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 21 st century technology and speed colliding head-on with 20th and 19th century institutions, rules and cultures.’’ – Amory Lovins
V olatile: change happens rapidly and on a large scale U ncertain: the future can not be predicted with any certainty C omplex: challenges have multiple interdependent and dynamic contributing factors and there are few single causes or solutions A mbiguous: there is little clarity on what events mean, and what effect they may have “There are no Boundaries Anymore” – Jeff Barnes Head of Global Leadership General Electric
“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 Ch-ch- changes… The illiterate of the 21 st 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
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) 1. Knowing parts explains wholes 2. Safe inferences re predicting future behavior 3. “What works, works” (Best Practice) 4. Systems are closed and controllable
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 or Attractor Vision or attractor Definition: A shared picture of the future that we want to create (a point in the future that shapes the Example: developing patterns of the ▪ IHI’s Triple Aim present) ▪ Alignment of sub-system goals
Shared Vision or Attractor Vision or attractor Definition: A shared picture of the future that we want to Example: create ▪ IHI’s Triple Aim (Optimizing Health Outcomes, Patient Experience, and Population Costs) ▪ Alignment of sub-system goals
Simple Rules Vision or attractor Three Simple Rules of birds flocking: Definition: 1. Avoid collisions 2. Match speed with neighbor Principle-based 3. Move towards centre of mass aims, prohibitions, of neighbors Examples: and resources ▪ Do no harm intended to ▪ Align incentives with “value” (outcomes/cost) govern system ▪ Nordstrom handbook – use your best behaviour toward judgement in all situations; there will be no a shared vision other rules
Simple Rules Vision or attractor Definition: Principle-based aims, prohibitions, Examples: and resources ▪ Do no harm intended to ▪ Do unto others… govern system ▪ Nordstrom handbook – use your best behaviour toward judgement in all situations; there will be no a shared vision other rules
Self- Organization Vision or attractor Definition: The process through which a CAS organizes in the absence of central control, Examples: with surprising ▪ Formation of specialties and sub-specialties results ▪ Interdisciplinary coalitions to tackle wicked problems
Self- Organization Vision or attractor Definition: The process through which a CAS organizes in the absence of central control, Examples: with surprising ▪ Formation of specialties and sub-specialties results ▪ Front Line Ownership and positive deviants ▪ Design thinking, fail fast/early, learning organizations
Emergence Vision or attractor Definition: The existence or spontaneous formation of Examples collective ▪ Care provider huddles behaviours ▪ Free Open Access Meducation (FOAMed) movement
Emergence Vision or attractor Definition: The existence or spontaneous formation of Examples collective ▪ Care provider huddles (work- arounds, “gaming”) behaviours ▪ Free Open Access Meducation (FOAMed) ▪ D alhousie I nterest G roups / I nterediciplinary T eams
D al I nter- I nterest disciplinary G roups T eams
Unintended Consequences Vision or attractor Definition: Unintended effects of inputs into a CAS, can Examples be positive or ▪ Increased costs / worse outcomes with some negative (often screening programs ▪ Increased bed capacity lowers performance counterintuitive) accountability
Unintended Consequences Vision or attractor Definition: Unintended effects of inputs into a CAS, can Examples be positive or ▪ Increased costs / worse outcomes with some negative (often screening programs ▪ Increased bed capacity lowers performance counterintuitive) accountability
Unintended Consequences Vision or attractor Definition: Unintended effects of inputs into a CAS, can Examples be positive or ▪ Increased costs / worse outcomes with some cancer negative (often screening programs ▪ Over emphasis on efficiency compromises counterintuitive) effectiveness
• 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 3 = Box 1 = Box 2 = Box 4 = Selectively Measure Manage the Create the Abandon the Past Present Future the Past • Performance management • Innovation and adaptation • Benchmark Best Practices • Create Next Practices • Focus on today’s patients • Focus on tomorrow’s patients • Focus on today’s technologies • Focus on tomorrow’s technologies • Focus on today’s constraints • Focus on tomorrow’s enablers • Centralize resource allocation • De-centralize resource allocation decision-making decision-making • Leverage current competencies • Build new competencies
Mental Models Vision or attractor Definition: Deeply engrained assumptions, generalizations, or images that Example influence how we ▪ How we formulate the problem is far more interpret the world, essential than the solutions – Einstein and how we take ▪ Polarity Management of conflicting principles action
Mental Models Vision or attractor Definition: Deeply engrained assumptions, generalizations, or images that Example influence how we ▪ Is Emergency Department access and flow a interpret the world, simple, complicated, or complex problem and how we take ▪ Polarity Management of conflicting principles action
Either/or… …both/and … Centralization vs Good and bad, I Decentralization defined these Efficiency vs terms, quite clear Effectiveness no-doubt Private vs Public somehow / but I was so much older MD autonomy vs Accountability then, I’m younger than that now Patient Rights vs Responsibilities - Bob Dylan Operational vs Strategic focus
Pro Con
Pro Con
Pro Con
Pro Con
Path Dependency Vision or attractor Definition: The tendency of Example actors and ▪ Spending millions after millions to “fix” the institutions in flawed assumption that low acuity patients CAS to follow cause ED access block precedent ▪ Fee-for-service high volume / low value incentives for physicians and institutions
Path Dependency Vision or attractor Definition: The tendency of Example actors and ▪ Spending millions after millions to “fix” the institutions in flawed assumption that low acuity patients CAS to follow cause ED access block precedent ▪ Fee-for-service high volume / low value incentives for physicians and institutions
Feedback Loops Vision or attractor Definition: Structures are built into a Example system where ▪ Patient and community engagement outputs feedback ▪ Public scrutiny of performance improves into the system as accountability ▪ Escalating surge capacity in face of threshold inputs (+ve / -ve) metrics
Feedback Loops Vision or attractor Definition: Structures are built into a Example system where ▪ Hospital funding based on “money follows the outputs feedback patient” principle (+ ve feedback) into the system as ▪ Pay for performance (+ve feedback) inputs (+ve / -ve) ▪ ED surge metrics automatically smooth ambulance patients to other hospitals (-ve feedback)
Non-Linearity Vision or attractor Definition: When the magnitude of a Example system’s ▪ A 5% increase in capacity of an acute care hospital leads to a 100% increase in ED wait times outputs is ▪ Tipping point impacts of adaptive change (vs disproportional technical change) to it’s inputs
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