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Please take a look at my weblog on INNOVATION. Here I explore the practical ins and outs of innovating in the healthcare exosystems of communities. I also look at governance, human behavior, and dynamic and systematic perspectives on innovating within a community’s health.

Adaptive Organizations

This post is a little summary of my reading of Stephan H. Haeckel’s book, Adaptive Enterprise.

In adaptive enterprises, strategy emerges from sensing and responding to customers’ requests and needs. The competitive winners will both sense and respond faster than competitors. Slower paced organizations (or parts of large organizations) in stable environments can still rely on annual strategy sessions with strategic plans and hierarchical deployment of those plans.

The key to leading adaptive, highly responsive organizations is clarity–with no ambiguity–about a few things: the context in which the organization exists, the outcomes the organizations is committed to, the accountable roles for those outcomes, and a protocol for “snapping” the modular capabilities together to create newly requested results faster than anyone else can.

Context setting is the number one role of leadership. Answering these three questions: 1) what is the reason the organization exists, 2) what are the governing rules (the key “musts” and “must nots”), and 3) what is the high level business design. The business design is different because it’s purpose is different–it must be responsive and it must be scanning and sensing customer needs all the time.

The high level business design of an adaptive, highly responsive organization has a few components: 1) a dispatcher role, 2) clearly defined capability roles, 3) clearly defined protocol for coordinating interactions among capability roles.

Perhaps the key distinction that would signal whether the organization (or part of a large organization) was a make and sell org structure or a sense and respond structure would be the role assigned to interface with the customer. If their main role is a sales force to make offers and sell current “in stock” services then it is a make and sell organization. If the interface role is a dispatcher who is empowered to make commitments to customers based upon the customers request AND is empowered to negotiate with the organization’s capability roles then you may be looking at a sense and respond organization. Selling what you offer vs. listening and responding to customer requests is the main difference. Of course hybrids will be the norm, but clarity about the differences is essential so you can actually be responsive AND so you don’t waste time and money when all you need to do is sell what you have planned and placed in stock.

Governing the Commons: an important idea for communities and the management of the limited resources for health and wellness along with illness.

Here are Elinor Ostrom list of rules for successful governance of a common pool resource:

1. Clearly defined boundaries

Individuals or households who have rights to withdraw resource units from the CPR must be clearly defined, as must the boundaries of the CPR itself.

2. Congruence between appropriation and provision rules and local conditions

Appropriation rules restricting time, place, technology, and/or quantity of resource units are related to local conditions and to provision rules requireing labor, material, and/or money.

3. Collective-choice arrangements

Most individuals affected by the operational rules can participate in modifying the institutional rules.

4. Monitoring

Monitors, who actively audit CPR conditions and appropriator behavior, are accountable to the appropriators or or the appropriators.

5. Graduated sanctions

Appropriators who violate operational rules are likely to be assessed graduated sanctions (depending on the seriousness and context of the offense) by other appropriators, by officials accountable to the appropriators, or by both.

6. Conflict-resolution mechanisms

Appropriators and their officials have rapid access to low-cost local arenas to resolve conflicts among appropriators or between appropriators and officials.

7. Minimal recognition of rights to organize

The rights of appropriators to devise their own institutions are not challenged by external governmental authorities.

8. Nested enterprises (CPRs that are parts of larger systems).

Appropriation (Rule 1), provision (Rule 2), monitoring (Rule 4), enforcement (Rule 5), conflict resolution Rule 6), and governance activities (Rules 3 & 7) are organized in multiple layers of nested enterprises.

Here are notes from a talk on a simply powerful way for those working at the front line to solve problems.

A3 Problem Solving

Below is a link to a PDF that can be printed on 11 X 17 paper (A3). Do your work in pencil. Make lots of changes. With an eraser in hand, shop it around to all the folks that have insight into the problem and especially with those who will be using the solution.

A3 PDF for printing

Upon what can the parts of health care come together into a coherent whole. No metaphor works well if extended very far; certainly not inorganic crystals. But let’s play with this for a moment to get some use from it. There are a lot of parts of health care swirling in the community. How can they come together into something that can be used? There is talk of Accountable Care Organizations (ACOs). What will come together in an ACO? For what (who’s) purpose and benefit will ACOs function? In the reorganization of healthcare we have a moment in history to have the parts and players come together differently and more effectively and more for the benefit of the people who’s health is at stake.

Do you think it can be organized around or by hospitals? Physicians? Payer/Insurers? Government? Something entirely new? Who will have a voice? Who should have a voice? Who can have a voice? Can the voices blend or will strident voices (or pressure to silence voices) prevent anything useful from coming into being? What is the desired use and shape of this possible crystal? Will it be strong or brittle? Beautiful or ugly? Useful or not so useful?

Dave Ford, of Care Oregon gave me a book to read–Governing the Commons, by Nobel Prize winner Elinor Ostrom. She has me thinking. That was Dave’s goal I believe. How did those successful instances of well managed COMMONS come about? How can we begin to see health as a “common pool resource” and manage it well over the long term–ourselves, as communities of appropriators–appropriators from the common pool of health resources?  This is a question worth serious reflection and design.

I am answering my own question in the post down the page, on Toyota and Chasing the Rabbit by Spear. I am reading Atul Gawande’s The Checklist Manifesto. I get it. Check lists are a way to build signals in to the work in real time. When the step on the check list is missed or cannot be carried out, THAT IS THE SIGNAL to swarm the problem and do an A3 (A3 Problem Solving for Healthcare) with those nearest the work and solve the problem. As John Kenagy says-“solve the NEXT PROBLEM”. It is an interesting possibility for health care–to get to the place where folks doing the work can fix problems as they arise, rather than having to have a whole system of collecting, prioritizing, and delaying the solutions.

Inserted photo–By the way this is my second daughter, Sofia.


Here is a simple presentation on a few transformational ideas. Judith Hibbard and I gave on-line presentations to a group of hospital quality improvement folks. I have included my presentation notes below. I claim that these ideas in the notes will be implemented. The only question is whether they will be implemented by hospitals and physicians or others. Disruptive or adaptive? Depends on who implements the changes doesn’t it? Here is a link to the presentation => between_patients__professionals

By the way, in the presentation “PAM” stands for Patient Activation Measure. More can be learned about it at this web site: http://www.insigniahealth.com/products/pam.html , Insignia Health, owner of the Patient Activation Measure intellectual property.

Steven Spear has done a nice job of exposing the four core competencies of Toyata in Chasing the Rabbit. I can imagine how to do three of the four. It is the First one that stumps me: “Highly specificed work with error signals build into the process”–more or less. The question for me is how do we design error anticipating signals or at worst signals that let us know that the process just failed, so we can take action to mitigate the defect, before it has it concensequence. I will begin my search for the answer, but if you have the answer, please point me toward it.

Second: Swarm problems where and when they occur.
Third: Share the improvements
Fourth: Teach and coach everyone in the first three.

A video podcast of Goran.

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