David X. Swenson PhD LPTerry Hill MPH

Brandon Olson, PhD

St. Louis County Health and Human Services Conference,

2013

A Grassroots and Multidisciplinary Approach to Systems Thinking About

Health and Human Service Issues

Agenda

• What is a system & why think systems?

• When & How to use systems mapping

• Individual & Family system examples

• Organizational & leadership examples

• Changes in healthcare

• When to use & not use systems thinking

• A grassroots approach to systems thinking

Lake Superior Systems Thinking Group

• Awareness of how siloed we have become in disciplines and discussions

• Frustrations about linear thinking and problem solving that didn’t work well

• Acknowledgement of the complexity and interconnectedness of the world, communities, organizations, and people

• Need for better understanding of how systems thinking can be used to better understand issues

• Form an interdisciplinary group of local people to discuss issues using systems thinking

• Meet once a month for a couple hours; make the “rounds” and focus on topic of interest

Familiar Systems

Family Genogram

Team and Organizational Social Network Analysis

Family-Provider System Ecomap

“You get exactly what a system is designed to do!”

W. Edward Deming asserted 80 percent (later 95%) of problems relate to the system, not individual performance

Characteristics of a “system”

• Systems are comprised of elements or components. These can be people, events, actions, etc.

• There are connections or relationships between and among these elements.

• There are usually some form of feedback or feedforward loops.

• Systems have boundaries that include some things and exclude others.

• Mechanisms in the system tend to maintain them; they resist change

• Systems are structured in ways that produce outcomes which can be viewed as a goal, purpose, or at least a functional direction.

• Cycles may have thresholds after which something else happens

• A system exchanges with its environment in a manner that enables it to adapt; not to adapt tends to risk adverse consequences

Mapping Complex Systems

What do you see?• Mud splatters• Satellite view of

islands• Tile floor• Frosted window• Tired horse• Dog eating• Human face• Rorschach inkblot…

Good intentions and hard work may not be sufficient....

Revenge Effects: http://faculty.css.edu/dswenson/web/revenge.htm

Expected Outcome

Criticize child for poor grades

Child’s behavior improves

Actual Outcome

Criticize the child

Child becomes angry & recalls past criticism

Too threated to react directly so is passive

Past criticism

Low esteem

Preoccupied, anxious thinking interferes with

study

Wants to indirectly defy and challenge

parent

Poor grades

Poor grades

Past Intimidation

Lack of systems thinking may be counterproductive

Same thing in the workplace: What we expect is not always what we get….

Some solutions are counterintuitive…

We need to understand “resistance”: Force-Field Analysis

Fishbone or Ishikawa Diagram for Identifying Resistance to Innovation

http://www.idrc.ca/events-swaminathan/ev-85414-201-1-DO_TOPIC.html

Systems Approach to Force Field Analysis for a Community Gardening Program

• Systems thinking is a way to visually represent a sequence of events and behaviors in a chain of interactions

• Identify a specific problem situation; start anywhere

• Elicit each event and corresponding thought/feeling/behavior

• Use a phrase to label each “node” or event.

• Use arrows to link it to the next event, and so on

• Note feedback loops

• Note how it often links back to the original node event

• Check with client to see if it is accurate

• Explore each node as potential change point

Causal Loop Mapping

Systems Thinking: Reinforcing connections between ADHD & Conduct

ADHD

Impulsive: act before thinking

Make mistakes

Get in trouble

Discipline

Feel it’s unfair

Resentment

Default to delinquent

peers

Act out

Hyperactivity

Out of seat, bother others

Inattention, poor

concentration

Misread social cues

Unpredictable relating Peer

avoidance rejectionPoor working

memory, slow processing

Difficulty learning,

get behind Repeated failure

Embarrassment, frustration,

discouragementWithdrawal

Non-attendance Defiance

Sample Family System Dynamics: It’s all tied together– More than ADHD

Father’s Strict

Mother’s leniency

Parental conflict Verbal

abuse

Physicalabuse

Withdrawal by eachSelf-

justification

Son observes

Angry about abuse

Depressed, preoccupied

about situation Poor

concentration at school

Poor academic

performance

Frustration with school

Truancy

Referred for discipline

Hypersensitive, reactive

Defiant with

teacherFighting

with peers

Son’s behavior

issues

ADHD

12

3

45

6

7

8Father’s subsystem of thoughts, feelings,

experiences that lead to strictness

1

2

3

4

5

6

7

8Mother’s subsystem of thoughts, feelings, experiences that lead

to leniency

• Consolidating services & merging units & departments

• Requiring accountability & evidence-based services to justify funding

• Triage of services (variable criteria and thresholds)

• Avoiding duplication/overlap of services

• Referral to other community or independent services

• Standardizing and streamlining procedures

• Relying more on technology (than staffing)

• Providing productivity feedback and coaching

• Outsourcing service components

Case: Human service organization response to economic downturn

Prolonged economic downturn

Level of funding

Work overloadStaff fatigue Illness

AbsenteeismTurnover

Competition for scarce

funds

Reputation

Political pressure Increased

reliance on county & local

resources

Reduced qualityErrors

Service delays

Change Drivers

Individual & family stress

Need for services

Referrals

Consolidate ProgramsEvidence-basedAccountability

Triage prioritiesStrategic alliances

Grant writingProductivity monitoring

Technology

Service availability

+ _

_

_

+

+

+

+

+

+

+

+

+

StaffingEarly retirementsNo replacements

Part timeStaff layoffs

+

Systems Mapping Model for Strategic Intervention

12

3

45

6

7

8What leverage is available at each node?

How feasible is the leverage for

each node?

What nodes present the greatest resistance or

barrier to change?

What can be done to reduce the

barrier?

Identify significant events & their

sequence

Are there spinoffs that will produce unexpected

risks/consequences?

• Start anywhere. Pick the element, for instance, of most immediate concern.

• Any element may go up or down at various points in time. What has the element been doing at this moment? Try out language which describes the movement: As resource funding goes up . . . goes down . . . improves . . . deteriorates. . . increases. . . decreases. . . rises. . . falls . . . soars . . . drops. . . waxes . . . wanes . . .

• Describe the impact this movement produces on the next element: For example, as staffing levels go down, the quality of client services also go down.

• Continue the story back to your starting place. Use phrases that show causal interrelationship: "This in turn, causes . . ." or ". . . which influences . . ." or ". . . then adversely affects . . ." As funding resources decrease, staffing is downsized, which decreases service quality, and places even greater demands on resources. . .”

• Try not to tell the story in cut-and-dried, mechanistic fashion. Instead, make it come alive. Add illustrations and short anecdotes so others know exactly what you mean.....

How to Tell the Story from a Loop

Resources

Staffing Levels

Service Quality

A Few Systems Principles

1. Today's problems come from yesterday's solutions.

2. The harder you push, the harder the system pushes back.

3. Behavior gets worse before it gets better. 4. Cause and effect are not closely related in time and space. 5. Small changes can produce big results-- the areas of highest

leverage are often the least obvious.9. Dividing an elephant in half does not produce two small

elephants. 10. There is no blame.

The American Health Care System

• High cost

• Low quality

• Inadequate access• Deteriorating population health

Systems Thinking Applied to Healthcare

American Health Outcomes

• Overtreatment

• Patient safety breakdowns

• Pharmaceutical errors• 60 million uninsured• Economic drain• Poor public health outcomes

“Every system is perfectly designed to produce the outcomes it is producing” --Paul Batalden

“A problem can never be solved on the same level of thinking that identified [or created] it” --Albert Einstein

…”when you have 20 days to find an answer to a problem, spend the first 19 days understanding the question.” --Albert Einstein

We need to change our ways of thinking about issues in HHS

Form Follows Financing: The current health business model

Based on volume :the more you do,

the more money you make

The New Premise

Finance Function Form

• Government• Private payers

• Cost & population management

• Risk management

• Aligned organizations managing populations

• High quality & value• Care coordination

New Health System Based on VALUE

Patient Value = Quality + Service Cost

Value = Triple Aim• Better care• Better Health• Lower Cost

Paying for Value Continuum

Measuring

Reporting

Pay for Performance

Value-based purchasing (VBP)

Medicare Shared Savings Program

• Creates accountable care organizations (ACOs)• Value Based Purchasing (VBP)

Improve quality

Improve patient experience

Reduce cost

= BONUS

++

VBP Demonstration Projects

• Prospective payment system (PPS) hospitals• Critical access hospitals (CAHs)• Home health agencies• Nursing homes• Medical clinics

• There are multiple perspectives on what the situation is and how to deal with it

• Things seem to oscillate endlessly

• A previously applied fix has created problems elsewhere

• After a fix is applied the problem returns in time

• Over time there is a tendency to settle for less

• The same fix is applied repeatedly

• Limited resources are shared by others

• Growth leads to decline elsewhere

When is Systems Thinking Appropriate?

Systems Thinking Habits

• Seek to understand the big picture• Identify the circular nature of complex cause-

effect relationships• Surface and test our implicit assumptions• Consider how mental models affect perception, beliefs & decisions• Locate unintended consequences• Understand how systems change over time & require different

approaches• Appreciate system structure for finding leverage points• Recognize the impact of delays in cause-effect relationships • Changing perspectives can change understanding• Consider an issue fully, resisting urge to jump to conclusion• Reflect on the process as well as the outcome• Recognize that a system’s structure generates the outcome

The River Metaphor & Illusion of Control

“Control is mostly an illusion; we need awareness of the system in order to

participate more fully”

Systems Thinking Group

• Grass roots-based multidisciplinary community members

• Learn and share ideas about systems thinking

• Apply systems thinking to current issues

• Invited guests/experts to present on current issues

• Form your own Systems Thinking Group

Survey of Perceptions of Systems Thinking

Question Average

1. Systems thinking has enabled participants to avoid overly quick reactions and conclusions to a significant event

4.4

2. ST has clarified a method for identifying multiple factors that contribute to a complex event

4.3

3. ST has clarified my own thinking on a complex event such as school violence

4.3

4. ST is more complex than it needs to be to understand a phenomenon 2.6

5. ST is very helpful in identification of potential intervention points in a problem

4.2

6. The use of ST on school violence has influenced how I go about understanding other issues

4.0

7. ST is very useful in modeling complex events 4.5

8. Identifying and understanding feedback loops is very helpful in understanding complex issues

4.7

1= Strongly Disagree 2=Disagree 3=Neither Agree/Disagree 4=Agree 5= Strongly Agree

Question Average

9. ST helps people move from a focus on single details to broader perspective 4.6

10. ST contributes to being able to think more clearly about patterns, trends and cycles.

4.7

11. ST enables appreciation of both short and longer term actions 4.3

12. ST helps perceive relationships and connections rather than things in isolation

4.6

13. ST enables asking more questions about a phenomenon. 4.6

14. How experienced or knowledgeable are you in ST? 3.7

15. What do you think are the major barriers that prevent people from using ST?

See comments

1= Strongly Disagree 2=Disagree 3=Neither Agree/Disagree 4=Agree 5= Strongly Agree

Some of the Challenges/Issues with Systems Thinking• It’s a challenge to “siloed” and analytic thinking–

give people time to adapt; start with small examples

• Some issues are so complex that trying to model them seems overwhelming– break it into smaller units and then connect them.

• Complexity involves personal preference and capacity– not everyone finds it useful.

• The method is based on best knowledge at the time– need to have diverse people & perspectives involved

• Very small events that might be overlooked could have great influence— take time, be thorough and consider minor events

• Systems mapping takes time to construct– take time and research thoroughly; test run if possible

What kind of issues have we examined with systems thinking?

• Factors influencing rampage school shootings

• The Malcolm Baldrige Award and leadership development

• Comparing outcomes of procedure- and outcome-based healthcare

• A systems view of ADHD and antisocial behavior

• Problems of staff and program cutbacks in human services

• Parallels between the Black Death in Europe and current pandemic concerns

• The challenge of electronic case notes in HHS

• Barriers to Vets services being adopted in rural communities

• “Gaming” the system: How system rules are used for system abuse (e.g., Enron crisis, Goldman Sachs aluminum scam)