Listing Excel Sheets

User frustration boils when they enter data one place and must enter it again someplace else.  In this user engagement video, we explain how to export SharePoint list data into Excel, where it can be shared and reused.

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Book Review-A Fearless Heart: How the Courage to Be Compassionate Can Transform Our Lives

Individually, compassion and courage make sense. Compassion is the awareness of the suffering of others and the desire to minimize it. Courage isn’t the absence of fear but the willingness to overcome it. Putting these together, we discover a subtle fear in being compassionate and what can be done to develop the courage to do so. That’s what A Fearless Heart is about – developing the courage to be compassionate in the face of circumstances, thoughts, and feelings that make that difficult.

Magic Penny

It was years ago now when I heard the song for the first time. I was in a grade school choir room, and the song was our next learning. It was an odd song. It was about giving something away and getting more. The first part of the lyrics of this Malvina Reynolds song begin:

“Love is something if you give it away,
Give it away, give it away.
Love is something if you give it away,
You end up having more.

“It’s just like a magic penny,
Hold it tight and you won’t have any.
Lend it, spend it, and you’ll have so many
They’ll roll all over the floor.”

Most things in life, if you give it away you have less. However, this magic penny – and, more importantly, love – is something you get more of the more you give away. I’ve mentioned before (see The Art of Loving) that there are three Greek words for the word we call “love” in the English language: eros, romantic love; philos, or brotherly love; and agape, which is God’s love or global love. I’ve also mentioned that agape and compassion are essentially the same thing. (See The Book of Joy.) So, what we have in this little song is the truism that, when you demonstrate your compassion for others, you become more compassionate – not less.

In the zero-sum game that most of us live with daily (if someone else wins, then we lose), it’s hard to understand how compassion begets compassion and how our worlds are enriched when we enrich the lives of others. The more that we live our lives for others, the more we get out of it for ourselves.

The Paradox of Happiness

I’ve mentioned before the two goddesses of wisdom (Lakshmi) and wealth (Sarawati). If you pursue wealth, it will run from you; but if you pursue wisdom, wealth will be attracted to you. (I covered the story in my review of The Heretic’s Guide to Management.) A similar thing happens with happiness. When we stop worrying about our own happiness, and we’re focused instead on the needs and happiness of others, we find that happiness comes our way.

Hedonistic happiness is a treadmill requiring increasingly greater amounts of pleasure to feed the same level of happiness (see Thinking, Fast and Slow for more on this). However, value-based happiness driven by our love (compassion) for our fellow man becomes an enduring characteristic of joy. To become happy, we then need to not worry about our happiness and instead focus on the happiness of others.

The Pit of Loneliness

If happiness defines one side of a continuum, loneliness sits on the opposite side. Loneliness is a painful form of suffering where we feel separate and apart from the others that we share this planet with. (See Loneliness for more.) Our compassion for one another helps to bridge the gap that loneliness creates by connecting us.

Empathy means that I understand this about you. Compassion, as mentioned above, is awareness of another’s suffering and the desire to minimize it. Thus, empathy connects us through understanding, and compassion connects us through action. Empathy’s near enemy (explained momentarily) is sympathy. Sympathy is based in understanding but separates by pity. Instead of being, I understand this about you, it’s an understanding that you don’t want to be where the other person is. (See Sympathy, Empathy, Compassion, and Altruism for more.)

Near Enemies

Near enemies is the idea that there are two concepts where one is bad but seems to be the same as a virtuous one. The two seem similar but really operate very differently. A Fearless Heart claims that the near enemy of compassion is pity, but I would refine this, as stated above, to say that sympathy is the near enemy of empathy, and pity leads to sympathy instead. Because I believe that compassion is built on empathy, this is a distinction of degree. Fundamentally, I believe that the presence of pity prevents the connection necessary for true compassion.

Near enemies are responsible for people not desiring a desirable state. Compassion is confused with submissiveness, weakness, or sentimentality. People fear compassion, because compassion isn’t seen as innate part of all of us (see Spiritual Evolution) or as a necessary trait.

Fear of Compassion

On some level, it’s difficult to conceive of someone who would be afraid of compassion. At another, it’s all too easy to see subtle forms of fear in our ability to give and receive compassion. Whether it’s an aversion to feeling indebted to someone else or the queasy feeling that we’re not enough if we need someone else’s compassion, we realize that there are times that both giving and receiving compassion can be difficult.

Paul Gilbert was the first to schematize fear of compassion, defining it as three different categories of fear: fear of compassion for others, from others, and to oneself. He defined this in more detail by articulating statements that we could rate how much we identify each.

  • Compassion for others:
    • People will take advantage of me if I am too compassionate and forgiving.
    • If I am too compassionate, others will become dependent on me.
      • I can’t tolerate others’ distress.
    • People should help themselves rather than waiting for others to help them.
    • There are some people in life who don’t deserve compassion.
  • Fear of compassion from others:
    • I am afraid that if I need other people to be kind they will not be so.
    • I worry that people are only kind and compassionate when they want something from me.
    • If I think someone is being kind and caring toward me, I put up a barrier.
  • Fear of compassion for oneself:
    • I fear that if I develop compassion for myself, I will become someone I don’t want to be.
    • I fear that if I am more self-compassionate, I will become weak.
    • I fear that if I start to feel compassion for myself, I will be overcome with sadness and grief.

Just because you’re afraid of compassion doesn’t make it any less the right approach. By identifying what the fears are, it’s possible to make them smaller.

Teaching Fishing

The cliché is you should teach a man to fish rather than give him a fish. Teaching him can feed him for a lifetime and giving him a fish feeds him for a day. However, this is substantially easier to say than it is to do in many cases. Compassion is a place where our best and highest work creates solutions for the other person that allows them to be self-sustaining in the future and not need any additional help to relieve their own suffering.

This aspect of helping people be more self-sufficient is both critical and often lacking. People who have psychological issues are often prescribed drugs that they’ll be on all their lives, making them dependent and never fully healing. (See Warning: Psychiatry Can Be Hazardous to Your Mental Health for more on the problems with these prescriptions.) Even counselors and psychologists who try to resolve problems with their patients often fail. (See The Heart and Soul of Change and Science and Pseudoscience in Clinical Psychology for more about effective and ineffective counseling.)

A different approach to psychology – and helping people to thrive – is what has been called “positive psychology.” It’s a movement founded by Martin Seligman and one he continues to champion today. Instead of focusing on deficits and gaps, positive psychology helps the patient to see that they already possess the things they need to be happy and to thrive. (See Martin Seligman’s book Flourish and Barbara Fredrickson’s book Positivity for more.) As we’re helping others, we should simultaneously be helping them to see the capacities they have within themselves. (See Motivational Interviewing for some more ideas on how to affirm people in their strengths.)

The Only Way Out Is Through

There’s a belief that people who are calm are in control of their emotions. The belief is that they can keep them at bay and constrain them even in the toughest times. This is a false belief. Emotions that are repressed and denied have a way of oozing their way to the surface and causing havoc. It’s a truer statement to say that people who are good at controlling their emotions just have a better awareness and acceptance of their emotions.

It’s not possible for the rational self (the rider in the elephant-rider-path model discussed in The Happiness Hypothesis) to restrain the emotions permanently. However, with a better relationship – driven by acceptance – there will be fewer times when the emotions will fight to have control. It’s acceptance of the emotions that are being felt, that our rationality can properly assess that we’re not in much real danger – and therefore dramatic actions are not called for.

It can be true that we’re threatened, but, to some degree, we choose what is a threat and what is a challenge to be overcome.

Challenging the Threat

There are two key components of ego-resiliency – which is a goal that everyone has. One of those is the ability to perceive difficulty as a challenge rather than a threat. Instead of looking at the lack of knowledge to do something, you can view it as an opportunity to learn or a challenge to be able to demonstrate that you can do things.

It’s cliché to describe problems as opportunities, but that really is the case. Edison’s work to find the incandescent lightbulb is similarly cliché, but in it rings a bit of truth. Edison’s work wasn’t always a commercial success. From his first patent for a voting machine to his extensive work trying to find alternative sources for natural rubber, it wasn’t that Edison was uniquely gifted to never fail. His unique gift was in his perspective that the things that he faced were challenges and not threats.

Adversity and the Rubber Ball

The other component to ego-resiliency and effective recovery from hardship is the capacity to bounce back from adversity. The agrarian saying is, “If the horse throws you off, get back on.” It’s simple to say, but harder to do – both physically in case of a horse and proverbially in the face of adversity causing a defeat. However, for the most part failure isn’t fatal.

What that means is that, though we may get knocked down and feel like we’re losing or failing, it isn’t permanent. The ability to recognize that the problems aren’t persistent – that they’re temporary and not pervasive – but are localized to one or a few small areas of our life can allow us to understand that adversity can get us down, it just can’t keep us down.

Vulnerability

There’s a bit of vulnerability in accepting that we’re going to get knocked down from time to time. There’s a bit of acceptance in our imperfect and often frail nature to know that we aren’t invincible. While we all intuitively know we’re not perfect, and we’re going to die, and vulnerability is a cloak that we’ll always wear, we seek to deny it from ourselves and from others.

The paradox of vulnerability is that to allow ourselves to be vulnerable, we must feel safe – we may not need to be safe, we just need to feel it. To admit our vulnerability, we must accept ourselves non-judgmentally. To be vulnerable with others, we’ve got to trust that they don’t intend us harm. (See Trust=>Vulnerability=>Intimacy for more.)

Self-Pity

Like anything, there can be too much of a good thing. Being vulnerable often leads to humility. (See Humilitas for more.) However, if we don’t non-judgmentally accept our vulnerability, we may find ourselves in the pit of self-pity. We may discover that we’re self-absorbed with only our limitations and our faults. We become so focused on ourselves that we can’t see that others have vulnerabilities too.

Self-pity is a form of self-absorption, where our fear and lack of self-compassion have limited our view of the outside world. It’s natural and normal that our focus is pulled towards intense and immediate threats; however, it’s not natural when those threats aren’t real and when they persistently prevent us from seeing the real world. (See The Anatomy of Peace for boxes that distort our perspective.)

Dysfunctional Relationships

It takes two to tango, they say. Relationships necessarily involve two people. While we may believe that we’re the root cause of everything that is wrong in a relationship or lament our poor decision-making that led us to be a part of a dysfunctional relationship, the reality is that one or even a few bad decisions does not poor judgement make. Every relationship has its dysfunction. The real question is what your role is in removing the dysfunction, either by changing your responses or exiting the relationship.

More than any other aspect of our world, relationships is key. Research supports our need for social connection, intimacy, and closeness – and in many areas of the world, it’s getting harder and harder to maintain and build connections. Having self-pity because we don’t have enough relationships or have too many dysfunctional relationships doesn’t help us.

Checking In

Whether it’s alone in a room or with a group of people, one way to be present and shape the future of your relationships with others – and with yourself – is to perform a check-in process. The process is simple but often overlooked. Whatever specific approach you take to get there, checking in has two goals. The first goal is to acknowledge your reality, including your thoughts and feelings, whether they seem reasonable or not. The second goal is to recognize your desire for the conversation, for the relationship, or for yourself.

The process of checking in helps you to reach clarity about where you really are and where you really want to go. Collectively, this makes finding the path between the two much easier to find even if the path itself isn’t easy. If the path doesn’t seem easy, maybe you need A Fearless Heart to guide you.

Video-How to Make the Right Messes

This year, I had the pleasure of delivering the keynote session at the Indianapolis World Information Architecture Day 2019 to a packed house. Here, I discuss how you can make the right messes with your information architecture.

We’ve uploaded the video to YouTube, so you can check it out there, or watch the video below.

Book Review-Happiness: A Guide to Developing Life’s Most Important Skill

Is happiness a skill? Most folks are looking for happiness – like searching for the lost city of Atlantis or the fountain of youth. However, few people look at happiness as a skill that can be cultivated. However, that’s the central idea behind Happiness: A Guide to Developing Life’s Most Important Skill. Matthieu Ricard is a scientist turned Buddhist scholar who believes that happiness isn’t something that you find, but it’s something that you develop.

Wiring in Happiness

Ricard isn’t the only one who believes that happiness comes from changing the patterns of our thoughts. It’s not that our external circumstances don’t matter when it comes to happiness, it’s just that it matters much less than we believe. We’ve heard stories of the lottery winners who, after a short time of happiness, return to their normal sense of happiness – or, rather, being unhappy. While we can’t change the circumstances around us, as much as we might like to, we can change our responses to the circumstances.

It was 2007 when a flight out of LaGuardia was cancelled, causing me to route through Regan National in Washington, DC. I mentioned that experience in my review of Stumbling on Happiness. I’m far from being able to say that I’ve got it all figured out, but, in that post, I share how different responses to a flight being cancelled could lead to anger and frustration or gratitude for the opportunity to read a book about happiness.

It wasn’t the external circumstances that changed – both passengers faced the same problem of a cancelled flight – but the responses are very different.

Rick Hansen in Hardwiring Happiness believes that it’s possible to change the way we think and thereby develop more happiness. It might be more accurate to say that Hansen encourages us to savor the happiness that we do have and remain grateful, so that we can be happier with our everyday life.

Healthy Mind

What Daniel Gilbert called a psychological immune system (in Stumbling on Happiness), Ricard would call a healthy mind. Instead of resisting the negative circumstances, Ricard encourages us to have our thoughts be healthy all the time. It’s not an antibody that your immune system releases in response to an attack, but is instead a natural part of daily living.

A healthy mind is free from troublesome internal conflicts. A healthy mind apprehends reality clearly – for the most part – and adapts quickly when a gap is discovered between perception and reality. The way that the person perceives themselves is also grounded in the way that they actually act. They aren’t always “minding the gap” between who they say they are and the way they actually behave. There’s a sense of peace that the way that they live their life is the way they want to be.

The Illusion of Control

Much of the reason why people aren’t happy is because they believe in the illusion of control. Those people afflicted with depression can apprehend the fact that they have no control more readily than the optimists among us who continue to believe that they have control even when they have none. (See The Hope Circuit for more on this.) The illusion of control helps us cling onto hope even when the chances are very slim. Snyder in The Psychology of Hope explained that there are two components to hope – willpower and waypower. Waypower is basically the belief that you know how to affect change. (Willpower has a more or less classical definition; you can find out more about this in the book titled Willpower.)

The illusion of control may give us hope – but, as Miller explains in Compelled to Control, it’s all too easy for us to believe that we have control of other people. The result is dysfunctional relationships that aren’t helpful in leading us towards happiness.

Pleasure and Joy

I read in Building Trust: In Business, Politics, Relationships and Life that many people know what trust is until you ask them to define it. When you do, you’ll invariably hear a definition of trustworthy and not a definition of trust. I believe a similar thing happens when you ask someone to define joy. Rarely would someone respond with a clear definition to this question. Even in The Book of Joy, definitions for joy are hard to come by. What is most frequently shared for joy is something shallower, more incidental, and fickle – pleasure. Pleasure may not have the lasting value that joy has, but it’s much easier to articulate.

Where pleasure is about the moment, joy is about the enduring characteristics of a person or situation. That’s great but how do you develop joy? Ricard explains that joy is the outward expression of the happiness that a person feels inside. It is happiness radiated on to others.

Integrated Self Image

We are quite literally and figuratively the center of our universes. We see everything from our eyes and construct reality through our senses. Our brain is designed to make leaps of inference. (This is the System 1 of Daniel Kahneman’s systems model in Thinking, Fast and Slow.) We’re designed to jump to conclusions. We use everything that we “know” to guide our predictions about what will happen next. The ability for us to predict what will be next is a remarkable feat of evolutionary engineering.

Evolution even equipped us with tools to help us adjust our prediction failures – to refine the efficacy. Jokes, it seems, are designed to test our predictive capacity. Laughter is the response to a failure to correctly predict – at least in a comedy club. (See Inside Jokes for more.) However, the correction mechanisms for our predictive capacity are hampered by the ego’s defenses and our need to be perceived as perfect to the outside world. (See Change or Die for more on our ego defenses.)

When we see ourselves in a distorted way – by failing to accept all of ourselves – we perceive the world in a distorted way. If we’re looking through ourselves through wavy lenses, we see the rest of the world in the same way. As a result, it’s critical that we learn how to see ourselves clearly so that we can see the world clearly. We won’t really end up with a perfect perception of the world – but at least we can work without any core distortions that are hard to find – and fix.

Constructing Happiness

If happiness is a skill, then how do we develop it? In other words, how do we construct happiness. The answer is a sort of side-step. I mentioned in my review of The Heretic’s Guide to Management that A Philosopher’s Notes spoke of two Hindu goddesses:

Lakshmi is the traditional Goddess of Wealth. The problem is, if you go straight after her (by constantly chasing the bling) she’ll tend to avoid you. Saraswati’s the Goddess of Knowledge. If you go after her (by pursuing self-knowledge, wisdom and all that goodness), an interesting thing happens. Apparently, Lakshmi’s a jealous Goddess. If she sees you flirting with Saraswati she’ll chase after you.

It turns out that happiness may be naturally attracted to wisdom in the same way that wealth is attracted to knowledge. Happiness has relatively consistently been related positively to age – you’re happier as you get older. There’s a peak in our 70s – when our bodies tend to start failing to a greater degree.

A different way of thinking about this, and the approach that Ricard takes is that if a wise man can be happy, then happiness must be possible. In other words, he solves the belief that happiness – sustained happiness – is unattainable. If there are wise men who were previously not happy but now are, then our ability to reach happiness is a measure of our willingness to pursue the wisdom that leads to it.

Obtaining wisdom is not necessarily a straight path either. However, it is a known path. It’s one that people have pursued for centuries. Hard work and dedicated practice can make anything possible – even wisdom and happiness. (See Peak for more on how to reach the pinnacle of any endeavor.)

Emotional Regulation

From the outside looking in, it appears that people who are happiest have overcome their negative emotions and have controlled their emotions into a channel of only positive experiences. However, this view is not correct – at least for those that I know. It’s more accurate to say that the people who I know who are the happiest are more in touch and in alignment with their emotions. They’re not transcending their emotions as much as they’re accepting and shaping them – what Ricard calls regulating them. Daniel Goleman – who wrote the foreword for Ricard – would likely agree, as this aligns with his beliefs about the development of Emotional Intelligence.

Looking at Jonathan Haidt’s Elephant-Rider-Path model from The Happiness Hypothesis, it’s not that the rider has usurped control from the elephant, rather that the elephant and rider have developed the kind of relationship that the elephant accepts the gentle hand of the rider even when it would have other ideas. That is the person is so integrated in their thoughts and feelings that they play together rather than as separate ideas.

Lisa Feldman Barrett argues in How Emotions Are Made that the separation that we’ve created between emotional areas of the brain and non-emotional areas are fiction and that we find that the neural circuitry that drives our thoughts is interconnected with the circuitry associated with emotion. Ricard notes, “The traditional languages of Buddhism have no word for emotion as such. That may be because according to Buddhism all types of mental activity, including rational thought, are associated with some kind of feeling, be it one of pleasure, pain, or indifference.” In short, our emotions may not be separable from our thoughts.

It’s more accurate to say that those who have happiness haven’t learned to transcend their emotions but rather have come to find a way of accepting them as a part of themselves.

Controlling but Not Repressing

Another way to think about this process is the idea of controlling emotions without repressing them. In the practice of meditation, we learn to accept our feelings and then gently guide our thoughts back to the object of meditation. The same approach is useful with our emotions.

When we gently recognize our emotions without reaction or judgement, we create a space where they can develop completely. Allowing them to develop completely doesn’t mean acting on them, it only means that they’re not shunned, judged, or repressed. Emotions, like thoughts, are subject to the Zeigarnik effect. That is, incomplete thoughts or emotions are given greater weight in our minds. (See The Science of Trust for more on the Zeigarnik effect.) So, repressing an emotion may drive it underground, but it will also strengthen it at the same time.

When we repress emotions, we believe they are shameful or that we shouldn’t be having them. This judgement separates the ability to control our emotions from repressing them. Acceptance is necessary for us to work with our emotions, rather than trying to repress them.

Loneliness and Depression

The striking statement “Fifteen percent of Americans report experiencing an intense feeling of loneliness once a week” captures part of the problem with trying to develop happiness. That statement is a scary contrast to the happiness that Ricard is speaking about. In my review of Loneliness, I explained that loneliness has nothing to do with being alone. It’s about feeling alone and disconnected. We cannot completely quiet our yearning to be with other people. It’s wired into our very being. (See Spiritual Evolution for more.) However, curing loneliness isn’t as easy as placing someone in a room full of people. It’s much harder for people to develop the trust necessary to be really seen and understood so that they can be vulnerable and thereby in a real relationship with others. (See Trust => Vulnerability => Intimacy for more on this.)

Accompanying loneliness at the other end of the happiness continuum is depression. It’s clinically recognized and too often medicated. Depression is like trying to fill a tub when the drain is open. It’s like having all the energy sucked out of you. It drains away your happiness. While there are chemical and clinical causes for which treatment is essential, there are also interesting perspectives, including Dr. Glasser’s, who suggests in Choice Theory that we may have more choices to make than we realize even when it comes to depression.

If depression is a choice, then perhaps happiness is a choice too. Perhaps to be happy, we must choose to do the things that we know will lead to happiness. One of those might be to read about Happiness.

Patent Issued: Dressing with Moisture Indicator

It was over four years ago on a trip to visit our son that we started a journey to create a way to help protect patients from developing life-threatening blood stream infections. The journey has been long, but today is the day that the US Patent and Trademark office issues our patent for a dressing with moisture indicator. We wanted to take this opportunity to explain why this is so desperately needed and why it works.

The Healthcare Associated Infection Problem

Central line-associated blood stream infections (CLABSI) are a special class of healthcare-associated infections (HAIs) and one that is particularly life threatening, because it can lead to sepsis. Each year in the US, roughly 100,000 people die of HAIs. That’s comparable to a commercial airliner crashing every single day, killing everyone on board. There has been a great deal of energy focused on reducing this problem, but still too many people are admitted to hospitals, have a central line inserted, and get sicker because of CLABSI or some other HAI. Some of those that develop a CLABSI die from this preventable infection.

The Story

It was 1:30 AM, and we were driving through western Pennsylvania when Terri exclaimed, because a young patient had developed a CLABSI and by the bacteria and the notes in the chart, she knew what happened. The patient had vomited on their central line’s dressing, and the parents, trying to be helpful, wiped it off. The problem is the moisture and the bacteria that naturally occur in the stomach were now on the dressing. Bacteria need two things to be able to replicate. They need food, and they need mobility. There’s food for bacteria nearly everywhere. The moisture from the stomach and from the washcloth made it easy for the bacteria to get to food and replicate.

Eventually, the bacteria penetrated the dressing, and the IV led them straight to the blood stream, where they could spread out and infect everywhere in the body.

The Dressing’s Role

IVs are used to deliver fluids and medicines to patients. Central lines are inserted into major blood vessels, so that greater volumes, multiple medications, and nutrition can be quickly infused without the complications of peripheral IVs. This is great when you need to be able to diffuse medicine quickly, but it makes them particularly vulnerable to bacteria getting the benefit of the same distribution. The IV dressing is designed to protect the insertion site of the IV from becoming contaminated with bacteria and serving as a direct pathway to the circulatory system.

Dressings, however, must be semipermeable. That is, they need to let the natural moisture emitted by our skin as small amounts of sweat escape to prevent reservoirs of liquid from forming under the dressing. This semipermeable nature means that it’s possible for external contaminants to make it through. The dressing creates a protective barrier but not an absolute one.

As a result, the CDC (and everyone else) says that dressings should be clean, dry, and intact. Cleanliness is an easy visual observation. While the exact standard for what constitutes clean and dirty can be argued, it’s easy to assess the degree of cleanliness by observation. Assessing whether the dressing is intact is slightly more invasive, as it requires that the nurse or provider lift the IV to see whether there are gaps between the dressing and the skin. However, dryness presents a particular challenge.

Assessing Dry

On the surface, assessing dryness – or wetness – of a dressing should be easy: just touch it. Except nurses and providers – for everyone’s protection – should always wear gloves when touching a patient’s dressing. You can’t tell if something is wet through gloves. It’s possible to assess cold-wetness, because it will feel colder; but because the fluids will be at body temperature, it’s very difficult to determine if a dressing is wet through gloves.

Because dryness is so hard to do, it’s not always done well. In truth, it’s not assessed as often as it should be based on research and healthcare system standards. This is the fundamental problem we solved. We found a way to make dressings tell you visually when moisture is present. The result is assessing dryness is as easy as assessing whether the dressing is clean.

Information Overload

We contributed a chapter to the American Nurses Association book Information Overload. It explains what nurses already know: they’re overloaded. They’re expected to document hundreds of observations per hour, and, for each observation, they may have to make multiple assessments – as is the case for dressings. There’s simply no time to do all that must be done to provide good care for their patients and properly document what is happening.

We recognized that, if we couldn’t make the assessment easy, we’d have no chance of changing behavior and helping nurses change dressings appropriately.

Antimicrobials

The industry has been moving down a path of using antimicrobials to combat infections. The idea is that, if you use something like chlorhexidine gluconate (CHG) in a dressing, you’ll kill the bacteria and eliminate the need to change the dressing. CHG-based dressings are better than non-CHG-based dressings for those patients that can tolerate it well; however, it creates a secondary set of issues. We have a limited number of chemicals (and metals) that we know to have antimicrobial properties. As a result, we use them frequently when timely cleaning isn’t practical or even possible.

Research indicates that some microbes are becoming resistant to the antimicrobial properties. In short, the antimicrobials are gradually becoming ineffective as the microbes adapt. At some point, we’ll overuse CHG and the other antimicrobials, and they’ll become completely ineffective. We see this already with multi-drug resistant organisms (MDROs) like Methicillin-resistant Staphylococcus aureus (MRSA) and carbapenem-resistant Enterobacteriaceae (CRE). We’ve killed the susceptible versions of the bacteria and the resulting bacteria replicates free of competition from its variants.

It’s not a question of if strategies using CHG will become ineffective – it’s a question of when. No one can predict when CHG will stop being sufficiently effective to continue its use, but the day is coming.

Unstoppable Humans

The good news is that humans are unstoppable. We’ve done amazing things as a species. This is particularly true when we make it easy to do the right thing. Evolutionary scientists have studied and modeled what has given us the power to be the dominant life form on the planet. Some of this has to do with our capacity to work together, but equally important is our capacity to adapt and to adopt behaviors that help us to protect ourselves and our communities. Caring for patients will never be easy, no matter how much we try to make it so. Having a dressing that signifies the need to be changed due to moisture helps make patient care easier. Making appropriate care easier improves the care we are able to provide and the outcomes for patients everywhere.

Dropping Files is Good

A consistent complaint from users is how difficult it is to work with files that are on websites, including the intranet.  In this engagement video, we explain how working with files on the intranet is as easy as dropping files.  Dropping files in real life is not all that fun. Dropping files online is easy, as we explain in this video.

If you want to share this video, you can get it ad-free. All you need to do is click here to sign up, and we’ll send all our engagement videos to you via email.

Book Review-Complications: A Surgeon’s Notes on an Imperfect Science

Complications impact every aspect of our life. We believe that we’ve got life all figured out, but then come the pesky complications to our orderly, perfect world. Atul Gawande speaks about medical complications in Complications: A Surgeon’s Notes on an Imperfect Science while simultaneously exposing the inner struggle that surgeons – and, indeed, anyone who provides care to another person – must struggle with. I’ve reviewed two of Gawande’s more recent books The Checklist Manifesto and Being Mortal – both are good and different from each other. They’re the reason I picked up Complications.

Imperfect Science

We’re wired by our nature to crave understanding of our world. We want to believe that we have it all figured out – or at least, if we don’t have it all figured out, someone else does. Someone else who will tell us the answers to the questions that we don’t even understand yet. In this yearning, we’re willing to overlook what we know to be reality.

Medical errors are the third leading cause of death in the United States. (See commentary about the research on NPR.) Let that sink in for a second. Heart disease and cancer are more likely to cause death, but nothing else. Given our concern for healthcare-associated infections, it’s interesting to me that the researchers didn’t include healthcare-associated infections in their list. Though they may be unwanted, they’re not considered 100% preventable and thus didn’t make the list – though they would add about 100,000 more deaths and move the needle from 250,000 deaths to 350,000 every year, all based on medical error.

However, most of us don’t think of this when we go to the doctor to ask them to evaluate our condition, adjust our medicines, or operate on us. We don’t consider that the chances are good that there will be some sort of an error if we stay in a hospital – whether inconsequential or not, it’s likely to be there. Gawande pushed for a solution to some of these errors in The Checklist Manifesto and made a compelling case that aviation doesn’t suffer from the same failure rates as medicine. Terri and I wrote a chapter in Information Overload that speaks to the unmanageable level of information that nurses must cope with.

The problem is that we speak of medicine as a practice and rarely pause to think that this means everyone is practicing. They’re practicing becoming good, but they aren’t good to start. (See Peak for more on how to become the best at anything.) Medicine isn’t nearly as much science as we’d all like it to be. The complexity of human systems and how to best support people isn’t always easy.

Systems

Just as we pass over practice and rarely pause to consider that it means no one has mastered it, we similarly toss out the word “system” in medicine like it’s well understood. We have the cardiovascular system, the digestive system, the endocrine system, the nervous system, and more. As we zoom into any one of those systems, there are a set of loops that keep the system running. Some of those are internal, and some of those are provided by outside systems. For instance, the nervous system relies upon the circulatory system to provide the neurons with glucose and oxygen. These, of course, come from the pulmonary systems and digestive systems. Technically, glucose is managed by the endocrine system, which is, in turn, fed by the digestive system.

I think you see the point. Even if you were to fully understand one of the systems, which would be a feat in and of itself, it’s unrealistic to expect that anyone would fully understand every system – and the interaction between the systems. There’s great discussion on the fundamentals of systems in Thinking in Systems and more unsolvable problems, called “wicked problems,” in Dialogue Mapping due to inherent instability in systems. We do a lot of writing about how systems are unknowable and uncontrollable – but we still expect that they are both knowable and controllable. (Something that is covered in more detail in The Black Swan and Antifragile.)

Systems are a simplification (which we are as humans prone to do). They allow us to manage the fact that we can’t everything in our head to be able to simulate everything. We use our understanding to create schemas which allow us to simplify our thinking into ways that (hopefully) we can manage. (See The Art of Explanation for more on schemas)

Rational Decisions and Irrational Intuition

Gary Klein’s work with firefighters helped me see that everything we know isn’t rational and explicit. Instead, we have intuition that is developed from seeing things and making models in our thinking. (See Sources of Power and Seeing What Others Don’t for more on his work.) Works like The Paradox of Choice and Lost Knowledge helped me to realize that teasing out some tacit knowledge is difficult and potentially disruptive to the professional that has the knowledge.

However, converting tacit knowledge into explicit knowledge dramatically increases the usefulness. Codifying what is and isn’t best practice through research and validation makes it possible to leverage the hard work and learning of a few and allow it to apply to the many. It was 2001 when the research was published for a study that I supported. The Diabetes Advantage Program, as it was called, was a grand experiment to see if a set of agreed-upon standards could inform the care of patients in a primary care setting. (The research published as “A Systematic Approach to Risk Stratification and Intervention Within a Managed Care Environment Improves Diabetes Outcomes and Patient Satisfaction”.) My responsibility was to take the protocols that were finally agreed upon and put them into a system that would identify opportunities for improvements in care for the primary care physicians to choose whether to implement or not. The system created a pretty report with model orders that the physician could accept or reject. The nurse typically made recommendations on the report before handing it to the physician, and, after appropriate consideration, they often signed it, allowing the nurse to complete the required orders.

The project was successful. I believe a large part of this was striking the right balance between physician intuition and systematic support to help the physicians make the right decisions based on the available research.

Accepting Input

Strangely enough, there’s a central paradox as it comes to physicians. They must acknowledge that they’re sometimes wrong – and simultaneously be confident that every decision they make is the right one. On the one hand, they know that they are just as fallible as anyone else. On the other hand, they must behave as if they know the right path forward. President Truman famously said, “Give me a one-handed economist.” Dealing with uncertainty is never fun, and, when it comes to medicine, there’s always uncertainty.

The problem is that the patients and their families want – or perhaps need – to feel like they’re doing the right thing. That means that the physician must appear confident even when they’re not. You might be protesting, but sometimes they give options, and they don’t know which way to go. Even then, they must appear confident in the diagnosis or possible diagnosis and the list of options they put on the table.

Gawande’s next book, The Checklist Manifesto, speaks of the power gradient that exists in healthcare, with the physician leading and the rest of the team following. More importantly, he explains how the humble checklist and a prior agreement about how things will work are designed to subtly shift the balance of power back to a more neutral state where physicians – and particularly surgeons – are still in power but not so much that the rest of the team can’t verify and even question the course being charted.

Beyond the land of questioning what is currently going on and what is about to happen is a place where a physician can accept input about the case, alternatives, and their performance. The morbidity and mortality conferences that are regularly held in most acute care settings are designed to gently remind physicians of the mistakes that are made and what can be done to mitigate them in the future. This is feedback from peers that isn’t intended to be done in a shaming way. Its design is to create the expectation that you’ll accept feedback – and somehow remain confident at the same time.

Great Idea, But You Go First

There are other conflicts in the medical system. We know that, in general, the more experienced physicians have better outcomes. We also know that to get that experience they must have the chance to practice – thus some people must accept the care of relative novices so that they can learn. There are, of course, protections built into the system so that these less experienced physicians are guided, mentored, trained, and supported by more experienced physicians. However, it’s not the same, and everyone knows it. When your loved ones go into the operating room, do you want the 20-year old veteran or the resident? Most would say they want the experience.

That’s the rub in this conflict. We know that to improve overall, we need to get more and better practice. However, when it comes to our loved ones, we get a bit squeamish. How would we feel if they make a mistake and there are consequences – including death – that could have been prevented?

Eliminating Humans

We know that human beings are finicky creatures. We have systematic biases that prevent us from seeing things clearly. (See Thinking, Fast and Slow and Predictably Irrational for more about our biases and their predictability.) For instance, Willpower explains that, if you are up for parole, you want a hearing in the morning instead of the afternoon, because it doubles your chances for parole. It shouldn’t matter whether your case is in the morning or the afternoon; after all, the facts are the same. However, somehow it does. Judges – who are prided on their ability to be impartial – feel and act differently in the morning than in the afternoon.

So, if humans are the problem, why not eliminate the humans? As my above story illustrated, I don’t believe that’s the answer. Instead, I believe the answer lies in supporting the humans with systems designed to identify for the physician what may be wrong or what may be indicated by best research.

EKGs are a frequently-used test to assess heart functioning. It works by measuring the electrical currents that drive the heart. It’s the familiar bobbing line that we all expect to see thanks to television medial dramas. It’s also very difficult to read. However, with practice experts can tell a healthy heart rhythm from one that is a signal for danger. The problem is that, even nearly 30 years ago, computers could do it better. Fed with enough data about what was right and what was wrong, a computer better identified issues than a top cardiologist – by 20 percent.

Even with nearly 30 years since the publication of the study and new research supporting that computers can evaluate various data sets, including EKGs, with better detection accuracy, they’re rarely used. Even devices that can continuously monitor patients and devices designed for patients to purchase themselves (e.g. Kardia) aren’t in widespread use.

We’re resistant to the idea that computers can do our jobs better than we can – even when there’s evidence that this is the case. We can’t accept that we’re turning our fate over to a machine – and we shouldn’t. However, at the same time, it’s foolish to not leverage the tools that we must improve our own performance. Instead of eliminating the humans, perhaps we can find strategies that allow the humans to focus on the things that are more consistent with our unique capacities that machines currently cannot – and may never – do. “Doctors,” comments Gawande, “can be stubborn about changing the way we do things.” The stubbornness can be an asset to fend off new fads and have the confidence to keep doing what works – but it can have tragic consequences when it prevents us from moving forward.

We Know So Little

Gawande moves from topic to topic like a gazelle, quickly explaining using stories how we don’t understand pain or vomiting before moving on to more ethical issues like the degree of control that a patient should have in their care. In all of it, there’s the clear sense that we know so little. We can only see into the forest as far as our flashlight will shine. We may get stronger and stronger flashlights in terms of technology, but, fundamentally, we will always only see so far.

Behind every certainty, there seems to lurk complications. Behind every diagnosis of a cause of death is an autopsy to contradict. (In 40% of cases, research says.) In life and medicine, it seems like we should be prepared for Complications. Maybe reading a surgeon’s notes on an imperfect science can help.

Living the Legacy: Legacy Auth in Office 365

Recently I discovered a problem with a client’s tenant. All the sudden, the authentication that I’ve used for a decade to get my command line utilities to authenticate to work wasn’t working. But it was just this tenant. No other clients had the problem, so it was a mystery as to why things were happening. Getting to the answer caused me to fire up some old neurons and get some clarity on the way things worked.

Joining the WS-Federation

Many moons ago, when claims-based authentication was still new in SharePoint, I was speaking about claims-based authentication and how it worked. I was the contract CTO for a startup who was trying to solve the authentication problem in K12. I was also helping write some of the guidance for authenticating in SharePoint with this new approach. See Remote Authentication in SharePoint Online Using Claims-Based Authentication. So, this isn’t something that’s new to me, but it is something I haven’t focused on for a while.

As I was warming up the old neurons, I began to remember that the way we bounce from location to location and server to server is a standard called WS-Federation. It’s a “passive” authentication flow where the browser bounces from place to place to authenticate a user. Ultimately, the browser gets the user to a site that authenticates them, and the site issues a ticket. This is passed back through a chain of sites until you get back to the site that originally requested authentication of the user, all the while reissuing tickets. The article above explains the process in substantially more detail.

Ultimately, it’s all about one site (the relying party) trusting another site (the issuing party) to authenticate the user That’s all fine, but what do you do when you want to authenticate in a program instead of a web browser? Well that requires WS-Trust.

A little bit of WS-Trust

A different approach, an “active” flow, is needed to take care of programs that want to authenticate on behalf of a user but can’t follow a series of redirects. Think about the program that’s calling an API: it expects the results, not a series of redirects, so WS-Federation won’t work. The good news is that WS-Trust performs the same function as WS-Federation except that the server for the API makes the request for authentication on behalf of the user. The bouncing around is handled as the servers negotiate between each other where to go and whether the authentication succeeds.

The WS-Trust standard accommodates the normal case of a username and password to authenticate a user – but it has some serious limitations in a world where we’re beginning to use multifactor authentication.

Modern Authentication

Modern authentication, according to Microsoft and others, doesn’t rely on usernames and passwords. The idea is that we’re moving to a more secure platform where users need to authenticate with something more than a username and password. This is fine, except what do you do about authenticating programs that need to take action on their own behalf or on behalf of the user? The answer is effectively a username and password.

Some will argue that the shared secrets we give to applications aren’t passwords – after all, they’re called shared secrets, or keys, or something else. However, they amount to a password, but a substantially longer password than any user could ever manage. We’ve addressed the security problem by making the password sufficiently long.

In any case, we’re moving towards greater security, which includes multifactor authentication – and that can’t be accomplished in a username/password combination way. The result is that we call the simple username/password situation “legacy.”

When Legacy isn’t Legacy

Microsoft introduced a switch that you can turn off to disable “legacy” authentication. It makes sense at some level. There’s a new modern authentication that we want people to use, and, until recently, you needed to actively enable modern authentication. So, what do you call the old approach? Well, you call it legacy.

The problem is that legacy conveys that it’s old and should be replaced or disabled. And that’s what this client did. However, most utilities that allow for a user identity associated with the results created by the tool. When they disabled legacy authentication, they broke an entire class of applications.

Modern Application Authentication

In defense, there are new ways to authenticate applications into Office 365. However, what the labeling doesn’t make clear is that those modern authentication approaches only work for a subset of the APIs. Thus, there are some places where you don’t have a choice but to use the “legacy” authentication approach.

Certainly, should we be moving to modern authentication for our applications? Yes. However, it needs to happen when the APIs we need to access work with the new authentication. In this case, the new APIs would work – if we recode the tool we are using.

So at least in this case, “legacy” may mean today –even if we’re new to the platform.

Book Review-Competing Against Luck: The Story of Innovation and Customer Choice

I’ve known for some time now that it’s better to be lucky than smart. The organizations and people that are successful are more frequently the result of luck than intelligence or skill. So, then the key question when you’re looking to compete is the one answered in Clayton Christensen’s title Competing Against Luck: The Story of Innovation and Customer Choice. The unfortunate thing is that there aren’t any easy answers.

Jobs to Be Done

The kernel at the core of Competing Against Luck is the thing Christensen has been working on for a while. Back in The Innovator’s DNA, he spoke about how consumers hire products to do jobs for them – to solve problems that they don’t want to have to solve for themselves, or at least not have to solve them over and over again. One story includes why people buy milkshakes, and the split between two different answers. The first answer is for the morning commute, to have something that will stick with people during their drive and through the morning. The second answer is as a way to say yes to a child to one thing – instead of having to say no to everything.

This example presents a problem, because the morning commuter wants a shake that lasts longer. It’s thicker, so it should be served through a smaller straw, and thus take longer to finish. (See Nudge for simple and unconscious ways to change the outcomes without people noticing.) However, the parent wants the shake they buy their child to be done as soon as possible, so they can move on with the next thing on their task list. The product is the same, but the job that the product is being hired to do is different.

Cheap Labor

One of the interesting things that happens when this “jobs to be done” theory is applied to innovation is that, frequently, the disruptor – the innovator – in the market enters the playing field at a significant disadvantage. Their products are technically inferior to the historical products – but much cheaper. This allows many people to try them out and allows the disruptor to develop more robust product offerings.

Even Khan Academy, which was started by Sal Khan to help his young cousin, was “cheaper and crappier” than the educational videos already online – but it allowed students to learn at their own pace, and that made the difference. The disruptors are those in the market who can focus on the aspects of the product that are essential and do it at a price that the market can bear.

Hiring for a Different Job

An important point when considering a potential innovation is whether it solves the same problem as the existing players in the market. For instance, Airbnb competes not just with hotels but also with not going on the trip or staying with friends or relatives. Uber competes not just with taxi and limousine services but also with public transportation and asking a friend to give you a lift.

The beauty of innovations is that they can help to redefine a category in ways that broaden the potential market. These changes are natural as the market evolves. Magical numbers happen in the market where utilization takes off. VCRs and DVD players – for instance – both started to take off in popularity when the mean price point for them hit around $200. Suddenly, they became viable alternatives to going out to the movies a few times a year. The same is true for high definition televisions. Once they became “affordable,” they changed how people started to think about where and when to buy them.

Needs and Behaviors

Behaviors aren’t explained by needs. There’s a stunning gap between what people say they want and are willing to spend money on and what they will part with money for. There’s a disconnect between the emotional brain that makes the buying decisions and the rational brain that answers survey questions. (See Thinking, Fast and Slow for more.) It seems what people will actually do is shaped by their perception of how OK the solution is – and how powerfully they feel the need.

Everett Rogers discovered that there are many factors for the rate of diffusion (or adoption) of an innovation with Iowa farmers as explained in The Diffusion of Innovations. He found that some people were willing to adopt very early, where others needed more social evidence that the innovation worked. So just having a need isn’t sufficient to cause a change in behavior. It takes a sufficiently large motivation to break the inertia of continuing to do the same thing.

Indicators and Causality

As Nassim Taleb points out in The Black Swan and Antifragile, causality and correlation are different things. Competing Against Luck quotes Nate Silver from The Signal and the Noise in his clarification about correlation and causation. It turns out that neither ice cream sales nor forest fires cause the other. It just so happens that they’re both correlated with warm weather.

Sometimes the key metric, the one that leads to the results, isn’t the one that you’d expect. (See How to Measure Anything for more on leading indicators.) Batting average isn’t – it turns out – the best way to measure offensive success in baseball – on-base percentage is. When looking for innovations, we need to consider whether we’re measuring our results against the right yardstick.

Ethnography

Christensen is effectively advocating for ethnography. He’s saying that someone needs to get to the point that they understand the culture of the target audience so well that they can see the product the people need – that they never even realized they needed. (See The Ethnographic Interview.) Sometimes, you can’t listen to what they’re saying. You must look for ways to experience the situation with them to learn more. (See Creative Confidence for more.)

It’s possible to do market research with the illusion of truth in quantitative numbers. However, to truly understand the nature of the situation, you need the qualitative answers. It’s only through these answers that you can see the struggles that are washed away by statistics and averaging. Qualitative answers give you a palpable feel for the people you’re studying as potential customers. It’s in this feel that you can often find the best insights.

Peace of Mind

If you stare deeply into the data about innovations, a strange thought starts to emerge. Peace of mind is a necessity in today’s world. It’s not a luxury upgrade. If you think about successful products, whatever they are, they’re likely selling peace of mind. (See The Deep Water of Affinity Groups.) Peace of mind is so hard to come by in today’s world, we often find ourselves seeking it out – and craving the relief it provides.

Peace of mind takes many forms. Some of the peace of mind can be conveyed by the brand, and some of the peace of mind is conveyed in how completely the solution solves the job for which the item was hired for.

Commanders Intent

The armed forces, and particularly the Army, has been known for its command and control attitude. Great plans are created and assumed to be how things need to happen. However, there’s an old army saying that “no plan survives engagement with the enemy.” That’s why orders now come with a specific “commander’s intent” component. That is, in addition to the specific details of the mission, the commander’s goal is clearly articulated, so that the army soldier can find a way to meet the intent, even if the specific plans are thwarted. This commander’s intent is key to soldiers operating in the uncertain world of today.

Luck and Timing

Much of luck, I believe, is timing. The market must be in the right spot for the right idea. We can try to time the market, outthink it, or outsmart it; but, in the end, it’s luck and, particularly, the right timing that drive a lot of success in business.

While I appreciate Christensen’s title, I’m not sure that there’s much specific to offer in the way of Competing Against Luck – unless you expect that your behaviors are going to bring you better luck. Still, trying to learn how to compete is better than not.

Rogue Revision Rewind

One of the frequent concerns of users that prevents adoption is what happens when you accidentally delete or corrupt a document. It used to be that, if you accidentally deleted something from a file and saved over it, there was no going back. SharePoint makes recovering from this a breeze, as we explain in this video.

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