Secondly, progress in the field of understanding the biology of perception is beginning to show that it is an untenable viewpoint…. The reason we have this love affair with this simple model of an external world is that it suggests a basis of certainty. We have a deep love of certainty. It starts our whole cognitive process off with an external point of reference — the reality that is out there. What we need to do is give up the belief that there is absolutely, intrinsically, an external reality. Rather than thinking about a causal loop diagram as either a description of the way the world really is, or a forecast of the future, we can actually begin to think of it as a tool of perception — a way of seeing certain things we otherwise might not see.
Without the linguistic distinction of a feedback loop, many people see a world where if demand rises and production capacity is out of line, we have problems left diagram. Some may or may not see the connection to quality. Some may or may not see the connection from quality to demand.
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Many do not even think in terms of the whole unit. In this worldview, when you eventually find yourself with falling demand, you blame the fickle customers or attribute it to tough competitors. However, if we recognize the language of systems thinking and its set of linguistic distinctions, we might draw a link between demand and production capacity right diagram. That is, we add capacity based on demand. By comparing these two diagrams we can see that, depending on what worldview we choose, we construct a whole different set of perceptions.
Perceiving through Our Distinctions We perceive the world by making distinctions — but where do those distinctions come from? That is the territory of culture, because by and large, how we make distinctions is inherited. Our perceptions are collective, not individual. To a much higher degree than we recognize, we, collectively, are the perceiving apparatus, not I. So what might be some of the implications? One implication is that it will begin to shift the perceptual center of gravity in our culture.
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Right now that center has shifted to the extreme of events and short-term orientation. The practical question is, what can we be doing to shift that perceptual center of gravity? Several years ago my friend Pierre Wack, the man who developed the scenario planning process at Royal Dutch Shell, was telling me an interesting story that highlighted the difference between prediction and forecasting.
He had lived in India for much of his life, and he told me that if it rains for seven days in the foothills of the Himalayas, you can predict the Ganges will flood.
If it rained for seven days in the middle of a tropical rain forest, there would be no flood. A prediction, however, is an understanding of certain predetermined consequences. But you have some appreciation of an underlying phenomenon…. If you close your eyes and raise your hand, you are aware your arm is upraised.
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When you close your eyes, you know where your body is. If that part of the brain is damaged, you have to learn to use visual cues to control your body, because you are no longer conscious of your body movements. It appears we have no proprioception regarding our thoughts — we just have them. Our perceptions just occur to us. We have to become proprioceptive of our thought and our perception…. Seeing into the future is not about our eyes.
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We need to be able to speed up time in a way that allows everybody to see it. We need to be able to see into the future and extend our time horizon, by virtue of the distinctions we invoke. Maybe the whole purpose of this systems thinking stuff is nothing but expanding our capacity for perception….
Our perceptions may be vastly more collective than we think. The exploration into dialogue is clearly in the right area, because it looks at the generative process whereby we invent cultural distinctions collectively. This is not an individual job. This is us, not me, not I…. One thing I keep coming back to, as a deep, deep, personal cornerstone in the changes that have to be made, is this business about certainty. There is something in all of us that loves certainty.
And my own experience in watching others is that one of the things that may be the hardest to give up is that rigid external point of reference — what is it really? If our old ways of perceiving the world are dysfunctional, then the institutions and structures that are a product of those perceptions need to be reviewed and redesigned. Russell Ackoff presented a different kind of organizational structure that is more closely aligned with the democratic ideals that govern the way we operate as a nation.
The TQM approach has been valuable in helping practitioners identify local process changes and tools to improve decision-making [ 24 ]; thus, TQM fits nicely into Execution portion of DEC cycle. In the Partners HealthCare case study, the reminder system was a valuable decision process to assist physicians to question their assumptions and expected outcomes. The TQM approach can also be useful for supporting single-loop learning; in the PSA example, when patient care teams deliberated and created better decisions around processes and outcomes, they became adept single-loop learning.
However, TQM, in its theoretical formulation, is insufficient to support other forms of loop learning [ 24 , 33 , 64 , 65 ]. In the PSA example, only the practice teams could identify patient considerations that required changes in expectations for the standard practices; maintaining executive control of these types of decisions risked losing these learning opportunities. In these instances, organizational leaders typically use knowledge from their own experience to form beliefs about necessary healthcare strategies, priorities, and initiatives, and these beliefs serve the basis for best policy or practice recommendations.
This is not to say that quality managers cannot organize successful double-loop learning processes; it is likely that, whenever the limitations of theory meet practicality, these successful managers draw upon other perspectives than TQM to fill the performance gaps [ 24 , 33 , 47 ]. We consolidated these frameworks into the ELO model to assist organizational leaders and scholars with the task of diagnosing organizational learning and knowledge sharing flaws.
The ELO model is constituted of four themes and their subthemes that represent the processes required for organizations to learn and share new knowledge more effectively. These processes are not necessarily sequential but can occur simultaneously and interactively:.
Acquiring: Do they possess technical skills related to locating resources and communicating feedback about this inquiry e. Informing: Do they possess the cognitive skills i. Transforming: Do they possess cognitive traits that facilitate behaviors for inquiry e. Deciding: Are members and teams utilizing effective decision processes to integrate evidence into healthcare decisions? Evaluating: Are they using adequate analytical methods qualitative or quantitative to measure outcomes of evidence-based decisions e.
Relating: Are members, teams, and organizations facilitating evidence-based practices through effective organizational communication and relationships? Sharing: Do the organizational communication structures and processes facilitate sharing knowledge e. Cooperating: Are teams available and functioning to facilitate efficient knowledge generation and evaluation e.
Advocating: Is there adequate and sufficient leadership with effective motivational strategies to induce organizational cultural change towards learning e. Interpreting: Are members and teams sensing the need for evidence-based practice innovations and explicitly describing their tacit knowledge? Judging: Are they properly evaluating judgments about the outcomes of decisions and needed practice changes i. Knowing: Are they building new models of shared understanding based upon the results of evidence-based decision-making i.
Formulating: Are they codifying this new knowledge e. To illustrate the application of this model, we return to our opening scenario to diagnose what went wrong Figure 1 :. With the ELO model in hand, you, the Quality Chief, do further investigation to discover why the guideline initiative failed.
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Over three days, you talk with providers from patient care units, observe their practice patterns, and review their charts. Additionally, you interview several individuals from leadership, management and hospital committees. After completing your investigation, you find several flaws that may be amenable to specific interventions:. Inquiring difficulty: Some physicians have yet to learn the reminder system and seem unmotivated to learn it or information shared through the other implementation strategies; thus they lose opportunities to adapt their practices, provide feedback about practical limitations of the initiative e.
Additionally, nurses from several nursing units possess a "punch-the-clock" norm, through which team members are discouraged by influential senior staff members to challenge team leadership with ideas about improving patient care flaw of transforming. Because of lost opportunities to improve decision-making processes single-loop and to address the quality of the clinical reminders and their limitations double-loop , teams do not have the capacity to take advantage of these learning opportunities. Also, the committee that oversees the reminder system fails to integrate into it the practice innovations identified by teams that enhance early diagnosis and to adjust the benchmarks with feedback about inappropriate reminders flaw of deutero-loop learning.
The latter flaw has led, in some cases, to an overestimation of the number of missed diagnoses.
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