capturing narrative to understand complex issues: adaptive action to shift culture
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Copyright © Tmiller 2016 . All Rights Reserved.
Welcome
Let’s get the ball rolling! Share an
experience. How much a patient gets involved in their own health care
may make a big difference in their well being and health
outcomes.
What example comes to mind that speaks to how health
care providers - or the patients themselves –
are truly embracing the idea of “patient engagement,”
OR give an example of how people are really missing the
boat when it comes to this approach?
Copyright © Tmiller 2016 . All Rights Reserved.
Harnessing the Power of Narrative &
approaches for Navigating within
Complexity
• How to work on the “listening”
side of stories.
• Deepen your understanding of
how to better manage complex
problems & systems
• Tools & Methods (scalable)
Copyright © Tmiller 2016 . All Rights Reserved.
Keep her
healthy &
safe
Show her
love and
kindness
Foster
independenc
e
Copyright © Tmiller 2016 . All Rights Reserved.
Foster
Independence
Keep her healthy & safe
Model love
and kindness
Copyright © Tmiller 2016 . All Rights Reserved.
Teenagers today are given too much freedom of
choice.
I strongly agree
I somewhat agree
I neither agree or disagree
I somewhat disagree
I strongly disagree
I prefer not to say
Traditional Surveys
Copyright © Tmiller 2016 . All Rights Reserved.
Complex
OR
DE
RE
D S
YS
TE
MS
U
N-O
RD
ER
ED
SY
ST
EM
S
Obvious
Complicated
Chaotic
Cynefin Framework – ref Snowden
Rules, Policies
Rigid Hierarchies
Best Practice
Experts
Analysis, Metrics
Good Practice
Agents interact freely
Modify the system
Emergent Practice
Transitory
Crisis, Innovation
Novel Practice
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Complex
Obvious
Complicated
Chaotic
Cynefin Framework – ref Snowden
Self organizing
networks
Stories &
metaphor
Too many
variables
to manage
Hang out in
Inquiry
“It all depends…”
“You need to know
this person…”
Adaptive
Action - Self-organizing
experimentation
- Guidelines
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T-1
T-2
D-1
On a piece of paper,
duplicate these
shapes and lines.
D-2
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Triad 1
circumstances
In this story, the challenge for the patient was their…
Not
applicable
understanding
attitude
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Triad 2
understanding the
patient
In this example, the patient could have benefited if the
key health care provider was better at …
Not
applicable
providing quality,
timely care
working with other
health care providers
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The patient’s engagement in their own health
was … too little
too much
D-1
The health care provider’s trust in this patient was …
absent altogether
blind trust, naïve,
unrealistic
D-2
Copyright © Tmiller 2016 . All Rights Reserved.
Narrative Capture – a tool for
engagement
In most circumstances, people are eager to have their
voices heard.
Sharing experiences is part of our DNA.
Reflection is a form of normative learning.
“I realized that I have an obligation to my co-workers to do my
part in making this a better place to work.”
“Well, I came here with my list of problems I wanted to identify,
but I just heard 4 people in a row complain, and I’m going to
change what I was going to say. It’s not as bad as everyone
thinks….”
1
4
Copyright © 2012 Cognitive Edge. All Rights Reserved.
Collection methods
• Live anecdote circle – recorded & transcribed OR written
• On-line
• I-Pad, I-Pod touch, I-Phone – Text OR Voice
16
Copyright © 2012 Cognitive Edge. All Rights Reserved.
Decision making & teamwork reflected in this story is …
Rudderless,
Confused, Group
paralysis,
Total
Dictatorship,
Working in
silos, Do it my
way
All perspectives
Nurse & other providers
Physicians
Understanding the nature of decision making
Copyright © 2012 Cognitive Edge. All Rights Reserved.
My Status at the hospital
I worked as a dietary aide, … when I would be around nurses and other staff, doctors et cetera you just kind of feel like you’re looked down upon in that they don’t really look at you. They just kind of walk by you in a hallway or on the stairs or. . .
But when I got promoted and moved up to admitting and I was in a uniform all of a sudden it was like I had advanced into an upper world. They were all saying, ‘Oh, hello,’ and ‘What are you doing now?’
It was like I was a different class of person.
I was in the invisible stage, I never really realized. I just kind of thought that’s how everybody was treated. And then when I moved up, I noticed the difference, big time.”
Copyright © 2012 Cognitive Edge. All Rights Reserved.
Understanding the world of Critical Incidents
(CI)
19
Copyright © 2012 Cognitive Edge. All Rights Reserved.
Understanding the world of Critical Incidents
(CI)
20
Wrist Surgery
We’ve had two incidences of
late in the O.R. and anesthesia.
When we called the first one in,
we got some pushback about
whether or not it was truly a
C.I. Most people who come to
have their wrists fixed aren’t
anticipating dying, so I’m not
quite sure how that wouldn’t be
a C.I.
Observation: more uncertainty about CI criteria in
more recent stories.
Copyright © 2012 Cognitive Edge. All Rights Reserved. 21
Scanning and monitoring in complex
environments
• Numbers derive meaning from their context.
• Understanding stories and experiences as collective
filters.
• Enables visualization - a key human sense-making
capability.
• Provides system to collect, analyze, inform, model
and monitor emerging strategic issues
Copyright © 2012 Cognitive Edge. All Rights Reserved.
So What?
How do we get more stories like these?
And fewer stories like these?
22
Copyright © 2012 Cognitive Edge. All Rights Reserved.
Complex
OR
DE
RE
D S
YS
TE
MS
U
N-O
RD
ER
ED
SY
ST
EM
S
Obvious
Complicated
Chaotic
4 – point contextualization exercise
Brainstorm elements
Negotiate domains
• Observe emergent
differences
Copyright © 2012 Cognitive Edge. All Rights Reserved.
• Large volume of information (patterns)
• Large proxy group
• Composite teams of physicians, managers & staff
• 30 action items developed (safe to fail probes) • Mgmt responsibility
• Staff responsibility
• Joint responsibility
Moving to action – Sensemaking workshop
Copyright © 2012 Cognitive Edge. All Rights Reserved.
Simple Rules for Senior’s Care (aka guidelines)
• Talk with all seniors about their
health plans.
• Support seniors where they call
home.
• Allow seniors to die when they
are ready.
26
Copyright © Tmiller 2016 . All Rights Reserved.
3
1
A comparison of approaches
Cognitive Edge Approach Traditional Survey Methods
Numbers with context of stories Numbers that do not inform the
context
Seeks narratives (experiences Seeks opinions of people
Use of indirect prompting questions
more honest and revealing
Use of direct questions which people
usually expect
Highlights visual alternative and
diverse points of view
Traditional statistical analysis often
“drowns out” weak signals
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