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Reposting for the third time in fifteen years:

Albert Camus on Community, Hope and Creativity

“Great ideas come into the world as quietly as doves. Perhaps then , if we listen attentively we shall hear, among the uproar of empires and nations, the faint fluttering of wings, the gentle stirrings of life and hope. Some will say this hope lies in a nation; others in a man. I believe rather that it is awakened, revived, nourished by millions of solitary individuals whose deeds and works every day negate frontiers and the crudest implications of history. Each and every one, on the foundations of their own suffering and joy builds for all.” –Albert Camus –

It’s important to diagnose the type of problem you have. Better said, it’s important to know the type of cause for problem you have–not only it’s symptoms.

What I see happening is very bright and well intentioned people are grabing whatever tool they are used to using and applying it to every problem. I see almost no one addressing structural problems. Of course unless you’re the founder it takes a huge amount of power and influence to restructure an organization–at least in the way people have been going about it lately. Most avoid diagnosing or addressing the structural problems and are usually using psychology or incentives or threats or business modeling or quality improvement tools to solve problems that are fundamentally structural. One way to know if it is a structural problem is to ask yourself if you were to replace all of the people with new people would you have the same problem. In other words, structural problems do not depend on the individual actors or anything about them. With too little science, Dee Hock and others have tried to address this problem; some with a modicum of success.

If we’re going to create structures that work, my belief is, we need to focus on how one can manage complexity, being very scientific about it. Stafford Beer’s Viable System Model is the strongest starting place I’m aware of. And it has a deep foundation in the rigorous science of complexity–and it works.

Warranty Work?

Neighborhoods produce health. Many neighborhoods are failing as health generating systems they are meant to be. If we choose to ignore the health generating capacity of our neighborhoods, our efforts a population health will simply be warranty work–trying to make up for failed neighborhoods.

Quality of life begins and exists in our neighborhoods, not in our medical and social service institutions, which are at best expensive and only partially effective safety nets for neighborhood failures.

Together we must find ways to help neighborhoods take care of themselves–through local action, for local issues.

Community (as a Commons) must scale up from a foundation of face-to-face interactions (Ostrom’s “cheap talk”)–without imposed middle men and their inevitable attendant costs, delays and misunderstanding. Experts and other resources must stand to the side of the primary relationships, not between them. The primary dyad is only temporarily a triad including the expert, not a linked list of three or more.
Example: The difference between the structure of lawyers’ relationship and arbitrators’ relationship. Linked list: (person 1)—(person 1’s lawyer)—(person 2’s lawyer)—(person 2)
vs. a temporary triadic closure with persons 1 and 2 assisted by arbitrator A:

It is worth noting that Miles Horton insisted on this approach at the Highlander Research and Education Center, a source spring of the Civil Rights Movement. If we are to improve health in this country we must nurture the roots of health. We must understand how to garden in neighborhoods. We must first do no harm. Improving the capability of institutions to separate neighbor from neighbor is “doing the wrong thing righter”–makes things worse, efficiently so. This institutional undermining of neighborhood capability and capacity is the main topic of John McKnight’s very small and readable book The Careless Society, Community and its Counterfeits. John McKnight provides a critical cautionary story for all of us who intend to help. Primum non nocerefirst do no harm.

Money and policies are being marshaled at the federal and state level to improve population health at a reduced per capita cost.
However health and wellbeing are emergent properties of all the face-to-face and local experiences individuals have.
Medical and social services are adjuncts to our day-to-day experiences in neighborhoods. They are not the primary source of wellbeing or health.
The best situations we can aim for are ones where all of our neighbors grow up and live in neighborhoods that are focused on the wellbeing and health of all the inhabitants.
The power to change health outcomes will come from what Elinor Ostrom referred to as “cheap talk”–face to face conversations among people who know each other.
I believe that our job is to support “cheap talk” in order to integrate the medical and social services in ways the do not further undermine the autonomy of neighborhoods nor alienate the service providers in their increasingly complex work lives.
We cannot buy our way out of neighborliness.
There is not enough money, and it is alienating–the opposite of wellbeing.
 .

The best protection for democracy is the practice of democracy itself. The need to use guns or arms to protect oneself again central government maybe a case of putting one’s head in the sand. The main reason that the problem would arise is because the population has not participated in decision-making at all levels. Democracy is about making choices together. It’s about solving problems together. Centralization is the default when problems have not been addressed and solved locally. I suggest that the main reason problems are not being solved locally is we are out of practice at solving problems together–in our families, in our neighborhoods, and our institutions and workplaces, in our communities, in our cities, in our counties, in our states, and therefore in our nation.

Guns in America

Many Americans sense something is terribly wrong. There is a group who believes that the current situation between the government and those governed still resembles the situation at the time our Constitution was written. That was a time at which illigetimate governmental control could plausibly be resisted with marshall force. Thus the insistence at the time on adding the Second Amendment.

Times have changed. Methods of control have changed. Methods of effective resistance have to change to match present power of government. Oppressive control is now through the media and through the political system itself, if there is actually any difference. 

The only method I can see for resisting these methods of control is massive active participation in governance at every level and massive organized grassroots communication. Both of these are theoretically available in America.

Compete or work together in an organized way?

When to play competitive games and when to play cooperative games? I have a personal bias toward cooperative games, though I don’t hesitate to compete. It seems that things work out better for me when the systems in my body cooperate and when the members of my family cooperate. We often choose competition rather than organization when we can no longer individually influence or control or the situation. This naturally happens when our  aspirations are bigger than what we can accomplish with our friendly associates.

Cooperation among friends is known to each of us. What are the possibilities for cooperation with strangers?

Fortunately much is known about how to devise and play cooperative games with strangers at large scales.  Elinor Ostrom, winner of the 2009 Nobel Memorial Prize in Economics, gives eight rules which she discovered are always followed when people have successfully managed to govern their common resources. The final rule is about “nesting”. I read her book Governing the Commons, and a few others. The idea of nesting seemed very important but mysterious.

I now understand it. Or I should say, I have “met” Stafford Beer who knows  how nesting works. It is his insights and life’s work that shows us how to create cooperation at scale. Stafford Beer’s Viable System Model (VSM) gives us the pattern, the standard structure, for cooperation at larger and larger scales.

How should we decide when to compete and when to cooperate? There are aesthetic, ethical, and scientific considerations; and there are considerations of expedience within these first three guides. These four roughly translate into, we should cooperate when is will be fun, fair, plausible and doable within the available time and budget. Cooperation is fun. It must be fair or it isn’t cooperation. It must have a viable structure or it is delusion. The big challenge is to get it going quickly and inexpensively–relative to the problem/opportunity that it is being directed toward. To get going quickly we are well advised to stand on Stafford Beer’s shoulders, to use his insights, to use the Viable System Model. The framework that Jönköping County Council used to rapidly become the most effective health care system that I am aware of has, in my estimation, the same pattern as Beer’s Viable System Model. That framework was the launching pad for Jönköping’s amazing rise–a model for us all to understand and learn from.

Here is a high level picture (linkage map) of a Viable System Model of health at the community level. Developing this framework and launching yourselves is quite possible in most communities.

CLICK ON IT TO EXPAND

VSM Healh

Marc Pierson, MD

360 594-2316

Shared purpose is not enough to fuel partnerships.

Most institutions and their leaders are in states of near overwhelm. Having one institution ask another to take on and solve any more problems is not helpful. However; if we approach their problems and our problems together and create ways which reduce one another’s overwhelm–such as only giving them clients or issues for which they are already designed to manage and profit from–then we become good partners.

This is the fundamental function and challenge for each Washington Accountable Community of Health (ACH)–to match problems to problem solvers in ways that reduce overwhelm, not increase it.

Should we cooperate?

1) Are there mutual benefits from working together that exceed what we could do alone?

2) Do the benefits from cooperating exceed the cost of cooperating?

3) Is there some purpose that we share?

4) How can we avoid hurting each other needlessly and accidentally?

5) Is it important to work together, to stick together?

I am responding to a Boston Globe column by Joan Vennochi  speculating that Partners HealthCare’s two flagship hospitals, Massachusetts General and Brigham and Women’s, might become independent again.

The Vennochi column, headlined “Breaking up is hard to do,”  starts with the sentence:

“GROW OR DIE. It’s the choice facing any business — including the health care business.”

This world view and its associated dynamics are very relevant in the current US healthcare situation.

Another extreme perspective would be, “GET SMALLER OR DIE”. I believe that there are things that scale well and others that fail at scale. Any business in a truly competitive context must consider these things.

They can be understood as the design principles: efficiency and effectiveness.

I hold, not uniquely, that for any institution to flourish in a competitive market it will need to be effective (or its clients will abandon it if they have that choice) and efficient—so that their costs are competitive (or its clients will choose the lower cost alternative with similar benefit).

Value = Benefit/Cost. Effectiveness in this discussion revolves around benefit and efficiency around cost.

In health and health care, effectiveness of service is primarily local because it is heavily influenced by such local conditions such as the economy, safety, the physical environment, culture, personal preferences, individual choices, and individual and group behaviors. 

But numerous support functions may be suitable for efficiency, such as IT, HR, purchasing, professional training, borrowing and lending, financing, facilities and general management consulting for example.

So there is a big opportunity to develop a franchise which can support local institutions through the scalable functions at competitive prices. The other side of this proposition is understanding local governance for its ability to support effective health and health services–to meet the needs of specific populations in specific places.

My advice is to:

GET EFFECTIVE AND GET EFFICIENT OR DIE.

Balance the small/local/participatory with the large/global/commoditizable.

Whoever fills this niche is going to have a winning business model. The others will adapt or be disintermediated–which is very different than dying–they get jobs in the winning institutions.

In social systems, you are the system and the system is you. There is no escaping it.

Our challenge is to discover how our systems’ intended  beneficiaries can find their way back into decision-making positions. All systems ultimately serve the decision makers. When control shifts from those who created the enterprise to solve their problems into the hands of those they hired to provide the service, it should be no surprise the system morphs away from serving the clients toward serving the operators.

Our major social systems are profoundly dysfunctional: 1) Health, 2) Safety/Justice, 3) Education, and 4) Government.

These systems are currently governed by their managers not by the originally intended beneficiaries. How did this happen?

The root cause of dysfunction is the same in each case–woeful lack of participation by key stakeholders–the purported beneficiaries: 1) patients, 2) communities, 3) students, and 4) citizens.

In each case, we must assert the rights of those who are paying for the system to design and govern the systems. Of course this requires matching the scale of system (subsystems) to the level of relevance and participation of the intended beneficiaries. This is the only way to avoid the structural stupidly inherent in bureaucracies. Scalable governance is the puzzle to be solved. When there is a model of scalable governance in hand the owners can engage in renewed, ongoing design and governance of their systems–at a  democratic scale, in a non-bureaucratic structure.

You are the system and the system is you. There is no escaping it.

The need for hyper-local governance has been solved for 700 years continuously in some places around the world. More on that later…

 

Are Insecurity and Betrayal of Trust ever Good Things?

We can create a better shared future by embracing insecurity and choosing to trust one another.

I conceptualize the dynamics of trusting start from sensing “we are in this together” and “hoping”, followed by caring and conversing (see the figure below). This diagram captures my lessons learned from two great and mind altering books: “The Wisdom of Insecurity” by Alan Watts (1951) “Building Trust: In Business, Politics, Relationships, and Life” by Flores and Solomon (2001).

Watts (1951) 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 (2001) turn broken trust and betrayal on their heads, as Watts (1951) did with insecurity. Flores and Solomon allow one to see that trust and betrayal are sides of the same coin—one meaningless without the possibility of the other. 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. As an accountable health community convener, I choose to embrace insecurity by trusting (and assisting to rebuild trust among community stakeholders) for the goal of building a better shared future together for now and the generations to come.

Below is a diagram that captures some of the ideas and relationships that came to mind as I read the book.

Dynamics of Trusting

Russell Ackoff along with Aristotle claim that the components noted in this diagram are the necessary and sufficient components or aspects of every social system. (see prior post)

I suggest that design directionality matters a lot if we care what kind of social systems and business institutions result from the interactions among these parts.

It seems that the quickest way to solve a business problem is to start in the middle and move outward, using our “power-over-others” until the immediate problem is solved. However, if we want the most effective solution for all of the participants, we are better off starting our problem solving from the outer domain and moving inward, designing into the economic/business solution the larger contexts.

In this way we embed the culture, values, wisdom and cooperation (power-with-others) of the society into the business and its products. That should be a long term competitive advantage over those relying on the more common power-over-others, quick fix approach.

Of course the more  inclusive and participatory approach requires more experience, wisdom and skill to orchestrate than a command and control solution does.

 

Expedient or Effective

Economic Constriction

Aristotle and Ackoff base quality of life and the quality of enterprises upon a  set of foundational concerns. They recommend that we balance these aspects of living. Ackoff claims that this set is a system and that its parts are necessary and sufficient.

Aristotle Ackoff (4)

It  is not hard to imagine that each part is necessary. The claim of sufficiency grabbed my attention.

Ackoff additionally cautions that because they are a system they should not be prioritized. He is probably right in some sense but in dynamic systems sequence and directionality often matter.

Russell Ackoff and his colleague  Jamshid Gharajedaghi discussed the usefulness of including a fifth concept, Power, to Aristotle’s four, Aesthetics, Ethics, Knowledge, Economy. Gharajedaghi came down on the side of adding Power.

Aristotle Ackoff

In my opinion it is good that he did because the dynamic of power is critical to the style with which one approaches art, justice, wisdom and business. If Power is not called into clear view it hides too near the heart of the teacher, judge, artist and business leader for it’s true nature to be seen. Maybe Power should be the primary consideration. I am afraid that it is the primary driver. If one is in a big hurry and also certain of one’s mission it is too easy to use Power Over others (and self). One easily sets up a tyranny of forcefulness driven by fear or excitement.

Over the last 25 years I reflected on a related set of concepts put forth by Donella Meadows in her famous “Leverage Points” paper, in which she convincingly argues for a kind of hierarchy of power or effectiveness among twelve conceptual domains or “levers”. I compressed her twelve into four sets of three each: Existential-Paradigmatic (Why?), Political-Complex-Social (Who?), Dynamic-Nonlinear-Surprising (How? [does it work]), and Linear-Intuitive (What? [do we do next])

Meadows-Pierson in 4 levels

Perhaps with some intellectual forced fitting I relate the two perspectives and then apply a nested logic in this drawing below.

Direction Matters (1)

 

For me Aesthetics (Beauty-Art-Care) form the driving force, the attractor, and as Ackoff and Gharajedaghi say, it is the only one of the five that is worthwhile in and of itself, the one where personal risk taking feels natural. The Aesthetic domain is not an instrumental aspect of life, though it can be subverted if we allow economics to overpower joy.

Creative risk is worth further consideration. We are all willing and able to invest our own lives (risk failure) in the creative effort required to bring forth our deep care into the world.  Intrinsic motivation. When our effort originates from economic interests we are too willing to risk others’ lives to promote and protect our economic interests. We do this by appealing to the extrinsic motivation of others.

For me, standing on a foundation of Aesthetics or personal meaning or care, it is easy to discover a coherent Ethic and a wonderful approach to Knowledge. With persistence and practice experience develops.  Through practice with others we discover  shared care. Together we develop Power to create  Enterprises which make sense for us to participate within.

There is a very  strong cultural drumbeat calling each of us to begin from Economics. In such businesses, or through employment, it is all too easy to adopt a style of Power Over others. This economic starting point narrows Knowledge to what is useful for the enterprise and discards wisdom. This path reduces Ethics to legal maneuvering to ensure that the penalties are economically manageable or sufficiently delayed. This path distorts Aesthetics into entertainment. In this way Currently more often than not employment is primarily about making money. Without beauty and joy at work our lives can feel shaky  and unbalanced, a means of surviving, without thriving. We are reduced to producers and consumers–less than the people we hope to be.

It is possible to step away from this  awkwardness back to a more human way of being that stays connected with others and to what we care about. We rediscover a easy sense of fairness, a curiosity which leads toward knowledge and wisdom, and enjoyable business associations.

Nothing very human flows when economics is the starting place.

Love of something is the best starting place.

Then people, communities and businesses can flourish.

A forced march?

No singing?

No dancing? 

Who would join? 

Why would you, other than fear? 

And what can come from joyless effort?

Reconsider.

Participation is in the balance

Pay attention. It is a signal.

Something important is at hand.

Understand everything you can.

Turn toward it. Open up. Dig deeper.

Don’t turn away from resistance.

Participation is in the balance.

In the Long Run

I have begun to like this expression. The idea feels like an old friend.

How long can you and your partners run?

Are you sprinters? Is the race a short race?
I look to see if people are preparing for marathons. I look to see whether they are running at measured paces, clear about the distance required and the importance of arriving intact.

I wish we embraced wisdom found in the long run more often.

The long run will expose both fools and wizards.

We may act and plan with the long run in front of us.

However, excitement often drives our behavior toward short runs.

We must discipline ourselves to hitch our enthusiasms to long runs.

When thinking of long runners Gandhi , King, Horton, Seeger, Pope Francis come to mind.

More than persistence of vision is required. There is the running. In the running there is risk and beauty.

The Arab Spring vividly reminds us that removal of problems is not the same thing as improving the system. Things can actually get worse. So how do we change complex situations for the better? How do we design something better rather than only reacting against things.

Destruction and tearing down are much easier than design and building up.

The current state of population health in the US is a mess caused by many interacting systems. We cannot get to a better place by destroying the present system. It would be replaced by something even less effective, less safe, less timely, less efficient.

Patching things up is not likely to dissolve the mess either. Patching is the current approach–quality improvement, process improvement which is directed toward the parts, rather than to the whole.

The best approach that I am aware of is to design “the system we wish we had today” and then begin adapting the current system to approximate this ideal design. This is Russell Ackoff’s great gift.

He evolved an approach through more than fifty years of practical work carried out with his peers across many companies and at least one community.

“Interactive Planning and Idealized Design” fits the urgent need we have to design and implement systems of health that our communities want and need.

Necessary and SUFFICIENT

The question that captivates me is “What parts and interactions are both necessary and sufficient for population health?”

I get excited, most of us get excited when we discover a new and necessary piece of a puzzle. Understandably so.

But we must curb our enthusiasm and understand the whole system in which this new part fits. Then get excited! So often we do not have a list of essential parts. Without that list we do not know whether the addition of the new, often necessary part will be sufficient. We need to spend time understanding the essentials of our systems so we can know when the parts are sufficient for successful operation.

A perfect car minus any essential part, say the carburetor, does not function, no matter how amazing the rest of the parts are.

We have been talking about patient centeredness since the Institute of Medicine’s Crossing the Quality Chasm published in 2000.

Healthcare and social service providers, often referred to people as patients, clients, consumers. People in this context are not always considered to be essential or active “parts” of the health or healthcare system.  If we are going to successfully address population health, then, in addition to medical care, we must understand that these people and their interactions with the other system components are core, not peripheral. They are more than patient, client,  and consumer. We would do well to rethink our relationships with them. In everyday, non-emergency situations, they are central, we are perhaps necessary and more peripheral than they are to health.

The Clue Train Manifesto is an enlightening read in this regard. It is now time to design with the people that are our communities and our neighbors. In fact they should convene the design session and invite us when we are needed, if we can behave well.

The architect, philosopher, and systems designer left us an important and essential legacy. We all need to study Russell Ackoff’s approach to “Interactive Planning and Idealized Design.” And apply it at the whole community level.

The triple aim, obviously has three parts. One part is revolutionary–population health.

We all understand that population health is mostly determined by social determinants and personal behaviors–which we know are also mostly socially determined.

So…

The medical service provider–client relationship cannot solve the problem. In other words business as usually, even when strengthened and generously funded, cannot possibly create population health. It is a serious, even disastrous mistake when medical institutions are selected to be the primary engine and the coordinating body for population health.

We should be exploring economic opportunity, education, housing, and neighborhood planning–they are not in the domain of medicine and they are sources of health.

So…

How would one go about addressing this new and ambitious national goal of improved population health?

Are we willing to look at the implications of these perspectives?

Equality?

Affordable and universal education and health?

Social activism? Integrating all voices even dissenting voices?

In 2005 I attended the US Patient Safety Conference where I heard Dr. Mamphela Ramphele draw uncomfortable parallels between US health care and South African experience with Apartheid in her talk, “Lessons for Health Care from Apartheid to Post-Apartheid South Africa Leadership.”

At the end of her compelling talk I ask her quietly, what is the role of a “white liberal” or in this case a physician in the current US health care system. I will never forget her response nor will I ever stop trying to act on it. She said simply, “Help them find their voice.” And to be clear, she is talking about the people that we too often call “patients”.

 

Bringing forth Identities

“Setting the context” is another way of understanding the idea of calling forth identities appropriate to the occasion.

How do we, how can we set context?

Art.

Songs, sounds, smells, movements, images and stories all  have the power to set the scene for me.

Cooperation requires some sense of community, some sense of being in the same scene.

War requires the sense of being excluded from the scene.

How clear are we about the available identities and their appropriateness for the occasion?.

Our many Identities

David Snowden pointed out that in social situations “the unit of analysis is the identity”. This is both a  profound and practical perspective.

The opportunity is more how to bring forth the most appropriate identity rather than how to change the mind of an inappropriate identity.

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