#TSisTM and 43 quintillion ways to witness…

Believe it or not I’ve halved the size of this blog already – the third installment of The Story is the Measure. I’ve suggested that this is true for any complex systems, particularly those involving people, so I first told a Story about people and then explained what happens when organisations try to Measure stuff. Now I’m going to have to explain some interesting things about people in terms of complexity, to prove my point. Brace yourself!

Norma…

In the 1940’s an eminent Doctor in Obstetrics & Gynaecology called Robert Latou Dickinson, teamed up with sculptor Abram Belskie, to create Norma. She was a statue described and marketed as the ideal girl and displayed at the Cleveland Health Museum (the source of the header image). Norma was sculpted based on anatomical measurements taken from fifteen thousand young women. Norma’s figure was in fact, the mathematical average of all of those dimensions. The notion that average is somehow ideal, doesn’t work for me, but hey ho, it was a different time.

They then proceeded to run a competition to find a ‘real girl’ who matched Norma’s perfection. Apparently, they assumed this would generate thousands of women near perfect and the competition would come down to a few millimetres here or there. In reality, Fewer than 40 of the 3,864 contestants were average-sized on half of the measures and not a single contestant – including the winner – came close on all nine dimensions. In other words, the average-size woman did not exist.

Further research in psychology, human factors engineering and ergonomics, have explored how the environment, technology and people interact and discovered some pretty dire consequences of designing things based on the fallacy of the average human. From unintentional social exclusion, to equipment that fits nobody and even to fighter planes blowing up: thousands of people, in all kinds of situations have suffered inequality, been harmed and even killed by the assumptions of average.

Act1: In the real world, anything designed for the average person is in fact, designed for nobody at all.

@ComplexWales

Wonkiness…

I found Norma in a book by Todd Rose called The End of Average. A bit more of Norma’s story and a nice summary of why averages are useless for measuring people, is covered in this short extract from the book. But, I’m not really doing a polemic on averages, which have some utility in monitoring inanimate objects. My point is that there’s a right way and a wrong way to represent things and lumping people together into convenient stereotypes, or averages, is definitely wrong. One of the lovely graphics from that article describes what it really means to measure something as simple as the size of a person. Which one is the big bloke?

The End of Average

Obviously, this is a specificity issue and I’m borrowing the image to introduce the idea of roughness, or as I prefer to think of it – that people are naturally and beautifully wonky. It’s a characteristic of most living things, but can be initially quite counterintuitive: the tallest person doesn’t necessarily have the broadest shoulders. The mathematics and methods required to measure the inherent roughness of natural things, is encompassed in the study of Fractals. The term was first coined by Benoit Mandelbrot in 1975.

What you may not realise is that Fractal Mathematics has had a huge impact on the world over the past few decades. Your mobile phone antenna, every digital animation you’ve ever watched and even analysing your own heartbeat are all now based on fractal mathematics. Nerd Alert: you can lose several days exploring fractals on YouTube.

Roughness, is not how we think about measurement and certainly not how we are taught maths in school, where things are assumed to be smooth and euclidean. Despite the fact that we have oceans that are 8 km deep and mountains that are 8 km high, the world is actually a very smooth ball. The ups and downs, so to speak, on the surface of the globe are tiny in comparison to its 13000 km diameter. If you could hold the Earth in your hand, it would be smoother than a snooker ball. Then zoom in and you’ll see some of the lumps and bumps created by the mountains. Zoom in closer to the huge mountains and you see that they are made of smaller lumps and bumps of little peaks and valleys, zoom into the little peak and so on and so forth down to a stone in the palm of your hand, which is also made of tiny lumps and bumps. This is the same for people, the closer you look, the more there is to see. In other words, when it comes to measuring complex living systems like people, a low level of specificity is the same as looking at them, from too far away.

If a subject as apparently simple as size, can only be properly measured by a wonky pattern of nine dimensions: how many different subjects, containing how many different dimensions, would it take to properly describe a person, in the context of their typical life? In healthcare, at the moment, there’s a worrying trend for inventing imaginary people based on half a dozen dimensions, cobbled together to represent a typical patient. These stereotypes are mostly used with nothing but the best of intentions, to justify planning decisions, in the absence of any close-up and personal engagement with actual patients.

Act2: In the real world, you can’t understand people from a distance, because they’ll appear smooth and similar, when they are not.

@complexwales

Scaling…

For wonky things like people, the perspective from which you view them, is clearly very important. But Mandelbrot has proven that there are simple mathematical rules that underpin roughness and these rules are recursive. In simple terms, wonky things exhibit the same patterns of wonkiness at different scales, so when it comes to measuring them, the device used to measure, must also function at a commensurate scale.

Sounds obvious, but relating that back to counting and quantify the Cider Apples from the previous post, it brings up another counterintuitive truth. The shorter the stick used to measure the size of the Apple Tree, the longer the measurement becomes.

Use a long stick say 10m in length and every single tree is 1LS (rounded up to the nearest long stick). Use a short stick, say 1mm in length and you can get in amongst all those lumpy folds in the bark and fine branches and the measurement is going to be considerably longer than 10m, for exactly the same tree. Use an extremely small stick, at a microscopic scale and the tree is going to be considerably longer than the lorry trip to the brewery. But the issue here, is not simply about measuring things to more decimal places, but using the right kind of measuring stick.

For example, can you measure the size of a tree with a stopwatch? Well you can do it, as there is a statistical range for the probable size of the Apple Tree compared to how old it is. But the time it’s been growing could be utterly irrelevant when compared to the more significant factors of the terroir, the species and even perhaps the effectiveness of the free range pigs in the orchard, keeping the pests at bay. At this scale the stopwatch is not the most convenient or accurate measurement device, even though the device itself can be really precise.

Because wonky things exhibit this self similarity at different scales, the closer you look, the greater the detail, the finer the measurement. This phenomena is true for river tributaries made of little rivers, broccoli made of little broccolis, trees made of little trees and perhaps most well known and studied, coastlines made of little coastlines.

So you have to choose the right measuring stick for the scale that you’re working at. Obviously after choosing the right scale or granularity to work at, which would need to suit whatever it is that your trying to understand. After all, that’s the purpose of measuring something, to better understand it.

Bearing in mind that I’m the one writing this, my head is starting to hurt and Mandelbrot’s original article doesn’t help. Mandelbrot had a gentle warmth and humility as you can see from the TED talk, but he was a mathematician not a storyteller.

The mathematics is not nearly as fascinating as how nonlinear scaling actually manifests within complex systems: as the system gets bigger, not all of its characteristics get bigger at the same rate. This is common to things as diverse as the rhythm of your heart, how much energy a mouse needs compared to an elephant and the population of cities. You won’t believe how quickly a severe case of analysis-paralysis can be cured, with an approximation to Zipf’s Law.

I hear all kinds of people in my improvement world banging on about scale and pace, scaling and spreading – I’m sure there’ll be Scaling Leadership next – and all of it completely oblivious to the actual science of Scaling. I’ve got another polemic on that due to land with a bang, but in short, systems do not scale by just doing more of the same, or just making everything bigger. You have to work at the right scale.

Geoffrey West’s mind blowing book is similarly, not an easy read, but well worth the effort if you deal with anything at Scale: The universal laws of life and death in organisms, cities and companies.

Act3: In the real world, the size of a living thing, is inversely proportional to the size of the stick used to measure it.

@complexwales

Equifinality…

A complex living system can exhibit a given state that can be attained or reached, through many different causal chains and from different initial conditions – this characteristic is called Equifinality.

So you can start at a slightly different place, go a completely different route and end up at pretty much the same place. There are plenty of things in your normal life that help you do this. They provide you with feedback, help you make sense of where you are at any point in time and effectively enable you to respond to stuff as you’re going along. But none of those things are more important than essentially, going along, in real time, in the moment doing your thing and making thousands of little decisions, choices and course corrections. This is sometimes referred to as The Science of Muddling Through a term coined by Charles Lindblom.

This may sound slightly mad, but that’s how an organisation actually works, it’s how you actually do your work and believe it or not, that’s how your body works too. There’s no right or wrong way, just lots of ways and within complexity science this continuous adjustment, is called far-from-equilibrium. I’ve explained this before, while ranting about the myth of patient safety, using my own preferred term for the phenomena: Frequilibrium.

As there are many ways of getting to the outcome, no single variable or dimension guarantees the delivery of the outcome. In fact the eventual outcome, doesn’t even have to be decided upon from the beginning, as the most effective route to the next outcome, may only emerge after the change has initiated and several adjustments have already taken place. That sounds remarkably similar to clinical practice!

As a result complex living systems, exhibit another characteristic called Nonlinearity, which mostly manifests as a scale free relationship between cause and effect. For any given input, there may be a significantly greater than or less than, proportional change in output. Particularly salient in terms of people: really big inputs can have no output at all, whereas small subtle changes can dramatically alter the current state of the whole system; their whole life. It’s a fundamental principle of working holistically.

In my world of healthcare, patient-centredness as we call it, is not new but it is often forgotten in the great scheme of things. Patients don’t really care what the policy says, they assume you got qualifications and they’ve no interest at all, in the fancy bit of kit in the operating theatre. The things that affect people’s experience of care are all small, within arms reach, they are personal, intimate and enduring. Despite the overwhelming evidence for this, you wouldn’t believe how easily and how often the small but essential matters are undervalued in organisations.

Just turning an Apple into some lovely Cider involves hundreds of people, thousands of actions and probably millions of measurements, just for you to get a couple of minutes of thirst quenching loveliness, sat outside a pub, in the sunshine, having a moment to yourself. For me, the entire purpose of an Apple. Now relate that back to my story about Rebecca’s Dad and how many people and actions and dimensions were measured and recorded over nine years … and not a single one on hugs.

Act4: In the real world, small things can have a big impact on what happens, and big things can do nothing at all.

@complexwales

Witnessing…

So what on earth has all this blather got to do with my assertion that in complex systems ‘The Story is the Measure’. Well the next step after Counting things and Specifying quantities, is to Witness the things situated in real time and real life, doing their thing, in the place their thing is done.

Afterall, data and information only come to life after being interpreted back into the real world, to make them meaningful. Remember this image from the previous post, this is the realm of Interpretation.

Very few organisations have really got to grips with this. For example in Healthcare we capture huge volumes of data and information in administrative systems and in individual patient records. Believe it or not that last part is still mostly on bits of paper, although in general primary care seems way ahead of secondary care. In most departments with a few exceptions like radiology, the administrative functions are computerised whereas the actual clinical care is still carved on to stone tablets. There is no better example of the effect of this disparity, than when something goes wrong and an investigation is triggered.

The first thing that happens, is someone goes to get the notes, the medical record. The best notes are in essence a story of the patient’s care. There are things, people and places, events strung together, construed consequences and eventually lessons to be learnt. Trouble is, the notes are usually a pretty crap story: fragmented, biased towards technicalities and missing pretty much anything at all, from the patient’s perspective. They are designed more for arse covering than storytelling, so what does the investigator do next? Go and ask the people involved to tell a fuller story of events, in the form of a statement and describing the context within which the technical details took place. It’s not just Health, that’s pretty much how Law, Journalism, Research and most scientific endeavours actually work, piecing together the real experiences of those involved, with a touch of proof.

In complex systems like healthcare – and pretty much anything involving interacting living things, like people – this is a bloody tall order. People are not nuts and bolts, they don’t vary slightly from perfect (Act1). People are beautifully wonky and to see them properly, you have to get up close and personal (Act2). The devil is in the detail and you have to work at many different scales at the same time (Act3). You can’t predict in advance what causes which effect, so you have to track things as you go along (Act4).

Surely there is no measurement device that can cope with all that and put everything together, in a way that normal humans can understand and work with. Imagine all those different subjects, containing a variety of dimensions, measured in all sorts of units, with all sorts of different devices, linked to loads of actions, by loads of people, in loads of different places, all on the same timeline. And then of course two different people can have two different experiences of exactly the same thing and they are both right. How many different permutations are there around just six subjects each with nine dimensions – like the size of the big bloke?

Fortunately there’s an ubernerd corner of mathematics called Combinatorics that is about counting things and working out permutations. Think of a Rubik’s Cube – six different colours (subjects) each with nine difference squares (dimensions) – how many different patterns are there? Don’t bother, it’s 43 252 003 274 489 856 000 (43 quintillion), a number that’s completely unimaginable. In fact if you could twist your cube to 100 different patterns per second and you started at the big bang 13.5 Billion years ago, you won’t have produced all the patterns for another couple of million years. I told you before, people have real trouble assimilating big numbers.

Hopefully for those who have followed #TSisTM, you now realise why I started the explanation with Rebecca’s Story. I’ve explained before, when something is best Represented in Story. Data is not the first thing you encounter or consider when measuring anything. The first thing is all about being there in the place looking at, smelling, getting hold of, interacting with and simply witnessing; the interesting thing.

Storyteller Doll

Anthropologically speaking, ‘being here’ or witnessing, came first. There’s compelling evidence that art and music came before language, to codify and categorise things and certainly way before mathematics to try and quantify the experience of well, being here!

People invented storytelling in order to try and understand the world and more importantly to share that knowledge. Story is the only device that can absorb all those permutations and authentically represent the rich colour, texture and complexity of being alive. In fact, it’s built into us so deeply, that many anthropologists think we should be reclassified as a species from Homo Sapiens to Homo Narrans: the storytelling ape.

Act5: The story is the measure, simply because stories have evolved alongside us, as the only way we know, to interpret the real world.

@complexwales

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