Building Trust, by Flores and Solomon is a really good book. I rank it with The Wisdom of Insecurity, by Alan Watts as two of the most mind altering books I have read. Watts turned the conventional wisdom of insecurity on it's head, essentially showing that security or fixedness is closer to death and that insecurity or uncertainty is closer to life. When his wisdom sinks in, one comes to appreciate insecurity for what it is--the experience life-giving growth. On can then quit amplifying a certain amount of natural stress, by dropping the judgment that insecurity is bad.

Flores and Solomon turn broken trust and betrayal on their heads, as Watts did with insecurity. They allow one to see that trust and betrayal are sides of the same coin (one meaningless without the possibility of the other) and they also allow one to see that creating and rebuilding trust is the key act in creating a better and shared future. Without such acts of trusting and rebuilding of trust from moments of betrayal, no better future is possible. Trust is not a thing to be shattered. Trusting is a competency for all forward looking people to practice and learn--a verb, not a noun.

Below is a kind of relationship diagram that captures some of the ideas that filled my head as I read the book.

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%.

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?

• http://www.patientpowered.org
• http://www.wwpp.org
• http://www.Google.com "Marc Pierson"
• Call Marc 360 756-6805
• http://www.ihi.org
• http://www.qualityhealthcare.org

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.

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.

After reading the though provoking article Chronic Illness, Comorbidities, and the Need for Medical Generalism, by Kevin Grumbach, MD, in the first edition of Annals of Family Medicine. I had these thoughts:

The idea of non-reductionist thinking and wholistic planning is so important and so non-western. A reductionist nightmare.

Placing the patient at the center begins to make sense of things. I am not yet sure that we aren't trying to put the PCP at the center; even though that may move in the right direction in some cases.

With the help of Robert Wood Johnson Foundation, we in Whatcom County, WA are building a system to deliver "patient-centered, community-wide, chronic disease management" based upon Wagner's chronic care model. Even that model may be too physician centric. See my post.

Conidering the chaotic non-system and it's misaligned reimbursement, I am not sure that the overburdened PCP can help all the patients navigate. We are using nurse care coordinators Connie Golas and Nancy Stothard to assist, and we also use a patient centered/patient designed Shared Care Plan

I will follow your new journal with interest. As you poit out in the article, we should not be too self congratulatory. For even the best approaches in the US are very inadequate from the patient's perspective. See the Commonwealth Fund report (pdf)

A chasm exists. Any narrow focus on the parts, even the PCP role, risks a further Balkanization of US healthcare. We must focus on the patient and their family, we must include the patient in all the discussions. So long as the journals exclude patients from the dialogue they will miss an opportunity for truly integrative solutions. Even the PCPs may be a "specialists" compared to patients and their families.

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:

1. Agreement upon clear aims (patient-centered, safe, equitable, etc.)
2. Follow a few simple rules (cooperation, relationship, transparency, etc.)
3. Ensure effective communication among the agents/parts
4. Provide opportunities and resources for experiments (fertilizing and watering)
5. 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:

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

 

 

Total quality management (TQM) and continuous quality improvement (CQI) have not had the expected results in healhtcare. Much effort and resources and enthusiasm has been spent. Some have said the TQM and CQI don't work in healhtcare.

Let's look deeper.
Click here to see a larger image.

I have just begun to document what will become a rather lengthy "story" or article with lots of reference and links. Click here to read it.

In my view David Snowden brings knowledge management into alignment with Karl Weick's world of sensemaking and positive organizational scolarship.
Dave Snowden is the director of the new IBM Cynefin Center for Organizational Complexity.
His Cynefin model (download PDF file) is the best integration of knowledge management that I have seen. It is profound and it addresses intersections of LEADERSHIP, CULTURE, COMMUNITY, BUREAUCRACY, CHAOS, EXPERTISE and more.
I am working to understand Dave Snowden's thinking on the third age of knowledge management. He moves beyond knowledge as a thing to "knowledge as an active process of relating."
With a little more work on this reader's part his ideas will be personally usable. Here are my notes on Snowden's article "Complex acts of knowing--paradox and descriptive self-awareness" from a special issue of the Journal of Knowledge Management.

We have been working on many fronts.

Carolyn Turkovich: Team development

Jack Homer and Gary Hirsch: Systems dynamics modeling and simulation for cross-organizational policy making.

Bill Mahoney: Social Network Modeling to understand, strategize, and communicate relationships and spread (contagion). Also, Bill thinks that teamwork at the microsystem level is the key to change and I certainly agree with him.

Gene Nelson: Bill has recently directed me to the work at Dartmouth on microsystems.

Bobby Milstein: innovated by linking System Dynamics and Social Network Modeling and he has focused on the community level.

Jack Silversin: teamwork and cooperation in health care.

I have worked for years on the information flow and human connections between microsystems and between organizations.

This interesting book pulls much together and I think the models articulated here will form the basis for models we can share in this community to show how the community health care system (however dysfunctional) works and how it can work. I recommend it for all of us: Small Groups as Complex Systems: Formation, Coordination, Development, and Adaptation.

http://www.amazon.com/exec/obidos/ASIN/080397230X/102-3988174-1364949

I am not a research scientist of any persuasion so I hope these authors stand up to your review. In any event I see lots of options for using System Dynamics and Social Network Modeling to help folks understand the world in this new way. We may be able to usher in the needed paradigm shift called for in the IOM report--shifting understanding and focus from the parts (generally disconnected and sometimes broken) to systems. Rearrangement of parts alone will not get us where we want to go.

Several of you have heard me say that I hope Whatcom County becomes the next Framingham, but instead of the domain being population medicine it will be the sociology of medical systems at the community level. I believe that it is here that the customers experience the disjunctions and here that the capacity for leverage exists. In the literature and among my acquaintances I see very little attention to connections or to community. People may to be working on the things that seem possible or amenable to research, even if they cannot provide the level of transformation called for it the IOM Chasm report.

I hope that we can explain the situation in these terms, reorganized by these authors, and I hope that we do it in graphical and understandable ways.

Let me know what you think.

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.

Bill Mahoney sends us a very useful web link: http://clinicalmicrosystem.org/ 

These folks give us much useful information on clinical work place improvements. Robert Wood Johnson Foundation supports their efforts. There is a strong team involved in the work and tools make available from this site. OD specialists and Process Engineers/Facilitators will find it useful as will folks in clinical work units.

If healthcare is more complex that most other business, then leaders in health care need these ten qualities in spades.

Carolyn Turkovich forwared an e-mail From: Patricia M Milton

[mailto:PatriciaMilton@interactionassociates.com]

Sent: Wednesday, June 26, 2002 4:08 PM

To: Turkovich, Carolyn

Subject: Wanted: Ten Critical Skills for Leaders

 

Dear Carolyn,

The Conference Board's recent research study, *Developing Business

Leaders for 2010*, outlines ten leadership qualities that will

make leaders successful in the year 2010. In brief, they are:

1. Cognitive ability

2. Strategic thinking skills

3. Analytical ability

4. The ability to make sound decisions in an environment of

complexity and ambiguity

5. Personal and organizational communication skills

6. Influence and persuasion

7. The ability to manage in an environment of diversity

8. The ability to delegate tasks and responsibilities to others,

while managing risks

9. The ability to identify, attract, develop and retain talent

10. Personal adaptability

Right now, Interaction Associates' leadership development programs

are developing many of these key competencies in leaders at companies

like America OnLine, Fidelity Investments, Kaiser Permanente, Cox

Communications, and GE Capital. Find out more about our Leadership

Development programs by clicking on the link below:

http://www.interactionassociates.com/html/leadership.html

As we come to understand (admit?) that organizations are not very much like mechanical systems at all, how will we deal with the complex, adaptive nature of our organizations and create a better future? I think that a special kind of dialogue will be essential. Please read some of David Bohm's Proposal.

The "systems dynamics model" that you have built with two consultants is a breakthrough.  This model would be of help to every Pursuing Perfection site, and gives a new tool to the industry for exploration of the "business case for improvement."

How do we begin to see more clearly the importance of connections?

What mental models and physical models can help us see the connections and the connected actions that can link the parts and pieces of health care?

The Chasm report challenges us to focus on the separations and the need for linkages. The ten simple rules or ideas essential for crossing the chasm include: cooperation among clinicians, knowledge is shared and information flows freely, care is based on continuous healing relationships, the patient is the source of control, safety is a property of the system, transparency is necessary, needs are anticipated, and waste is continuously decreased.

Simple yet compelling metaphors are needed. Bridges may be such a simple strong image that can help us change the culture to focus on the gaps and barriers that prevent the system from working on the patient's behalf. These same gaps constantly frustrate and demoralize health care workers. Can we begin to see ourselves and our organizations as islands that the patient must get to and from? Our patients may be swimming in cold water between our islands. If we can see ourselves as islands then we may be able to begin to see the bridges, or land fills, or boats that can connect the patient to us and each of us to the other island that patients must navigate to and from. I believe that the patient frequently must carry the cargo from island to island, since it does not reliably get across the gulf or chasm consistently in any other way. How shall we assist our patients as the journey from our island to other islands?

James Robertson of [Column Two] has been musing about how complexity theory relates to business and knowledge management.

He's been drawing some interesting parallels between the complexity of human behaviour in organizations, the complexity of information in evolving systems and the behaviour of such complex systems as cellular automata, genetic algorithms and neural networks.

Read more at:

(I)

(II)

 

[Curiouser and curiouser!]

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!]

Systems and relationships are inadequate for patient care. The real innovations will be sociological, not technical.