Human Error: A Problem With the Envelope

via Human Error: A Problem With the Envelope

A Problem With the Envelope

Human error

On February 26th 2017, The Academy of Motion Picture Arts and Sciences held its 89th award ceremony, celebrating the best films of 2016. The ceremony went swimmingly until the very last award for best picture.

Faye Dunaway and Warren Beatty mounted the stage. They read aloud the nominees, then Warren Beatty opened the envelope that held the name of the winner. He looked a bit puzzled. He checked the inside of the envelope to make sure he wasn’t missing something and gave Faye Dunaway a quizzical look. Then he started to announce the award, and stopped. With a bemused expression on his face he looked inside the envelope again.

Mr Beatty passed the card to Faye Dunaway to see what she made of it. Thinking he was clowning about and not genuinely confused Ms Dunaway stated the winner.

“La La Land”

Two minutes later, halfway through the acceptance speeches, all hell broke loose. Stage managers and organisers crowded onto the stage. Faye Dunaway had read out the wrong card.

La La Land’s producer rectified the error.

I’m sorry, no, there has been a mistake, Moonlight, you guys won best picture.

Jordan Horowitz

What did you do Warren?

Jimmy Kimmel, the shows host regained control of the situation and asked in mock outrage “What did you do Warren?”

Continues in source: Human Error: A Problem With the Envelope

Alexandrian Pattern Languages online – Pattern Language – Open Learning Commons – David Ing

via Alexandrian Pattern Languages online – Pattern Language – Open Learning Commons

The master site for pattern language is at https://www.patternlanguage.com/ . The web site is a good archive for Christopher Alexander’s papers – some unpublished – and pointers to the books.

On the Internet Archive, there’s a copy of A Pattern Language at https://archive.org/details/patternlanguage00chri that can be borrowed for 14 days. There also seems to be another version labelled as “Ecological Building” that could be less restrictive at https://archive.org/details/eb_A_Pattern_Language/ 1 . However, since the patterns are often used non-linearly, a sequential text may not be the best presentation for synthesizing patterns into a design.

One site that was really great at providing links to “higher order” and “lower order” patterns was on the Jacana House site. It now seems to be offline, but since it seems to have been coded in days of simpler HTML, the version archived at https://web.archive.org/web/20190906082635/http://www.jacana.plus.com/pattern/P0.htm 1 still surfs well.

On a more modern infrastructure is a collection that might have been the impetus for a set of New Patterns, at https://patterns-dev.github.io/patterns/newpat/newpat0/new-patterns-introduction.htm . This was dated 2012, from Theo Armour.

Many of the constraints on electronic publishing of A Pattern Language come from original agreements on the 1977 edition from Oxford University Press. From that site, there’s a “Google Preview” that is searchable, if you want to search and view specific pages.

via Alexandrian Pattern Languages online – Pattern Language – Open Learning Commons

 

‘COVID-19: Safety-II in action’ – with Suzette Woodward, Simon Gill and Paul Stretton | Q Community – 23 April 2020, 12:30pm BST

via ‘COVID-19: Safety-II in action’ – with Suzette Woodward, Simon Gill and Paul Stretton | Q Community

23 Apr 2020
12:30 – 13:30

Zoom video call – online/phone (all welcome) *12.30pm*

The COVID-19 crisis has swept aside business as usual – confronting us with an urgent need to respond effectively, and also to share and learn quickly across departmental/organisational/national boundaries.

** Please register here to receive your personal login for the meeting **

Our usual simplistic and reactive ‘find and fix’ approach of looking for error and variation compared to ‘work as prescribed’ in clinical practice guidelines etc does not foster the rapid learning and innovation needed in today’s complex – even chaotic – coronavirus situation.

The focus of the emerging Safety-II movement on learning from ‘work as done’ – the work of the frontline (in all its complexity) – and from what goes well rather than error, is particularly suited to today’s current need for rapid cross-boundary learning. (It has inspired movements such as ‘Learning from Excellence’).

This session will offer a space for us to share our practical knowing-as-doing, what we’re learning in the current work situation – and look at ways we can do it better. To notice these things that are new that will shortly become the ‘new normal’, the new habits that we will develop.

This will help us to adapt, and a new order emerge from the unpredictability and chaos – fostering team-wide, even system-wide resilience, and reducing burnout.

Further reading

Bios

Suzette Woodward
Suzette is an internationally renowned expert in patient safety, who worked in the NHS for 40 years, as a general nurse at St Thomas’ Hospital and a paediatric intensive care nurse at Guy’s Hospital. For the last five years she was the National Clinical Director for the Sign up to Safety Campaign. She is also a Visiting Professor for the Institute of Global Health Innovation at Imperial College University London. Her main area of interest and research relates to translating policy into action and the implementation of a just culture and Safety II. She is the author of two books, Rethinking Patient Safety and Implementing Patient Safety. She is a Q Community member.
To find out more about Suzette, visit her website; @SuzetteWoodward

Simon Gill
Simon’s background is in risk, safety and resilience within the aviation industry. With a degree in engineering and a PhD in psychology, he has always sought a better way of developing products and services to put people at the centre, preventing error and managing risks to individuals and organisations. He now lectures on Safety Risk Management for City University, London and continues to research and implement these concepts in aviation.

Simon now adapts concepts of risk and resilience for critical infrastructure and specifically within a health and social care setting, training practitioners, developing policies, methods iand software and also supporting decision-makyers.

Simon is the convenor of the Q Community’s Organisational Resilience group all welcome to join)

Paul Stretton
Paul is a trainer, teacher, writer, award winning speaker, coach and insatiable boundary pusher.

He has developed the Quantum Safety approach developed over years of working with risk industries. Despite what we are conventionally taught, he found that the approaches and models we are expected to use were inadequate. Safety Triangles, Swiss Cheese Models, Dominos – they are all linear models and often apply outdated or overly simplistic methodology.

Quantum Safety is an approach that evolves our understanding of safety outcomes so that they offer real insight within high risk industries and complex adaptive systems.

His most recent paper explores the idea of causation in greater detail within the Lilypond Model. It challenges ideas used in non complex systems such as Root Cause Analysis, 5 Whys, and offers a new approach to greater learning within complex adaptive systems.

See Paul’s website.

 

via ‘COVID-19: Safety-II in action’ – with Suzette Woodward, Simon Gill and Paul Stretton | Q Community

Colectivo de Impacto – videos with Humberto Maturana

via Colectivo de Impacto – YouTube

https://www.youtube.com/channel/UCoJ1a0NDc-BfL9appBEX3RA/videos

Whom, when + where do Systems Changes situate? – Coevolving Innovations – David Ing

A series of pieces on coevolving.com from January-March of this year, which I’ll be linking out one per week (but all are on David Ing’s blog already). Here is 4/5

via Whom, when + where do Systems Changes situate? – Coevolving Innovations

Whom, when + where do Systems Changes situate?

Covering practical wisdom (phronesis), the third of four lectures again was compressed for the Systemic Design course in the Master’s program in Strategic Foresight and Innovation at OCAD University. The students in the part-time session on February 7 extended their discussion period longer than those in the full-time session on February 5. I again jumped slides in the sequence to stay within the timebox.

The agenda was in four sections:

  • [preamble] Episteme, Techne, Phronesis (reordered)
    • Intellectual Pursuits (Rethinking Systems Thinking)
    • Systems changes as situated c.f. ideal-seeking
  • A. Value(s), Judgment, Soft Systems Thinking
    • Appreciative Systems (Vickers, Checkland)
    • Policy, impacts and consequences of systems changes
  • B. Service Systems (c.f. Production Systems)
    • Science of Service Systems (Spohrer, Kijima)
    • Material-products c.f. information-services as systems changes
  • C. Socio-Technical Systems Perspective
    • Tavistock Institute + Legacy (Trist, Emery, Ramirez)
    • Coproduction and design principles guiding systems changes

The web video can be streamed on Youtube.

Copies of the video files are downloadable for disconnected viewing.

Video H.264 MP4 WebM
February 7
(1h21m)
[20200207_OCADU_Ing HD m4v]
(HD 2477kbps 1.6GB)
[20200207_OCADU_Ing nHD m4v]
(nHD 1344kps 866MB)
[20200207_OCADU_Ing HD webm]
(HD VP8 375kbps 349MB)
[20200207_OCADU_Ing nHD webm]
(nHD VP8 139kbps 206MB)

Readers who want to follow through on web link references may want to review the slides directly.

Whom, when + where do Systems Changes situated?

The same presentation slides were used for both lectures.  The questions from the students were considerably different across the class sections, so the diligent listener might want to compare them.  Versions boosted by 3db may make the audience discussion more audible.

Audio
February 5
(57m12s)
[202002-5_OCADU_Ing ValuesServicesSociotechnical .mp3]
(53MB)
[20200205_OCADU_Ing ValuesServicesSociotechnical plus3db.mp3]
(53MB)
February 7
(1h21m)
[2020207_OCADU_Ing ValuesServicesSociotechnical.mp3]
(75MB)
[20200207_OCADU_Ing ValuesServicesSociotechnical plus3db.mp3]
(75MB)

Whereas the second lecture tended to focus outside a system of interest towards other systems of influence, this third lecture oriented more inside the system of interest.

Don’t put too much faith in Covid-19 metrics – UnHerd – Tom Chivers

via Don’t put too much faith in Covid-19 metrics – UnHerd

Don’t put too much faith in Covid-19 metrics

Facts and figures are vital to fighting the pandemic, but they can also be hugely misleading

BY 

April 14, 2020

In this new era, we’re all becoming data nerds, or hobby-level epidemiologists. We’re all suddenly conversant in things like case fatality rates and R0.

It makes for an attractive amateur pastime because lots of the things we are trying to know — such as how many people are infected, or how deadly the disease is — are hugely uncertain. But there’s another problem, which is that the things we measure are affected by the simple fact that we’re measuring them — and that the right things to measure change with every passing day.

For instance, we’re all wondering about the “exit strategy” — how, now that we’re all in lockdown, we’re going to get out of it. It’s going to involve some combination of testing, contact tracing, perhaps (eventually) immunity passports, and hopefully in the not-too-distant future vaccines and treatments.

But it’s also going to involve — probably — see-sawing back and forth between tight controls and more relaxed ones, trying to eke out the cases over months to avoid overwhelming the NHS. And those controls will have to be imposed and relaxed, to some degree, on the basis of metrics.

In the UK, it might look a bit like this. The 16 March Imperial modelproposed a sequence of automated triggers: specifically, when the number of ICU cases in a week reaches a certain number, say 100, the lockdown (school closures, social distancing, etc) is imposed; when they drop below another certain number, say 60, they are relaxed. The outcome — hopefully — will be a saw-toothed line on the chart: ICU cases jagging up, coming down, jagging up, coming down, but never breaching the line of health service capacity.

But once you start using ICU beds as a metric, you hit a problem. There’s this thing, “Goodhart’s law”. It’s named after the economist Charles Goodhart, and is usually formulated as “When a measure becomes a target, it ceases to be a good measure.” Goodhart proposed it (in more technical language) when discussing Margaret Thatcher’s economic policies, but it applies everywhere.

 

Continues in source: Don’t put too much faith in Covid-19 metrics – UnHerd

 

When it comes to solving complex problems, collaborating isn’t enough – Adam Jones blog, Systems Unit, UK government

A very Senge-flavoured blog!

via When it comes to solving complex problems, collaborating isn’t enough – Systems thinking

When it comes to solving complex problems, collaborating isn’t enough

Adam Jones

‘Collaborate’ has become something of a rallying cry in the public sector over the past few years. We’ve heard how collaboration leads to better outcomes for citizens, how it has enabled civil servants to better spot (and avoid) unnecessary duplication and how it can improve morale. All good things.

However, when it comes to designing systemic policy solutions to complex problems, I believe that collaboration, on its own, is not enough. So what is needed beyond collaboration? I thought I’d share my thoughts in a blog post and share three concepts that might help you engage with stakeholders on the topic.

 

more and add comments When it comes to solving complex problems, collaborating isn’t enough – Systems thinking

Trespassing Horizons – The New Inquiry

An unclear and, I think, misunderstood take on cybernetics – unfortunately the author passed away last year, and the note of introduction explains this as the cause of some lack of clarity. It is interesting to see what people think, and both the facts and arguments in here are fascinating, but should be treated separately, I think.

via Trespassing Horizons – The New Inquiry

The Axelrod Tournaments | The Law Rules Blog

via The Axelrod Tournaments | The Law Rules Blog

Matriztica Knowledge Community – with Humberto Maturana

 

Main site – http://matriztica.cl/

Knowledge Community – Knowledge Community – This is a space for reflection and scientific knowledge through carefully selected content and meaningful conversations in the different areas of contingency and trends in our understanding and work as biological-cultural human beings.

Authors: Ximena Dávila Humberto Maturana Abstract: In this essay, the authors invite us to take a different look at the fundamental phenomena of education today, imagining an event that can guide us to follow a co-drift that results in a reflective transformation of education for the year 2021. This invitation is accepted with … READ MORE

2007 The Great Opportunity: End of the Leadership Psyche in the Emergence of the Co-inspirational Management Psyche

Authors: Ximena Dávila Humberto Maturana Abstract: This essay proposes the replacement of leadership as a way of managing organizations by co-inspirational management. The authors affirm that we currently live in a post-post modern era, whose main characteristic is that human beings know what we know we know and we understand what we understand that we understand …. READ MORE

1992 The Origin of Species through Natural Drift

Autores: Humberto Maturana, Jorge Mpodozis Resumen: El problema de la evolución de las especies es una cuestión que desde hace mucho tiempo preocupa al hombre. La naturaleza compleja de este problema hizo que durante mucho tiempo su discusión suscitara controversias muy profundas, en las que se entremezclaban aspectos científicos, teológicos y filosóficos. Hoy dia ya hay consenso en…

LEER MÁS

Democracia en fase cuatro

Columna escrita por Ximena Dávila y Humberto Maturana para el diario «El Mercurio», publicada el domingo 29 de marzo del 2020. –

¿Qué es y cómo se vive el dolor de la pérdida de algo o de alguien, al que se le tiene cariño o afecto, en nuestra cultura occidental?: Una aproximación reflexiva desde lo biológico-cultural.

Este escrito es parte del libro Pérdida y duelos. Intersubjetividades en contexto de la Fundación Mente – Mind International Foundation, departamento de investigación y promoción del conocer humano. Editores: Modernel, P. y Bahamones, J. (agosto 2019) pp 73-91. El duelo como dolor de la pérdida de un ser amado, es el resultado de la aceptación…

LEER MÁS

Navidad

En el sentir mítico, la palabra navidad hace referencia al nacimiento del Dios niño con el comienzo de la primavera al fin del invierno en el hemisferio norte; entre nosotros la navidad no tiene que ver con el fin del invierno, lo que nos conmueve es la alegría de la íntima relación materno-paterno infantil que…

LEER MÁS

1 2 3  17 
 

Covid-19 means systems thinking is no longer optional

via Covid-19 means systems thinking is no longer optional

Never has the interdependence of our world been experienced by so many, so directly, so rapidly and so simultaneously. Our response to one threat, Covid-19, has unleashed a deluge of secondary and tertiary consequences that have swept the globe faster than the virus itself. The butterfly effect has taken on new dimensions as the hard reality of system interdependence at multiple levels is brought directly into our homes and news feeds:

  • Individually, an innocuous bus journey sends a stranger to intensive care in a fortnight.
  • Societally, health charities are warning that actions taken in response to one health crisis – Covid-19 – could lead to up to 11,000 deaths of women in childbirth globally because of another – namely, 9.5m women not getting access to family planning intervention.
  • Governmentally, some systemic consequences of decision-making are there for all to see, others less immediately apparent – for example, Trump’s false proclamation of testing availability “for anyone that wants one”  ended up actually reducing the availability of tests by immediately increasing demand.  It even reduced the already scarce supply of protective masks, which must be disposed of after testing.

Students will be studying coronavirus for years. What lessons will we learn? What changes will it bring? Covid-19 presents many clear examples of effective systemic action, and stark lessons in the consequences of non-systemic thinking. Leaders and decision-makers everywhere are being compelled to think broader and deeper about causation and consequence. Decisions taken, even words spoken, without systemic awareness can have – indeed have had – profoundly damaging effects.

Systemic thinking, planning, action and leadership must now be mainstreamed – individually, organisationally, societally, across public, private and charity sectors. As an American diplomat reflected: “from climate change to the coronavirus, complex adaptive systems thinking is key to handling crises”. But currently, we do not think and act in accordance with how our complex systems function. In fact, some epidemiologists, suddenly the world’s most valuable profession, have been calling for more systemic ways of working for years.

 

more in source: Covid-19 means systems thinking is no longer optional

Yvonne Agazarian – Systems-centered therapy

via Systems-centered therapy – Wikipedia

Not enough https://en.wikipedia.org/wiki/Yvonne_Agazarian on here!

Loads more at https://www.systemscentered.com/

Systems Thinking Ontario – 2020-04-20

via Systems Thinking Ontario – 2020-04-20

2020-04-20

April 20 (the third Monday of the month, following Easter) is the 78th meeting for Systems Thinking Ontario. The registration is on Eventbrite at https://systems-thinking-practical-wisdom.eventbrite.com.

Systems Thinking and Practical Wisdom

Whom, when and where do Systems Changes situate? We won’t necessary cover the whole agenda, but we have a complete set of slides that include:

  • [preamble] Episteme, Techne, Phronesis (reordered)
    • Intellectual Pursuits (Rethinking Systems Thinking)
    • Systems changes as situated c.f. ideal-seeking
  • A. Value(s), Judgment, Soft Systems Thinking
    • Appreciative Systems (Vickers, Checkland)
    • Policy, impacts and consequences of systems changes
  • B. Service Systems (c.f. Production Systems)
    • Science of Service Systems (Spohrer, Kijima)
    • Material-products c.f. information-services as systems changes
  • C. Socio-Technical Systems Perspective
    • Tavistock Institute + Legacy (Trist, Emery, Ramirez)
    • Coproduction and design principles guiding systems changes

For April, we’ll continue with the online, modified program, following the agenda for a lecture in the Systemic Design course, of the master’s program in Strategic Foresight & Innovation at OCADU. As in the March session, we still step through the slides slowly, and nurture a conversation that encourages participants to develop a personal appreciation through collective sensemaking.

Venue:

  • We will meet online. Please register on Eventbrite, and the web link will be sent to you.

Suggested pre-reading:

Keeners may want to listen to the video or digital audio of the lecture at:

Agenda

SEE LINK

Post-meeting artifacts

Bloggers are encouraged to write about their learning and experiences at the meeting. Links will be added to this page.

via Systems Thinking Ontario – 2020-04-20

Learning in Development: Those who only know about football, don’t know about football | footblogball

More great systems thinking from this excellent football coaching blog!

via Learning in Development: Those who only know about football, don’t know about football | footblogball

Teasers:

A training session is just the expression of the coach and what he thinks his role is.

Within each team there can be 20 different game models because of the players.

Should coaches see themselves as designers (architects of an environment)?

Can we design context to create situations where the player decides so that they can connect their intentions with actions?

What coaches are doing with players is more or less what governing sports bodies, or federations or coach education institutions are doing with the coaches.

We can possibly learn more (about football) from attending a seminar on culture than one given by a professional coach

Those who only know about football, don’t know about football (Cesar Menotti)

 

Guiding the Self-Organization of Cyber-Physical Systems, Gershenon (2020) cf Beyond hierarchy: A complexity management perspective , Espinosa, Harnden, and Walker (2007)

via Frontiers | Guiding the Self-Organization of Cyber-Physical Systems | Robotics and AI

HYPOTHESIS AND THEORY ARTICLE

Front. Robot. AI, 03 April 2020 | https://doi.org/10.3389/frobt.2020.00041

Guiding the Self-Organization of Cyber-Physical Systems

Self-organization offers a promising approach for designing adaptive systems. Given the inherent complexity of most cyber-physical systems, adaptivity is desired, as predictability is limited. Here I summarize different concepts and approaches that can facilitate self-organization in cyber-physical systems, and thus be exploited for design. Then I mention real-world examples of systems where self-organization has managed to provide solutions that outperform classical approaches, in particular related to urban mobility. Finally, I identify when a centralized, distributed, or self-organizing control is more appropriate.

 

via Beyond hierarchy: A complexity management perspective

Beyond hierarchy: A complexity management perspective
  • April 2007
  • Kybernetes 36(3/4):333-347
Purpose – This paper aims to contribute to current research on complexity management by re-visiting Beer’s paradigm on control and self-organization and explaining its usefulness to support non-hierarchical organizations and networks and its complementarities to new development in complexity sciences. Design/methodology/approach – The paper explains the current crisis of hierarchical structures and then summarises new proposals on non-hierarchical organizations from the perspective of complexity sciences. It then summarises Beer’s provenance of control and, in particular, the ideas of requisite variety and meta-systemic management. It explains how these ideas transform the way of approaching management and presents examples of real-life businesses transformed by following this approach. Findings – The analysis highlights limitations in current management theory and practice that can be overcome by embracing the paradigm of control suggested by some of the pioneer cybernetitians. It shows that the model has unprecedented powers to describe and analyse the network characteristics of contemporary social organizations from the perspective of effective management and lays down a new and democratic paradigm of control. Research limitations/implications – This paper concentrates on explaining the main arguments of meta-systemic management suggested originally by Beer and exploring its implications for managing complex networked organizations; more applied research would be convenient to experiment the suggested model. Originality/value – This study hopefully has shown that core ideas from the tradition of cybernetics a​d​d​
Overview also at https://www.emerald.com/insight/content/doi/10.1108/03684920710746995/full/html
Readable and dowloadable (in a slightly weird system) at https://vdocuments.mx/beyond-hierarchy-a-complexity-management-perspective.html

 

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