waking themselves up to
habits which collapse
on every block
like a tidal wave
of Hokusai’s sketches
Forest Gander, Kata: Bus Stop
Life is full of curious coincidences. Late last week, I discovered that I had missed publication last November of the report by AIDH and Oracle on drivers of change in the Future of Digital Health. That report was the outcome of facilitation work I did with my colleague Mirinda O’Gorman in mid 2024. This week, I was lucky to be able to participate in a discussion with Adam Kahane on his new book, Everyday Habits For Transforming Systems. Two deep conversations about the drivers of transformational change resonated deeply. I wish now I had Adam Kahane’s book as we summarised the discussions in the report, but I thought in this blog with 20/20 hindsight I would draw out the connections and how Kahane’s work might contribute to Australian digital health practices.
Everyday Habits
And they call again, "It's simple," they say,
"and you too have come
into the world to do this, to go easy, to be filled
with light, and to shine."
Mary Oliver - When I am among the trees
I read Every Day Habits for Transforming Systems over the last month since its publication. My initial reaction was one of validation. The Every Day Habits felt like old friends that I have worked with often. It was powerful to have them called out explicitly and drawn together in conversation. Like many longstanding relationships, the discussion in the book also prompted me to reconsider the application and use of each. I realised my practice of the habits can improve if I take each at greater depth and also consider them more as a system of practice.
With a long discussion of transforming the Australian healthcare system at the forefront of my mind I realised I had a case study with which to review the book in practice. The book describes seven habits that facilitate transformation in systems. I will look at the relationships of the seven habits in the context of the ongoing transformations described in the Future of Digital Health work. Adam Kahane’s habits are:
- Habit 1: Acting Responsibly
- Habit 2: Relating in 3-Dimensions
- Habit 3: Looking for What is Unseen
- Habit 4: Working with Cracks
- Habit 5: Experimenting a way forward
- Habit 6: Collaborating with Unlike Others
- Habit 7: Persevering and Resting
The workshops in 2024 were interactive thought leadership discussions with a wide range of practitioners and participants across the Australian healthcare systems. Habit 1 of understanding and leveraging your role in systems was at the forefront of the participants in the workshop as they were all chosen for their active engagement and contributions in digital health. The rooms of high powered system-oriented change-makers represented healthcare practitioners, institutions, government, vendors, academics and more and put that representation into their work driving change.
Many people in the room naturally understood and practised elements of Habit 2, particularly balancing the system as a whole and self-interest in relationships. Extensive discussion of the importance of user-centred design, consumer preferences, capability and social equity began to draw in the other elements of Habit 2, in the capability to understand wider and more nuanced relationships across the system, those that Kahane refers to as relations of kin, drawing on First Nations perspectives.
Habits 3, 4 & 5 were the bread and butter practices that had much of the discussion in the rooms through the facilitation. As learning oriented leaders, the AIDH guests were used to looking deeply at systems and taking new perspectives in pursuit of their changes. The report calls out some of these whether it is understanding the oft-ignored implications for system users and consumers of healthcare systems, focus on risks, regulation and the critical role of trust. We discussed at length the kinds of painpoints that drive tension in the system and are insights for future transformation leverage – conservatism, safety regulation, bureaucracy, funding models, adoption issues, unnecessary hierarchy or power structures.
Habit 5 of experimentation was a key refrain. A lot of the discussion was also about taking experiments forward beyond their test bed and generalising them across the system. In healthcare this can be surprisingly slow and hard to achieve. Some of the simplest experiments, like a NZ experiment in paying specialists differently around GP referrals delivered huge benefits in wait times, abandoned appointments, patient outcomes, cost and system outcomes but were struggling to be adopted more widely given the changes required in technology, practitioner and payment systems to accomodate it.
A key frustration in the room was around the many agendas in healthcare, its regulators and funders. Habit 6 of Collaborating with Unlike Others was an essential part of many of the changes being pursued in the room. Adoption of AI solutions involved technology, regulation, privacy, safety and even the capabilities to appropriately leverage both the data and the outcomes of such a process. One technology that everyone in the room was pursuing for value demanded almost all the participants of the system to realise value and came with huge cost and complexity as a result. Separating simple experiments like producing patient guides to be reviewed by expert specialists were practical but large scale projects like application of AI in imaging demanded much more significant investments of time and expertise across the healthcare system.
I have already touched on the frustration in the room that things were not going faster. Habit 7 of persevering and resting was a theme. Change makers can’t do everything that they want to do. Many people in the room were already wearing multiple hats as practitioner, administrator, educator and more. That is exhausting, demands perseverance and careful husbandry of resources. In an environment where talent is scarce and budgets are inadequate we all need to take care of our projects and people.
Gathering the Friends
One day, I will write you a letter
after I have gathered enough words
and enough courage
Maria Luisa Arroyo Cruzado, gathering words
Elements of all seven habits were present in this facilitation work across the Australian healthcare system. I suspect any healthcare change maker could point to such old friends in their work. In hindsight what was not as consistent was the breadth of application of all seven habits and the depth of work.
Habits that are simple to describe are deceptively hard to do. Some of the habits fully adopted like Habit 2 and Habit 6 overturn existing relationships, power structures and understandings. They demand change at a fundamental level to the point, purpose and process of the systems in question. Truly great digital transformation that tackles the needs and opportunities in Australian healthcare demands this level of work and willingness to be overthrown.
Improving any everyday habit is an exercise in mastery. Kahane’s book gives us the simple steps to start this journey, but also highlights how far we have to go and how long change truly takes. As the old adage goes, “the best time to plant a tree was twenty years ago and the next best time is today”. While the habits can be challenging, their consistent and integrated practice helps us with tools to break logjams in our work in transformation and reflecting on the system of the habits brings new insights to shape the next phase of our work.
As we move beyond arguments about data and integration in Australian healthcare, we start to tackle real challenges of equity, capability, and sustainability. Addressing these issues will demand coordinated collaboration across government, industry, practitioners and consumers as we seek to leverage new digital technologies, particularly AI, without deepening social divides and breaking the system financially. That’s where the value lies and it will demand us to implement the recommendations of the report but also to tackle the consistent everyday practice of Kahane’s Seven Habits on a wider scale across the system.
And thus, with you believing me, I made
My prophecies, rebellious, unafraid . . . .
And that was foolish, wasn’t it, my dear?
Sterling A Brown, Challenge
