Nov 2, 2018 1. What is a system and how do systems behave? ( How we - - PowerPoint PPT Presentation

DA Petrie Department of Emergency Medicine Nov 2, 2018

• 1. What is a system… and how do systems behave? (How we

formulate a problem is far more essential than the solution – Einstein)

▪ Simple Systems (if this, then that) ▪ Complicated Reductionistic (machine)-Systems ▪ Complex Adaptive (eco)-Systems

• 2. How is system change and leadership fundamentally different

in Complex Adaptive Systems?

• 3. What? So What? Now What?

‘‘We’ve got 21st century technology and speed colliding head-on with 20th and 19th century institutions, rules and cultures.’’ –Amory Lovins

“There are no Boundaries Anymore” – Jeff Barnes Head of Global Leadership General Electric

Volatile: change happens rapidly and on a large scale Uncertain: the future can not be predicted with any certainty Complex: challenges have multiple interdependent and

dynamic contributing factors and there are few single causes

• r solutions

Ambiguous: there is little clarity on what events mean, and

what effect they may have

“Man-made systems become unstable, creating uncontrollable situations even when decision-makers are well-skilled, have all the data and technology at their disposal, and do their best”.

Pt outcomes

Value

The illiterate of the 21st century will not be those that cannot read and write, it will be those with the inability to learn, un-learn, and re- learn

• Alvin Toffler

Ch-ch-changes…

Complicated System

• Works like clockwork
• Well-oiled machine
• Firing on all cylinders
• Humming like an engine
• The wheels are falling off
• Broken non-system
• Overheating of the gears
• Gumming up the works

Reductionist thinking (hypothetico-deductive reasoning)

• 3. “What works, works” (Best Practice) 4. Systems are closed and controllable
• 1. Knowing parts explains wholes 2. Safe inferences re predicting future behavior

Understanding relationships between parts, and their implications to the whole… and how they co-evolve over time

The medium is the message

I don’t know who discovered water, but I’m pretty sure it wasn’t a fish

• Marshall McLuhan

Shared Vision

• r Attractor

 Example: ▪ IHI’s Triple Aim ▪ Alignment of sub-system goals

Definition: A shared picture of the future that we want to create (a point in the future that shapes the developing patterns of the present)

Vision or attractor

Shared Vision

• r Attractor

 Example:

▪ IHI’s Triple Aim (Optimizing Health Outcomes,

Patient Experience, and Population Costs)

▪ Alignment of sub-system goals

Definition: A shared picture

• f the future

that we want to create

Vision or attractor

Simple Rules

 Examples: ▪ Do no harm ▪ Align incentives with “value” (outcomes/cost) ▪ Nordstrom handbook – use your best

judgement in all situations; there will be no

• ther rules

Definition: Principle-based aims, prohibitions, and resources intended to govern system behaviour toward a shared vision

Vision or attractor

Three Simple Rules of birds flocking:

• 1. Avoid collisions
• 2. Match speed with neighbor
• 3. Move towards centre of mass
• f neighbors

Simple Rules

 Examples: ▪ Do no harm ▪ Do unto others… ▪ Nordstrom handbook – use your best

judgement in all situations; there will be no

• ther rules

Definition: Principle-based aims, prohibitions, and resources intended to govern system behaviour toward a shared vision

Vision or attractor

Self- Organization

 Examples: ▪ Formation of specialties and sub-specialties ▪ Interdisciplinary coalitions to tackle wicked

problems

Definition: The process through which a CAS organizes in the absence of central control, with surprising results

Vision or attractor

Self- Organization

 Examples:

▪ Formation of specialties and sub-specialties ▪ Front Line Ownership and positive deviants ▪ Design thinking, fail fast/early, learning organizations

Definition: The process through which a CAS organizes in the absence of central control, with surprising results

Vision or attractor

Emergence

 Examples

▪ Care provider huddles ▪ Free Open Access Meducation (FOAMed)

movement

Definition: The existence or spontaneous formation of collective behaviours

Vision or attractor

Emergence

 Examples

▪ Care provider huddles (work-arounds, “gaming”) ▪ Free Open Access Meducation (FOAMed) ▪ Dalhousie Interest Groups / Interediciplinary Teams

Definition: The existence or spontaneous formation of collective behaviours

Vision or attractor

Dal Interest Groups Inter- disciplinary Teams

Unintended Consequences

 Examples

▪ Increased costs / worse outcomes with some

screening programs

▪ Increased bed capacity lowers performance

accountability

Definition: Unintended effects of inputs into a CAS, can be positive or negative (often counterintuitive)

Vision or attractor

Unintended Consequences

 Examples

▪ Increased costs / worse outcomes with some

screening programs

▪ Increased bed capacity lowers performance

accountability

Definition: Unintended effects of inputs into a CAS, can be positive or negative (often counterintuitive)

Vision or attractor

Unintended Consequences

 Examples

▪ Increased costs / worse outcomes with some cancer

screening programs

▪ Over emphasis on efficiency compromises

effectiveness

Definition: Unintended effects of inputs into a CAS, can be positive or negative (often counterintuitive)

Vision or attractor

• Shadow billing purportedly measures the # and type of

clinical widgets and beans produced but NOT what improves quality of care, and whether outcomes are improved

Box 1 = Measure the Past Box 2 = Manage the Present Box 3 = Selectively Abandon the Past Box 4 = Create the Future

• Performance management
• Benchmark Best Practices
• Focus on today’s patients
• Focus on today’s technologies
• Focus on today’s constraints
• Centralize resource allocation

decision-making

• Leverage current competencies
• Innovation and adaptation
• Create Next Practices
• Focus on tomorrow’s patients
• Focus on tomorrow’s technologies
• Focus on tomorrow’s enablers
• De-centralize resource allocation

decision-making

• Build new competencies

Mental Models

 Example ▪ How we formulate the problem is far more

essential than the solutions – Einstein

▪ Polarity Management of conflicting principles

Definition: Deeply engrained assumptions, generalizations, or images that influence how we interpret the world, and how we take action

Vision or attractor

Mental Models

 Example ▪ Is Emergency Department access and flow a

simple, complicated, or complex problem

▪ Polarity Management of conflicting principles

Definition: Deeply engrained assumptions, generalizations, or images that influence how we interpret the world, and how we take action

Vision or attractor

Either/or…

Centralization vs Decentralization Efficiency vs Effectiveness Private vs Public MD autonomy vs Accountability Patient Rights vs Responsibilities Operational vs Strategic focus

Good and bad, I defined these terms, quite clear no-doubt somehow / but I was so much older then, I’m younger than that now

• Bob Dylan

…both/and…

Pro Con

Pro Con

Pro Con

Pro Con

Path Dependency

 Example ▪ Spending millions after millions to “fix” the

flawed assumption that low acuity patients cause ED access block

▪ Fee-for-service high volume / low value

incentives for physicians and institutions

Definition: The tendency of actors and institutions in CAS to follow precedent

Vision or attractor

Path Dependency

 Example ▪ Spending millions after millions to “fix” the

flawed assumption that low acuity patients cause ED access block

▪ Fee-for-service high volume / low value

incentives for physicians and institutions

Definition: The tendency of actors and institutions in CAS to follow precedent

Vision or attractor

Feedback Loops

 Example ▪ Patient and community engagement ▪ Public scrutiny of performance improves

accountability

▪ Escalating surge capacity in face of threshold

metrics

Definition: Structures are built into a system where

• utputs feedback

into the system as inputs (+ve / -ve)

Vision or attractor

Feedback Loops

 Example

▪ Hospital funding based on “money follows the

patient” principle (+ve feedback)

▪ Pay for performance (+ve feedback) ▪ ED surge metrics automatically smooth ambulance

patients to other hospitals (-ve feedback)

Definition: Structures are built into a system where

• utputs feedback

into the system as inputs (+ve / -ve)

Vision or attractor

Non-Linearity

 Example ▪ A 5% increase in capacity of an acute care hospital

leads to a 100% increase in ED wait times

▪ Tipping point impacts of adaptive change (vs

technical change)

Definition: When the magnitude of a system’s

• utputs is

disproportional to it’s inputs

Vision or attractor

Non-Linearity

 Example ▪ A 5% increase in capacity of an acute care hospital

leads to a 100% increase in ED wait times

▪ Tipping point impacts of adaptive change (vs

incremental impact of technical change)

Definition: When the magnitude of a system’s

• utputs is

disproportional to it’s inputs

Vision or attractor

Interdependencies

 Example ▪ Acute care system depends upon Primary Care ▪ Hospital Care depends upon Community/Home

care

▪ Health outcomes depends upon social

determinants of health

Definition: Relationships, interactions, and dependencies between individuals, groups, and

• rganizations

Vision or attractor

Interdependencies

 Example ▪ Acute care system depends upon Primary Care ▪ Hospital Care depends upon Community/Home

care

▪ Health outcomes depends upon social

determinants of health

Definition: Relationships, interactions, and dependencies between individuals, groups, and

• rganizations

Vision or attractor

Complexity Leadership

Definition: Individuals who challenge mental models, unite stakeholders around a shared vision, and utilize systems thinking, CAS principles / practices / tool-kits

Vision or attractor

• 1. Boundary Conditions and constraints in the current system

▪

Health care demand vs capacity, structure, and integration of response

• 2. Responsiveness of the system to an intervention

▪

Length of delay relative to imperative for change (status quo inertia)

• 3. Negative Feedback loops

▪

Strengthen appropriate (high volumes of amb redistributes trip destination)

• 4. Positive Feedback loops

▪

Strengthen appropriate (pay for performance, hosp funding follows pts)

• 5. Information flow

▪

Who has access to what information (radical transparency)

• 6. Rules of the system

▪

Legislative framework, Governance, Incentives, and Policies

• 7. Enablers, space, and power to self-organize / innovate

▪

Balance bottom up with top down, reward front line ownership

• 8. The goals of the system

▪

Clarity of purpose, alignment, and focus on overarching vision

• 9. Mindsets / paradigm out of which the system (goals, structure,

rules, relationships, delays, parameters) arise

• 10. The power to transcend paradigms so that a future system arises

▪

Mindsets of leaders in the emerging system

Leadership & Complexity

An evidence-based formative assessment of skills for leadership decision-making under complexity

David Petrie, MD, Theo L. Dawson, Ph.D.

Toronto Iinternational Summit on Leadership Education for Physicians (TISLEP) Conference - October 16, 2018 – Halifax, Nova Scotia

https://medium.com/@theo_dawson

Advanced Linear Thinking

(1050-1099)

Complicated What’s in focus?

Individuals with personalities, skills, attitudes, & points-of- view

Early Systems Thinking

(1100-1149)

Complex What’s in focus?

Integrated groups of individuals with different roles and relationships

Advanced Systems Thinking

(1150-1199)

Highly complex What’s in focus?

Multiple integrated groups interacting with dynamic organizational systems

Early Principles Thinking

(1200-1249)

Elegantly simple What’s in focus?

Multiple dynamic

• rganizational systems

that form marketplaces, economies, & societies

Peter Drucker: “Hospitals are the most complex organizations ever devised”

Interdependent Agents Dynamic Co-evolution Non-linear feedback loops and threshold effects Self organization and Emergence No single point of control Hind sight does not give foresight

Health Care as a Complex Adaptive Eco-System

Leader

• People have long confused the notion of

leadership with authority, power, and influence. We find it extremely useful to see leadership as a practice, an activity that some people do some of the time.

• Leaders facilitate the necessary adaptive work

that needs to be done by the people connected to the problem.

• Heifetz (Learning/Adapting in a Complex World)