Archivi del mese: luglio 2014

10 Great Resources for Systems Thinking and Complexity in Health

Letture interessanti!

Systems Thinking for Capacity in Health

Fred Nelson

We believe the following ten resources to be great systems thinking and complexity in health resources for health professionals in all fields seeking to apply these ideas to their work.

1. No list of systems thinking resources would be complete without includingSystems thinking for Health Systems Strengthening by the Alliance for Health Systems Research and WHO Geneva. This is the third in a series of flagship reports by the Alliance for Health Systems Research and has had a widespread, and increasing influence. This Report provides a realistic understanding of effective approaches to strengthening systems, especially in low-income countries and global health initiatives. The report also outlines simple steps to take when seeking to apply the often-elusive systems thinking. The ten steps it gives to applying systems thinking to a health system are (1) convene stakeholders, (2) collectively brainstorm, (3) conceptualize effects (4) adapt and redesign, (5) determine…

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There Are No Super Influencers: The Reality about Influencers @leadmedit @Medici_Manager @WRicciardi

Phil Willburn

The influence of influencers is overhyped. We all want to believe that there are these super-hero influencers that can make dramatic changes to organizations, countries, and societies. The idea has been spread in pop-culture in books like Malcolm Gladwell’s the Tipping Point. Recent developments in Network Science have shown that our understanding of influencers – the super-connected individuals in our organizations and society – is more or less wrong.

So what is the truth behind influencers? The science is still figuring it out, but here is what we have learned so far.

It’s all about Micro-Influencers

The super-connected influencer do not exist, instead there are micro-influencers – those that have slightly more influence than the rest of the population influencing those around them to spread their ideas and messages about certain topics. (I would consider my friend Andrew a micro-influencer, he got our whole group of friends drinking high-quality craft beer after he himself jumped into the cult of American craft beer drinking).

We use to think that the human social network was constructed like our airport network (also called scale-free networks), there are hubs in which most traffic can get to most places, thus have huge influence on the flow of information.

The truth is that there are no Chicago O’Hare, or London Heathrow individuals.  Why? Because the human network does not work like the airport transportation network. The human capacity to manage relationships is finite. Unlike our major airports, we cannot just construct another terminal in ourselves to deal with more traffic. We have a limited number of relationships we can actively manage and the reach of our direct influence is limited by the relationships we manage.

The average number of friends people have on Facebook is around 200 – but there are some Facebook users who have 2000 friends (the max for an individual account), which is only 1 magnitude greater, not 10 or 20 times greater like we would expect if our human networks were more like airports: like the difference between Colorado Springs Airport traffic and Chicago O’Hare.

Ideas Become Viral Through Micro-Influencers

Things still go viral and our common sense would tell us that it is because some super-connected influencer made it go that way … but then we would be wrong. Common sense is so wrong when it comes to influencers (see Duncan’s new book for a full explanation of why). We cannot predict viralness from super-connectors. We can, however, narrow down on a group of people where the viral ideas are likely to come from. The best probability of making something go viral is to know who your micro-influencers are. And there are ways to find them, see my post on how to make leadership contagious.

Micro-influencers at best can cause diffusion of ideas and changes in their immediate network that may cascade for up to three levels (from you – to your mom – to your mom’s yoga teacher – to your mom’s yoga teacher’s kid). Which btw is the same degree of influence Christakis and Fowlers noted in their book connected.

Susceptibles are just as important as Influencers

The role of susceptibles – those who get influenced – is just as important as the role of the influencer. If there is no audience to your message, is the person delivering the message, or message influential?

The truth is, until recently we didn’t know a whole lot about who we influenced, we just focused on who was doing the influencing. A recent study in Science by NYU professor Sinan Aral looked at the role of susceptibles in product adoption and what they found was pretty interesting.

One of the most important findings from this study is that the most influential people are the least able to be influenced … that can become an issue if you are trying to use these people to roll out some message or idea in an organization.

What does this mean for organizational change initiatives?

Here are my thoughts …

  1. Don’t be naive about the impact a super-connector can have on your change initiatives (they probably won’t have that much power)
  2. Don’t ignore the “little guys” individuals who are popular inside their own peer group – these are your micro-influencers
  3. Influencers are hard to influence – if your initiative is important – get them on board, or move them to the periphery
  4. Don’t neglect your audience – are they susceptible to influence around your ideas – you better do some profiling and discovery of your audience before you jump in there trying to influence
  5. It takes more than just a org network analysis to figure out what people are influenced in your organization – don’t neglect the power of messaging, and the strength of alignment from the top

BTW – worth watching if you want to learn more about the Science behind Measuring Influence

Why you should reframe your strategy as transformational @leadmedit @helenbevan @Medici_Manager @muirgray

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In my last post, I talked about strategy as logic; that is, a system of reasoning we utilise, based on our views and beliefs, about how to achieve change.

My own strategic logic for change (and therefore my practice as a leader of healthcare improvement) has been particularly influenced by Marshall Ganz. Ganz spent decades as a community organiser, leader and enabler of campaigns and social movements before joining the Kennedy School of Government to teach, research and write about leadership of change from a social movement perspective.

It’s very helpful for healthcare leaders to reflect on Ganz’s logic and definition of strategy: how we as leaders turn what we have (resources) into what we need (power) to achieve what we want (outcomes) by focusing on clear strategic objectives. I’m concentrating on this perspective specifically in this blog and will discuss resources next time.

The Montgomery bus boycott

We can see these strategic principles in action in so many of the inspiring stories of social change. Let’s take the example of the Montgomery bus boycott which was a pivotal point in the genesis of the American civil rights movement in 1955-56. Following the arrest of Rosa Parkes for refusing to give up her seat on a bus to a white passenger, the black population of Montgomery, Alabama, boycotted the town’s buses in protest at racial segregation of buses.

By organising for civil rights, a group of largely dispossessed marginalised African Americans was able to pool resources to create collective power for change (enough people withdrawing their use of buses and payment of bus fares so that it had a profound impact). They built power both by pressing the authorities for reform through united action and growing their movement by winning other people across the nation to support and take action for their cause.

And they achieved the outcomes they sought: pressure for change increased across the country and eventually the segregation rules were deemed unconstitutional by the courts.

Ganz, along with other commentators, concludes that the leaders of social movements (“voluntary organisations”) typically have fewer levers and resources for enacting change than leaders of formal organisations have. This makes the strategic focus of leaders, to turn potential resources into power for change, even more important.

Ganz quotes James Q. Wilson:

“In most voluntary associations, authority is uncertain and leadership is precarious. Because the association is voluntary, its chief officer has neither the effective power nor the acknowledged right to coerce the members – they are, after all, members and not employees. In a business firm, the chief officer may, within limits, hire and fire, promote or demote, his subordinates…

“In most associations, power, or the ability to get a subordinate to do what the superior wants, is limited, and authority, or the right toexercises such power as exists, is circumscribed and contingent.”

Use your levers

I concur with Wilson that the kinds of levers and resources available to organisational leaders can create an easier set of circumstances for enacting change (when compared with social movement leaders who have none of these resources). However, on their own, coercion, compliance and other organisational mechanisms won’t create sustainable transformational change within and across organisations.

So I don’t necessarily agree that organisational leaders have a more straightforward task in leading change. In fact, I think that leaders of health and healthcare who are seeking radical changes across their organisations and systems in an ever more complex and unpredictable world have got more in common with social movement leaders than they have differences.

Many NHS change strategies are driven by logic based on extrinsic levers for change: incentivising payment systems, regulatory and quality assurance systems and holding leaders to account to deliver change outcomes. The strategic logic of social movement leaders is essentially based on igniting intrinsic motivation: building shared purpose, connecting with values, mobilising actions and taking meaningful action.

Transformational change across the NHS system requires both intrinsic and extrinsic factors and we as leaders need to find ways to align them and balance the tension between them. Otherwise there is a tendency to overemphasise the extrinsic factors and inadvertently kill off the energy, creativity and sense of psychological safety that people need to innovate and deliver goals for change.

Peter Drucker got it right when he advised organisational leaders to “accept the fact that we have to treat almost anybody as a volunteer”. We can learn greatly from the strategic approaches of social movement leaders who led change that succeeded because people wanted to be part of the change, not because they had to be. They have a lot to teach us about motivating, mobilising and building power for change through the assets and resources of a communitybased on common interests and a common goal, creating capacity for change from within.

Some questions to consider:

    • What is the shared purpose underpinning our change efforts? Is it framed in a way that connects with values and builds intrinsic motivation?
    • What leadership actions can we take to shift power in the system and get the outcomes we seek?
    • Think about loss and gain: what control/power might we have to surrender in a hierarchical sense to enable a more distributed leadership system and quicker, wider progress of change across the system?


From The NHS Change Agent

Helen Bevan is chief of service transformation at the NHS Institute for Innovation and Improvement. From 1 April 2013, she will be joining the delivery team of NHS Improving Quality. All views are personal.

How do you create a curious culture? @muirgray @wricciardi @leadmedit

How do you create a curious culture? I struggled with this question until the January 2013 issue of National Geographic landed in my mailbox with this cover theme: “Why We Explore.” Inside was a fascinating article called “Restless Genes”, written by David Dobbs. The article provided panoply of scientific evidence as to why humans explore.

“The compulsion to see what lies beyond the far ridge or that ocean – or this planet—is a defining part of human identity and success.” – David Dobbs

The article helped me conceptualize a framework for enabling a curiosity-based culture inside an organization. I learned three aspects of human behavior that encourage us to explore – why we are curious – and what we as leaders can do to unleash this in our organizations.

I discussed the first two lessons learned in yesterday’s blog post. Here is the conclusion to my thoughts on this subject.

I already knew that human hands with our five fingers, including a thumb, were a competitive advantage for Homo sapiens in the battle for resources. In the final lesson from the article, what I didn’t’ know is that societies tended to develop mythology around those people who excelled at “clever hands,” as author Dobbs refers to innovations created by those hands.

Societies tended to develop mythology around those people who excelled at “clever hands”

Mythology made it “cool” to be “clever;” a little like the adulation the Steve Jobs’ of the world receive today. The marine vocabulary of the Polynesians conferred great status on ship builders, as Dobbs says, “like today’s astronauts.” This social standing was a motivating force to continue exploring.

I recently visited Cisco’s customer briefing center in Tokyo, and as I walked down the hallway past a bank of Cisco equipment, I stopped because I saw a box that was a different color from all the others – white with red lettering. I knew right away when my eyes focused specifically on this box that I was looking at a Cisco “AGS” router; the product that was used in the first-ever commercial Internet connection. A group of us just stood there for a few minutes and talked about what this AGS box meant to Cisco – and the world. It is not an understatement to say the AGS changed the world.

I’ve always believed that culture is built on the backs of important symbols. The mythology around the Cisco AGS router is every bit in our vocabulary as the sail is in the Polynesian marine vocabulary.

Culture is built on the backs of important symbols

The lesson:  Nostalgia is what keeps an organization from moving forward, but the myths of what symbolizes the great accomplishments of your organization should be celebrated and must be front and center in your team’s culture.

“When you set sail to find new lands, you became mythologized – even if you didn’t come back.” – National Geographic Explorer-in-Residence Wade Davis quoted in “Restless Genes.”

Great accomplishments of your organization should be celebrated and must be front and center in your team’s culture

Cisco CEO John Chambers frequently says culture is the responsibility of leaders. Curiosity may kill the cat, but it may be the most important attribute of a resilient organization in a constant state of evolution to win in today’s markets. As leaders, it’s our responsibility to set curiosity free inside our organizations, in the same way the great human explorers dared to go places that others feared and few ventured.

It’s our responsibility to set curiosity free inside our organizations

“…for the larger powers we gain through culture…it gives our malleable genomes, imaginative minds, and clever hands the power to transform even the strongest forces in our environment — wind, water, current — from threat to opportunity.” – David Dobbs

Teoria degli errori e piloti di aerei – Errori in sanita’


Nefrologia Dialisi.

La teoria dell’errore viene dal mondo aeronautico. allora chi salirebbe in un aereo dove i piloti oltre al turno normale devono fare altre 12 ore di volo e poi ripartire immediatamente?

Nessuno,  neanche i quelli che nei loro luoghi di lavoro usano di re che  vale l’assioma “prima lavorate e poi vedremo” . Da spiaccicato si vede poco. Ma lo sapete cosa fanno notare i piloti ai medici? Che quando c’e’ qualcosa che non va i piloti fanno la stessa fine dei loro clienti. Ecco,  ci vorrebbe la stessa cosa in medicina e negli ospedali.


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Mindfulness can improve leadership in times of instability @leadmedit @muirgray

A mindful leader can respond to change with focus and clarity, and avoid repeating the same mistakes

by Cheryl Rezek

What does the ancient eastern practice of mindfulness, often associated with orange-clothed chanting monks, have to do with the fast-paced, performance-driven style of western leadership? In tough times, it could act as an influential asset in the public service’s fight for survival.

Mindfulness is about paying attention to what is happening in the present moment, a moment in time. It is about focusing attention on the present in a way that allows that moment to be experienced and observed closely. It involves developing the skills to allow yourself to engage actively with whatever is happening at the time, as well as concurrently viewing that moment from a more strategic standpoint.

Developing a more aware and considered approach helps leaders to respond to situations (whether internal thoughts or external events), rather than react to them. It encourages a less critical view which, in turn, creates a more flexible and attuned response. When there is less clutter and fewer distractions within one’s own head it is easier to gain clarity and perspective; mindfulness allows one to both notice more detail and see the bigger picture.

A mindful leader can reduce disorder by bringing focus and intent to the situation. By acknowledging and accepting change, the leader can step back, observe and respond with composure and purpose.

Sometimes our past experiences or immediate reactions will interfere with our ability to view the present in an unbiased way. Once we acknowledge this, we can quieten internal commentaries and assumptions. This process of stepping aside from ourselves allows us to decide what approach will best support the situation at hand, and the agendas and strategies of the organisation.

Dealing with change

If leaders realise that change is inevitable, they can encourage sufficient resilience in individuals, teams and organisations. To lead knowing that change is inevitable – though unpredictable in its timing – allows for flexibility, and a realisation that what worked in the past may not necessarily be appropriate today. This helps to safeguard an organisation from disillusionment and destruction by enforcing outdated rules and processes.

Research on mindfulness suggests that it can also help to:

• reduce the cost of staff absenteeism caused by illness, injury and stress

• improve cognitive functioning, memory, learning ability and creativity

• improve productivity and improve overall staff and business wellbeing

• reduce staff turnover and associated costs.

Mindful leadership is not a patronising fad implying that, if we are calm, everything will be fine. The reality of our working world is that all may not be fine. What mindfulness can do is develop a thinking, emotional and instinctual mind so that the leader can do the best for self, team and organisation.


The full version of Cheryl Rezek’s article can be accessed free-of-charge by Public Leaders readers for a limited time on the International Journal of Public Leadership.

Dr Cheryl Rezek is a consultant clinical psychologist, workshop leader and author of Life Happens: Waking up to yourself and your life in a mindful way and Brilliant Mindfulness: How the mindful approach can help you towards a better life.

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I dati Ocse e il declino della sanità italiana – Quotidiano Sanità – Il declino NON e’ dovuto solo alle risorse mancanti ma alla cecita’ ed ignoranza della dirigenza sanitaria a tutti i livelli


I dati Ocse e il declino della sanità italiana – Quotidiano Sanità.

Un assioma dice che non potrai cambiare le cose se continui a farle come le hai sempre fatte.

I niovi vincoli e le nuove malattie costringono a nuovi modelli organizzativi, ma se i dirigenti sono ignoranti, incolti ed hanno arroganza come migliorare?

Questo e’ il problema, le malattie croniche sono la sfida e il sistema deve tararsi su esse. Come: non certo coprendo i buchi dell’orario ma dando ed affidando resposnabilita’ e sviluppando piani di azione

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