Archivi del mese: gennaio 2013

Physician credentialing needs better standardization @Medici_Manager @kevinMD


There is one aspect of our relentlessly rising healthcare costs that seems particularly out of control — administrative costs. An interesting editorial ( in the New England Journal of Medicine provides some sobering details.

Every physician confronts daily the burden of dealing with healthcare bureaucrats of various sorts. The average doctor personally spends 43 minutes each day at it, and behind every physician there is an army of coders. They all communicate (inefficiently) with another army of insurance company employees and Medicare and Medicaid workers. What is the added cost of all this baked into the system? Do we have any idea? Can we do anything about it?

The Institute of Medicine, a component of the National Academy of Sciences, estimates the yearly administrative costs to be 361 billion dollars. This is a staggering sum — twice the amount of money we spend on heart disease and three times what we spend on treating cancer. Can we do anything about this?

Many have suggested that a single payer system would be the obvious answer, since providers would not be dealing with dozens of insurance and governmental entities. Although this is my view, I realize that right now it is just not politically feasible. It is the standardization of methods and procedures that matters most. The question, as well laid out by the editorial authors, is if we can reap some of the benefits of standardization without a single payer system? The authors think we can, and I agree.

One issue that really, really needs better standardization is physician credentialing. Each healthcare entity, be it a hospital or a payer, has its own way and standards of reviewing the credentials of physicians. And believe me, it’s a mess that just gets worse and worse. I have practice privileges at several hospitals and medical licenses in several states. Each one of these has its own, often idiosyncratic, standards for credentialing physicians, and these credentials need to be redone every couple of years. The process takes many hours and causes many headaches. There are national databases that keep relevant information about physicians — medical school and residency information, medical license information, information on disciplinary actions. You might think this would have made the process faster, but it just added another layer to the mess. Hospitals spend millions of dollars duplicating work that has already been done. It’s crazy.

Credentialing and other systems that are used to establish contracts between providers and health plans are riddled with redundancy, with many organizations collecting virtually identical information from providers. The typical physician spends more than 3 hours annually submitting nearly 18 different credentialing forms, with staff spending an additional 20 hours.

This sort of craziness is found all through the system (which really isn’t a system at all) that we have. The editorial’s authors go on to suggest several useful things which, if implemented in the context of the Affordable Care Act, would save billions:

The possibilities for reducing administrative complexity are immense. The reforms we describe could save as much as $20 billion annually for providers (roughly $29,000 per physician), or $40 billion annually for all stakeholders. And $2 billion of these savings would accrue to the federal government — a relatively small but valuable contribution to reducing the deficit. For the individual physician, these savings could translate into more time and resources for direct patient care — and therefore into improved professional satisfaction.

As we look for ways to make our healthcare system more efficient, this sort of thing truly is low-hanging fruit. It wastes resources we should be putting toward patient care.

Christopher Johnson is a pediatric intensive care physician and author of Your Critically Ill Child: Life and Death Choices Parents Must FaceHow to Talk to Your Child’s Doctor: A Handbook for Parents, and How Your Child Heals: An Inside Look At Common Childhood Ailments.  He blogs at his self-titled site, Christopher Johnson, MD.

The Effective Health Care Program (AHRQ) @Medici_Manager

Comparative effectiveness research is designed to inform health-care decisions by providing evidence on the effectiveness, benefits, and harms of different treatment options. The evidence is generated from research studies that compare drugs, medical devices, tests, surgeries, or ways to deliver health care.

There are two ways that this evidence is found:

  • Researchers look at all of the available evidence about the benefits and harms of each choice for different groups of people from existing clinical trials, clinical studies, and other research. These are called research reviews, because they are systematic reviews of existing evidence.
  • Researchers conduct studies that generate new evidence of effectiveness or comparative effectiveness of a test, treatment, procedure, or health-care service.

Comparative effectiveness research requires the development, expansion, and use of a variety of data sources and methods to conduct timely and relevant research and disseminate the results in a form that is quickly usable by clinicians, patients, policymakers, and health plans and other payers. Seven steps are involved in conducting this research and in ensuring continued development of the research infrastructure to sustain and advance these efforts:

  1. Identify new and emerging clinical interventions.
  2. Review and synthesize current medical research.
  3. Identify gaps between existing medical research and the needs of clinical practice.
  4. Promote and generate new scientific evidence and analytic tools.
  5. Train and develop clinical researchers.
  6. Translate and disseminate research findings to diverse stakeholders.
  7. Reach out to stakeholders via a citizens forum.

Common questions about comparative effectiveness research

Q: Why is comparative effectiveness research needed? What problem is it trying to solve?

  • If you don’t get the best possible information about your treatment choices, you might not make an informed decision on what treatment is best for you.
  • When you shop for a new car, phone or camera, you have lots of information about your choices. But when it comes to choosing the right medicine or the best health-care treatment, clear and dependable information can be very hard to find.
  • It’s true that some treatments may not work for everyone, and that some treatments may work better for some people than others. This research can help identify the treatments that may work best for you.

Q: What are the practical benefits of comparative effectiveness research?

  • You deserve the best and most objective information about treating your sickness or condition. With this research in hand, you and your doctor can work together to make the best possible treatment choices.
  • For example, someone with high blood pressure might have more than a dozen medicines to choose from. Someone with heart disease might need to choose between having heart surgery or taking medicine to open a clogged artery. Reports on these topics and others include the pros and cons of all the options so that you and your doctor can make the best possible treatment decision for you or someone in your family.
  • Every patient is different — different circumstances, different medical history, different values. These reports don’t tell you and your doctor which treatment to choose. Instead, they offer an important tool to help you and your doctor understand the facts about different treatments.

“Choosing Wisely”: Physicians Step to the Front in Health Care Reform @Madici_Manager

The war-torn landscape of health care policy debate has left much of the public confused and frightened. At the center has been the Affordable Care Act, promising broader coverage for the uninsured and a better deal for people who have insurance, but under continuing barrage in Congress, the courts, and the media. Combined with the certain knowledge that health costs are far too high, this conflict leaves average people wondering what they will lose, and when.

Silver linings are in short supply, but one appeared last week in the form of a new initiative called “Choosing Wisely,” catalyzed by the American Board of Internal Medicine Foundation. Its goal is to identify medical interventions — like tests, procedures, drugs, and even surgery — that are often overused without benefit to patients, and, in their words, “whose necessity should be questioned and discussed” between physicians and their patients. For this initiative, the ABIM Foundation worked with specialty societies, such as the American College of Cardiology and the American College of Radiology — nine societies so far and more to come — to identify “Five Things Physicians and Patients Should Question” in each specialty. For example, the American College of Radiology included, “Don’t do imaging for uncomplicated headache,” in its list; the cardiologists included, “Don’t perform stress cardiac imaging or coronary angiography in patients without cardiac symptoms unless high-risk markers are present.”

Blunt, unfeeling cuts in health care benefits, coverage, or payments are one way to bring health care costs under control, but they are not the right way. Far better is to identify the many ways in which health care wastes money doing things that do not help patients and, too often, hurt them. But, public officials or payers are not trusted to point that out; when they try to call attention to harmful overuse of care, they are tarred as favoring “rationing,” even when their motives are to help patients and the science is strong.

But, “Choosing Wisely” is a game-changer. The advice comes not from payers or politicos, but from pedigreed physician groups. The specialty societies are not guessing; their lists of procedures contain copious scientific citations supporting the claims of overuse. Their advice earns further trust because, in many cases, by suggesting that physicians and patients think twice before using certain tests and treatments, the specialty societies are speaking against their own economic self-interest, which in fee-for-service payment attaches income to volume. The American College of Gastroenterology, for example, recommends certain limits on colonoscopy frequency, even though more colonoscopies mean more income.

As one would predict and hope, the organizations carefully couch their recommendations in terms that leave room for doctors and patients to customize care to individual circumstances; they are, correctly, suggestions, not handcuffs. Payers, even while they celebrate this step of professional leadership, should exercise restraint in converting these lists into hard-wired payment rules.

However, these lists do no good if they remain on paper, only. The ABIM Foundation, these forward-thinking specialty societies, and many other professional groups should now help physicians, nurses, and other clinicians take concrete, local steps to reduce harmful overuse of ineffective care. And, equally important, these same physician-leaders ought to let the American public know boldly, repeatedly, and through every possible channel that asking questions about the need for and effectiveness of these practices is in each person’s self-interest. If physicians and nurses explain it, the public can come to understand that avoiding unhelpful care is not rationing, but rational. It is a way to make sure that all Americans can get all of the care that helps them; avoiding care that hurts makes American health care more affordable. Happily, Consumer Reports, AARP, and other organizations representing the lay public are connecting tightly to “Choosing Wisely.”

We are witnessing a horse race between those who would simply cut care and those, like me, who believe firmly that we can improve our way out of unsustainable costs. Overuse of unhelpful care is just one category of costs we ought not to agree to, but it is a fine place to start.

Recommended Reading: Reflecting on the Choosing Wisely Journal Articles of 2012 @Medici_Manager @ABIMFoundation

Written by Amy Cunningham on December 21, 2012

Since nine medical specialty societies announced their lists of “Five Things Physicians and Patients Should Question” in April, 55 published journal articles have referenced the Choosing Wisely® campaign. For the final Recommended Reading post of 2012, we’ve culled a selection of those articles, and will share more in the new year.

In order of publication date:

  • In From an Ethics of Rationing to an Ethics of Waste Avoidance, Howard Brody argued for a stepwise strategy to eliminate unnecessary care given the limitations of comparative-effectiveness research, saying, “it is better first to eliminate interventions for which we have the most solid and indisputable evidence of a lack of benefit.”
  • In Application of “Less Is More” to Low Back Pain, the authors found strong evidence supporting the American Academy of Family Physicians’ recommendation as part of theChoosing Wisely campaign, “Don’t do imaging for low back pain within the first 6 weeks unless red flags are present.” The article was accompanied by a commentary by ABIM Foundation Executive Vice President and Chief Operating Officer Daniel Wolfson.
  • In the New England Journal of Medicine article, A Systemic Approach to Containing Health Care Spending, Ezekiel Emanuel, MD, PhD and co-authors outlined a number of recommendations for bending the health care cost curve, including the development of credible practice guidelines.
  • British Medical Journal piece on unnecessary care said that a “newly launched movement lead by prominent doctors is challenging the basic assumption in U.S. healthcare that more is better” and cited Choosing Wisely as part of the movement
  • Authors of a JAMA commentary mentioned the Choosing Wisely campaign as one of several recent initiatives addressing the physician’s role in health care expenditures. They then call for a new model of medical education that celebrates restraint in ordering health care tests and procedures.
  • An Annals of Internal Medicine piece discussed the potential impact of Choosing Wisely recommendations for radiology and argues, “Current campaigns that draw attention to overuse of imaging studies coupled with greater physician knowledge and use of the criteria for appropriate imaging can help to ensure a further reduction in unnecessary testing—a result that would benefit both patients and our health care system.”
  • In Choosing Wisely: Low-Value Services, Utilization, and Patient Cost Sharing, researchers from the University of Pennsylvania reflected on the Choosing Wisely campaign and asked, “But if it is difficult in many situations for patients to choose wisely, and if there are significant challenges in getting physicians to choose wisely, then who should be doing the choosing?”

We look forward to continuing the conversations on professionalism and Choosing Wisely in 2013, and wish our readers a happy and healthy new year.

Six memos on the future of healthcare @Richard56 @Medici_Manager

31 Dec, 12 | by BMJ Group

Richard SmithHow many of us can expect a year after we die to have some 500 people attend a meeting to celebrate our life, discuss our work, and think about the future agenda that flows from our work? “Almost none of us” is the answer, but it happened for Alessandro Liberati in Bologna in December. Most of us in the audience knew Alessandro personally, and we were celebrating not only his work but his great personal warmth. He was fun to be with, and his warmth and ideas have been captured in a video filmed over two days at Forte Dei Marmi when shortly before he died he sat with his friends and talked. The video will be available online soon.

Alessandro founded the Italian Cochrane Centre and promoted evidence based healthcare and policy in Italy. He was passionate that research should be relevant to patients’ problems and easily available to them, and these passions were strengthened by the poor quality of research and the unavailability of evidence on the myeloma that eventually killed him. Several speakers during the day quoted the letter he published in the Lancetshortly before his death in which he wrote: “How far can we tolerate,” he wrote, “the butterfly behaviour of researchers, moving onto the next flower well before the previous one has been fully exploited.”

The friends of Alessandro who organised the meeting had the interesting idea of constructing the day around Italo Calvino’s  Six Memos for the Next Millennium. Calvino is one of the most original and unusual writers there has been, and his book comprises five of the six lectures he was due to give at Harvard in 1985-6. He died before he could give the lectures, but he had written five and thought about the sixth. They all have one word titles—lightness, quickness, exactitude, visibility, multiplicity, and the unwritten consistency—and they are all built around books. The past millennium, write Calvino, was “the millennium of the book. In that it [saw] the object we call a book take on the form now familiar to us.” He thought about the future of the book confident in the future of literature because of “the knowledge that there are things that only literature can give us, by means specific to it.”

Some mental gymnastics were needed to relate medical knowledge and Alessandro’s ideas to these themes, but the two dozen or so speakers rose to the challenge, some sticking close to Calvino, others concentrating on Alessandro, and some doing their own thing.

Lightness was characterised as “removing weight” and avoiding dogmatism. Alessandro was strongly opposed to dogmatism, which has been a failing of some zealots for evidence based medicine. He believed as well in a light style of writing, often using the first person and aiming for the opposite of what Micheal O’Donnell famously called “decorated municipal gothic,” the favoured style of the pompous, a large group within medicine. Medicine too should be light, concentrating on what can bring benefit to patients, and avoiding the overdiagnosis and overtreatment that are now weighing it down.

Quickness or rapidity can be a problem for those who believe medicine and health policy should pay close attention to systematic reviews because such reviews take a long time. Policymakers often want evidence quickly, and systematic reviewers must balance providing the evidence they need with producing reliable reviews. Researchers might be able to do better by thinking harder about the opportunity costs of not supplying evidence and the risks of getting advice wrong.

Exactitude is difficult for clinicians because healthcare is characterised by uncertainty. There is more that we don’t know than we do know.  It is important not only to be clear about what we don’t know, healthcare’s uncertainties, but also to develop mechanisms to help doctors and patients prioritise the uncertainties that should be addressed through research. The James Lind Alliance has helped people do this, and Testing Treatments Interactive is an inspiring and sometimes amusing website that helps people understand how treatments can be tested. This understanding is worth having because an important systematic review recently published in the Cochrane Library showed that new treatments are hardly any better than existing ones.  Progress is slow and possibly an illusion.

Systematic reviews could be said, however, to aim at some kind of exactness, and Alessandro weighed in on their behalf in some fierce intellectual battles. Alvan Feinstein, one of America’s leading epidemiologists, argued in the Journal of Clinical Epidemiology in 1995 that systematic reviews were just the modern equivalent of alchemy, trying through dubious methods to create intellectual gold from rubbish. Alessandro argued against him in the same journal and gave as good as he got, and history has come down on his side. (This debate was played out again in a less intellectual, but more gladiatorial and show business form between me and one of the editors of the New England Journal of Medicine, which took Feinstein’s view, at the Cochrane Colloqium in Rome organised by Alessandro.)

Impossible to intimidate, Alessandro also debated with Hans-Georg Gadamer, a leading German philosopher, who argued that the relationship between a patient and a doctor was more important than the discipline of medicine or the evidence. Alessandro retorted that this was a false dichotomy.

In his essay on visibility Calvino discusses the question of the priority of the visual image or verbal expression. He leans towards the visual image, and when asked to think of health systems people, I suspect, see doctors in white coats, surgeons operating, and large, sparkling hospitals.  Some four fifths of people in all countries also think of medicine as an exact or almost exact science. These images were destroyed in a session that showed how health systems are actually characterised by complexity, uncertainty, opacity, poor measurement, variability in decision making, asymmetry of information, conflict of interest, and corruption. I’ve already blogged on this session, and as of today (29 December) the short blog has been Tweeted some 200 times, suggesting it struck a chord.

I spoke on multiplicity and the core of my argument, which I must confess was far from coherent, was that everything is connected to everything else and that most of the time the many will do better than the few. I plan a separate blog on this.

Calvino never wrote his essay on consistency, but we were taken back at the meeting to an earlier lecturer in the same Harvard series—Leonard Bernstein, the great American conductor and composer. Bernstein talked about the crisis in music in the first decade of the 20th century when Wagner and Liszt had pushed traditional musical systems to their limits. Then came atonality with the fear that music would collapse into anarchy, noise. In fact new and beautiful music emerged, showing how there can be at least two forms of consistency.

Consistency matters in public health as well as music, and Austin Bradford Hill described consistency as one of the features that suggests not simply association but causality.  But we were reminded that results that might seem inconsistent might actually be consistent on deeper analysis.

This very special day, which Alessandro’s widow and two daughters attended, ended with the federal minister of health paying tribute to Alessandro. He had driven across the Apennines from Rome specifically for the meeting. The whole day was captured on video, and you can learn and see more on the Facebook site.

Competing interest: RS spoke at the meeting and had his expenses paid by the health department of Emilia-Romagna.  He was a friend of Alessandro Liberati, and when RS was editor of the BMJ and chief executive of the BMJ Publishing Group there were both intellectual and business collaborations between the group and enterprises involving Alessandro.

Bologna on La Sanità tra Ragione e passione (Health through reason and passion). The meeting was held to celebrate the life and work of Alessandro Liberati, the founder of the Italian Cochrane Centre, who died last year.

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.

Posted in Richard Smith.

What Being an “Authentic Leader” Really Means @Medici_Manager

by Charalambos Vlachoutsicos  |  12:00 PM December 7, 2012

Being an effective manager requires that you behave authentically. “Why?” you might ask. “Maybe the ‘real me’ isn’t the most effective boss, but if I can just act the way an effective boss should act and get good results, what’s wrong with that?”

In my experience, two things are wrong with that, and they both amount to the same thing: It almost certainly won’t work. First, it won’t work because, sooner or later, the people who work for you and with you will see through it. Even if your leadership and your instructions are sensible and productive people will feel uncomfortable with someone who doesn’t really mean what he or she says.

Second, trying to act like a different kind of person than you really are won’t work because you yourself will not be able to keep it up day after day, year after year. Your words and your body language as well as your actions and decisions will reveal that you are not what you present yourself to be and people will be more and more reluctant to trust you as a leader. In both ways, then, “authenticity” is as much a practical virtue as an ethical one. You simply won’t be able to lead effectively if people perceive you as disingenuous.

Students are often worried — at first — about my emphasis on authenticity. “Isn’t being your true self a license to say whatever you think and vent whatever you feel at a particular moment?” It seems obvious to them that this would cause at least as many problems as it solves — and, of course, they are right. Being your true self is not the same as being spontaneous. It is one thing to be authentic, quite another to “shoot from the hip.”

Let’s imagine, for example, that you are running a brainstorming meeting and someone comes up with an idea that you think is pretty stupid. Let’s also imagine that patience is not your strong suit, so you shoot back with something like: “That’s a dumb idea.” Not very nice, but you’re the boss and in a way, it is authentic, isn’t it?

Now let’s imagine a different response to your subordinate’s idea. You have learned — from experience, practice, and your self-awareness — that your impatience with that idea might well be a signal that you don’t understand what your subordinate really meant. If you knew more about what he was thinking, his idea might not seem so stupid.

With that in mind, you control your impulse — authentic as it is — to snap at him. Instead you hand the controls over to your other impulse — also authentic — to act in a spirit of mutual respect and grant that your subordinate might have something valuable to offer which escapes you. So you say something like, “I don´t understand what you mean by this. Can you tell us more about it?”

So which of these two authentic responses should you choose?

First of all, it should be the one that reflects more of you. The “dumb idea” response only reflects your feeling that the idea doesn’t make sense and it fails to reflect your awareness that you might not know what the person really means. Indeed, the immediate feeling that someone else is being stupid very often stems from the irritation that we feel when we don’t understand what the other person says or does. And an irritating idea is not necessarily a stupid idea.

With the “tell me more” response, however, you are reflecting yourself more truly. You admit honestly that you don’t always understand everything immediately and, most importantly, you express your inner value of fairness.

It’s not only more authentic, it’s also more effective, which is the whole point of authenticity. The spontaneous offensive response would inhibit the free flow of ideas in the meeting. Even if the other people there agree with you that their colleague’s idea is stupid, they’re not going to be so quick to stick their own necks out in the future. You might well lose out on good ideas and important information. Thus, failure to differentiate authentic from unthinkingly impulsive behavior is likely to undermine the basic project which authenticity serves; namely, establishing and sustaining effective managerial interaction.

The second response will have just the opposite effect. Even if the other people there think that their colleague’s idea is stupid, to see that he didn’t get his head chopped off for that will assure them that they need not be nervous about expressing their ideas openly. They will be more likely than ever to offer you whatever ideas and important information they have. Thus, your leadership will be much more effective.

You might wonder: Would it have been an even better idea to pretend to like the dumb idea, just for the sake of encouraging everyone to share their ideas freely? No, it wouldn’t. If the idea really is a bad one, as it might well be, it’s likely that most of the other people there can see that, too. Pretending to appreciate it will strike a false note and people will get confused and suspicious as they try to figure out what you are really up to. That would certainly not be conducive to effective managerial interaction.

It is crucial to recognize that authenticity is a social ability. Implicit in the concept of being authentic — “being actually what is claimed” — are qualities of interactive behavior. We regard a person as authentic to the extent that her conduct towards others accords with what she truly believes in. Authenticity, then, is about giving a message about your true self — one you must continually shape and deliver by thoughtfully choosing your words and behaviors to suit the people you interact with and the specific purpose at hand.

Charalambos Vlachoutsicos


A former businessman and consultant, Charalambos A. Vlachoutsicos is an Adjunct Professor at Athens University of Economics and Business in Greece.

When is it Time to Pivot or Quit? @Medici_Manager @timkastelle

Entrepreneurs aren’t quitters. To succeed you need to be resilient, thick skinned and borderline crazy. You need to have just the right amount of delusion to believe you can succeed, spurring you on despite the absurd odds. But sometimes, you have to quit.

On the other hand, sometimes you need to pivot. Unfortunately, many entrepreneurs use the pivot as an excuse to remain delusional and shift their fleeting attention to something else, after the slightest setback. Alistair Croll calls this the “lazy pivot.” Truth be told, most of these “lazy pivots” aren’t really pivots, they’re “do-overs.” Pivots and do-overs work, but not when they’re done with a minimal amount of effort and rigor.

So, when should you pivot or quit?

It’s a hard question to answer, and for each individual it’s going to be a bit different. There are examples of entrepreneurs sticking things out through really dark days and coming out years later with an “overnight success.” Other entrepreneurs pivot or change businesses entirely and win. There are no absolutes. But speaking with an entrepreneur yesterday about this very topic, here’s what I suggested:

1. Be pragmatic and intellectually honest with yourself.

The best way to poke a hole in your reality distortion field is to use practical, straightforward tools to evaluate your progress. Take the Lean Canvas as an example. If you look at your Lean Canvas, can you honestly say you’ve got enough of the answers to keep going? Do you really understand the problem you’re trying to solve? Do you really know if the solution is right? Do you understand the channels to market? Do you have an unfair advantage?

Answer those questions with as much truth as you can muster and the patch is clearer.

Metrics can help as well. Here’s a rough draft of the Lean Analytics Cycle that Alistair and I are including in our book, Lean Analytics:

Lean Analytics cycle

It provides a basic framework for focusing on what’s important, testing things, and then measuring results.

To pivot, you need to have learned something through your previous efforts that gives you clues as to where you should focus. You can’t pivot without some form of validated learning and new assumptions. If you don’t have new insight that gives you even a hint of a direction, you need to really question whether it’s worth continuing. Pivoting for the sake of pivoting isn’t the answer (although you can get lucky…)

Before you pivot, you still need to look at the emotional side of things.

2. Do you care anymore?

Let’s say you’ve found something interesting that you think you can pivot to from your current business. Before doing so, you have to ask yourself whether you’re passionate about the new idea/problem/market/etc. If you’re not, it’ll be tough to succeed, even if you have proof that pivoting is the right move.

I’ve met quite a few people (it’s happened to me too) that get so lost in what they’re doing, and they invest so much into it, that they actually forget why they got into the business in the first place. So as you investigate the potential of a pivot, you have to ask yourself, “Why am I even going to do this? Will I be passionate about this new thing?”

If the answer is yes, you pivot. If the answer is no, you stop.

Maybe you take a step back to reevaluate, give yourself some time to breathe and think … or maybe, it’s time to quit, admit defeat, lick your wounds and come back another day to fight the fight once more.

Pragmatism + Passion (or Lean + Guts)

Lean Startup provides the framework for helping you make honest, pragmatic decisions about your progress and what to do next. You know if you’re not making fast enough progress. You don’t need someone else to tell you that. And you know if you’ve gained any insights worth exploring further or if you’re at a dead end. The pivot is either there and fairly obvious or it’s not. If you get into fabricating pivots wildly, you need to rethink your strategy.

At the same time, entrepreneurs don’t do anything without their guts. We need our guts, our instincts and our delusions to drive us off cliffs without any parachutes. Guts matter; you’ve just got to test them. Instincts are experiments. Data is proof.

If you get to the point where you don’t know what to experiment on anymore, and you’ve lost your purpose (in terms of why you started the business in the first place), you need to seriously look at shutting it down. If you don’t know what to do anymore, pragmatically, but you’ve still got a fire in your belly for what you set out to do, take a break and look for a restart. Don’t hang on, experimenting for the sake of experimenting, pivoting for the sake of pivoting. Pivot when you know what you’re pivoting to, quit if you don’t.

As a quick aside, the book that Alistair and I are writing about Lean + analytics is almost finished! I’m excited (and nervous!) about getting it into people’s hands. Publication date is April 2013. In the meantime, you can pre-order it here: Lean Analytics: Use Data to Build a Better Startup Faster

Private healthcare: the lessons from Sweden @Medici_Manager

On Kungsholmen, one of the islands on which the Swedish capital Stockholm is built, stands what some consider to be the future of National Health Service under David Cameron: St Göran, a six-storey redbrick hospital that makes profits from the state by treating patients.

Emblazoned with the name of its corporate manager, Capio – rather than the Swedish state, which constructed it – the hospital has for a decade been the mascot of pro-market Scandinavian policies that are widely admired by the coalition in Westminster.

Despite its reputation as a leftwing utopia, Sweden is now a laboratory for rightwing radicalism. Over the past 15 years a coalition of liberals and conservatives has brought in for-profit free schools in education, has sliced welfare to pay off the deficit and has privatised large parts of the health service.

Their success is envied by the centre right in Britain. Despite predictions of doom, Sweden’s economy continues to grow and its pro-business coalition has remained in power since 2006. The last election was the first time since the war that a centre-right government had been re-elected after serving a full term.

As the state has been shrunk, the private sector has moved in. Göran Dahlgren, a former head civil servant at the Swedish department of health and a visiting professor at the University of Liverpool, says that “almost all welfare services are now owned by private equity firms”.

Thanks in part to the outsourcing of the state, Sweden’s private equity industry has grown into the largest in Europe relative to the size of its economy, with deals worth almost £3bn agreed last year. The key to this takeover was allowing private firms to enter the healthcare market, introducing competition into what had been one of the world’s most “socialised” medical systems.

Business-backed medical chains have sprung up: patients can see a GP in a centre owned by Capio, be sent to a physician in the community employed by Capio, and if their medical condition is serious enough end up being treated by a consultant in a hospital bed in St Göran, run by Capio. For every visit Capio, owned by venture capitalists based in London and Stockholm, is paid with Swedish taxpayers’ cash.

The company’s Swedish operation now has 4,500 employees, with a turnover of about £500m. Westminster wonks have monitored Capio’s success closely ever since St Göran was allowed to be taken over in 2000. There are now six private hospitals funded by the taxpayer in Sweden, about 8% of the total.

In Britain the coalition has mimicked this approach. Circle, backed by private equity firms, runs Hinchingbrooke hospital in Cambridge. Serco, a FTSE 100 company, is eyeing the George Eliot hospital in Nuneaton, and two hospitals may be privatised in south London as a result of bankruptcy.

Dahlgren says: “The difference between Sweden and England is thatprivatisation of a hospital was only considered when you had big financial problems. St Göran was considered one of the best when it was sold.”

Capio’s executives dispute that they have simply “made the best better”. They say they focus on improving standards, arguing that only by attracting more patients and managing costs can they make money from healthcare.

During an hour-long presentation to the Guardian, St Göran’s chief executive, Britta Wallgren, says the 310-bed hospital, serving 430,000 people, outperforms state-owned rivals inside and outside the country.

She says emergency patients see a doctor within half an hour, compared with A&E waits of up to four hours in the NHS. “We took an A&E department that dealt with 35,000 patients a year and now treats 75,000,” Wallgren says. “As admissions grow and we have an increasingly elderly population so must our performance improve.”

Capio stresses that St Göran has low levels of hospital-acquired infections, and patient surveys record high levels of public satisfaction. It has also produced year-on-year productivity gains – something the state cannot match. Thomas Berglund, Capio’s president, says the “profit motive works in healthcare” and companies run on “capitalism, not altruism”.

He adds: “We have just won the right to run the hospital again and will have to reduce costs by 120m Swedish krona [£11.2m] over 10 years. That’s our profit gone unless we keep reducing costs here.”

At the busy entrance to the hospital, Swedish patients appear resigned to the end of state ownership in health, once a cornerstone of the country’s generous welfare system.

“I am one of those Swedes who do not agree that private hospitals should exist,” says Christina Rigert, 62, who used to work as an administrator in the hospital but resigned “on principle” when it was privatised a decade ago.

Now back as a patient after gastric band surgery, she says: “The experience was very good. I had no complaints. There’s less waiting than other hospitals. I still do not think there should be private hospitals in Sweden but it’s happening.”

Since 2010 private companies have had the right to set up large GP-style services anywhere in the country – and to be paid for it out of taxpayers’ money. Corporates have set up 200 healthcare centres in two years, although critics point out that the majority have been in wealthier urban areas.

Dahlgren says that inequalities are growing, adding that the law is “fundamentally antidemocratic”. Sweden, he explains, has a long history of local governments deciding where GPs should be sited to ensure poor or rural areas do not lose out.

“The local councils can now neither determine the number of for-profit providers to be financed by taxes nor where these tax-financed services are to be located,” he says. “This is determined by the private providers on the basis of profitability rather than the health need for these tax-financed services. It is remarkably antidemocratic.”

There are distinct differences between Sweden and Britain. Swedish political culture is much more consensual than in Britain, and strongly centred on people choosing where to get healthcare.

Leftwing governments in Sweden, who ran the country for 65 of the last 80 years, promoted patient choice between state-owned hospitals. The real shock was when centre-right governments argued in the 1990s that for patient choice to work, competition and privatisation in healthcare were needed.

The Social Democrats, the main Swedish opposition party, have given up the idea of renationalising the health service and instead argue that profits should be capped and quality of care more tightly regulated. With hardline opposition to private healthcare limited to the far-left parties, Swedes are likely to see more changes.

In Stockholm, more than 500 beds are being removed from the country’s best known health centre, the Karolinska University hospital, and the services are being moved into the community to be run by private companies, a policy that in England would almost certainly lead to demonstrations.

Pro-marketeers argue that companies can improve patient experience at a reduced cost, and expand provision at a time when the state cannot afford to do so. This view was challenged last year when a business-backed research institute, the Centre for Business and Policy Studies, looked at the privatisation of public services in Sweden and concluded that the policy had made no difference to the services’ productivity. The academic author of the report, who stood by the findings, resigned after a public row.

There have also been scandals involving claims of shocking treatment of some patients. Last year Stockholm county council, which controls healthcare for a fifth of the Swedish population, withdrew contracts from a private company after staff in a hospital were allegedly told to weigh elderly patients’ incontinence pants to see if they were full or could be used for longer.

Stig Nyman, a Christian Democrat member of the council instrumental in ushering in a pro-market health policy for 20 years, says he still believes private business is necessary.

Over coffee and biscuits in his modern office amid the 19th-century neoclassical columns of the council building, Nyman dismisses the allegations of mistreatment. “We have hundreds of contracts with private firms. In this case journalists found five or six mistakes. It’s not a big deal.

“In healthcare, companies drive up standards. We pay 5,000 Swedish krona [£465] a patient on average. We force people to compete on the quality of service and treatment.”

Perhaps most damaging for private investors drawn by the potential profits to be made from the state has been the probing of their affairs by tax inspectors. The industry has been under scrutiny since 2007, when a spate of high-profile deals, including the buyout of Capio, led to investigations into financiers.

The charge is that private equity firms siphon profits out of the state’s coffers while avoiding their fair share of taxes. Berglund, of Capio, says: “It is always thrown about that we are not paying taxes but it is not true.”

Swedish tax authorities are, however, taking some companies to court because pay in private equity groups is often linked to the profits made on deals and has been incorrectly taxed for years, it is said, at rates lower than that required for income in Sweden.

Earlier this month one of Capio’s owners, a private equity firm called Nordic Capital, lost a court case against the Swedish tax agency, leavingit with a bill of 672m Swedish krona [£63m]. The authorities, it is reported, will also slap a tax bill collectively of 2.6bn krona on another 34 individuals.

“There has been a strong reaction in Sweden. These people have been paying themselves enormous sums of money,” says Dahlgren. “It should be a worry for every health system where you have competition and private firms arriving.”

Continuity of care. Needed now more than ever. @Medici_Manager @nedwards_1

Abetternhs’s Blog

The political restructuring of the NHS is increasing the range of hospital and community health care providers[1]. This fragmentation of care risks what Michael Balint referred to as the “collusion of anonymity” in which different parts of the patient’s health are cared for by different specialists and consequently important aspects are neglected because they fall outside the specialist’s remit. [2] Consequently, now more than ever, a comprehensive, generalist primary care physician providing continuity of care, is essential.

Continuity of care is the care of an individual patient over time. Various attempts have been made to define continuity, many of which try break down comprehensive continuity of care into subsets of continuity, for example,informational, management and relational continuity.[3]

All subsets are essential components of patient care. Continuity of information on the electronic record and continuity of management through the use of shared guidelines and protocols get more attention because they are more easily assessed than relational continuity which is complex and difficult to measure. Relational continuity is the basis of the doctor-patient relationship and requires doctors and patients to understand each other’s personalities and remember past experiences and not simply recognise professional roles and clinical features. [4]

I  would define relational continuity as the therapeutic relationship between a doctor and a patient, developed over time in which the doctor takes responsibility for coordinating the patient’s care.

In measuring the effects of continuity of care, the question might not be, “Does continuity of care makea difference at a population level?” but rather, “Are there specific subpopulations for which continuity of care is especially valuable?”For most healthy, wealthy, young individuals, contact with aphysician is unlikely to have a measurable impact on their alreadygood health.[5]

Approximately 75% of all GP consultations are with people over the age of 70 and 75% of these people have multiple chronic conditions. In a deprived inner city environment where we work, the incidence of serious mental illnesses, drug and alcohol addiction and chronic stress due to social determinants such as unemployment, poor housing, crime and violence results in high re-attendance rates from a significant proportion of our practice population. For these people relational continuity is particularly important. [6]

Multiple conditions interact in ways that fall outside the remit of clinical guidelines.  For example deterioration in mental health or social stress may result in a patient with diabetes neglecting their diet and medication with a subsequent loss of diabetic and hypertensive control.  Regaining control of one disease is inextricably bound up with recognising and supporting them as they deal with the others. A frail patient with multiple problems may appear to a clinician with whom they have a relationship to look seriously unwell or their usual frail self the moment they walk through the consulting room door depending on their usual appearance and levels of stoicism or distress.

“The implicit choice between personal continuity and modern care is false; what evidence there is suggests that patients prefer services providing personal continuity, and this may also reduce the use of investigations and admissions to hospital”  [7] There is also evidence that improved continuity of care results in better preventative care and lower costs. [8] Other benefits include:

  1. Greater efficiency due to better communication and trust, facilitating information gathering.
  2. Increased safety because communication and awareness of subtle changes not included in the electronic record or clinical guidelines. Many critical incidents we have investigated involve lack of continuity and have resulted in changes to improve relational continuity.
  3. Higher patient satisfaction because of better reassurance and confidence in care. In patients with serious mental illness this is particularly important because the individual nature of the illness.

I believe that continuity of relationship is essential to organise and coordinate the increasingly fragmented care that patients receive. Continuity of relationship is most important in the care of patients with multiple chronic diseases, mental illnesses and social distress. These are the greatest users of the NHS. Prioritising speed of access and choice of provider risks damaging continuity of care for those who most need it.

Jonathon Tomlinson  October 7th 2009

See also: Boosting continuity of care could save millions Pulse 10.04.2012 (source link £)

[1] Our Health, Our Choice, Our Say. Department of Health White Paper 2006

[2] Balint, Michael. The Doctor, His Patient and The Illness. 1954

[3] Haggerty JL, Reid RJ, Freeman GK, Starfield B, Adair CE, McKendry R. Continuity of care: a multidisciplinary review. BMJ 2003;327:1219-21.

[4] Greenhalgh, Trisha. Narrative based medicine in an evidence based world.BMJ 1999;318:323-325 ( 30 January )

[5] Christakis, Dimitri A. Continuity of Care: Process or outcome? Annals of Family Medicine 1:131-133 (2003)

[6] Guthrie Continuity matters. BMJ 2008; 377: a867

[7] Guthrie B, Wyke S. Does continuity in general practice really matter? BMJ.2000;321:734–736.

[8] Saultz, J. W., Lochner, J. (2005). Interpersonal Continuity of Care and Care Outcomes: A Critical Review. Ann Fam Med 3: 159-166

Defining and measuring interpersonal continuity of care.

A Seven Step Program for Innovating RIGHT NOW! @Medici_Manager @timkastelle

by  on 9 December 2012 in experiments

You can’t wait for permission to innovate – you’ll never get it.

You need to start changing things on your own – right now.

Here are three things I ran across this week that make this point.  First up, a great quote from artist Ron English – in the introduction to the special issue of Juxtapoz that he edited on the topic of politics and art:

Every time I do a lecture there is the inevitable question from a guy who is miffed that I don’t do anything to address the issue of our military’s use of uranium tipped war heads in Iraq, Monsanto’s ware on independent farmers, the Mayan apocalypse, or some other issue that they are deeply passionate about, and my usual reply is, “Why don’t YOU do something?” This is usually followed by “Well, I’m not an artist” or “I don’t have access to the media.” Got photoshop? Know where a Kinko’s is located? Know where a wall is? The thing is, nobody in this issue was born with a megaphone in their hand, and they didn’t wait for an invitation or an art degree to express themselves. I know a lot of people reading this are already out on the streets doing art and I just want to let you know your art can serve a higher purpose than advertising your own career. Art has been successfully used by liberators and dictators alike. It is a powerful tool that is in your possession.

It is a powerful tool that is in your possession.

Here’s an example from this issue – a remarkable piece from Molly Crabapple:

Innovation is a pretty powerful tool as well, and it is also in your possession.

Hugh MacLeod says that business needs more art, and he’s right – that’s one way to access the tool of innovation.  The second thing that crossed my path was this cartoon from Hugh’s daily newsletter:

It’s a tool that’s in your possession.

And then there’s this from Nilofer Merchant:

Not everyone will, but anyone can.

Innovation is a powerful tool, and it’s in your possession – so what do you do?

Here’s my prescription:

  1. Think about how much you can get away with – if you manage a budget, how much discretion to you have? If you don’t have a budget, what are the parts of your job that you control?
  2. Make a list of 10 things that you can do within the current scope of your work that will make things better for the people with whom you interact – customers, co-workers, bosses, whoever.
  3. Do those things.
  4. Figure out which ones worked, and do those more.
  5. Figure out which ones didn’t work, learn why not, then forget about them.
  6. Apply what you learned to the next set of ideas.
  7. Do it all again.
Focus on the ideas that went well – even if only one of them works, you just made your work a better place.

The point with this is to just get started with innovation. Try things that are cheap experiments. Learn from failures, amplify successes. Try a lot of ideas at once so that you don’t get too attached to them – if you only have one idea, the stakes are much higher, even for a cheap and quick experiment.  And remember what English says about serving a higher purpose – that’s just as important for innovation as it is for art.

That’s how you can start to get the future out of your head, and out into the world where it will do some good.

About Tim

Idea Connector – Studies innovation networks – author, speaker & consultant on innovation – University of Queensland Business School – links to academic papers, twitter, and so on can be found here.


DoriMidnightSpiralFaced with strong, overwhelming feelings of hopelessness I’ve been asking myself how do we sustain ourselves in dark times?

Last week, I responded to a tender for work with a failing organisation: I felt I could offer nothing. Later that day, after a conversation with my wife, who offered a listening ear, I remembered that I should take my feelings of hopelessness seriously, but not personally.

I reflected on what I had been blind to earlier, which now seemed obvious; a narrative, set out in 300 pages in the tender documents, assumed that a clear vision, confident leadership, cascading communications and a rational blueprint plan would move this  troubled organisation in a linear fashion to the desired destination.  The failure in the tender to acknowledge the brutal facts of the current situation lay at the root of my feelings of hopelessness: we first have to acknowledge we are lost if…

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TNT-The Network Thinkers @Medici_Manager @timkastelle

Most community and organizational networks we see in our consulting practice have a shape similar to the network above.  These are called a core-periphery networks.
The core is made up of people with many connections to each other — it is the dense center of the network, represented here by the pink/magenta nodes.  The periphery, shown by the grey nodes, are people that provide data, information and knowledge to the core, but are usually outside of the dense work ties in the core.  They are resources to the core, allowing access to data, information and knowledge that does not reside in the core, but is necessary for the core members to accomplish their goals.  The grey links show who has collaborated with whom on a project in the last year.
The three blue nodes in the above network are the formal leaders of the network — they are the social entrepreneurs who formed a non-profit organization to support green businesses in NE Ohio.  The disconnected groups, in the upper right of the map, are also involved in sustainability projects, but they have not worked with any of the core members yet.  These are satellites of the current core-periphery network.  There may be network weaving opportunities to connect the satellites to parts of the network where they can best provide information, expertise, and experience.  For more on how networks form and evolve see our white paper “Building Smart Communities through Network Weaving
On-line communities also have core-periphery structures and many satellite clusters.  They also have a unique set of passive members — people who share an interest with the core, but who are not active in the network (they have not collaborated with anyone in the network), they just observe what is happening.  They are often called lurkers.  For more on the network patterns in online communities see our post “Connecting the Community

Knowing the net, helps us knit/nudge/navigate the net!

These network maps help community managers build more innovative and resilient social networks.  First you see the present structure of the network… where are the gaps, where are the bridges, who are the linchpins that keep things together, who is in the core, and who is in the periphery?  Knowing the net, helps us knit the net!  The maps show us where we are today, allowing the community (along with their consultants) to plan where they want to be tomorrow.

What possibilities do you want to be ready for?

Don’t Ask Employees To Do These 8 Things @Medici_Manager @CEOdotcom

You’re the boss. You have the power.

Great — just don’t use your power to do things like the following:

1. Ask employees to evaluate themselves. Employees who do a great job always question why they need to evaluate themselves. Shouldn’t you already know they do a great job? Employees who do a poor job rarely rate themselves as poor, turning what could have been a constructive feedback session into an argument.

Self-evaluations may sound empowering or inclusive but are almost always a waste of time.  If you want feedback from the employee, ask them what more you can do to help them further develop their skills or their career.

2. Ask an employee to do something you already asked another employee to do.

You assign Steve a project. The day you needed it completed you realize Steve hasn’t finished… and probably won’t. You’re frustrated with Steve, and you really need it done, so you plop it on Susan’s desk. You know she’ll get it done.

Maybe so, but she’ll resent it.

Leave Susan alone. Deal with Steve.

3. Pressure employees to attend “social” events.  Any time your employees are with people they work with, it’s like they’re at work. Worst case, whatever happens there doesn’t stay there; it comes back to work.

Embarrassing behavior aside, some people just don’t want to socialize outside of work. And that’s their choice — unless you do something that can make them feel like they should attend. Then it no longer feels like they have a choice, and what you intended as a positive get-together is anything but.

And keep in mind that “pressure” can be as simple as saying, “Hey, Steve, I hope you can come to the Christmas party… I hope we see you there…” While you may simply be letting Steve know how much you enjoy his company, if he doesn’t want to go he hears, “Steve, you better be at the party… or I will be very disappointed in you.”

If you really want to hold outside social events, pick themes that work for your employees. Have Santa attend a kids’ Christmas party. Have a picnic at a theme park. Take anyone who wants to go to a ballgame. Pick one or two themes that cover the majority of your employees’ interests, and let that be that. Don’t try to force a spirit of togetherness or camaraderie. It never works.

4. Pressure employees to donate to a charity. The United Way was the charity of choice at a company where I once worked. Participation was measured; the stated company goal was 100 percent participation.

Pressure enough? It got worse; every supervisor reported results from their direct reports to the head of the fundraising effort… and the head of the fundraising effort also happened to be the plant manager.

I’m sure the United Way is a great charity, one worthy of support.

But don’t, even implicitly, pressure employees to donate to a charity. Sure, make it easy. Match their contributions if you like. But make donating voluntary, and never leave the impression that results are monitored on an individual basis.

And don’t do the “support my kid’s fundraiser” thing either, especially when you’re the boss. That’s tacky.

What employees do with their money is their business, not yours. Make sure they feel that way.

5. Ask employees to evaluate their peers. I’ve done peer evaluations. It sucks. “Peer” means “work together.” Who wants to criticize someone they have to work with afterwards? You can claim evaluations will remain confidential, but people always figure out who said what about whom.

As the boss, you should know your employee’s performance inside-out. If you don’t, don’t use an employee’s peers as a crutch. Dig in, pay attention, and truly know the people you claim to lead.

6. Reveal personal information in the interest of “teambuilding.”  I was once part of a transformational leadership offsite session where we were asked to make small boxes out of cardboard. (Yes, this was in the ‘80s when transformational leadership was the next big thing… until back to basics became the next big thing, followed by….)

Then we were asked to cut pictures out of magazines that represented the “outer” us, the part of us we show to the world.

Then we were asked to write down things no one knew about us on slips of paper, put them inside our box (get it?), and reveal our slips – and our inner selves – to the group when it was our turn.

I was okay with putting pictures on the outside of my poorly constructed box even though my lack of scissoring skill was pretty embarrassing. I didn’t want to create “reveal” strips, though, and said so.

“Why not?” the facilitator asked.

“Because it’s private,” I said.

“That’s the point!” he cried. “The goal is to reveal things people don’t know about you.”

“They don’t know those things about me because I don’t want them to know those things about me,” I said.

“But think about how much better you will be able to work together when you truly know each other as individuals,” he said.

“Sometimes I think it’s possible to know too much,” I said. “If Steve likes to dress up as a Star Wars character in his spare time that’s cool, but I’d really rather not know.”

I didn’t end up participating, a potentially career-limiting move that turned out fine when we went “Back to Basics” and I was back in vogue.

You don’t need to know your employees’ innermost thoughts and feelings. More to the point, you have no right to their innermost thoughts and feelings. You do have a right to expect acceptable performance.

Talk about performance, and leave all the deep dark secrets where they belong.

7. Ask employees to alert you when you “veer off course.” One of my bosses was really long-winded. He knew it and asked me to signal him when I thought he was monopolizing a meeting. I did that a couple times; each time he waved me off, probably because what he was saying was just too darned important.

Never ask employees to monitor your performance. To the employee it’s a no-win situation.

8. Ask employees to do something you don’t do. Not something you “wouldn’t” do, but that you don’t do. “Would” is irrelevant. Actions are everything.

Lead by example. Help out on the crappiest jobs. Stay later. Come in earlier. Not every time, but definitely some of the time. Employees will never care as much as you do — and, really, they probably shouldn’t — but they will care a lot more when they know you do whatever it takes.

EMBRACE COMPLEXITY – IT’S NATURAL @Medici_Manager @timkastelle @JosieJosieg

‘No man is an island, entire of itself’, British poet John Donne wrote back in 1624. ‘Each is a piece of the continent, a part of the main’.

Centuries before scientists developed the knowhow to map networks mathematically, Donne was alluding to the web of relationships and interdependencies that shape us all.

In Donne’s era, smart leaders recognised critical connections and exploited them. They made it their business to identify influential actors, their strengths and foibles, their role within a bigger system, and how those alliances and networks could be manipulated for the larger good (or not). Mastery entailed intervening in the system at just the right point to set in motion a chain reaction that would hopefully deliver something like the desired result.

So, what’s changed?

Simplification. Or rather, the Quixotic quest to reduce and ‘manage’ everything.

To simplify is to ‘make (something) simpler or easier to do or understand’, a noble aim, especially for leaders. It’s a deep human yearning to want a simple life, yet it’s misguided.

The ‘business simplification’ trade has boomed in recent years in response to the emergence of network-enabling technologies, the growth and spread of transnational corporations and an explosion of data sources that track, record and mine our every move. People want a solution, a way to cope, fast.

Compared with Elizabethan England, there are indeed many more moving parts. The tsunami of complexity, the speed of change, has many executives grasping at anything that will make life manageable.

Without doubt, matrix organisational structures should be rationalised, red tape cut and investment be channelled into value-creating rather than self-justifying activities. Without doubt, layers of needless complexity could be eradicated with a stroke of a pen.

That, however, won’t alter the fact that we operate in a complex environment. Nothing we do or say can change that. Leaders have a responsibility to acknowledge the world as it is, not as they’d prefer it to be. As Steven Johnsonillustrated in his superb 2010 book, Where Good Ideas Come Fromhow we humans create and interact mirrors the natural world in terms of obeying the laws of complex systems.

Scientists and philosophers have long wrestled with complexity in an effort to better understand and navigate it, but in business it still gets short shrift. It’s rarely dealt with in depth in management training and on the job is largely ignored, letalone embraced for the opportunities it offers.

Technology, the great enabler of interconnections, the devilish disruptor, will bring a painful end to that.

While some leading companies are now beginning to recognise how patently ill-equipped their executives are to cope with the emergent properties of complex systems, most maintain – proudly, loudly – an industrial-era mindset. They continue to work on pieces and projects and businesses as if they aren’t part of something bigger.

Those leaders who talk about the whole, who acknowledge the vast unknowns inherent in complexity and the need to think long-term, are out of step with the majority.

Complexity remains a dirty word, misunderstood and maligned, something to be addressed and dealt with so leaders can then ‘get on with business’.

What folly.

What if, instead, we were to acknowledge and embrace complexity as the natural order of things instead of fearing and fighting it? How much more effective would we be, in life and not just business, if we cultivated the mindsets and skills to confidently navigate the currents of change?

‘Abandon the urge to simplify everything,” advised psychiatrist and author, M Scott Peck, “to look for formulas and easy answers, and begin to think multidimensionally, to glory in the mystery and paradoxes of life, not to be dismayed by the multitude of causes and consequences that are inherent in each experience – to appreciate the fact that life is complex.’