Thursday, August 24, 2006

Feedback cited as the core concept in Systems Dynamics

Cornell's SD site, in "Other Resources", at the bottom line, lists this:

The main concept behind system dynamics is feedback thinking. To explore the history of feedback thinking, see:

  • Richardson, George P. (1991, 1999) Feedback Thought in Social Science and Systems Theory. Now available from Pegasus Communications (Click on the System Dynamics link in the “Browse Products by Subject box on the left-hand side.)

Systems thinking and health care - reflection

Thursday, August 24, 2006

Systems thinking about assembly line health care

Why are the Big Three auto companies going broke, and if their high-tech Detroit area assembly-line operation is our model for health care, is that our destiny as well?

Consider this recent news.

New York Times
August 19, 2006
Ford Is Slashing Production 20% for 4th Quarter
By MICHELINE MAYNARD
DEARBORN, Mich., Aug. 18 — The Ford Motor Company, which is struggling to keep its grip on second place in the American car market, said Friday that it would cut by one-fifth the number of vehicles it plans to build in the final three months of the year.

The slowdown represented the deepest production cuts since the industry’s crisis of the 1980’s. It also underscored the difficulty that Detroit, whose business relies on sales of sport utility vehicles and pickup trucks, is having as gas prices remain around $3 a gallon. Detroit’s market share has dropped to its lowest level in history, while Asian brands, known for their fuel efficiency, are setting sales records...

On Friday, Ford officials contended that no one in the industry could have anticipated that gasoline prices would remain so high ... [emphasis added]

The mental-model of fine-tuning assembly-line clinical medicine may break down when seen through public health's wider lens, or in light of the impact on the humans whose bodies and lives provide the pixels on which this video is displayed, or be fine in both those contexts but have issues when seen in terms of globalization and the increasing ability of patients to fly to Singapore for surgical care at a total cost well less than similar care here.

The "systems thinking" approach suggests that we should spin through all those lenses on our microscope and consider whether each one makes sense, before we fixate, as Ford and GM seem to have, on activities that are perfectly sensible when removed from global context, but that look different when viewed in situ.

In clinical care systems we know that the parts do not exactly fit, and are not always well-coordinated. We take as an unexamined given that with just a little better training, a few more messages here and a new EHR message-store component there, surely this will come-together, click, and emerge as a dynamically stable and scalable system that cranks out top-notch patient care and dollars like a fine-tuned machine. Won't it?

In the 21st century, Peter Senge said, it is not enough that organizations persist well, they also must be able to change well. And Cybernetics 101 teaches us that in order to change well, a system needs to be able to see well. Perception is everything. We should confirm that those specs are reflected in the Electronic Health Record brave new world we're building nationally, before too much concrete is poured that will need to be ripped out and redone.

Like GM, we both face the twin questions of how humans fit into the assembly line model, over extended time periods, and, stepping back, whether the product those lines are producing is, viewed in global context, the product consumers will be buying next year.

We have to make sure not only that we're solving the problem right, but that we're solving the right problem. And, in the way of systems, we have to ask whether the way we're structuring humans and machines to solve the one problem doesn't create, as an "unintended side-effect", an emergent interference with our ability to see many small signs on the front lines that things are changing and the old model doesn't really fit the new reality.

Or are we somehow blinding ourselves to marketplace changes that seem obvious to the world not embedded in our own internal story? Ford executives asked who could have known that gas prices might rise? Hmm. Somehow they managed to assemble a workforce of half a million people with a resultant net organizational IQ of less than the average teenager. We need to ask where their collective common-sense-emerging process broke down, to be sure we're not following in their footsteps and mimicking their behaviors a little too closely.

Obviously, the problem is subtle. This is the way with most system problems.

There's lots of blame being spread around for "obvious" events and causes and decisions, including health care costs in another reflexive feedback loop, but we of systems thinking world know those are typically red-herrings and just symptoms of far more subtle problems in systems dynamics space. We are in desperate need of a "macroscope" that makes this almost invisible tissue stained and visible to the naked eye at last so we can see not just the microbes that we deal with daily, but the living dysfunctions that appear capable of infecting human organizations and causing Detroit blindness.

I'm not forecasting what tomorrows customer and problems will be, only that they will not be the same as yesterday's, in some really important ways. But I am saying that, based on the inexorable evidence and outcomes of the US automobile industry, there is something deeply but subtly wrong with the assembly-line model on a system dynamics basis - something that results in organizational blindness and incapacity to adapt.

It would seem the better part of valor to figure out exactly what that is, and make sure we don't inadvertently copy that into health care delivery systems as well.

Bottom line, literally: it would seem worth easily a billon dollars and a million votes to the Michigan economy to understand that answer in depth, and not just superficially. Whatever it is, there's a lot more where it came from.

Saturday, August 12, 2006

Packaged simulators for Health Care insight

The Systems Dynamics Society web-pages on "Other Resources" have a link to the K-12 education SD community, and to the newsletter "The Creative Learning Exchange".
Volume 15 number 2 (Spring, 2006) issue of that has an article by Gary B. Hirsch, Consultant and Creator of Learning Environments, Wayland MA, USA, titled "Packaged Simulators and Simulation-Based Learning Environments: An Alternative to Model-Building That Can Expand the Audience for System Dynamics.

Examples shown are a driving simulator on "curve safety", a house-temperature simulator, and a Retail Store simulator game, and a Public School Reform simulator (for adults). Multiple available exploratoriums are described at the end of the article, including a "health care simulator".

MPH Curriculum Systems Thinking Competencies

ASPH Education Committee

Master's Degree in Public Health
Core Competency Development Project
Version 2.1 (June 2006)

Systems Thinking List -pdf page #25 (shown below)
Systems Thinking membership: pdf page # 40
http://www.asph.org/UserFiles/FinalVersion2.1.pdf

Systems Thinking

The ability to recognize system level properties that result from dynamic interactions among human and social systems and how they affect the relationships among individuals, groups, organizations, communities, and environments.

Competencies: Upon graduation a student with an MPH should be able to ...

1) Indentify characteristics of a system.

2) Identify unintended consequences produced by changes made to a public heatlh system.

3) Provide examples of feedback loops and "stocks and flows" within a public health system.

4) Explain how systems (e.g., individuals, social networks,organizations, and communities) may be viewed as systems within systems in the analysis of public health problems.

5) Explain how systems models can be tested and validated.

6) Explain how the contexts of gender, race, poverty, history, migration, and culture are important in the design of interventions within public health systems.

7) Illustrate how changes in public health systems (including input, processes, and output) can be measured.

8) Analyze inter-relationships among systems that influence the quality of life of people in their communities.

9) Analyze the effects of political, social, and economic policies on public health systems at the local, state, national, and international levels.

10) Analyze the impact of global trends and interdependencies on public health related problems and systems.

Lewis Thomas on interventions in complex systems

Sterman quotes Lewis Thomas in Lives of a Cell, 1974 (p90):

When you are confronted by any complex social system, such as an urban center or a hamster, with things about it that you're dissatisfied with and anxious to fix, you cannot just step in and set about fixing with much hope of helping. This realization is one of the sore discouragements of our century. You cannot meddle with one part of a complex system from the outside without the almost certain risk of setting off disastrous events that you hadn't counted on in other, remote parts. If you want to fix something you are first obligated to understand... the whole system.. Intervening is a way of causing trouble.

Thursday, January 26, 2006

Connection of newspapers and public health

In my earlier post "Black, White, and Dead" I discuss potential changes in the way news organizations report the news, and news-reader software.

The question came up as to how this relates to public health, and the answer is important, so I'm making a whole new post on that.

Recently my wife Cheryll and I attended the Knight-Wallace Fellows Ninth Annual Conference on Journalism, focusing on Journalism and Women's Health, at the University of Michigan (November 7, 2005). (see previous post here.) There were two major take-away messages we got from that conference.

1) We were very frustrated by the lack of a way to follow up on the topics that captured our interests.

2) There was universal agreement from the panel that journalists are key players in getting public health messages out to the public, and out to government officials, but that the process was basically broken because public health issues are complex, and reporters don't have the time or space to get into that complexity. And, if they did get into that complexity, they'd lose most of their readers that wanted something easier to grasp, and a better "sound bite."

This second problem parallels a subject I've raised here before, that the complexity of problems is becoming larger than what we have to cope with them. ( Health Policy's Core Problem. )

So, Michael Kinsley's article got me thinking about news readers, and the "shape" of a news release in an abstract sense, but with some concrete conclusions.

I think what we need is to make news items more like multi-layered pyramids, with several different levels of detail and complexity available, but initially hidden.

So, like any manager, readers want something very short and sweet (the "sound bite") as an anchor for the reference. But then, when they have time to come back and pay attention to it, they are going to want to "drill down" into the story.

Journalists, authors, educators, writers have been trying to accomplish that task through structured linear text, but the truth is that just isn't very effective. First, no one today has read Mortimer Adler's classic "How to Read a Book", and we have generations that are clueless about top-down comprehension of complex topics, or how to start with the major headings and work their way down into the details. This isn't a skill we can assume.

Secondly, for many people, actual reading literacy and fluency is not very high. They simply get tired out after reading "X" words, where X is a number that's smaller each year. No one has time or mental energy, after getting the paper out of the bushes, to finish reading long articles, at least not at that time. They get put aside for "later", then discarded when "later" just doesn't seem to come any more as much as it used to.

So, we have functional specs here that say we need three changes:

1) "articles" need a top surface level that's fast and easy, but they need "drill-down" capacity to expand, or recursively expand details when the reader is "ready to copy." The details have to be hidden or re-hidable when they are just clutter. This is is classic task of "hypertext."

2) The "articles" need to persist until it's a good time to "get to" them for each reader, which may not be the day they are issued.

Readers need a "point-and-click" way to say - "save this for later, tag it this way, put it in this "inbox", where later might mean 3 weeks from now.

3) Many readers are not sufficiently organized to have their own inboxes set up and organized to support this process. It would be good, along with a "clipping service", to provide a very easy way to end up, after clipping, with more than just a heap of things to read that now looks more like a burden than a resource.

So what's the vision? Journalists, working with say researchers who have new "findings", put together a pyramid news release. There's the 100 word version, the 300 word version,
the somewhat in-depth version, and the full-version. The shortest, sweetest, sound-bite version probably is what's visibly published, where space is short - but it has a link to the drill-down versions. Maybe the deeper versions are assembled by the researchers and the research organization's public relations department, working with the journalist.

The point is that, once the news item has caught people's attention, it has to be trivial for them to find this again, get to it, and drill down into the actual complexity and details in a carefully supported way.

Maybe we could think of this as "just in time" publication of fragments of text-books, one tiny topic at a time.

Since these items will persist, they also need to be updated, annotated, and kept current by some other process. As with any classroom subject, it actually might be nice to have 20 other people say "Well, I didn't understand the teacher's explanation, but here's what brought this home to me in my own words, that might help you understand it ..."

I don't know exactly where these items would persist, but weblog space seems suited for that, as it's free, and publicly accessible globally.

Journalists could spend their effort at thetop of the pyramid, making hooks to bring these topics into the public view at the right time. Researchers could spend their time at the bottom of the pyramid, adding detailed technical content, journal articles, etc. Academic educators could spend time in the middle, cleaning up the flow-lines from the simplistic sound-bite to deeper and deeper levels of understanding the complexities of the subject matter, and making those accessible to, say, the aides to the Governor who actually are tasked with following up on something.

And schools of Public Health could adopt these public pyramids of knowledge and work to keep them current and refreshed and to find ever better ways to make each successive layer of detail more accessible to people, where the people range from students to politicians to the general public that is trying to inform itself on what is really going on in the world and why.

If anything would be worthy of federal funding, the catalyzing of this sort of public resource, as a value-added layer on top of our electronic library system, would seem to be justified as having a high impact per dollar spent. It tackles directly the problem that knowledge is increasing "over there" while the decision-makers are operating "over here", and the two never meet.

To me, that describes a powerful ecology of journalism, research, and public health that can work to slowly make even very complex topics accessible.

The pyramid can be adorned with podcasts, video-clips, tutorials, links to free on-line courseware, links to on-line discussion groups, etc. for those who want to educate themselves further on subjects.

Tuesday, January 17, 2006

Teen's Bold Blogs Alarm DC Area Schools

Teen's Bold Blogs Alarm Area Schools
Uninhibited Online Remarks Full of Risks, Officials Warn

"after she gave a talk recently at the Lab School in the District, students raced to their computers to delete information."

By Tara Bahrampour and Lori Aratani
Washington Post Staff Writers
Tuesday, January 17, 2006; A01

No one under 18 would be surprised to hear that teenagers like to post their intimate thoughts and photographs online -- they've done it for years. But school administrators have begun to take notice, and some are warning students that their online activities may affect not only their safety, but also their academic and professional lives.

In recent weeks, several Washington area schools have taken action against the use of blog sites, in particular Facebook.com but also the sites MySpace.com and Xanga.com, which allow teenagers -- and sometimes younger children -- to post details of their lives for all to see.

Exclusive private schools such as these have so far been more aggressive than public schools in specifically targeting the use of blogs, but local public schools have begun to warn parents and students about the dangers of Internet use. Fairfax County will hold seminars on the subject for parents this week, and Arlington County, at the suggestion of a parent who is a computer safety consultant, plans a similar meeting next week.

...ssistant head of school ... said officials there were "shocked and amazed" to see how many students use Facebook, which began for college students in 2004 and was expanded late last year to include high school students.

Besides the most obvious danger -- adult stalkers enticing teenagers into face-to-face meetings -- Cole warned that personal information posted online can also be read by college admissions officers and future employers.

...said that the issue came to the attention of administrators only recently, when they became aware of "inappropriate material that was being posted on Facebook."

In some ways, the Web sites are the modern equivalent of diaries kept by generations of teenagers.

But lockable journals and triple-underlined threats of "PRIVATE, KEEP OUT!" have given way to instant messaging, reality shows and a cyberculture that many adults find naive at best and exhibitionist and dangerous at worst.

... rules forbid students to "use technology ...that defames individual members of any community."

In November, after a student ...posted derogatory comments about black students on a blog, printouts of the comments were circulated on campus. The student eventually left; administrators would not say whether disciplinary action was taken.

Many schools forbid the use of school computers for anything not school-related. But it is much harder to regulate what students do on home computers.

Schools are scrambling to come up with policies on the issue.

...

Ironically, many teenagers are outraged or embarrassed when parents or other adults go to their sites. "I think they see it as a violation of their personal space," said Madeira's Cole. "They feel as if their diaries are being read."

But adults do read the sites. The National Center for Missing and Exploited Children reported 1,224 incidents last year of "online enticement" of children by adults and estimates that one in five children gets sexual solicitations online. Staff members of NetSmartz, an arm of the national center, discuss the issue with local students. Staca Urie, a NetSmartz manager, said that after she gave a talk recently at the Lab School in the District, students raced to their computers to delete information.

And yet to many teenagers, the sites are irresistible.

"I'm in seventh grade," the girl said. "It's really hard to be in seventh grade these days. It's really hard if you're shy and you're not a cheerleader or extraordinarily popular. I travel, I take pictures, I write poetry. I'm a nice kid, and if I can write a profile that will make people notice me, why shouldn't I?"

To Aftab, "It's a very sad testimonial these days that a kid has to post something on a site where potentially 700 million people can see it in order to attract the attention of a kid two seats down."

Her mother, said that she and her husband have talked to [their daughter] about smart Internet use and that she is not worried. ...[but] hasn't looked at her daughter's page., "This offers them a way to have a sense of community."

But it can also be isolating. "They do less face-to-face talking, less phone talking, less playing outside than any other generation, and because of that, the Internet is real to them, but the risks aren't," Aftab said.

Neither are some of the worlds they create. Experts, and teenagers themselves, say that much of what is on the sites is made up.

Teenagers often act online in ways they wouldn't off-line -- bullying each other, posing in underwear, using foul language or sporting guns and Ku Klux Klan hoods.

Increasingly, many teenagers feel pressured to show themselves doing more risque things, even if they are not actually doing them. Aftab cited an example of girls who had blogged about weekends of drinking and debauchery, while in reality they were coloring with their younger siblings or watching old movies with Grandma.

"Even if you weren't out drunk and partying on the weekend, you have to pretend you were," Aftab said. "Maybe parents should be relieved."

Staff writer Jamie Stockwell contributed to this report.

© 2006 The Washington Post Company

Saturday, December 10, 2005

meme tracker

Thank you for clicking that link.
This helps us track how far a webpost idea (meme) can travel per day!

Monday, November 15, 2004

My other blog is a Mercedes

Posts prior to November, 2006 are in the
previous version of this weblog, which
had technical problems in indexing so I
had to discontinue it.

See http://cscwteam.blogspot.com