how to save the world

Likewise, I’m a fan of Rob Cross’ approach to social network mapping — focusing on the assessed quality of relationships rather than just their quantity or frequency. And I think the most important value of social network maps lies in self-assessment — what a map of others’ perceptions of your social networks tells you about yourself and the nature and quality of your own relationships..

So I was intrigued to discover that one of the most popular social network maps on the web (reproduced above) looks utterly different from most of the maps I’ve seen before, which tend to be hub-and-spoke type drawings with a few overly-busy people with too many links and a few loners with too few. This particular map was developed by a professor in the US based on a survey of every student in a typical American high school, and depicts all their ‘sexual or romantic’ relationships over the past half-year.

Far from hub (the sexual athletes) and spoke (their conquests) with disconnected outliers (the school nerds et al), the picture is one of remarkable fidelity and many tiny, almost nuclear clusters. Sixty-three couples (126 students) had sex only with each other, and 63 other students were involved in closed triads — one or two partners with no overlap with anyone else in the school. Another 94 students were involved in other small clusters, and of them 79 had only one sexual partner in that cluster. Then there was a long, thin network connecting 288 students with up to 37 degrees of separation, the vast majority of whom also had only sexual partner. Most of the students in this giant cluster would have been flabbergasted to realize they were part of such a network, and (unless shown otherwise) would justifiably perceive their relationship map no differently from those in the nuclear clusters with two or three participants.

What does this mean? The link above is illuminating, but it is quite narrowly focused on preventing STDs (i.e. forget looking for hubs to teach/treat; a much broader approach is needed). I think this map raises more questions than it answers, and also has some important implications for the value of network maps in the first place:

• It suggests we don’t know much about networks. Networks, like all human and ecological systems are, after all, complex systems. By definition they can never be even close to fully known, nor can causality be inferred from them, nor reliable predictions be made from what we do know of them. We can look for patterns, but we can only hazard intelligent guesses about what those patterns might mean. 
• If we’re lucky, and reasonably perceptive in our guesses, we might be able to succeed in bringing about some modest changes in these patterns or the behaviour that gives rise to them through interventions: attractors (incentives) or barriers (disincentives). But that’s a huge ‘if’.
• Suppose we had done the survey again six months later. Would there still be one large and a hundred very small, isolated clusters? Two large clusters? None at all? Would the people in the large cluster(s) be very similar or utterly different from those who had been in the large cluster in the previous six months? If the survey was a year long, or three months long, instead of six, how different would the patterns be? If it was done at the high school a mile away, how different would the patterns be?

As intriguing as the map is, to me it poses the same huge risk as any other analysis of complex information: the risk that people will draw simple conclusions and propose complicated ‘solutions’ by misinterpreting or oversimplifying or placing far too much importance on this tiny, flawed, partial picture of a profoundly complex phenomenon, in this case the phenomenon of human networks and relationships.

It reminds me a bit of the old John Saxe poem about the six blind men trying to describe an elephant. We cannot hope to fathom human relationships, so we try to simplify them down in some way that will allow us to see the patterns and therefore come up with a course of action that, if imperfect, is better than doing nothing. The problem is that it isn’t necessarily better than doing nothing. AsJames Cascio said (perhaps quoting someone else — thanks to Martin Cleaver for the citation) the map is not the terrain.

His book is based on three propositions (I’m paraphrasing):

1. People starting their own businesses tend to confuse the work of their business (“technician” role) with the work of running a business (“manager” and “entrepreneur” roles) and often find they are neither competent at nor fond of the latter roles.
2. The solution is to create a replicable idiot-proof business model for the business that will ‘automate’ the management and entrepreneur roles, so that the business can grow without limit even without manager or entrepreneur skills, and so everyone in the business can concentrate on the “technician” role. This is the process of creating a ‘franchise’. “Replace yourself with a system”, urges Gerber, and have written Standard Operating Procedures for everything.
3. A standard business development planning process, all of it conventional business wisdom, virtual guarantees business success.

I agree with the first proposition. That’s why I have always believed that it is folly to go into business alone. What’s more, I think there are more than three roles in most successful businesses. There can be at least eight: You need partners to research, to teach, to imagine, to design, to create, to cultivate, to sustain and to connect. A successful business has people with all these competencies, directed at affordably meeting an identified unmet need. A sustainable business has people that not only do these things well, but love doing them, and whose competencies don’t significantly overlap. These are businesses in Area 3 of my graphic above, at the intersection of your people’s collective gift, passion and purpose.

Such a sustainable enterprise, which I have called a ‘Natural Enterprise’, is a true partnership based on trust instead of hierarchy. Why? Because such an organization is self-managing, and hence is more resilient to absences of, judgement errors by and disagreements among one or two key people. Gerber’s ‘franchise model’ may be fine for mass-production businesses like McDonalds whose product line is small and rarely changes, but it will rarely work when every product needs to be customized. You just can’t automate or make such businesses idiot-proof, because there’s too much judgement and individual craftsmanship required by many people involved. And those who have a flair for such custom work are usually not content to work in an inflexible business run by someone else for which they’re paid very little. Researchers, teachers, ‘imagineers’, designers, creators, nurturers, connectors and sustainers tend to get impatient when someone else (or worse, something else, a ‘system’) is making all the decisions for them. For that reason franchises and branches have notoriously high turnover, and most franchisees (except those who are both uncreative and luck into very profitable franchises) tend to be very unhappy people.

So I don’t buy Gerber’s second proposition, except for a very narrow range of businesses that I don’t think appeal to a lot of people. And while business planning is never a bad idea, most business plans are naive and inflexible, so what is needed more than planning is good improvisational skill. And improvisation isn’t fighting fires, it’s being alert to the changes that are affecting your business and industry and adapting to them, and, most important of all, continually innovating.

Gerber argues that there are seven critical skills in entrepreneurship: Leadership, marketing, money, management, client fulfillment, lead conversion and lead generation. My experience has been that, except in the most mundane businesses, six of these are overrated and largely unnecessary:

• The cult of leadership in the US is foolish and dangerous; as I’ve argued before, leadership is largely irrelevant to organizational success. 
• Marketing and selling (lead conversion and lead generation) are only necessary if you aren’t filling an unmet need so well that your customers do these things for you — viral marketing beats the regular kind hands-down. 
• Money skills are only necessary if you’re caught up in the ‘grow or die’ myth ’Äì sustainable enterprises are organically financed. 
• Self-management trumps the best hierarchical management through the wisdom of crowds. 
• Client fulfillment is important, but it is inherent and intuitive in Natural Enterprises that are meeting a real human need better than anyone else can, where the line between supplier and client/customer is blurred and you co-develop your products and services with your customers.

If your ambition is to create a pyramidal growing organization providing a large volume of identical goods competently, then I’m sure Gerber’s advice will work. But is working as part of a hierarchical machine, even one churning out a lot of profits, really what most entrepreneurs are looking for to replace their exhausting and boring jobs? The prototype for Gerber’s book is a woman who quits her job baking because she wants to start a baking business. Then she finds out she doesn’t want to start a baking business, she just wants out from under a lousy boss. She loves to bake. The problems of managing (all by herself) a baking business almost kill her. Gerber shows her how to be the next Sara Lee: She learns the skills Gerber thinks she needs to be a good manager and entrepreneur.

But is this really what she, and so many others who leave their boring, dead-end jobs (voluntarily or not), and what so many young people who blanch at the thought of starting at the bottom of some mammoth Evil Empire corporation, really want?

I don’t think it is. And I think by perpetuating the myths that entrepreneurship is usually grueling, administrative work, requires lots of money, opportunism (regardless of its social and environmental costs), endless selling and marketing, incessant growth and mindless low-paid drones to do what the ‘franchise machine’ tells them to do, Gerber is doing a bit of a disservice to most prospective entrepreneurs.

There is a better way, one that’s sustainable, joyful, egalitarian, low-stress, responsive to real human needs, recession-proof, virally marketed, organically financed, creatively stimulating and good for society and the environment. It’s Natural Enterprise.

Now if only I could find a publisher to get the word out.

It was the best presentation on knowledge management I have seen in over a decade.

He began, as all good presentations do, with a story that set the context, engaged the audience, and created a sense of urgency. It was the story of Vanessa Young, who died seven years ago at the age of fifteen as a result of a reaction to a stomach drug called Prepulsid she was prescribed. The heart damage this drug can cause to patients with eating disorders was known to some, but alas, not to her doctor. Vanessa died of knowledge management failure.

Doctors are a conservative and sometimes ornery group. They balance what they’ve learned in medical school, personal experience, colleagues’ experiences and judgements, their own instincts, and whatever they can glean from current reading and research they can fit into their schedule. They do their best, though some do much better than others. Dr. Davis’ goal is to help them do better.

Traditional KM lore has it that you buy and deploy appropriate knowledge content, processes, and technologies to bring about ‘culture change’ and hence make people more effective in their work. Davis takes a different approach: He starts by trying to understand why doctors aren’t already figuring out how to do their best with what’s available. They are, after all, smart, motivated people.

So he starts by looking for objective measures of the quality care ‘gap’: the measurable difference between what is reasonably achievable in a complex health system and what is actually being achieved. This gap is analyzed into components:

• underuse of knowledge and tools (e.g. poor diagnosis and treatment of depression, alcoholism, pneumonia, and diabetes)
• overuse (e.g. of antibiotics, tranquilizer prescriptions to seniors)
• frequent misuse or error

Then, the possible sources and causes of the gap are identified:

• problems originating with the clinician (e.g. age, training, disincentives, poor self-directed learning skills, inability of some clinicians to self-assess their knowledge well); there is a model called the Pathman model that analyzes these problems into four sequential components: awareness, agreement, adoption and adherence, and identifies reasons for failures in each component
• problems with the continuing medical education system (e.g. ‘predispositional’ just-in-case training that tells you ‘what you should do if’ is ineffective, training that isn’t patient-mediated, doesn’t have known thought leaders behind it, or isn’t reinforced at point-of-care rarely gets deployed)
• problems in the health care system (we all know about them)
• problems with the evidence/knowledge (e.g. quality, useful format, credibility, consistency, complexity of understanding and applying, cost, degree of change to establish procedures, access)
• problems originating with the patient or family (e.g. ignorance, unwillingness or inability to follow a regimen, lack of engagement in their own health management)

The next step is to identify the best available clinical evidence from the firehose of research, reports, trials and other data. To do that, they’ve created an organization called Guidelines Advisory Committee to review everything written about the areas where the gap was identified as being greatest, and assess, endorse and summarize Guidelines based on research and other knowledge (‘evidence’) in those areas. You can see what they’ve done on the GAC Canada website (take a look, for example, at their review of this Guideline on how to treat endometriosis). These reviews are governed by a rigorous system of evidence assessment called the AGREE system, and are just one of the mechanisms that the GAC is sponsoring to improve practices and policies informed by evidence. They are hoping to extend their reach beyond direct-to-practitioner actions, to include medical faculty development and curriculum reform, and to help nurses and pharmacists, and eventually patients as well (though the Guidelines are carefully written to be understandable and useful to the public, and they are available to everyone on the GAC website).

And then, they look at what Davis calls the ‘barriers’ (yes, that’s complex adaptive systems language) to effective use of best available evidence — i.e. knowledge transfer. In other words, why are perfectly intelligent clinicians not already using this best available evidence? Some reasons:

• too much information to keep up with (solution: distill it into endorsed Guideline summaries)
• delivered just-in-case instead of just-in-time (solution: embed it in tools used at point-of-care e.g. anaesthesia nozzles that are different sizes so you can’t accidentally connect the wrong gas to the patient’s mask)
• not clearly communicated (solution: more effective education programs, multiple communication media)
• not consistently or completely delivered or implemented (solution: coordinated delivery programs)

Davis summarizes all this with his Seven Steps to Better Care:

1. Collect information and gain deep understanding of where the gaps are, what the possible causes are, and why they are occurring despite the best intentions of those in the system i.e. know what is happening today and why
2. Identify and collect the best available evidence relevant to each identified gap
3. Conduct an analysis of the barriers that preclude this evidence from being effectively used
4. Identify interventions, tools, methods and strategies to get around these barriers
5. Use a combination of methods and media to communicate and implement these interventions, tools, methods and strategies
6. Create better linkages between the stakeholders in each process, to enable reinforcement, feedback and evolution of the interventions and capture additional evidence
7. Create continuous measures of effectiveness of these interventions

These seven steps won’t work in every industry or environment, for reasons I’ve written about elsewhere (best available evidence, like ‘best practices’, only applies in situations where many people are doing, at least some of the time, very similar activities, like diagnosing or treating specific diseases). And Davis is pragmatic — he sees the value of intuition and personal judgement sometimes overriding what best available evidence might suggest is appropriate, in specific situations, as long as the best available evidence has at least been considered.

I can see this approach working in quite a few areas, at least by analogy, and I’m already at work seeing if it will apply in the context of my current work project. If it could save some of the victims of knowledge management failure, people like Vanessa Young, it deserves serious study and consideration. In one hour Dr Davis managed to change my perceptions about what KM can and cannotachieve. Very impressive stuff.