Tag: systems

Everyday habits for Transforming Australian HealthCare

Posted on by simongterry in Future of Work 
        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

Share the Rules, Not the Outcome, & Realise Potential

Posted on by simongterry in Working out loud

One of the remarkable discoveries of the field of study called complex systems is how order, or what physicists call a lack of entropy, can be created out of seeming randomness by individuals or agents following a small number of very simple local rules. Such systems are said to be self-organising or self-assembling, and often have so-called emergent properties that were not part of any of the rules. The study of these emergent properties teaches us that it is the local rules themselves, not the finished product, that natural selection or some other selective products sculpted to make the finished product. – Mark Paget, Wired for Culture

Management loves order.  That desire for order translates to efforts to plan and specify all the outcomes in the system. Instead, we need to leverage the potential of our organisations by allowing autonomy with simple rules.

The Deadly Entropy of Specifications

Specifying everything in a complex system calcifies the ability of the system to adapt to change. This is when management becomes bureaucracy. If there is only one predetermined process and one predetermined outcome, then individual employees are just cogs in a machine of work to achieve that outcome. However, we rarely find the expected efficiency in that machine. To start, the complexity of the machine prevents us from specifying our outcomes as clearly as we would like. 

In addition, people are not machines and the world is not static or predictable. People can do more. They want to help and they want to respond to their environment. They learn more, change things, interpret, and reorganise things locally. However, our fixed system of outcomes won’t allow it. We find other people and a changing environment rarely enable us to execute the outcomes as simply as we believed.

All our effort to impose order accelerate chaos. Disconnected employees, disconnected processes, silos, poor design and mismatches to the environment accelerate entropy. Our system is not broken. It is working exactly as we intended it just doesn’t prove to be effective enough for a changing competitive environment.

The chaos of disruption is just the force of our environment selecting another organisation that is more effective. The chaos of decay sets in as our predetermined outcomes fall short of the require effectiveness of those who make the selection decisions: 

  • our employees who can work elsewhere
  • our customers who can buy elsewhere
  • our communities who can support other businesses (with infrastructure, regulation, licenses to operate and valuable reputation); and 
  • our investors who can seek better returns elsewhere.

An Alternative: Share Simple Rules & More Potential

Most managers use a few simple pragmatic rules (or heuristics) to do their job. The challenge in organisations is that these heuristic rules aren’t discussed. Manager’s rules are all slightly different in their effectiveness. Some of these rules will survive by promotion and be shared by role modelling, but many won’t surface, simply becoming the mystery of high performance. If nobody shares their rules, there is little ability to learn from more effective rules.

Managers should focus on fostering discussion around these simple rules and encouraging people to adopt the more effective ones.  Working out loud is a great vehicle to foster these discussions as it surfaces the how of work in progress.  More formally, organisations are experimenting with approaches like holocracy that force the organisation to surface these conversations about the effectiveness of rules, responsibilities and approaches.  In time, as these experiments continue we will discover better ways to work and to manage.

Allowing people to operate within the bounds of simple rules enables them to exercise their potential, their local information and the judgment to make the organisation more effective. Simple rules tested for effectiveness are a great bureaucracy killer. For years, Nordstrom had an enviable reputation for customer service by having the simple guideline of “Use your good judgement in all situations.” 

Importantly, focusing on simple local rules allows each part of a system to play its role as it sees fit without needing to align to a fixed objective or a higher set of instructions. Employees are challenged to bring their best potential and to be more human, not cogs in a machine.

The focus of this approach is to create enduring effectiveness and a competitive advantage in the organisation based in some simple expectations of the local rules of behaviour. Culture like that represents a critical competitive advantage.

The Inefficiency of Relentless Efficiency

Posted on by simongterry in Uncategorized

Any efficiency measure applied relentlessly ultimately becomes inefficient

Business loves too much of a good thing. Relentlessness is a characteristic widely admired in business leaders. Efficiency is a classic area where the impact of a relentless focus on a single practice can be self-defeating. Engineers know this, but managers have not yet learned the lesson.

The first clue to this outcome is the Pareto principle which is widely misunderstood. Pareto highlighted that in many phenomenon a small part of the population has the largest impact i.e. 20% achieves 80% of the impact. Applied to efficiency it highlights that the cost of achieving incremental efficiency using the same measure will increase over time. 

Nicholas Taleb has highlighted in Antifragile that slack in a system is often the source of its Antifragility.  Slack is what enables systems to effectively respond to shocks. We can’t remove the shocks but we can ensure the system does not collapse when a shock hits because it has no capacity to change and respond.

Business practices are widely copied. People develop expertise in a single practice and become like those described by the phrase “to a man with a hammer every problem looks like a nail”. We over-apply efficiency measures because they worked before or they worked elsewhere. We rarely consider their systemic impact on effectiveness

Consider a few of the efficiency measure applied relentlessly in the corporate world that have created new inefficiencies and damaged effectiveness:

  • Time Management: ever waited for a meeting to start because someone is so scheduled that they keep everyone else waiting? Our relentless focus on managing the efficiency of time at an individual level creates collective inefficiency. 
  • Outsourcing and Offshoring: the labour arbitrage and other efficiencies of these measures are often overwhelmed when pushed too far by the inefficiency of the system with fixed processes, misaligned performance standards and poor communication and collaboration. Too many organisations have discovered they no longer can respond effectively to customer needs when they overstepped the efficiency measures.
  • Expense control: Organisations that ruthlessly manage employee ability to spend in a low trust approach often discover employees are far more creative and also spend what they can to retain budgets. New constraints and processes just create new wasteful behaviours because trust has broken down.
  • Specialisation: Similar to outsourcing and offshoring, removing people from connection to customers and fragmenting processes unnecessarily in the name of efficiency creates its own lack of accountabilities and inefficiencies
  • Scale: We live in a world where big likely means too big to sense, decide and react.
  • Performance Management: Employees can calculate expected average returns too. Even with that purpose, autonomy, mastery and relationships are more likely to shape their effort than a relentlessly redesigned reward scheme. The relentless focus on efficiency of performance management schemes and the sense that the rules will be changed to suit the corporate is ultimately ineffective. 

Responsive Organisations recognise that efficiency is not the only goal. Efficiency does not deliver on the purpose of the organisation. It merely ensures resources are well applied. Effectiveness delivers the purpose of the organisation and needs to be a greater part of the management toolkit.  Efficiency measures need to be tempered to reflect their effectiveness and their impact on the effectiveness on the organisation as a whole.