Marcus Pierson, MD: Spread

Systems and Maps, Actions and Theories

Sun, 10 Oct 2004 14:51:45 GMT

Well I have been silent for quite a long time.

I have been trying to find my way forward for months.

The groups working on Pursuing Perfection in Whatcom County have accomplished much: Direct involvement of patients in the design of chronic care system and processes, Shared Care Plan, Clinical Care Specialist role, Groups Visits, Shared Governance, Teamwork and process improvement expertise, interaction and learning from some systems with some of the best practices in the country and in Europe. The patients who have experienced benefits of this effort are appreciative.

In order that we continue to improve our system of care (see by line above) we need to see it, literally have a map of Whatcom County as a health care system. And when we can see it, we must have some idea of what to do from there. We are lost without a shared map. A map of the system (parts and interactions between those parts) alone does not develop the territory of the map--the system which produces or limits the health of people in Whatcom County. We then must learn what ideas (theories) work and which do not work. We must use the theories and the associated tools to improve the system (a system which is currently invisible among the parts).

One year ago we learned that Jonkoping County Council, Sweden has taken a systems view, developed a map of the health care system, and made dramatic improvements in the experiences and health of their inhabitants--within the same budget. Well that is Sweden. They are slightly more disposed toward working together, cooperating, than the average American community, where the prevailing theory is that competition at most levels is the way forward. Win-Loose.

This week I have had the privilege of spending four days with a group of the gentlemen who worked with doctor W. Edward Deming for the last 10 or more years of his life. I have since reread "The New Economics, for Industry, Government, Education" Second Edition, by W. Edward Deming.

With the knowledge in that book, with help from those who have gone ahead, with maps of the system of healthcare in Whatcom County in hand, it is clear that we have the compelling reason to be hopeful, to be bold, to improve the system (interactions) that produce the quality of healthcare in this county. I would suggest the same is possible for each community where you can begin to mix theories of systems (cooperation, win-win) with our prevailing common sense that competition (isolation, win-lose, zero-sum games) are the route to improved value and happiness.

From Programs to Movements

Tue, 21 Oct 2003 20:02:03 GMT

The Bureau of Primary Health Care has successfully jump started the 100% Access 0 Disparity movement in America. Spokane, WA area is implementing a similar approch.

There is a summary of the BPHC experience that is very enlightening, if you wish to switch from projects and programs to "movements". I highly recommend reading it if you need to scale up some initiative to include more stakeholders.

A remarkable overview of the journy and the liberating concepts is chronicaled by John Scanlon in "Extrordinary Results on National Goals: Networks and Partnerships in the Bureau of Primary Healht Care's 100%/0 Campaign". The PDF file can be downloaded from THIS LINK on IBM Center for The Business of Government site. The site section is "New Ways to Manage". I agree that it is a real revolutionary way to think about how to manage large scale change.

Advanced Access--a Key to System Improvement

Sat, 20 Sep 2003 21:29:31 GMT

Several doctors at the WA State Medical Society meeting ask for more information on what Advanced Access is. So I put a web page together with some good references. Just click on "web page".

I am skeptical that rapid improvement can occur until most physicians have taken this step. It is a happy circumstance that their profit should increase about 9% and their number of visits should simultaneously decrease about 16%.

Presentation to WA State Medical Society House of Delegates

Sat, 20 Sep 2003 21:12:51 GMT

Yesterday I had the privilege of talking about our Pursuing Perfection initiative with the house of delegates for the Washington State Medical Society. Below I have included to content of my 11 slides and my notes.

PURSUING PERFECTION in Whatcom County, WA

SLIDE 1, TITLE SLIDE:

PURSUING PERFECTION

WHAT'S IN A NAME?

Perfection? ...when things seem pretty bleak. When the pace and complexity of practicing medicine is at this highest yet. When frustration or even cynicism seems ready to overwhelm many. But in a culture that takes the charge "first do no harm" seriously. A culture where each of us carries the desire and burden for faultless care with us each working moment. I suggest that by admitting to ourselves and to the public that we are all in the pursuit of perfect care may allow each of us to get some help. As the Chasm Report points out, the problem is with the system. The system that should help us do the right thing. The problem is not with the effort of doctors and nurses nor with a lack of desire or to do the right thing. The pursuit of perfect care leads directly into systems thinking.

SLIDE 2, OUR JOURNEY

1990 vision
Persistence
Access for uninsured, level 2 trauma system, seamless care?, Whatcom Integrated Delivery System, Community Health Record, Whatcom Health Information Network, Whatcom Community Health Improvement Consortium, diabetes collaborative, registry system
IOM: To Err is Human & Quality Chasm
Pursuing Perfection, Robert Wood Johnson Foundation & Institute for Healthcare Improvement, +16 others

Like many of your communities, cooperation has a long history in the community. Community wide efforts developed access for under-insured OB patients and others including dental patients. The community developed a common sense, yet bold vision to have seamless care and the best outcomes in the state within 10 years (It will happen but it will take 20 years. Who knew?) A series of large-scale initiatives have occurred in Whatcom County. The most audacious effort may be the current P2 initiative to transform healthcare in our community and in the nation.

SLIDE 3, PARTNERS & FRIENDS LOCAL AND REGIONAL
This P2 initiative has caught the imagination of lots of folks.

3000 patients with diabetes & congestive heart failure
Family Care Network
SeaMar Clinic
NorthCascade Cardiology
SJH Center for Senior Health
St. Joseph Hospital/PeaceHealth
Group Health Cooperative
Regence Blue Shield,
Community Health Plans of Washington
Olympic/Sterling/Aon

SLIDE 4, PARTNERS & FRIENDS NATIONAL & INTERNATIONAL

NATIONALLY
Cambridge Health Alliance,
Cincinnati Children?s Medical Center,
Tallahassee Memorial Hospital,
Hackensack University Medical Center,
HealthPartners,
McLeod Medical Center, and
Whatcom County coalition
INTERNATIONALLY
8 communities in Great Britain,
1 in the Netherlands,
1 in Sweden

SLIDE 5, LEARNING

Advanced Access
Patient input into design
We did not have to wait
Collaboration among all sectors
Leadership by physicians for collaboration

So, in this P2 initiative what have we learned to date: a year and a half into it? Doing Advanced Access, in primary care and specialty care, seems to me to be the only thing that can free up people and time to take on the work of redesigning the acute care system into one that provides chronic care. HealthPartners and Jonkoeping County, Sweden point to this conclusion. We have been working with Catherine Tantau, RN. Others have worked with Mark Murray, MD. Patients are of surprising help in redesigning care systems. Their insights are generally lead to simpler and cheaper solutions that we imagine on our own. We could have been doing this 5 years ago. Without working together little will occur. The innovations almost all require cooperation of others beyond your organization. Fortunately the benefits are that diffuse too. Physicians can lead their organizations into cooperation. It will not happen otherwise.

SLIDE 6, 80/20 SYSTEMS THINKING

Baby boomer demographic bulge
Chronic care in acute care system
Winners and losers (modeled)
Collaborators (relationships between parts on behalf of all stakeholders)

There are a lot of things we all consider doing. but which are the most important? The biggest problem and opportunity is heading our way--the aging baby boomers. Chronic care accounts for almost 80% of the healthcare costs and it is going to get higher. If we can effect this dynamic it will have more impact that almost any other change. (Possibly at the same or lower cost for a given population.) We have reviewed the literature on chronic care, we have worked with our patients and our physicians. We have designed a system for patient-centered, community-wide chronic care management. We have modeled the outcomes. We know who the winners and losers are likely to be. Nothing big will happen if the winners don?? help the losers. Medicare, pharmaceutical companies, employers, and taxpayers will need to rethink their roles if the benefits are to be gained and sustained.

SLIDE 7, SOLUTION SPACES

Care management and managers
Navigators and insider advocates for patients
Activated informed patients
Group visits
Shared care plan (electronic and paper versions)
Advanced access
Results based advocacy

Our approach combines community-based care managers (nurses). Improved access to information for patients with DM and CHF and for the members of their care team. There are group visits, web access to tailored information and to a personal medical record called the shared care plan. I now call our previous medical records business medical records, not patient medical records. The shared care plan may be a step toward a real patient medical record. None of the changes are manageable in physician offices or with physician staff until excess capacity for seeing patients and for improvement work is created. Advanced access has this great side effect. Modeling the effects of the changes and getting those affected to participate in the solution is essential. Otherwise it is not sustainable. Medicare (thus Congress), pharmaceutical companies, local businesses and government, and patients as purchasers and voters.

SLIDE 8, INTERESTED PARTIES

Robert Wood Johnson Foundation
Institute for Healthcare Improvement
Medicare (CMS)
Healthcare insurance companies
Our community as well as other communities and healthcare organizations
Other foundations

The work and learning going on in Whatcom County has captured the interest of numerous organizations and communities. Many of whom we are working with. There are now 17 communities or healthcare provider organizations. We are hoping to spread this to Ketchikan, AK. beginning this year. We hope to spread to more of the patients and providers in Whatcom County.

SLIDE 9, COOPERATION

Necessity or preference?
System? ...or only parts?
How? or YES!
Leaders?

Somehow we think this is optional, on an organizational level. We do cooperate as individuals. Our organizations must understand the experience of the patients and design and connect our processes so that they work as a system. Peter Block has written a book called The Answer to How? Is Yes! It is a kind of Nike "Just do it!" attitude. On can delay starting assuming the worst and endlessly asking how, rather than experimenting and working our way forward together, with the patients. A new kind of leader is needed--courageous in collaboration, not in war.

SLIDE 10, MORE?

You may find the details and the tools at these websites. Do feel free to contact me. I put some of what I think on my web log, as do many of the people working in this endeavor.

SLIDE 11, PARTNERS?

Already down this road?
Learn together?
Tipping points?

The Institute for Halthcare Improvement is attempting to spread the learning from Pursuing Perfection communities.
We have time for those who want to transform healthcare locally, in their communities.

Thank you for your time and attention.

Health system innovation, ORGANIC or MECHANICAL?

Mon, 11 Aug 2003 21:29:07 GMT

Imagine this. You are asked to create a human body. You choose a hospital in California to create a gastrointestinal system, a health system in New York to create a heart and blood vessels, a city in Vermont to create a brain, a hospital Iowa to create a peripheral nervous system, a group of hospitals in Illinois to create the lungs, etc., etc.

Enough. Some things can't be done separately, some can. Organic things typically cannot. Some complex things can be "componentized" and assembled, some things must interact to even come into existence.

Some people at the Robert Wood Johnson Foundation read the Institute of Medicine Report, Crossing the Quality Chasm and ask organizations to make proposals to radically improve American health care.

Experienced people in organizations in Whatcom County took the request very seriously. We had the same hopes and desires and we had been working separately and collectively for the same goal for more than ten years.

With much thought and discussion and in collaboration with patients we developed a radical plan for a radical change--no individual piece of it was radical, it was the understanding that it all had to be done together that was radical. To extend the analogy started above, we understand the we needed a small GI system, a small cardiovascular system, a small nervous system, etc. for any of it to work. And that with all the essential systems working to support each other they could grow together to a mature effective health system of care--better than anything in existence.

We have been at this for just over one year. It no longer seems unattainable. It is clearly attainable. What is difficult is getting all of this done in less than two years so that it is self-sustaining.

We are hopeful that some of the agencies and foundations that fund parallel, sequential, or distributed "demonstration" "projects" can see the difference here and fund an organic, systematic approach. Nothing less will create the radical transformation called for by the IOM Chasm Report and needed by the American public.

Reductionist approaches can do much. They cannot build an organism, not yet, perhaps never. Supporting the growth of a small, complete, organism (community health system) may be the right approach to radical transformation of US healthcare. We believe it is. Do you?

The minimum essential small "parts" or "organ systems" that we have in Whatcom County, WA are:

1) direct patient involvement in all teams and in governance,
2) using evidence as the basis for care design,
3) starting with two chronic medical conditions[heart failure and congestive heart failure] and then moving to all others over a few years,
4) information systems designed and deployed so that everyone including the patient has the information that the patient wants them to have when and where they need it,
5) clinical office and hospital work flow reconfituration so that the new work is integrated into the old and the old is made less frustrating and more efficient for everyone, and finally
6) modeling of the health care benefits and the economic impact on all of the stakeholders so that potential winners and losers can cooperate for the good of the patients and the whole community.

"...program is so simple, it's brilliant, "Bellingham Herald editorial board

Tue, 15 Jul 2003 15:52:41 GMT

Link to Bellingham Herald Editorial

Link to more about program

Helping chronically ill manage care improves lives, cuts costs
HEALTH CARE: "Pursuing Perfection" program is so simple, it's brilliant.

The whole point of "managed care" started out, at least in theory, as an attempt to contain health-care costs through prevention. It's no secret that's not what happened. In fact, navigating the medical maze has become more difficult than ever, it seems.

But there is a solid movement afoot to change that and Whatcom County is one of the ground-zero sites for a program called "Pursuing Perfection: Raising the Bar for Healthcare Performance." Its method isn't complicated. It seeks to help people manage their own health care, sometimes by doing something as simple as regular telephone calls to check up on patients and answer their questions. By heading off potential problems, extensive and pricey hospital visits can often be avoided and a patient's health better maintained. It's so simple, it's brilliant.

The Whatcom Community Health Improvement Consortium last year was one of seven groups in the nation to win a $20.9 million grant from Robert Wood Johnson Foundation and the Institute for Healthcare Improvement that funds the program. It's not just some kind of feel-good program, either. The foundation wants to document measurable results in improvement of patients' access to care, patients' self-management and satisfaction, and a decrease in medical errors.

Caring for chronically ill people consumes as much as 70 percent of the nation's health-care dollars, so it makes sense that helping them manage their own conditions would reduce those costs and help those people lead more productive and less frustrating lives.

In Whatcom County, two of the most common chronic illnesses are diabetes and congestive heart failure. In 2000, St. Joseph Hospital had almost 700 admissions related to diabetes and almost 900 related to congestive heart failure.

Empowering patients with better information and better access to people who monitor their progress and can quickly answer questions can help keep many from becoming dangerously ill and compromising their health further. Medical advances happen quickly as new drugs are developed, more information is discovered about drug interactions and new technologies help people monitor their blood sugar. Keeping patients active in helping to make their own decisions will result in better outcomes. After all, who better to "manage" the care than the person living with the illness?

Streaming Stories Sooner than Later

Thu, 15 May 2003 07:15:33 GMT

We have the streaming audio and video (QuickTime) server installed and will begin the learning curve to enhance the patients' and healthcare workers' stories with multimedia on the web. We have begun a discussion to track our progress: http://www.wwpp.org:8080/wwppDiscuss/discuss/msgReader$50. Follow along if you are interested.

LEADING COALITIONS, a few observations from Whatcom County, Washington

Thu, 01 May 2003 00:41:08 GMT

A few local ideas about leading community coalitions: It is about shared values--creating, unearthing and polishing them.

Jim Reinertsen, on behalf of the Institute for Healthcare Improvement, ask me to prepare some thoughts on leading coalitions from our learnings in Whatcom County's Pursuing Perfection work.

First I disclaim: I don't know. We are improvising. In fact, the key is probably improvisation.

Next, a recommendation: find at least one person that is or will become consumed by the opportunities.

Here are ten ideas we seem to be using in Whatcom County Washington as we pursue perfection in health care delivery across a community.

1. Bring the outside in.

Don't assimilate it. Protect it. Pay the money. Don't expect double duty.

Trust is the key. Find those known to be "pure of heart" and help them stay that way. If you have this role (outside brought in) understand that the relationship with the outside is the key value on the inside. Invite the Trojan Horse in. Don't lose the affiliation and affection.

You are looking for someone who represents the positive values that you share with the community and who understands the conflicting values.

2. Hire and empower successful revolutionaries as leaders.

Transformation is a kind of revolution.

They must want and see the new way more and clearer than you do.

You must support and protect them. Trust them. Trust your job to them--to the cause.

Be willing to be overthrown if necessary (but try to keep up with the revolution--the loss of your job probably helps no one except your successor.)

Ask your team and others in the coalition about their credentials as revolutionaries. Encourage a radically transformative stance. Model it. Be irreverent.

We have wonderful revolutionaries. We have people with years of successful experience with coalition building.

3. Become a story junky.

Find them, tell them, get others tell them. Make them up if necessary.

Stories around campfires have created and sustained the tribes and communities for thousands of years. Long before Excel and PowerPoint. We are programmed to create meaning from stories. Stories go to the heart and heart is what is needed for transformation.

Become the story you need.

Make sense, create new meaning with stories. From the chaos of "facts" pull out the relevance you need and storify it.

This is the job of a leader.

4. Revert to common values. Technique will not work here (yet?).

Explore values all the time.

Talk about values.

Tell stories about values.

Hire strong value-based leaders and staff for this work.

Values trump power (status quo). You must ensure this.

5. Make it up as you go.

Karl Weick talks about bricolage. A French word that does not translate well. A bricoleur is a person that can routinely make what they need from what is at hand. They can make a uniquely useful machine from spare parts in a barn and it may do the job better than anything on the market. Gather all the bricoleurs you can find for this kind of work.

Bricolage--A form of improvisation practiced by some, using whatever resources and repertoire come to hand, in order to perform the immediate task. A person who practices bricolage is called a bricoleur.

In a paper called Organizational Redesign as Improvisation, Karl Weick identifies the following requirements for successful bricolage.

intimate knowledge of resources
careful observation and listening
trusting one's ideas
self-correcting structures, with feedback

Improvisation is a related idea. Quite different than "experimentation".

Think of the "improvisational organization" as a variant on the "learning organization." More real time, more masterful. That is what is needed.

For an in depth understanding of this concept and also a related exploration of "wisdom as improvisation " see these articles by Karl Weick .

The Attitude of Wisdom: Ambivalence as the Optimal Compromise, Karl E. Weick. At this web link (on Tuesday March the 4th, '03) is a useful simple diagram and explanation.

6. Appreciative Engagement.

I have coined this term to combine two profound yet simple ideas. "Appreciative" points to a stance and techniques that are well explained by David Cooperrider of Case Western Reserve and Gervase Bushe of Simon Frasier University as well as others. The idea most simply stated is look for what you appreciate and want to see more of instead of focusing first on what you don't like and want to see less of. "Engagement" points to Axelrod's thesis that many of the problems of change can be avoided by investing in the engagement up front, at the beginning of the exploration, in all the folks who have to implement or change. Pay, listen, and engage now to avoid failure in the implementation phase.

7. Systems thinking must trump liner, simplistic planning.

Complex adaptive systems (CAS) are a useful way to think about health care and especially across organizations--coalitions. Plsek's Appendix B in the Chasm Report is the most important part of the book. The challenge of the book is to create a coherent system that will dramatically reduce the burden of illness in the citizens of this nation. Success is impossible without understanding the way complex, adaptive systems work.

Rules for optimizing a CAS:

Agreement upon clear aims (patient-centered, safe, equitable, etc.)
Follow a few simple rules (cooperation, relationship, transparency, etc.)
Ensure effective communication among the agents/parts
Provide opportunities and resources for experiments (fertilizing and watering)
Pruning (removing resources from experiments that fail to move the system closer to the aims)

Explicitly model the sytem for policy making if you can afford it.

Robert Wood Johnson Foundation paid for the modeling of Congestive Heart Failure and Diabetes care in Whatcom County. The understanding of the local health care system's dynamics is already helping our key stakeholders to come together and prevent misaligned incentives preventing cooperation. I have never seen anything like this before.

8. Get committed.

Karl Weick gives a useful operational definition of commitment. I am probably paraphrasing but my memory of it is: 1) personal, 2) voluntary, 3) public, and 4) irrevocable statement of intentions and agreements.

In a coalition, don't assume you have commitment without having all parts of this formula for each key stakeholder and leader. Get boards, CEOs, opinion leaders, and front line staff to tell their stories in a way that fulfill these criteria. Model it yourself and invite others.

9. It's about LOVE, FAITH, and FORGIVENESS.

The fuel for transformation is passion and freedom.

Only love of others and self will get you through the maze and confusion. It is the beacon and fundamental value.

Generate your faith that others will find their love and their forgiveness and that you will continually rediscover yours. Generate your faith that something great will result even if it is not what you anticipated. Generate your faith that transformation will come from clear and agreed upon aims with a few simple rules all of which are guided by love and forgiveness.

Forgiveness of self and others is the moment-by-moment skill and key competency for transformation. Pursuing perfection is not about punishing self or others for lack of perfection. We are all so hard on ourselves and others that we create an unbearable burden. Drop it. Again and again.

10. Give away (through stories) all the success.

Take responsibility for all the screw ups. There will be plenty.

--------------------------------------------

MY REQUEST--please invite new IHI faculty, specifically:

Karl E. Weick (Sensemaking and High Reliability Organizations)
David Cooperrider and Gervase Bushe (Appreciative Inquiry and Clear Leadership)
David Snowden (Cynefin Model and Cynefin Centre)
Jack Homer and Gary Hirsch (Group System Dynamics Modeling and Simulation for cross organizations, cross industry policy making.)

More on Our Meeting with Policy Makers In Washington, D.C.

Fri, 21 Feb 2003 02:53:03 GMT

When we (Rebecca Bryson--patient, John Hayward--CEO of PeaceHealth, and Marc Pierson--Exec of Perusing Perfection in Whatcom County) went to Capital Hill to present our ideas for consideration last week we created a "one pager" to leave behind. You may find it interesting. Obviously, it is brief, hopefully concise, but not complete. It may be useful to explain Pursuing Perfection to friends or acquaintances. It is a MS Word document.

Premier has been helping Whatcom county advocate our position in Washington D.C. They they reported on John Hayward's participation in a National Health Policy Forum meeting on Capital Hill in Washington, D.C. last Wednesday. The news article is captioned "CEO of Premier owner PeaceHealth: Breakdown of health system silos would go a long way toward sustained improvement of patient care." Rebecca Bryson and I, along with 15 others from other Pursuing Perfection sites were in the audience. This forum and our meetings with our Congressional Members was arranged by Robert Wood Johnson Foundation through their CONNECT group.

CONNECT--First Trip to Washington DC to meet our Members of Congress

Sat, 15 Feb 2003 19:56:12 GMT

Robert Wood Johnson Foundation's CONNECT PROJECT guided meetings in Washington DC this week. Six of the seven US pursuing perfection sites met with their congressional members. The Whatcom county team consisted of Rebecca Bryson (patient), Marc Pierson (me, project executive), and John Hayward (CEO of PeaceHealth). We met with Senators Patty Murray and Maria Cantwell and with Representatives Rick Larsen and Jim McDermott. The meetings were informational and well received. Each member agreed to work with us to learn more about what we are doing and to lend their support to comprehensive clinical quality improvement efforts.

There was also a meeting with the National Health Policy Forum. The subject was "Pursuing Perfection in Health Care Delivery: Insights from Innovators". There was good attendance by congressional staffers and health agency leaders. Donald Berwick, MD, led off and presented context for the briefing. Honor Page, the mother a patient with cyclic fibrosis spoke next. She gave the patient's or consumer perspective on the current status of health care as well as on her interactions with Pursuing Perfection project at Cincinnati Children's Hospital. Next was Dr. Brian Rank from HealthPartners, Bloomington, Minnesota, explaining the frustration and challenges from the perspective of a physician leader pursuing perfect care in today's environment. Finally John Hayward spoke about the need for change and his rationale for the work going on in Whatcom County, WA, as well as explaining his personal commitment to transformational change in his organization.

Rebecca, John, and I all felt like the relationship building with our congressional members is off to a good start. As you all know, for the improvement that we have started to be sustainable, both Medicare and Medicaid will need to become more flexible in matching payment to innovations in care. Our short and long term goals will be some small appropriation to help cover the short fall on our start up of this transformation, then a demonstration project that will provide the needed flexibility to this county. Ultimately the payment structure of Medicare and Medicare will need to be modified based upon the successes of the demonstration projects.

Click on this link if you would like to study most current recommendations by the Institute of Medicine to CMS (medicare/medicaid) for demonstration projects aimed an transforming health care and aligning payment. Four out of five proposed types of demonstration projects are highly aligned with what we have already begun with Pursuing Perfection and Robert Wood Johnson Foundation.

Light at the End of the Tunnel for Ideal Office Practice

Sun, 19 Jan 2003 13:32:45 GMT

Here are three new documents on Idealized Design of Clinical Office Practice. Each is well worth the time to read, study, and then implement the ideas and suggestions contained in them.

Microsystems in Healthcare: The Essential Building Blocks of High Performing Systems (Exec. Summary for Health Care Leaders. (PDF file format)

Clinical Microsystems Action Guide (PDF file format)

Putting the Pieces Together--a complete primary care system redesign (PowerPoint file format)

Be patient all three are large files and will take some time to down load. The first two documents are from Dartmouth, the thrid is from Alaska Native Medical Center, an internationally recognized leader in implementation of these innovations. Happy reading. What you learn will prove to be critically important to your business and your persoanl satisfaction with medicine.

Appreciative Inquiry Video Clip--a positive orientation for change

Thu, 02 Jan 2003 09:56:34 GMT

Here is an interesting streaming video clip on Appreciative Inquiry from Ernst and Young and The Corporation for Positive Change. David Cooperrider and Diana Whitney are featured. You do need to have RealPlayer installed.

Here are my notes from it:

Three sources of strategic advantage: 1) Engagement of the talent and capacity of every person at every level of the organization. 2) Magnifying the speed for innovation 3) Creating a magnetic setting for the attraction of the best talent.

Get to the value faster.

Go beyond the deficit based ideas of management that we have grown up with. Burning platforms, analysis of what is broken, or what is wrong.

The best you have ever been. Your most successful.

What do you want more of?

When we search for and listen to the stories of the true, the good, the better, the possible, one finds that the system begins to move in that direction with a tremendous amount of energy.

You have to find ways to keep the hearts and the minds of people engaged. Any you have got to find ways to keep them thinking about the future.

Looking at what is possible in the organization or the community.

People move in the direction of what they study, what we think about, and what we ask questions about.

Everyone engaged in the success of the company and committed to the success of each other.

Problem solving can yield incremental gains. Appreciative inquiry can yield breakthrough gains.

Focus on the things that work, the days that result are best, and discover what was happening.

A way to really get people engaged.

Tied back to the bottom line, to tangible outcomes.

Increase throughput

Ernst and Young: ePositive Change. They have an alliance with the Organization for Positive Change

Isabella teaches me about leadership

Thu, 02 Jan 2003 00:17:52 GMT

I relearned an important truth from my daughter Isabella today.

I asked her to go for a walk in the rain with me. Almost immediately I missed the first opportunity to learn.

She first said no to my suggestion of a walk.. Later she negotiated her terms for the trip, through a third party--her mother. Isabella decided what shoes, what cloths (a dress rather than the practical pants I suggested), no gloves (it was cold raining), colorful stockings, and no hat. She did allow her mother to suggest a rain coat with a hood. She also chose to bring Miko a completely untrained Portuguese water dog puppy.

Not much of this was practical from my point of view, but none of it was dangerous. I did not protest.

We started off. She immediately fell behind. It was not the pace. Without going in to details, things began to deteriorate. Tears accompanied request to go to her grandmother's house or to return home. She turned Miko over to me. Her pace slowed even more.

I dimly recalled a similarly flavored a trip in the Rocky Mountains with a girl friend when I was in my early 20s. Ah! I simply said to Isabella, "I am following you."

Everything shifted. No more tears or complaints. She even did some skipping and hopping as she lead. Next she engaged in determining how to get home. She did not know where we were since there had been little reason for her to think about it while following me. We talked it over and agreed that our house was down hill from where we were. From there on she made every decision. She got us home and was proud of it. She had a great time. And so did I.

Innovation in cooperation, the rate limiting factor?

Thu, 08 Aug 2002 14:41:50 GMT

I have not posted anything for a while.

I have been studying and "worrying" with ideas about and approaches to leadership, cooperation, trust within communities. All of these must come to life if we are to spread the innovations we are currently working on and if we are to create a sustainable approach to the six aims of the Institute of Medicine Chasm report. Most of the leadership material is focused within corporations and teams. There is a very useful literature on "social networks" that deals with relationships which generate or degenerate trust and cooperation. Bill Mahoney and I are trying to make this usable for Pursuing Perfection in healthcare.

I have come to believe that the fate of American medicine rests with sociological and anthropological innovations more than it rest on technical or financial innovations. Call me weird. (a both/and thing, not either/or)

Graphing Relationships, Specifically referrals from one web site to another, but look at the possibilities

Sat, 06 Jul 2002 15:32:10 GMT

TouchGraph GoogleBrowser.

3. TouchGraph GoogleBrowser V1.00 (12.1 points). touchgraph googlebrowser ... TouchGraph ... The TouchGraph GoogleBrowser [( blogdex : recent )]

» Interesting to look at but I'm not sure of the practical applications for this yet.

What does a visualization of these backlinks tell you?

Why is it useful to be able to visualize these particular networks?

Are there useful metrics that can be applied to give conrete information?

[Curiouser and curiouser!]

Spread of the innovations in care delivery must be pursued.

Wed, 26 Jun 2002 03:59:36 GMT

Spread will require that value be created by the innovation and that relationships be build from the pilot sites to the rest of the community.