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Academic turned consultant shares her opinion ahead of July session Better Health Care: How do we learn about improvement?

Nancy Dixon is an academic turned consultant and principal at Common Knowledge Associates who will be attending the upcoming session Better Health Care: How do we learn about improvement?. In this pre-session blog post, she shares her opinion on the issue: “How Do We Know That No Other Factors Are Influencing The Results—For Example, Other Changes Of Which We Are Not Aware, Or Secular Trends?”

I want to offer some thinking on one of the key questions session chair Rashad Massood has asked us to consider at the Salzburg Global Seminar program: “How do we know that no other factors are influencing the results—for example, other changes of which we are not aware, or secular trends?” 

During the implementation of a project the following steps occur: 1) team members take actions, 2) those actions result in outcomes, 3) to understand the meaning of those outcomes, the action takers spend time exploring the relationship between their actions and the outcomes, and 4) that exploration leads to knowledge about the intervention expressed as conclusions, new hypotheses to be tested, and/or new actions to take.  

The third step – to explore the relationship between actions and outcomes – is critical. That exploration needs to be viewed as an act of “Collective Sensemaking,” because the team members who have that conversation are attempting to make sense of the connections between actions and outcomes.  

I acknowledge that any attempt to make sense of the relationship between actions and outcomes is an interpretation. It is a creative act of finding patterns, rather than an act of discovering truth.  However, the addition of more perspectives allows for a wider range of patterns and a broader understanding to emerge. Karl Wieck notes, “The same event means different things to different people, and more information will not help them. What will help them is the setting where they can argue, using rich data pulled from a variety of media, to construct fresh frameworks of action outcome linkages that include their multiple interpretations. The variety of data needed to pull off this difficult task are most available in variants of the face to face meeting.”[1]  

John Seely Brown and Paul Duguid have written, “Experience at work creates its own knowledge, and as most work is a collective, cooperative feature, so most dispositional knowledge is intriguingly collective – less held by individuals than shared by workgroups.”[2] Collective Sensemaking is a group process that moves the unique knowledge that each individual has constructed into a group or public space so that the knowledge can be integrated and made sense of by the whole group. But collective sense making is more complex than just team members reporting out their knowledge so that others in the group are aware of it. Individual members use what others have said to reinterpret how they themselves understand the situation. The facts will not change during Collective Sensemaking, but the way one fact relates to another fact will change. This integration of ideas spawns the reconsideration of cause and effect, it produces the if/then that leads to a new understanding, it identifies discrepancies in the perception of what occurred and it develops “fresh frameworks of action outcome linkages.”

The third step – understanding the relationship between action and outcome – is where the greatest vulnerability lies in the evaluation of an implementation effort, but also where the greatest promise for deepening understanding lies. I offer six design principles for Collective Sensemaking as a way to increase the probability that all actions have been taken into account and that the process will result in “fresh frameworks of action outcome linkages.”   

1) Set aside the time required to reflect together
Most outcomes have multiple causes, not just one, and teasing those causal relationships out of the experience of project members takes time. Over the length of a project, Collective Sensemaking meetings need to be held periodically rather than waiting until the end of a project. Human memory is notoriously fallible, especially with the passage of time. Coming together at three-month intervals is a minimum in order to retain an accurate memory of actions as well as the reasoning behind each action, which is even more fleeting than is the memory of the actions. 

2) Include multiple perspectives
The most functional way to create useful and valuable knowledge from experience is to use the checks and balances that multiple perspectives provide, especially when they are offered in the spirit of learning. Diverse views bring fresh perspectives to an issue that enables members to view their actions from outside their own perspective. One of the value-adds for holding a group meeting rather than relying on individual sensemaking, is the variety of perspectives from which an action and/or outcome may be approached. A useful rule of thumb is that everyone who performs actions during the intervention also participates in the Collective Sensemaking process. No one is so unimportant as not to share responsibility for understanding the action/outcome relationships. Likewise, no one is so important that his or her perspective should not be challenged.  Being inclusive also implies involving patients, whose actions clearly influence outcomes, as well as sponsors and government officials whose actions, and the reasoning behind those actions, must be taken into account.   

3) Create a psychologically safe space for Collective Sensemaking
The more the design for a Collective Sensemaking gathering takes into account psychological safety, the closer members come to a robust and useful understanding. Edmondson describes psychological safety as the shared belief among members that the team will not embarrass, reject, or punish members for speaking up. This shared belief allows members to engage in learning behaviors, for example, to ask for feedback, share information, ask for help, talk about errors, experiment, raise differences in opinion and discuss unexpected outcomes of action. All of these behaviors are potentially risky to the individual because an individual who admits an error or asks for help may fear he or she will appear incompetent to others. If the admission is made in front of a leader, the perceived risk has even greater potential consequences such as loss of promotion or bonus. An individual, who offers opinions that differ from the group’s opinion, risks being seen as “not a team player” or worse as being obstructive. At a minimum, the individual risks damaging his or her own self-image. Yet, “It is through such [learning behaviors] that teams can detect changes in the environment, learn about customers’ requirements, improve members’ collective understanding of the situation, or discover unexpected consequences of their previous actions.”[3]    

4) Connect People Through Circles
Circles represent unity. They help individuals in a group view themselves as part of the whole.  A circle also represents equality – there is no “head of the table.” The circle declares that all voices are equally valued and is a clear indication to those in the room that they will be expected to actively participate. Ideally it is a circle of just chairs, without a table. People have a profoundly different experience when they converse in a group without a table. Tables put us across from each other in a position reminiscent of negotiation. Conveners and even some participants feel a bit awkward for the first few minutes without a table, but that feeling goes away quickly as people become connected. Circles also allow everyone to see everyone else’s eyes. It is difficult to have a conversation with someone whose eyes you cannot see. 

5) Connect before Content 
When a group is convened, members need to build a sense of connection and rapport with each other before they can attempt to make collective sense together.[4] If a group is going to concentrate on a difficult issue, they first need to learn who others are, the skills they bring, the experience they represent, and the values they hold. That level of connection requires more than the typical recital of name and position at the beginning of a meeting. Members need to understand, How are these other people like or different from me? Are they open to hearing an idea if it contradicts their own? Do they regard me, as an equal, naïve, too assertive? That level of awareness grows over time and with shared experiences. Stasser has found that “Group performance increases when everyone in a group is aware of each other member’s expertise.”[5]

6) Make ideas visible
Making an idea visible through models, drawings, or white boarding enhances the communication of ideas, especially when different disciplines come together. Members can literally “see” what another is trying to communicate. A visible idea also creates a sense of shared ownership because others have the ability to re-draw or modify the object allowing the ownership of the idea to shift from the originator, to being jointly held. Collective Sensemaking is primarily about finding patterns in seemingly unrelated data. One of the great advantages of making ideas visible is that it is easier to hold all the pieces in mind when data is displayed.  

Applying these principles of Collective Sensemaking to step three of the cycle increases the likelihood of the group identifying factors of which team members were previously unaware, but that nevertheless influence the outcome. What Collective Sensemaking can do is to discover relationships that the team would not have found otherwise.