

Grasping and implementing that truth certainly looks like it could give us far more "bang per buck" than investing in new technology, new weapon systems, new gizmos and gadgets, and other ways to shift the detail complexity around.

Also, see my early post Virtue drives the bottom line with many links at the end to such literature. (excuse the formatting near the top of that post - I'm technically challenged by the html editor.)

Another author's take on this subject is "Spirituality in the Workplace - The Sixth Discipline of a learning organization, by Harish Midha at the University of Toronto.

Peter Senge's latest book is Presence: Human Purpose and the Field of the Future and readers interested in that book might also be interested in Stephen Covey's book The Eighth Habit. All these books teach the same gospel - that we are going to have to come to grips with the nature of community to "make it" through our social problems of this century, and that community requires us to realize the power and impact of "virtues" when amplified by the feedback properties of complex systems.

Another post I wrote exploring the role of community, virtues, and organizational learning and agility is The Importance of Social Relationships (short)

I also recommend: Pathways to Peace - beautiful slides and reflections to music on the value of virtues

A general summary of what I think are my best dozen posts on related subjects is here.

This is also relevant:

Spiritual solutions for technical problems

Enjoy, and please, for reasons this whole post embraces, send me feedback! A human can't sustain a thought without some measure of social support! Criticisms and objections are welcome. Use the comment box below, or send to my email in my "profile" box above.

Wade

The Sixth Discipline for Learning Organizations

There are some things common to the diverse fields of medicine, public health, business, religion, science, and the military.

• They all tackle problems which result in "success" or "failure" in a changing world.
• Failure can cost property, lives, or even entire nations and cultures.
  
• "Success" depends on how well they can detect failure and adapt to it.
• They all have bright people, but really operate more at the organizational level
  
• Adaptation depends on how good the organization is at seeing and learning.

So, a book like Peter Senge's The Fifth Discipline - The Art and Practice of the Learning Organization is very important to us all, and impacts us on many fronts.

Senge points out an extremely pivotal insight: there are two different kinds of complexity, and most of what we do is focused on the wrong one.

He describes "detail complexity", which is the type we are familiar with, where there are thousands or even millions of details to be kept track of and managed. That one we're pretty good at, with the help of computers.

But then he goes on (on page 71 of the 2006 revision):

But there is a second type of complexity. The second type is dynamic complexity, situations where the cause and effect are subtle, and where the effects over time of interventions are not obvious. Conventional forecasting, planning, and analysis methods are not equipped to deal with dynamic complexity...

When the same action has dramatically different effects in the short run and the long, there is dynamic complexity. When an action has one set of consequences locally and a very different set of consequences in a different part of the system, there is dynamic complexity. When obvious interventions produce non-obvious consequences, there is dynamic complexity.

He adds

"The real leverage in most management situations lie in understanding dynamic complexity, not detail complexity."

This understanding comes from "system thinking" and that, in turn "starts with understanding a simple concept called feedback."

Of course, to say feedback is "simple" is misleading. The impact of feedback is wildly subtle, counter-intuitive, perplexing, and paradoxical to most of us. Some simply refuse to accept the concept at all because it overturns so many cherished notions of how the world works and how things "should" be.

Senge goes on, echoing many others and American Indian culture, "Reality is made up of circles but we see straight lines."

The point is that when people or things form a causal loop, where each thing influences the next one down the chain, and the chain is closed, then all our notions of "causality" are thrown out the window. Every actor in that loop is both the cause and the prisoner of the effects of the entire loop. In many ways, the shape of the loop becomes the dominant "cause" of what unfolds, far more so than the people caught up within it.

Senge describes a person filling a glass of water. As seen by a person, their hand is controlling the level of water in the glass, and adjusting it as the glass fills. A perfectly valid alternative description is that the level of the water in the glass is controlling the hand, causing the hand to close the faucet as the level reaches the right place.

Both descriptions are partially correct. The hand affects the water level, and the water level, in turn affects the hand. There is a feedback loop in place. Both are "causes" and both are "effects," and "which came first" is an irrelevant question.

It is the intrinsic property of complex systems to be dense with such feedback loops between the people inside them, making everyone a cause and everyone a trapped recipient of effects.

This means bad news and good news.

The bad news is that, if the output of "the system" is wrong, then the blame should be shared among everyone in the system, not just the last person to touch something that failed.

The good news is that every person in the system therefore also has the opportunity to change the flows and impact the system's output. In conflict situations, either party has the ability to increase the tension or decrease the tension.

In fact, in most conflict situations, the whole reason for the conflict in the first place is that there are feedback loops that are reflecting each sides actions into later behaviors by the other side, which are misinterpreted as new "actions", not "reactions."

Thus, in 2006, when Hezbollah forces in Syria reacted to Israel's capture of many of their own, they captured two Israeli soldiers in return. However, Israel saw this not as a reaction, but as a new "unprovoked action", which therefore demanded a new massive "reaction" and counter strike - a 34 day assault by Israel. The counter strike, in turn, was perceived by Hezbollah as a new "unprovoked attack", and the cycle simply continues to feed itself.

This is a classic no-win situation, where each side downplays the value of lives of the other side, and feels that the loss of one of their own should be responded to by killing two of the "others",
in order to "get even" and also "be even." By that flawed match, the conflict spirals out of control because there will never be an "even" situation.

On a smaller scale, within organizations, the same phenomenon occurs - but generally without actual explosives and death. The vast majority of conflicts can actually be traced back to people, or teams, or departments, or divisions, or managers blaming others for behavior that is simply the downstream result of their own earlier behavior, reflected and sometimes amplified through the structure of "the system" of feedback loops and lags. Similarly, management and labor can get into the same endless loop of conflict over "getting even" for behaviors that are the result of their own, forgotten, earlier actions.

In a bizarre sort of hallucinogenic dance, at all levels from personal to national, we are fighting demons that are simply the delayed reflections of our own earlier behavior, which we fail to recognize and blame instead on the "others" being "bad."

Senge mentioned the problem with dynamic complexity over space and over time, but he missed the third dimension, namely, over scale, or location in the hierarchy of life. Actions or interventions may look very different, ranging from great to wretched, as we rotate the lenses in our microscope stage and view different time-horizons, different space-horizons, and different perspectives from the bottom of the organization to the top.

Worse, actors in one place who perceive, at their location, time, and scale that their own actions are "good" may be completely baffled by hostile responses coming from actors at other locations, times, or level who are only responding to the "terrible" thing being done to them by that obviously uncaring and bad person somewhere else. And, of course, this would mean that those people responding with hostility must be "bad people" and need to be fired, neutralized, or killed, depending on the context of the conflict.

Dennis Severance describes the same kind of error being made by a mythical management in the book Making I/T Work. That management tries to impose an an enterprise-wide computer system, runs into "hostility", tries to "deal with" the "opponents" by firing them, and then is blind-sided when the computer system, "out of the blue, with no notice", fails to operate as intended, and they can't grasp why no one ever warned them of problems. The fact that those who raised these issues at the start were fired for their "hostility" is completely lost. This is a very common problem across industries.

These problems are not, as they might seem, problems of perception, but are actually problems of the intrinsic properties of systems. The people in these systems are all well-intended, doing "good jobs" locally, and yet, like M.C. Escher's pictures, taken together form an impossible loop that simply can't operate.

The variables that depend on the horizon of space, time, or scale are the keys here, and are as surprising as seeing an object that is red close up turn to look green when you back up several steps. This seems "impossible". Actually, New Scientist published a marvelous picture a month ago that, if viewed close up, was Albert Einstein, but if you backed up across the room, changed into Marilyn Monroe.

( Hybrid images: Now you see them…

• 31 March 2007
• NewScientist.com
• Gregory T. Huang )
  

These system effects are much more prevalent than people realize, and are the things that are "to blame" for most of the conflict and corporate dysfunction and national conflict around us.

It is clear to me, and I'd say to Peter Senge, that these effects need to be somehow made visible and accessible to everyone, at every level, from every country, so that we can get enough comprehension for people to see that, in Walt Kelly's Pogo's words, "We have met the enemy and he is us."

Of course, many scientists, working a small scales, would have a hard time accepting wisdom from theologians, working at large scales, who see different pictures in the same world. Biomedical researchers, used to looking down the microscope for the cause of problems, are not prone to look out the window instead, and even less to consider that their own scientific culture could be implicated in producing the conditions that produced the cancer that they are now working to "cure".

Still, the logic of Senge's arguments is sound. "All" that is required is for people to stop blaming others for all the pain and recognize that the others are just as good people and are just as trapped in the pain, and, in any case, as with Jimmy Buffet in Margaritaville, they might realize that, yes, maybe, they themselves might be partly to blame.

If this looks remarkably like the basic golden rule of most religions ("Do unto others what you would have them do unto you") that's because it is. Other really annoying commandments like "Forgive us our sins as we forgive others" also come readily to mind.

Like the "Marilyn Einstein" photo, reality is multi-scaled, and the scientists have the fine-detail or high-frequency detail right, and the religions may be wrong on details but have the long-wavelength, larger picture right.

All of this should be something that can be animated, simulated, and taught in K-12 school, as well as in continuing education. And it should be.

We shall not cease from exploration
And the end of all our exploring
Will be to arrive where we started
And know the place for the first time.
T.S. Eliot

Baha'i views

The weblog Baha'i Views offers "Pithy excerpts & mentions of Baha'i in the blogosphere" and looks like a nice daily "clipping service" for who's doing what where. It has nice pictures and short postings by different people of their very individual thoughts and experiences.

It's at http://bahaiviews.blogspot.com/ and I added it to my permanent links list.

Here's a few sample topics on there today:

On Speaking of Religion: Being open-minded and contemplative

On Resisting Divisive Influences: God Unites, Man Divides

On Harmfully Divisive Influences to Humanity's Unity: Unlearning the the prideful nationalistic feelings that drive us apart

On Another Way to Participate in the "Cultivating the Roots" Conference: Audio Streaming and Blogging from the Event

On Wealth and Poverty: Thought-Provoking Reflections

On Baha'i Devotionals: One Buddhist quote was meant for me

Wade

Agile Links for Busy Health Executives

"Agile Links for Busy Health Executives" is the description of the weblog HealthCxecLynx at "http://www.healthexeclynx.org/".

That site is maintained by Department of Health Policy and Administration at the School of Public Health of the University of North Carolina at Chapel Hill.

It's a nice clearinghouse. I added it to my permanent links (on the right side of this page).

Wade

Subtle nuances matter

It's not obvious what matters.

Whether we are just thinking, or doing fancy math, there's the stuff we leave in our model, and the stuff that we throw out, because it doesn't matter. Sometimes we think things don't matter because they have such a small effect that they are "negligible."

Sometimes we are wrong.

A classic example was the mistake that pouring toxins, like mercury, into the sea would dilute them to the point where they didn't matter. We forgot that nature has natural filters and amplifiers that recollected all those dilute molecules in one place, namely, the tissue of fish, so that the concentration was again dangerous or lethal to humans.

Or sometimes we forget some other factor. Nuclear scientists at Dugway Proving ground computed how much fallout would land on the ground and how much would wash away and "go away", and figured it was safe. After the sheep died and many people got cancer they found out, oopsie, that grass is remarkably good at harvesting water and holding onto it, so instead of the toxins washing away, they were recollected.

So, sometimes things that look like "small" effects do "go away", and sometimes they don't.

One conceptual problem we have is that we're not used to math where the answer depends on what time scale or geogrphic scale we're working in. So, yes, in the short run, "rock" is stronger than "water". In the long run, "rock" is demolished and destroyed by "water".

Or, in the short range, electromagnetic forces dominate gravity. A balloon, rubbed on the sleeve, will stick on the wall, not fall. For many purposes, gravity "goes away." But, if you look on longer time scales, it's the "strong" force of electromagnetism that "goes away", and the end state of the world is determined by that "weak" force of gravity, on a cosmological scale.

Or, if you look at an M.C. Escher painting of a staircase or waterfall, locally, there is nothing wrong, aside from a very slight noise or error -- but that error accumulates and on the larger scale, the total painting is absurd, even though locally any small part of it makes sense.

So we need to be careful about not "throwing out the baby with the bathwater."
It's not always obvious which is which.

Then there are other effects even more insidious or subtle. As the philosopher "Snoopy" observed one day, lying on top of his doghouse in the cartoon strip "Peanuts",

"Did you ever notice, that if you think about something at 2 am, and then again at noon the next day, you get two different answers?"

Or, another example I love, the story of two stone masons working on a church in the 1600's. One was doing very good work, and the other was doing work that needed to be redone often. The supervisor came to talk to each and asked them what they were doing. The one with poor outcomes replied "I'm building a wall." The one with great outcomes replied "I'm building a cathedral."

So, at least to human beings, it seems to matter a great deal whether the work they are doing makes sense in a larger context, whether it has "meaning" to them or not.

Is this true for people who write computer programs or "provide" health care services as well? Probably. How would we know for sure? And if it does matter, are we designing our systems in light of that effect, whatever it's called?

And is this just some "mental" or "psychological" effect, or is it an effect so "real" or fundamental that it would show up even if the agents building things were robots not people? Does this sort of thing matter to ants or bees or termites or bird swarms or swarms of viruses or bacteria?
Does it matter to the US Army?

Do real, tangible outcomes depend on "meaning"?

Certainly, from the model I described yesterday of nested contexts, the outer, distant contexts matter a great deal, although, again, the effects may take longer and longer as the context gets more distant. So, as many computer system designers and nation builders have discovered, "culture matters", and the survival of some change imposed from outside on a system depends, in the long run, on whether it fits with culture or not. If it fits, or can transform the culture to fit, it will remain. If it doesn't fit, the cultural equivalent of the body's immune system will identify it as "foreign tissue" and reject it. You can take that one to the bank.

Today's International Herald Tribune has an opinion piece on this subject at the scale of nation building, reflecting on Iraq and Afghanistan. Here's a brief snippet.

Do Not Neglect Culture
International Herald Tribune (on-line)
May 8, 2007
by Nassrine Azimi (Hiroshima, Japan)

The Rand Corporation recently published a study called "The Beginner's Guide to Nation-Building." It covers the basics with clarity and objectivity, defining the roles of the military, the police and the judiciary; distinguishing humanitarian relief from economic stabilization and development, explaining the complexities of governance and democratization.

But the book has almost nothing about what is clearly the Achilles' heel of recent nation-building adventures: culture. No single chapter is devoted to it - nothing on the role of culture in countries being rebuilt and, just as importantly, nothing on the culture of the nation-builders themselves.

Though we are reminded that six of the seven cases of nation-building initiated in the last decade by the United States were in Islamic countries, we do not learn much of the lessons of this extraordinary experience.

How, for example, did it inform the dispatch of some 120,000 mostly Christian soldiers to Iraq - a Muslim country and one of the most ancient civilizations on earth?

Neither do we learn much about what kind of cultural preparations, if any, were undertaken in advance of embarking in Afghanistan, also an ancient and proud land, with subtle values and vulnerabilities not readily accessible to the Western mind.

The fault, however, may not lie as much with the Rand book as with nation-building operations themselves. In most, culture has been at best an afterthought and at worst a shallow and cynical exercise in public relations.

This was not always so. The U.S. occupation of Japan between 1945 and 1952, so often cited as a model for Iraq, was quite different. American planners then appeared to have asked themselves some hard questions about dealing with a country they barely knew or understood, with which they had fought for almost four years, and which lay in ruins....

Perhaps this same effect is as evident in the many failed efforts across the country to install "Electronic Medical Record systems" where the system did not fit the culture or "the way we do things here", and the hope that the culture would "come to the system" was dashed by the fact that the system yielded to the culture.

This phenomenon is very well known and studied in public health, after a century or so of attempting to impose behavioral patterns on indiginous people who tended, as soon as the intervention team was gone, to keep the goodies and discard the behaviors that the strangers had imposed. The natives happily nodded "Yes!" while thinking to themselves "In your dreams!"

The lessons are that lasting change has to be rooted, and, in a mixed metaphor, rooted "deeper and deeper" upwards into the hierarchy of contexts that surround the point of intervention, or the unit of the hierarchy of life that is being tinkered with.

This effect is dimly and incorrectly perceived by many in McGregor's "Theory X" camp as "resistance to management", and as something that needs to be attacked, proponents of such resistance located and rooted out and fired, and overcome by brute force. In the short run, rock beats water. But, in the long run, water beats rock. If the intervention is "not me", the culture will ultimately find some way to reject it, or perhaps the culture will simply collapse under the conflict.

I think the prophet Yogi Berra once said "You can hear a lot by listening" , or words to that effect. It seems advisable that those messing with systems behavior at any scale should first investigate the system's "culture" before investing a lot in a particular change that seems, from the outside, to make sense. There are subtleties that are not obvious, "small things" that don't fit that turn out not to be so small after all, as the mercury or the fallout or the stone mason examples showed.

Whether a piece of the developmental puzzle "fits" or "is good" or "goes there" needs to be assessed at the cultural level, after all the "small things" have been given a chance to accumulate and add up again. This is a "complex adapative system" and the behavior at large scale is not reflected, in any obvious way, by the behavior at small scale.

The very fact that that's the problem is not widely understood.

There is no way that, for example, the CCHIT assessment of electronic medical record systems, at the individual user level, can possibly reveal whether this overall system will "fit" or "work" if "installed" at a particular site, in a particular "culture".

Collaboration-ware needs a completely different scale approach than classic IT software.
Again, that's not recognized as a problem to even fret about.

We are desperately short of good tools and accepted practices in this area. Maybe public health informatics can address that in the coming decade.

W.

Credits: Photo above is "The Hierarchy of Consciousness" by slark on flickr.

The hierarchy of life and implications for interventions

Apparently, we don't exist.

Every day more studies come out showing something that we'd suspected all along - namely, we actually have very little control over our own lives and even over our own decisions.

The people around us and our neighborhoods, at work and at home, are increasingly seen as the main cause of our beliefs, our decisions, and our actions.

Well, that just messes up everything, thank you. Our whole system of justice, and education, and rewards at work, and "the American way" are all based on the concept of rugged individualism, on one dominant person surrounded by a sea of "environment", making decisions, navigating the shoals of life, and deserving rich rewards for success or punishment for "being bad."

But that concept doesn't seem to survive the light of day, or a careful look at the evidence. And much of the evidence lately is coming from public health, including studies of the "health" of the "healthcare system" itself.

A very "robust" finding of the field of "social epidemiology" is that the physical health of a person seems to be very strongly associated with his or her "connectedness" with the tissue of society around them. The more someone is connected to the social fabric, the healthier they will generally be. The more someone disconnects and drops out of social interactions, the worse they will tend to be, across the board, in terms of almost every measure of morbidity and mortality. They'll be more depressed, more fatigued, less successful, less wealthy, more likely to be obese, more likely to have depression, diabetes, heart disease, asthma, the flu, common colds, etc.

But, does disconnection cause disease, or does disease cause disconnection?

The answer is "yes" to both, because this is not a linear chain of causality, but a causal loop. That means it can spiral downwards or upwards.

That's familiar. The more a person becomes depressed, the more likely they are to fail to cope, to get into trouble at work and home, and to worsen their situation at work and home. And, the worse their situation becomes, the more depressed they become. It's a "vicious cycle."

The ultimate end of that death spiral is, in fact death. There is complete disconnection and isolation, total dropping out, followed by catching the next excuse to die, from natural disease or neglect or violence, or violence against others (death by police). Just as a human cell, removed from the body, will lose the will to live and commit suicide ("apoptosis"), humans,
disconnected from the social body, lose the will to live, and find a way to die.

This is a real bummer in several ways. One unexpected way is that almost all research studies are based on statistics developed by a guy (Sir R. A. Fisher) studying crop yields where the causality only goes one way. The crops do not realizing they aren't growing and make midnight raids on the fertilizer shed. People, however, do. In fact, almost everything people do, or collections of people, are just drenched and dominated by feedback loops. And feedback loops invalidate classical statistics based on lines, not circles. (It's based on the "General Linear Model"). So, it's hard to study. So, people don't study it and go study something else.

Of course, there are tools that can easily handle such loops, including electronic circuit design or "system dynamics" or "feedback control system engineering." But those are almost unknown in public health so don't hold your breath.

Despite that, the evidence just leaps off the page. The most successful interventions in health care, as described in "Health Program Planning - An Educational and Ecological Approach" (4th ed) by Green and Kreuter, apologizes for abandoning classical models on page 3, with the comment that

"Ecological approaches, however have proven difficult to evaluate because the units of analysis do not lend themselves to the random assignment, experimental control, and manipulation characteristic of preferred scientific approaches to establishing causation."

Which is a long way of saying that the old set of "linear" tools and linear thinking really doesn't work, if you try to apply it to the real world that people, not billiard balls, deal with daily - a world dominated by feedback.

But, all is not lost. Even despite that, the healers of the healers, the designers of the health care system itself, have studied their own problem and concluded that the right unit of intervention is the small team on the front lines, which they call a "microsystem." In between the one doctor who is hard to change, and the hospital, which is hard to change, is the small practice team, which, fascinatingly, the Institute of Medicine has found easy to change.
(See Crossing the Quality Chasm.)

And, ta da!, big surprise, the recommended method of changing that unit of life, the small team, turns out to be "feedback." Well, of course it's feedback - that much becomes obvious once you shift lenses and realize that everything, at every scale, is more defined by what's outside it than what's inside it. (Mach's principle in cosmology.)

So, a single doctor or staff member can't really be changed by an intervention, because their behavior isn't really "theirs" -- it is a feedback property of the small team they work with. So, if a doctor or nurse "makes a mistake", it usually turns out that the place to fix isn't the individual, it's the larger structural team around them that effectively forced them to make the mistake. The system buys the gun, loads the gun, cocks the gun, hands it to the person on the front line who pulls the trigger.

And, on the flip side, there is no such thing as "the patient." Patients are people, and people come with a posse, an aura, their own small team of friends and family that mutually influence each other. So, ta da!, if you want to change how "a patient" behaves, or go a step further upstream and change what they believe, you have to address how the patient's "microsystem" behaves. The IOM didn't make that leap, but the rest of health education has realized that "family-centered" interventions are way more effective than "patient" interventions.

Of course, this really only changes the geographic and time scale, something the IOM hasn't yet realized.

This property of being defined by the outside peers is not restricted to cells or to people - it's a universal property of living things or any regulatory control system.

So, it's "scale invariant". That means if we flip to the next lens on our microscope and stand back another hundred yards, now we see the unit we are messing with is "the microsystem" but it is swimming in a sea of other "microsystems", and is ultimately dominated by the other microsystems as a peer group. Now, the time constant is much longer, so it may take months not days, but simply changing one small team and leaving its environment unchanged will sooner or later result in the change being undone, rejected like foreign tissue, and discarded by the larger living tissue of the body of the health care system. People will revert in hours. Clincial services may take months or years to revert, once the intervention pressure is released.

Man, how far does this thing go? Well, according to many people such as myself or Ken Wilber, it just keeps on going upwards. Wilber refers to one of these structural ladders of the hierarchy of life as a "holon." Norm Anderson, when at the NIH, refered to the same hierarchy from cells to tissues to organs to people to groups to neighborhoods to populations -- but nobody really wanted to hear that, so Norm left. The tissue rejected the novel idea.

Well, that math just gets impossible then, doesn't it? Not really, it just rotates. Large, tall, hierarchical structures have their own basic modes, as does anything else. There are almost certainly solutions that can be found, or descriptions, based on combinations of scale-invariant (symmetric) properties as basis vectors. And one such scale-invariant property is the concept of a regulatory feedback loop. At every level of this nested hierarchy, exactly the same problem has to be solved - how to maintain the equivalent of homeostatis in a sea of change. Cells do it. The pancreas does it. The Endocrine system does it. The body does it. People do it. Small teams (microsystems) do it. Hospitals do it. Health care chains do it. Whole cultures do it. Nations do it. They're all doing the same abstract dance, of seeking to reestablish their own feedback loop that works for them.

So it's kind of a fractal, a Christmas tree shape, where each branch is the same shape as the tree itself. The question is, what are the fundamental modes of vibration of such thingies? If it were made of steel and you plucked a branch, what would it sound like? (There would surely be harmonics of harmonics of harmonics.)

And, do such things have "resonant frequencies"? Is there some speed of change that will work far better than other speeds, or one that is far easier to "fall into" because it "aligns" with the larger resonance of the larger system around it?

Those are the interesting questions. In the short run, we have some immediate insights that don't need years of theoretical simulation and wisdom, based on this model or framework or lens, whatever you call it.

Here's a few:

1) To change a person, you have to change their peer group. They can move to a different peer group, or the peer group itself can be altered, but it has to happen.

2) etcetera. That is, you can't change that peer group, stably, without clicking up one more rung of the ladder, using a new power lens, and finding the peer-group's peer group.

3) Therefore, either you have a cascading, exponentially growing evangelical type of change, or you have a diminishing, exponentially decreasing, tissue-rejection kind of change. There is no such thing as a stable change of one "unit" at any scale. Life doesn't support constants, only growth or decay.

4) Our whole system of justice, education, rewards, and punishments is based on a flawed model of the world. That's all going to have to be rethought. All this emphasis on individual education has already run into the increasing emphasis on "teamwork" and "groupwork" and a realization that the unit of research, of discovery, of industrial production, of making or preventing errors is not a person, but a "Microsystem", a team, a cockpit crew, an operating room team, etc.

5) We're going to have to "bite the bullet" and start using the right tools to address these problems. They don't fit into the general linear model. All linear statistics break down and all linear thinking leads to erroneous intuition.

6) Collaborative IT systems are feedback loop generators, not huge replications of a single human-machine interaction. The "electronic health record", viewed this way, is part of the feedback loops that a patient uses to control his own life, or a doctor uses to control and manage their care for the patient, each side also calling on their own "microsystem" team to support this activity. Such systems cannot be evaluated or tested as if they were an Excel spreadsheet with a Graphic User Interface -- the human factors are feedback loops that can't possibly even show up in single user testing. The system will be made or broken on how the larger social fabric changes feedback loops when the system is put in place. That won't be revealed by the current CCHIT test suite.

7) This model would say that the right thing to be tracking for hospital adminstrators would be microsystems and teams, more so than individuals. The "dashboards" should reveal whether the microsystems are working, and, moreover, the people who need the dashboard aren't just the management outside the team, which is post-hoc, but the team members themselves for real-time self-management, steering and navigation. (That's straight out of the IOM's Crossing the Quality Chasm.)

8) Ditto for patients. This model would say that patient teams need their own Personal Health Record as part of a real-time feedback self-management model, that the doctors or clinical staff are only a very small remote second-order part of, for chronic disease management that involves life-style changes.

9) And, ultimately, this model points ever upwards. It says that people cannot be healthy unless their peer-group is healthy, and that cannot be healthy unless it's peer group is healthy, and, ultimately, all this depends on the national culture and planetary population being healthy.

So, yes, not only are you your brother's keeper, but your brother is, in many real ways, your keeper.

10) The "public" that "public health" must be concerned with (among others) is actually a fractal, nested, hierarchical part of the hierarchy of life. This cannot be made to "go away."
We need to "go to the mountain." Predictions as to the value of interventions in the behavior of a part of that hierarchy, on some level, whether cellular drugs or pancreas care of health system regulations, have to take into account that the parts are connected and will determine each other's behavior through feedback responses to interventional pressures.

It doesn't make sense to say "we put in a good system but the culture rejected it." The word "good" needs to be defined with respect to the whole hierarchy of life including culture. If the system is "good' in that metric, then the culture will, almost by definition, not reject it.

Well, that's pretty pedantic, and maybe you have a different view or some contrary evidence. I'd love to hear it. Let's have a good debate! See that "comment box" down there? Please use it and tell me whether you think I'm right, wrong, or need to increase my meds! Or email me. My email is in my profile.

Wade

Patient team empowered diabetes care in LA

Much of the model I suggest in my Capstone presentation is in use in Los Angeles - including teams of caregivers amplified by teams of local residents in a cascading help-your-neighbor approach.

Here's excerpts from an article Diabetics Need Much More Than a Shot from today's LA Times.

Managing the disease requires constant support and substantial investment, but would pay off in the end for thousands of people.

By Susan Brink
[Los Angleles] Times Staff Writer

May 7, 2007

Diabetes is afflicting more people, at younger and younger ages, sending doctors, insurers and public health officials into a tizzy as the epidemic threatens to overwhelm the healthcare delivery system. The annual cost of healthcare for an adult with diabetes is more than $13,000, and rates of Type 2 have risen sharply in the wake of the upsurge in obesity in this country.

A bold experiment is unfolding in Los Angeles County that may serve as a lesson for the nation as it battles the epidemic.

Experts know that the cost of care could be much lower if patients could take simple measures to control their disease and avoid complications: nerve damage, amputations, heart disease, blindness, even death. But surveys show that many, even those with adequate health insurance, do not get that care, which is costly and labor intensive, demanding daily attention from patients and timely responsiveness from doctors.

Poverty creates additional obstacles, such as finding fresh vegetables or a safe place to exercise. Study after study shows that low-income people have less access to healthcare and a greater risk of getting sick and dying prematurely.

But in an odd twist to the usual healthcare disparity story, more than 1,000 L.A. residents in low-income areas, most of them uninsured or on MediCal, are getting the gold standard of aggressive diabetes management — better, even, than many with insurance who live in ritzy ZIP codes.

The care is taking place at clinics in East L.A. and South L.A., two communities with the highest rates of diabetes in the county, as well as three other outlying clinics. A team of L.A. doctors is participating in the experiment, training nurse practitioners, pharmacists, social workers and community educators to intervene in a way that doctors cannot do.

They're offering frequent patient checkups to monitor the disease, and teaching patients to track blood sugar, get out and take a walk, cut out the doughnuts, all the things they need to do to keep complications at bay.

They are reaching people with uncontrolled disease in some of the county's poorest pockets.

"The county patients [in the program] receive care that is as good, and probably better, as anywhere in the country," says Dr. Mayer B. Davidson, endocrinology professor at Charles Drew Medical Center and UCLA.

There are signs that it's working. Studies so far show that patients in the program have improved blood sugar and have had fewer emergency room visits and hospitalizations.

Local pioneers

The intensive program is a response from local academic and public health experts to the crisis ahead. One of those experts, Dr. Anne Peters, professor at USC's Keck School of Medicine and an endocrinologist who specializes in diabetes, works both sides of the disease's socioeconomic divide.

Peters has a Beverly Hills practice ... But she also has a second job: supervising teams of workers on the same intensive model at five clinics including the Edward Roybal Health Center in East L.A., and the Hubert Humphrey Health Center in South L.A.

Reducing complications is key to protecting patients and controlling costs. It's not rocket science: lose weight, watch your diet, exercise, monitor blood sugar, blood pressure and cholesterol, take your medications, have regular eye and foot exams.

But often, these simple things aren't done.

Doctors needed

Peters' practice is an exception. She's a private practice doctor who spends as much time with her patients as they need. Her practice follows a team model, with a staff of nutritionists, educators, nurses and nurse practitioners to advise and prod patients via face-to-face discussions, phone calls and e-mails.

"I personally believe that anyone can take good care of their diabetes, no matter who they are or what their level of education," she says. "But they need a team, or at least a guide."

So successful has Peters' method been, that six years ago, she launched a pilot program for the county, supervising a team of professionals trained to educate, monitor and, when necessary, nag. The program took off in four other county centers in 2005.

The treatment team members make phone calls, hold classes, help patients change their diets, prescriptions or medication doses. They will even visit patients' homes to keep treatment on track.

Community members who speak the same language and share the same culture and who have successfully controlled their diabetes are recruited to teach classes and help coordinate care for newcomers to diabetes management. The idea is to allow specialist physicians to become consultants to community-savvy teams who offer up a steady drumbeat of medical attention and lifestyle education.

"It makes more sense to reach out to people where they live 24/7, and not think that a visit every three months to a provider is where all the care happens," says Dr. Jeffrey Guterman, medical director of the L.A. County Department of Health Services.

Before being accepted, patients in the county program sign an agreement that they will keep appointments and follow medical instructions. If they fail to comply, they're out. [editor note - it's hard to evaluate the success rate if failures are excluded. The point of my Capstone is to try to figure out what determines the drop-out rate and address that.]

Because funding is limited, patients can stay with the program only 6 to 9 months, but the expectation is that they can learn to control their disease in that time, then go back to a primary care physician. Those county doctors are ready, having been trained in how to manage diabetes patients.

Early studies suggest that the program works. A report in the April 2006 American Journal of Managed Care looked at how a key blood sugar test, called A1c, was controlled in 367 patients in the L.A. County program the year before and the year after they entered the program.

The A1c guideline was met by only 28% of participants when they were under traditional medical care. After a year in the program, 60% of patients met the blood sugar level goal.

[Effective Diabetes Care by a Registered Nurse Following Treatment Algorithms in a Minority Population -

Conclusion: A nurse making clinical decisions based on detailed treatment algorithms did a better job of achieving ADA-recommended process and outcome measures than physicians providing usual care.

(Am J Manag Care. 2006;12:226-232)

A second study published in February in the journal Diabetes Care found that diabetic patients in the program reduced their use of emergency rooms by half and cut down on hospitalizations. Total hospital charges dropped that year for the 331 patients studied to $24,630, from $129,176 the year before.

[ Effect of a Nurse-Directed Diabetes Disease Management Program on Urgent Care/Emergency Room Visits and Hospitalizations in a Minority Population

Mayer B. Davidson, MD¹, Adeela Ansari, MD¹ and Vicki J. Karlan, MPH

Diabetes Care 30:224-227, 2007]



Peters, ... keeps her private practice going only through donations from grateful, wealthy diabetic patients to a foundation she has started.

The health insurance benefits that her Westside patients have cover visits — generally about every three months. They don't cover extra visits to change medications or search out the reason blood sugar has fallen out of control. They don't cover time spent analyzing complex blood glucose printouts, insulin pump data or teaching patients to adjust insulin and drug doses.

Nor do they cover time for long discussions, phone calls, e-mails or the nutritionist, educators and nurses she employs to advise and prod patients....

---

susan.brink@latimes.com

Microsystem? What's that?

The confusing concept of a "microsystem" is central to the Institute of Medicine's recommendations for improving hospital-based health care, as presented in Crossing the Quality Chasm. What do they mean by that term? Where do we have to stand so that it becomes as obvious to us as it is to them that microsystems are important?

In this post I want to try to address those questions.
Here's two links to the IOM report:

IOM's "Executive summary

Entire IOM "Crossing the Quality Chasm" book (readable on-line)
http://www.nap.edu/catalog/10027.html#toc

First, where does the IOM refer to this? Searching the full text of the IOM report doesn't even hit that word? We have to start with the main author's after-thought (reformatted for clarity below):

A User's Manual for the IOM's 'Quality Chasm' Report
by Donald M. Berwick, Health Affairs, V 21 No. 3 May/June 2002, p 80-90,
http://content.healthaffairs.org/cgi/reprint/21/3/80.pdf

ABSTRACT: Fifteen months after releasing its report on patient safety (To Err Is Human), the Institute of Medicine released Crossing the Quality Chasm. Although less sensational than the patient safety report, the Quality Chasm report is more comprehensive and, in the long run, more important. It calls for improvements in six dimensions of health care performance: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity; and it asserts that those improvements cannot be achieved within the constraints of the existing system of care. It provides a rationale and a framework for the redesign of the U.S. health care system at four levels: patients’ experiences; the “microsystems” that actually give care; the organizations that house and support microsystems; and the environment of laws, rules, payment, accreditation, and professional training that shape organizational action.

From the "Prologue" to the article

One of the architects of the [IOM] report, Donald Berwick, decided that it would be
worthwhile to condense the message into a “user’s manual” for interested readers
in the United States and abroad. In this paper he synthesizes the report’s structural
themes and presents them, executive summary–style, as a framework that
did not appear in the final report but was the basis for the months of discussion
that led up to the report’s writing and dissemination.

This framework comprises four levels of interest:

• the experience of patients (Level A),
• the functioning of small units of care delivery (or “microsystems”) (Level B);
• the functioning of the organizations that house or otherwise support microsystems (Level C);
• and the environment of policy, payment, regulation, accreditation, and other such factors (Level D) that shape the behavior, interests, and opportunities of the organizations at Level C...

As the author of more than 100 peer-reviewed papers in numerous journals,
Berwick was ideal for the task. A pediatrician by training, Berwick is chief executive
officer of the Institute forHealthcare Improvement (IHI).

So we can see here a four-level multi-level model of patient care with a very surprising twist - namely, it seems to have skipped over the doctor, going from the patient right up to the whole small team that includes the doctor(s), nurses, and other staff who collectively deliver care within that clinic or unit.

This gap is no oversight. It embodies two more very critical, dramatic, and profound concepts:

#1) when caught up in an institutional environment, the boundaries of individuals blur, because doctors behave differently than they would in solo practice. Their behavior is as much a function of the team they are in as it is of their own "self".

and

#2) if we want to intervene in this 4-level health care system to improve things, the place we should intervene is at the small team level, not at the level of the individual doctor.

The first concept is an inevitable consequence of putting together groups of any kind of actor that is aware of and sensitive to its environment, in a social setting where collective action is the norm. It shows up in primates where there is a rule that "There is no thing as one chimpanzee," because the behavior of the "one", when isolated in a room, is so different than when the "one" is in social context. This phenomenon shows up among interacting robots, or interacting electronic components in some device. This is a "systems" concept, and as primal as any physical law, such as conservation of energy or conservation of momentum.

The second concept then, that this is the place to intervene, follows from the first. Again, experience robustly supports this in public health, where trying to change the behavior of "an individual" while not changing their peer group or family has proven to be extremly difficult, and the trend is dramatically shifting to "family-centered" interventions.

But, this is not just a theoretical model. Experience in the field shows that this does in fact appear to be universally true in institutional health care, and that interventions at the team level are, in fact, dramatically successful.

This document discusses 20 different health systems in which this was found to be true.

Executive Summary for Health Care Leaders
Microsystems in Health Care
Robert Wood Johnson Foundation
Dartmouth

Third, what sort of "Intervention" is necessary to improve the performance and behavior of this team level entity and produce safer care in a more cost-effective manner? Very little. In fact, the primary intervention required is simply to provide them sufficient real-time feedback of how they are doing, and trust them to respond to it appropriately, without any further management intervention. This is a mix of "Theory Y" of management, and Deming's models of the behavior of employees, who, he asserted, given the tools to do their jobs, would do them.
(But note that the team remains within the context of a larger health system, and that is important too.)

Here's a detailed but readable discussion of how that feedback can work:
Microsystems in Health Care, part 2:
Creating a Rich Information Environment
Joint Commission Journal of Quality and Safety

So, what does this tell us about the role of Information Technology (IT) within a health system? It seems to me that this clearly indicates crucial role for the real-time capturing of outcomes and visible feedback to the team, as well as a crucial role for interactive collaboration tools between the team members.

This is IT at the microsystem level, and is almost entirely absent in many health systems, in which IT is considered the exclusive province of levels C and D - the enterprise and national statistics. This focuses on "technology-mediated collaboration."

Fourth, a fully-integrated national health care system would actually provide the necessary IT support for all four levels - A,B,C and D in a coherent fashion.

In other posts, such as the Capstone presentation below, I discuss why empowering teams of patients, or the patient and the patient's family or "posse", is equally important for dealing with chronic care for such diseases as diabetes or obesity, in which the patient is the locus of control.
That need increasingly will be met by RHIO's and Personal Health Records, although, for reasons I discuss elsewhere, I think PHR's will be far more able to cover this gap than RHIOs because they are so much less risk-averse and more able to experiment, adapt, and fill small niches.

In conclusion, the national health information infrastructure model, as perceived by the IOM, really includes providing real-time self-managment tools as the crucial, key IT support to small teams of caregivers, whether the caregivers are "providers" in a hospital, or patients and their friends and family.

This is not a familiar role to IT, and so far has been embraced more by the School of Information at the University of Michigan ("technology-mediated collaboration") than by health systems in the USA.

This needs to be more central to the discussion of IT in a health-care environment, and it is a very different subject than simply automating medical records -- it is empowering small-team collaboration. That, according to the IOM, is where we need to focus our energies.