healthcare

Intelligence and Governance

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Katy Steward of @TheKingsFund asks What Makes a Board Effective? (Feb 2013). She’s looking specifically at the role of the Board in the National Health Service, but there is much that can be generalized to other contexts. She asks some key questions for any given board.

  • Are its members individually effective and do they communicate effectively – for example, do they challenge themselves and others?
  • Do they use energetic presentations and have insightful conversations?
  • Do they support their colleagues and have good decision-making skills?

In this post, I want to develop this line of thinking further by exploring what the concept of organizational intelligence implies for boards.

1. Boards need to know what is going on.

  • Multiple and diverse sources of information – both quantitative and qualitative
  • Understanding how information is filtered, and a willingness to view unfiltered information as necessary. 
  • Ability to identify areas of concern, and initiate detailed investigation 

2. Boards need to make sense of what is going on.

  • Ability to see things from different perspectives – patient quality, professional excellence, financial accountability, social accountability. 
  • Ability to see the detail as well as the big picture. 
  • Courage to investigate and explore any discrepancies, and not to be satisfied with easy denial.

3. Boards need to ensure that all decisions, policies and procedures are guided by both vision and reality. This includes decisions taken by the board itself, as well as decisions taken at all levels of management.

  • Decisions and actions are informed by values and priorities, and reinforce these values. (People both inside and outside the organization will infer your true values not from your words but from your actions.) 
  • Decisions and actions are guided by evidence wherever possible. Ongoing decisions and policies are open to revision according to the outcomes they yield.
  • Decision-making by consent (Robertson)

4. Boards need to encourage learning.

  • Effective feedback loops are established, monitoring outcomes and revising decisions and policies where necessary. 
  • Courage to experiment. Ability to tolerate temporary reduction in productivity during problem-solving and learning curve. Supporting people and teams when they are out of their comfort zone. 
  • Willingness to learn lessons from anywhere, not just a narrow set of approved exemplars.

5. Boards need to encourage knowledge-sharing

  • All kinds of experience and expertise may be relevant 
  • Overcoming the “silos” and cultural differences 
  • The collective memory should be strong and coherent enough to support the organization’s values, but not so strong as to inhibit change.

6. Boards work as a team, and collaborate with other teams

  • Effective communication and collaboration within the board – don’t expect each board member to do everything. 
  • Effective communication and collaboration with other groups and organizations.
  • Circle Organization (Robertson)

Note: The six points I’ve discussed here correspond to the six core capabilities of organizational intelligence, as described in my Organizational Intelligence eBook and my Organizational Intelligence workshop.

See also

Brian Robertson, The Sociocratic Method. A Dutch model of corporate governance harnesses self-organization to provide agility and a voice to all participants (Strategy+Business Aug 2006)

Steve Waddell, Wicked Problems, Governance as Learning Systems (Feb 2013)

Updated 1 March 2013

Intelligence and Governance

by

Katy Steward of @TheKingsFund asks What Makes a Board Effective? (Feb 2013). She’s looking specifically at the role of the Board in the National Health Service, but there is much that can be generalized to other contexts. She asks some key questions for any given board.

  • Are its members individually effective and do they communicate effectively – for example, do they challenge themselves and others?
  • Do they use energetic presentations and have insightful conversations?
  • Do they support their colleagues and have good decision-making skills?

In this post, I want to develop this line of thinking further by exploring what the concept of organizational intelligence implies for boards.

1. Boards need to know what is going on.

  • Multiple and diverse sources of information – both quantitative and qualitative
  • Understanding how information is filtered, and a willingness to view unfiltered information as necessary. 
  • Ability to identify areas of concern, and initiate detailed investigation 

2. Boards need to make sense of what is going on.

  • Ability to see things from different perspectives – patient quality, professional excellence, financial accountability, social accountability. 
  • Ability to see the detail as well as the big picture. 
  • Courage to investigate and explore any discrepancies, and not to be satisfied with easy denial.

3. Boards need to ensure that all decisions, policies and procedures are guided by both vision and reality. This includes decisions taken by the board itself, as well as decisions taken at all levels of management.

  • Decisions and actions are informed by values and priorities, and reinforce these values. (People both inside and outside the organization will infer your true values not from your words but from your actions.) 
  • Decisions and actions are guided by evidence wherever possible. Ongoing decisions and policies are open to revision according to the outcomes they yield.
  • Decision-making by consent (Robertson)

4. Boards need to encourage learning.

  • Effective feedback loops are established, monitoring outcomes and revising decisions and policies where necessary. 
  • Courage to experiment. Ability to tolerate temporary reduction in productivity during problem-solving and learning curve. Supporting people and teams when they are out of their comfort zone. 
  • Willingness to learn lessons from anywhere, not just a narrow set of approved exemplars.

5. Boards need to encourage knowledge-sharing

  • All kinds of experience and expertise may be relevant 
  • Overcoming the “silos” and cultural differences 
  • The collective memory should be strong and coherent enough to support the organization’s values, but not so strong as to inhibit change.

6. Boards work as a team, and collaborate with other teams

  • Effective communication and collaboration within the board – don’t expect each board member to do everything. 
  • Effective communication and collaboration with other groups and organizations.
  • Circle Organization (Robertson)

Note: The six points I’ve discussed here correspond to the six core capabilities of organizational intelligence, as described in my Organizational Intelligence eBook and my Organizational Intelligence workshop.

See also

Brian Robertson, The Sociocratic Method. A Dutch model of corporate governance harnesses self-organization to provide agility and a voice to all participants (Strategy+Business Aug 2006)

Steve Waddell, Wicked Problems, Governance as Learning Systems (Feb 2013)

Updated 1 March 2013

Expert Generalists and Innovative Organizations

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What do the great innovators have in common? Looking at examples from Picasso to Kepler, Art Markman calls these men expert generalists. They seem to know a lot about a wide variety of topics, and their wide knowledge base supports their creativity.

Markman identifies two personality traits that are key for expert generalists: Openness to Experience and Need for Cognition. Can we also expect to find these traits in innovative organizations?

Openness to Experience entails a willingness to explore new ideas and opportunities. Obviously many organizations prefer to stick with familiar ideas and activities, and have built-in ways of maintaining the status quo.

Need for Cognition entails a joy of learning, and a willingness to devote the time and effort necessary to master new things. 

In his post on the origins of modern science, Tim Johnson compares the rival claims of magic and commerce. He points out that good science is open whereas magic is hidden and secretive; he traces the foundations of modern science to European financial practice, on the grounds that markets are social, collaborative, open, forums. But perhaps it makes more sense to see modern science as having two parents: from magic it inherits its Need for Cognition, a deep and passionate interest in explaining how things work; while from commerce it inherits its Openness to Experience, a broad fascination with the unknown. Obviously there have been individual scientists who have had more of one than the other, and some outstanding individual scientists who have excelled at both, but the collective project of science has relied on an effective combination of these two qualities.

Read more »

Expert Generalists and Innovative Organizations

by

What do the great innovators have in common? Looking at examples from Picasso to Kepler, Art Markman calls these men expert generalists. They seem to know a lot about a wide variety of topics, and their wide knowledge base supports their creativity.

Markman identifies two personality traits that are key for expert generalists: Openness to Experience and Need for Cognition. Can we also expect to find these traits in innovative organizations?

Openness to Experience entails a willingness to explore new ideas and opportunities. Obviously many organizations prefer to stick with familiar ideas and activities, and have built-in ways of maintaining the status quo.

Need for Cognition entails a joy of learning, and a willingness to devote the time and effort necessary to master new things. 

In his post on the origins of modern science, Tim Johnson compares the rival claims of magic and commerce. He points out that good science is open whereas magic is hidden and secretive; he traces the foundations of modern science to European financial practice, on the grounds that markets are social, collaborative, open, forums. But perhaps it makes more sense to see modern science as having two parents: from magic it inherits its Need for Cognition, a deep and passionate interest in explaining how things work; while from commerce it inherits its Openness to Experience, a broad fascination with the unknown. Obviously there have been individual scientists who have had more of one than the other, and some outstanding individual scientists who have excelled at both, but the collective project of science has relied on an effective combination of these two qualities.

Read more »

Is Organizational Integration a Good Thing?

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Some members of the UK Government are keen on integrating health and social services. In his first speech as Minister of State for Care Services, @NormanLamb said

“The consensus behind integrated care is pretty universal. In government,
in think tanks, in patient groups everyone sees it as A Good Thing.” (Transcript of speech at @TheKingsFund, 11 September 2012)

And Junior Health Minister Dan Poulter is just as passionate. Integration of NHS and social care “is like the holy grail”, he told the Guardian recently (30 Oct 2012).

But not everyone agrees. Jane Young is a disability consultant and campaigner. She asks Would the integration of health and social care promote independent living?
(Guardian 8 Nov 2012), and argues that it would not.

“Rather than medical treatment, disabled people need assistance to
perform such varied everyday tasks as driving, bathing, dressing,
typing, cooking, parenting activities etc. None of these functions
is normally carried out by medically trained professionals, so on this
basis it is illogical for the Department of Health to be wedded to the
integration of health and social care services.”

Meanwhile Jeremy Hunt, the Secretary of State for Health, sounds an ambivalent note.

“But structures are only a means to an end.  What really matters is better health and care outcomes.” (25 October 2012)

 What are the problems that integration might tackle. There are many symptoms of poorly joined-up services. Jonathon Tomlinson documents some from his practice as an East London GP.

  • Adverse social factors, such as poverty and social exclusion, have a critical impact on
    the efficiency and productivity of healthcare.
  • It is impossible to discuss diabetic control or smoking cessation with
    someone whose housing depends on her benefits which have just been cut.  
  • Patients cannot follow routine healthcare advice when their lives are disorganized as a result of financial stress, or when they cannot afford to pay for prescriptions.
  • Hospitals, clinics and surgeries are full of people who don’t know where else to go. Hospitals beds are blocked by patients who lack sufficient social
    support for them to be cared for elsewhere. 
    Hospital staff report readmitting the same patients week after week
    because they cannot cope at home.

Based on: A perfect storm: welfare meets healthcare (June 2012)
(slightly reworded)

I agree with Jeremy Hunt that outcomes matter more than structures. Obviously this covers the individual needs of patients and their carers, but also includes broader economic and social outcomes, such as higher quality and value-for-money, to be achieved through innovation and leadership.

Hunt describes integration in terms of “a culture of cooperation”, “meaningful contact” (e.g. between GPs, consultants, local authorities and social care providers) and “bringing people together”. But how are these things to be achieved? By better processes? By heroic leadership? Hunt merely appeals to new structural mechanisms – specifically the Health and Wellbeing Boards, and Healthwatch – which will somehow bring about a sufficient level of “meaningful contact”.

I presume that Jane Young has no objection to some level of “meaningful contact”. Her main objection to “integration” seems to be that she doesn’t want to see the Department of Health managing services that do not require medical training, thereby implying that organizational boundaries should be primarily aligned to skills rather than outcomes.

But it seems to me that “meaningful contact” alone cannot bridge the structural barriers to joined-up care. If patients are getting the wrong (expensive and inconvenient) care package because there isn’t funding for the right care package, this needs to be addressed during the budgeting and commissioning phase, not by better coordination in the delivery phase. Surely we need to start by understanding what overall capabilities and processes are required for effective management and delivery and governance of care, before we start allocating responsibility for these capabilities and processes to various agencies.

Let me just take a step back for a moment. Something
called “integration” is being put forward as a structural solution to
some set of problems. But there is a great deal of confusion about what
“integration” actually means, what this “integration” might achieve, and
whether there are any unpleasant side-effects. Some people may think that “integration” between A and B merely means establishing effective channels of communication between A and B, while others may think “integration” means shared planning and commissioning, integrated governance, or even full merger.

In my
opinion, structural solutions to complex problems is (or should be) the
job of the business architect, and I believe that business architecture
can play a vital role in clarifying the requirements for “integration”
and working out the practical details. So we need to apply some of
the business architecture viewpoints to thinking about the integration
of care.

We might imagine that the ultimate in integration would be to put all healthcare and social care into a single monolithic organization, but there needs to be some differentiation of structure even within an apparently monolithic organization, so that would merely reframe the problem rather than solving it. There is still a challenging architectural question – what structuring and organizational design principles to use for carving up responsibilities and negotiating exchanges between different units.

There is nothing logically wrong with the idea that
responsibility goes with expertise, as Jane Young favours, except for the fact that it doesn’t deal with the observed symptoms. Evidence-based healthcare is taken very seriously, and there would be strong objection to applying some quack nostrum without proper study, but the evidence base for organizational change in the NHS seems to be very much weaker.

See my earlier posts Resistance to Architecture and Illusion of Architecture.

(Update) Of course integration is not just a concern for the public sector. Compare the latest changes in leadership at Microsoft “aimed at
ensuring the firm continues to be a dominant player in the sector”. Microsoft CEO Steve Ballmer said “The products and services we have delivered to the market in
the past few months mark the launch of a new era at Microsoft. To continue this success it is imperative that we continue
to drive alignment across all Microsoft teams, and have more integrated
and rapid development cycles for our offerings.” (BBC News 13 November 2012) See my post Functional Organization at Microsoft (Nov 2012)

This is one of a series of posts on The Purpose of Business Architecture.

By the way, places are still available on my Business Architecture Workshops (January 29th-31st)

CoProduction and OrgIntelligence in Healthcare

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At @TheKingsFund today for a workshop on implementing healthcare reforms, with particular focus on the introduction of Health and Well-Being Boards. In this blogpost, I want to pick up the topic of Co-Production, which may appear at three logical levels:

  1. Healthcare delivery (orchestration and service delivery)
  2. Healthcare planning (commissioning and service design)
  3. Strategic healthcare development (experimentation, innovation and learning)

There are various versions of Co-Production in the literature, in Healthcare and in other domains, but there are several related themes.

  • Services rely as much upon the unacknowledged knowledge, assets and efforts of service ‘users’ as the expertise of professional providers (Elinor Ostrom, via Wikipedia)
  • Collaborative co-production requires users to be experts in their own circumstances and
    capable of making decisions, while professionals must move from being fixers to facilitators. (Health Foundation)
  • Sharing experiences, mutual aid, mutual problem-solving, shared ownership (Guardian)
  • Combining professional and lay perpectives (Owens)

    Coproduction provides a very interesting example of what I call organizational intelligence, involving a connected set of information gathering, feedback and learning loops. Paying attention to these collective intelligence loops helps us see how effective patient participation and coproduction should contribute to the quality and productivity of healthcare delivery, healthcare planning and healthcare strategy.

    @BenP1972 tweeted that this sounded like a job for @patientopinion … “must b other existing models where feedback and user experience transformed service offering”. Meanwhile @PatientVoicesUK quoted Donald Schön (1988) “Storytelling is the mode of description best suited to transformation in new situations of action.”

    Storytelling and sensemaking are vital elements of organizational intelligence. Professionals are trained to see the world according to a fairly prescribed set of narratives. These narratives give them considerable expertise and power, but they may also constrain thinking. For example, so-called “evidence-based medicine” may be dominated by professionally approved modes of evidence (double blind or triple blind studies) and it may be hard to accommodate the patient experience in this process. Interaction between different professional disciplines, together with the interjection of the (lay) patient voice, potentially brings in a much richer diversity of narratives.

    But this diversity in turn calls for greater organizational intelligence – the collective ability to create a meaningful synthesis. What are the (organizational, political, cultural) conditions for successfully and flexibly integrating patient thinking with professional thinking?

    Sources

    Becky Malby, Involving service users in design: Four steps to co-production (Guardian, Aug 2012)

    John Owens, Conflict in medical co-production: The challenge of combining professional and lay perspectives (Centre for Public Policy Research)

    Alba Realpe and Louise M Wallace, What is co-production? (Health Foundation, 2010)

    Wikipedia: Coproduction (public services) 

    Richard Veryard, Organizational Intelligence Primer (LeanPub, 2012) 

    The Meaning of Iteration

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    There is a curious ambiguity about the word “iteration”. Sometimes it means doing exactly the same thing, over and over again; sometimes it means doing something slightly different each time.

    When a process is drawn as a loop, we need to understand wh…

    The Illusion of Architecture

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    #bizarch #entarch @hspplease Following my post on the Resistance to Architecture within the National Health Service, I came across this cynical remark by Tony Riley of the Health Solutions Partnership.

    “We really don’t know why the term ‘healthcare c…