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Systems Thinking:Thinking & Acting in a Complex World

Ministry of Health9th December 2009

Philip GandarSynergia Ltd &Honorary LecturerUniversity of AucklandNational Institute for HealthInnovation

David ReesSynergia Ltd &Honorary LecturerUniversity of AucklandSchool of Population Health


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Topics forTodayDealing with Complexity

Describing Health systems

purpose & context

boundary critiqueunderstanding whats causing what

modelling plausible futures

Finding Places to Intervene


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Systems thinking practices

Engagement processes participative, action research oriented

Processes for inquiry and multi-perspective issue/boundary critique

Analysis of events / patterns / structure / mental models & decision rules soft and hard data

Visual mapping tools to portray structural relationships

Simulation modelling, (systems dynamics, exploring network and agentbased simulation)

Scenario based plausible & desired futures exploration

Soft systems and viable systems informed policy & design advice


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Examples of work

Whole system engagement and design Lets Beat Diabetes

Multi-stakeholder system conceptual definition A strategy for familyservices

Systems based modelling of health policy and service strategy Long

Term Conditions Framework Model

Multi-organisational/network infrastructure design Healthy EatingHealthy Action National Network

Systems based process design - Responding to incidents of family

violence

Systems based evaluation CMDHB chronic care management

Systems based research Structure and function of self-care


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DEALIN

GW

ITH

COMPL

EXIT

Y


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Policy Resistance in Health

Economic growth and improved incomes has led to improved lifestyles formany people. This increased affluence has also lead to a more sedentarylifestyle.

Increased access to and consumption of empty calories has brought

about a drastic increase in obesity and a host of conditions that arise fromit.

Efforts to increase access to primary care have contributed to overload ofGPs; leading to burnout, turnover, shorter visits and therefore less timeto focus on long-term health rather than short term symptom relief


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Things Bounce Back

Push back is a sign that the boundaries of our mental modelsare too narrow, our time horizons too short.

UnintendedConsequences

UnderminingEffects

ActionIntendedConsequence

NormalBoundary ofConsideration

There is no away to throw things anymore

Donella Meadows


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Todays Fix is Tomorrows Problem

ProblemSymptom

SideEffect

Fix

+-

+

+

B2short-term

fix

B2long-termproblem

Illustrative examples:

Many cost-cutting initiativesResponding to the squeaky wheelImproving access to meet demand


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Avoiding the Problem Makes theProblem Worse Problem

Symptomatic Solution

ProblemSymptom

AddictiveSide-Effect

Fundamental Solution

+

-+

-

+

-

B1tackling theroot cause

B2avoiding thereal problem

R1making

matters worse

Illustrative examples:

Addictive behaviours

Use of top down authority


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Could you make this?(why or why not?)


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Somebody has?


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12it all depends where you stand


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Cognitive Mapping(Understanding where people stand meaning making)

Links withprimarycare

Managingrising costs

and capitalrequirements

Vascular

access

Managing risingdemand


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The Linear View of Planning & ProcessImprovement

goals

situation

decisionsproblem results


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goals

situation decisions

problem

results

The Feedback View of Planning & ProcessImprovement


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goals

situation decisions

problem

sideeffects

results



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goals

situation decisions

problem

sideeffects

decisions

by others

goals of

othersproblem asperceived by

others

results



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If a factory is torn down but the rationalitywhich produced it is left standing, then thatrationality will simply produce anotherfactory. If a revolution destroys agovernment, but the systematic patterns of

thought that produced that government areleft intact, then those patterns will repeatthemselves.Theres so much talk aboutthe system. And so little understanding

Robert Pirsig,Zen and the Art of Motorcycle Maintenance


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Tools for Dealing with Complexity

The macroscope filters detailsand amplifies that which links

things together. It is not used tomake things larger or smallerbut to observe what is at oncetoo great, too slow, and toocomplex for our eyes.

The Macroscope: A New World Scientific SystemJoel de Rosnay, 1979


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Framework for Understanding &Changing Complex Systems

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Meaning &Context

CausalDynamics

PlausibleFutures

Sustainable

Actions

Meaning & Context1. What is the system we are

concerned with?2. What are the key

performance issues weare concerned with?

3. What meanings do peopleattribute to that system?


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Meaning &Context

CausalDynamic

s

PlausibleFutures

Sustainable

Actions

Causal Dynamics1. Why is performance

following the path that itis?

2. Where will it go if wecarry on as we are?

3. What can we do toimprove performance inthe future?


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Meaning &Context

CausalDynamics

PlausibleFutures

Sustainable

Actions

Plausible Futures1. What is the set of

plausible scenarios for thissystem?

2. How could things evolveand over what timescale?

3. What are the key leversand how much impactcould they have?


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Meaning &Context

CausalDynamics

PlausibleFutures

Sustainable

Actions

Sustainable Actions1. Where are the places we

could intervene in thissystem?

2. How will the change bemanaged and whatmeasures will guide it?

3. Who will manage thechange and....according to

whose values?


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U

NDER S

TA

NDING

MEANIN

G&

CONT E

XT


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Ulrich W. Boundary critique. In: Daellenbach HG, Flood RL, editors. The Informed Student Guide to ManagementScience.

London: Thomson; 2002. p. 41-42. .

Ulrich W. Reflective practice in the civil society: the contribution of critically systemic thinking.Reflective Practice 2000;1(2):247-268. http://www.geocities.com/csh_home/downloads/ulrich_2000a.pdf

Boundary CritiqueCreating a new theory is not like destroying an old barn and erecting a

skyscraper in its place. It is rather like climbing a mountain, gaining new andwider views, discovering unexpected connections between our starting point and

its rich environment. -- Albert Einstein

Boundary Judgments(System of Reference)

Observations

(Facts)

Evaluations

(Values)


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Making Boundary Judgements


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Making Boundary Judgements(with a systems perspective)

SYSTEM

VALUESFACTS

EvaluationsObservations

Boundary

Judgements The facts that we observe andthe way we evaluate them dependupon how we bound the system ofconcern. Different value

judgements can make us changeboundary judgements, which inturn makes the facts lookdifferent. Knowledge of new factscan equally make us changeboundary judgements, which in

turn makes previous evaluationslook different.

Dr. Bobby Milstein

Syndemics Prevention NetworkCenters for Disease Control & Prevention (CDC)


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Network systems - working with hubs& nodes

Who makes up the network?

A more effective way of analysing stakeholders, not as a list but in terms of their mutualinfluence

Where are the hubs that matter? (or could matter!)

Richness of connections and influence

Range of perspective on the system as a whole

What is already working within each hub that forms the solid base to build on?

Innovation happens at the edge what are the small seeds of future success, thefunctional elements we want to amplify & propagate through the network?

How could we influence self organisation and emergent behaviour?

connectivity

diversity

rate of information flow

N t k l i l ti hi &


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Relative influence of organisations and networks in the

HEHA system as identified by 610 survey respondents

Network analysis relationships &influence


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National HEHA


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Agencies for Nutrition Action


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Pacific networks


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Research networks


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UND

ER

STA N

DING

W

HAT

CAUSES

WH

AT

Learning in and About Complex


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Unknown structure Dynamic complexity Time delays Impossibleexperiments

Real World

Information

Feedback

Decisions

MentalModels

Strategy, Structure,Decision Rules

Selected Missing Delayed

Biased Ambiguous

Implementation Game playing

Inconsistency Short term

Misperceptions Unscientific BiasesDefensiveness

Inability toinfer

dynamicsfrom

mentalmodels

Known structure Controlledexperiments Enhanced learning

VirtualWorld

Sterman JD. Learning in and about complex systems. System Dynamics Review 1994;10(2-3):291-330.

Sterman JD. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin McGraw-Hill,

Learning in and About ComplexSystems


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CausalLoop

DiagramStock & Flow

DiagramDynamic

Computer Simulation

Thought

Bubble

DynamicStatic

MentalModels

VisualModels

SimulationModels

Models

M d l h l t h t i t


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EVENTS

PATTERNS

STRUCTURE

MENTAL MODELS

VALUES

Increa

singL

everage

Models help us to see what is notimmediately obvious


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.and what may happen through time

The EconomistDecember 2006

and explore the consequences of


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.and explore the consequences ofour actions


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Understanding the Dynamics of ChickenBehaviour


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Positive Feedback

ChickensEggs

+

+

R

A systems feedback structure

Generates its dynamicschickens

eggs

Time

No.


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Negative Feedback

Chickens Road

Crossings

+

-

B

A systems feedback structure

Generates its dynamics

Time

No.

chickens

road crossings


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Dynamics of Multiple-Loop Systems

Chickens Road

Crossings

+

-

BEggs

+

+

R

What are the dynamics of the chicken population when both loops are

active simultaneously?

Sketch a graph showing the behaviour of the chicken population over

time. Assume the initial population is small - but includes at least onerooster

Dynamics of chicken behaviour
http://chicken%20dynamics.itm/http://chicken%20dynamics.itm/


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DeadlinesMore Bloody Deadlines!!

Schedule

Time Remaining

Pressure

-

Work

Rate

Completion

Overtime

Remaining

+

-

+B1

+

Time Per

Task

-

-

B2

Fatigue

Productivity

+

-

+R1

Error Rate

--

R2

Delay

DelayHaste Makes

Waste

Midnight

Oil

Cut

Corners

Burnout

P bl ti B h i i C l


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Problematic Behaviour in a ComplexSystem

Historic & Forecast Dialysis Volumes 1994 to 2012(Wellington & Palmerston North)

DialysisPatie

nts

A St t f Thi ki Ab t th


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A Structure for Thinking About theProblem

ScaleScale

TimeTime2003 2004 2005 2006 2007 2008

today

Why?

Why has performance

followed the time paththat it has?

Where?

Where is performance

heading into the futureunder current policies?

How?

How can we alter thatfuture for the better?

2009

Every system is perfectly designed to achieve the results it gets

Th P i d C d


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The Perceived Causes andConsequences


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cost ofRRT

effectivemanagement of

CKD

- level ofdependency

treatmentmodalityoptions

pct patientsrequiringin-centretreatment

-

-

-

+

+

$ available toinvest in upstream

interventions

investment in

upstreaminterventions

-

+

+

ModalityOptions

Demand for

RRT

avg time on

RRT

incidence of

CKFincidence of

CKD

risk of CKD

level ofco-morbidities

age profile ofpopulation

deprivation level ofpopulation

+

-

+

+

++

+

+

+

level of diabetesand other risk

factors

PopulationDynamics

DiseaseDynamics

-

+

time between FSAwith renal physician

and dialysis

percent withappropriate

access-

-

VascularAccess

use of diagnosticand otherservices hospitalisation

rates

renal staffresources

specialist support

for upstreaminterventions

+

+

availability of

support services

Resources

-

quality ofcare

surfacing ofunmet need

ServiceQuality

A Different Hypothesis .


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Fallacies of Cause and EffectCause and effect are separate and the effect comes after the cause.

Cause and effect are different words but may refer to the same event. The effect of a causecan be the cause of an effect

Does the shortage cause the hoarding; or the hoarding cause the shortage?

Do lower prices drive lower margins or do lower margins drive lower prices?

Go along a line far enough and you will come back to where you started. Which comes firstdepends on where you started. In systems cause and effect are circular

Whether it is cause or effect depends where we punctuate the loop. And that is a choice.

Effect follows cause closely in time and space

There are delays and effects can appear in other parts of the system We have to extend our time horizon and look further afield than the end of our nose or the

boundaries of our department

The effect is proportional to the cause A huge epidemic can be cause by a small virus. A small shift in price can lead to a significant

change in revenue.

Some actions have no effect until a threshold is achieved and then significant changes can

occur almost immediately. Small changes in marketing effort can bring about large changes in market response


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MODEL

LING

PLAUS

IBL

E

FUTU

RR

ES

Seeing Beyond the Probable


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PossibleWhat may happen?

Plausible

What could happen?

ProbableWhat will likely happen?

PreferableWhat do we want to have happen?

Bezold C, Hancock T. An overview of the health futuresfield.

Geneva: WHO Health Futures Consultation; 1983 July 19-23.

Most organizations plan around what is most likely. In so doing they reinforce what is,

even though they want something very different.

-- Clement Bezold

Seeing Beyond the Probable

Plausible Futures:


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154 Dialysis Patients

113 Dialysis Patients

Plausible Futures:(Numbers)

1.

2.

3.

4.

Plausible Futures:


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$8.7 million

$5.8 million

Plausible Futures:(Costs)

1.

2.

3.

4.

Service Improvement Increases Demand


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In-Centre Patient Volumes

0

5

10

15

20

25

30

35

40

Ju

l-05

Aug-05

Sep

-05

Oct-05

Nov-05

Dec-05

Jan

-06

Feb

-06

Ma

r-06

Ap

r-06

May

-06

Jun

-06

Ju

l-06

Aug-06

Sep

-06

Oct-06

Nov-06

Dec-06

Jan

-07

Feb

-07

Mar-07

Apr-07

May

-07

Jun

-07

Jul-07

Aug

-07

Sep

-07

Oct-07

Nov-07

Dec-07

Arrival of renal

physicianIn-Centre Patient Volumes

0

5

10

15

20

25

30

35

40

Ju

l-05

Aug-05

Sep

-05

Oct-05

Nov-05

Dec-05

Jan

-06

Feb

-06

Ma

r-06

Ap

r-06

May

-06

Jun

-06

Ju

l-06

Aug-06

Sep

-06

Oct-06

Nov-06

Dec-06

Jan

-07

Feb

-07

Mar-07

Apr-07

May

-07

Jun

-07

Jul-07

Aug

-07

Sep

-07

Oct-07

Nov-07

Dec-07

Arrival of renal

physician

Service Improvement Increases Demand

Modelling Renal Demand

Modelling for Learning in Dynamic
http://../Libraries/Model_Library/Model_Library.Data/Health_Models/HBDHB_Renal/HBDHB_Renal%20Model_200308.itmhttp://../Libraries/Model_Library/Model_Library.Data/Health_Models/HBDHB_Renal/HBDHB_Renal%20Model_200308.itm


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Modelling for Learning in DynamicSystems

Multi-stakeholderDialogue

Dynamic Hypothesis (Causal Structure)

X Y

Plausible Futures (Policy Experiments)

Obese fraction of Adults (Ages 20-74)

0%

10%

20%

30%

40%

50%

1970 1980 1990 2000 2010 2020 2030 2040 2050

Fraction

ofpopn

20-74

Syndemics

Prevention Network

Dr. Bobby MilsteinCenters for Disease Control & Prevention

September 2007


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Places to Intervene in a System

12. Constants, parameters, numbers

11. Size of buffers, relative to their flows

10. Structure of material stocks & flows

9. Lengths of delays relative to rate of change

8. Strength of negative feedback loops

7. Positive feedback loops

6. Structure of information flows

5. The rules of the system

4. The power to change system structure

3. The goals of the system

2. The mindset out of which the system arises

1. Changing the mindset

This section is based on:

Meadows, Donella.

"Leverage Points: Places to Intervene in a System.

Sustainability Institute (1999).

Physical System

Information& Control

Values

SelfOrganisation

Changing constants parameters


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Changing constants, parameters,numbers

How much of a discrepancy, between what isperceived to be and the goal, affects whichflow and how fast.

The focus is on turning the taps to adjust therates of flow

e.g. national debt: tax income raises the levelin the bathtub, government expendituredrops it.

e.g. people waiting for treatment: treatmentsdecrease the numbers, while referralsincrease it.

BUT, if its the same taps. Plumbed into thesame system, turned according to the sameold information, goals and rules nothing muchis going to change.

Changing flow parameters can be important,especially to those standing directly in it butthey rarely change behaviour.

They can also have a big impact IF they kick-off some of the other items in the list

e.g. 6 hour wait target in ED

The State

of the

System

inflows outflows

perceived state

discrepancy

goal


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Structure of Material Stocks and Flows

Instead of simply changing the flowthrough the taps, or building a bigger orsmaller bathtub this is about changing thestructure of the plumbing.

The only way to fix a system that is laidout wrong is to rebuild it.

e.g. new models of care, IFHCS.

Changing structure is difficult andexpensive but we seem to do lots of it inhealth.

The real solution is proper design in thefirst place, but in our rush to change thesystem we forget the need for design.

The Stateof the

System

inflows outflows

perceived state

discrepancy

goal

outflows2

Length of Delays Relative to Rate of System


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Length of Delays Relative to Rate of Systemchange

Delays often cause oscillating behaviour.e.g. trying to reduce numbers waiting in ED

but only received delayed informationabout the state of the system oftenovershoot or undershoot targets.

e.g. it takes many years to build a hospitalwhich makes it difficult to build exactlythe right number of beds, theatres etc

to meet demand.

A system cant respond to short-termchanges when it has long-term delays

e.g. Climate change policies and CO2in the

atmosphere

The State

of the

System

inflows outflows

perceived state

discrepancy

goal

time to affect

inflows


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Strength of Negative Feedback Loops

This shifts us away from the physicalaspects of the system to issues ofinformation and control.

The strength of a negative loop is itsability to keep its adjacent stock at or nearits goal

The challenge is to strengthen the loop so

as to increase the system's ability torespond to change away from its goal.

The State

of the

System

inflows outflows

perceived state

discrepancy

goal

time to affect

inflows

-

-


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Driving Positive Feedback Loops

A negative loop is self correcting; apositive loop is self-reinforcing. E.g.

Infectious disease: the more people catchthe flu the more they infect other people.

Positive loops are the source of growthAND collapse in a system.

Positive loops cant go on forever, or the

system would destroy itself after awhilethe epidemic will run out of infectablepeople, or people will take measures toavoid being infect. The first outcome iswhat will happen if the positive loop runs itcourse, the second is what will happen ifthere is an intervention.

The Stateof the

System

inflows outflows

impact of system

state on inflow

inflow

rate+

+


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Structure of Information Flows

This is about developing a new loop,getting information to where it wasnt gongbefore and thereby causing people tobehave differently.

Its can be very powerful to get the missingfeedback to the place where it can be used

and to do so in a compelling manner

Even more so when that feedback loopmakes those who made the decisionaccountable for the outcomes of thatdecision.

The State

of the

System

inflows outflows

perceived state

discrepancy

goal

actions that

affect inflows

information

about the state

of the system


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Rules of the System

Rules define scope, boundaries, degrees offreedom:

How far upstream on the inflow pipe dowe look

How far down the outflow pipe are weconcerned with

What are the rules that determine theparameters of the flows

What are the rules around goal setting

What are the consequences of notclosing the gap

It can be very useful to explore these rulesfor any initiative. e.g. the recent EOI many

applicants changed the rules aroundscope and boundaries, redefining theinitiative in terms of networks and modelsof care rather than centres.

The State

of the

System

inflows outflows

perceived state

discrepancy

goal


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Power to Change

Where is the power to add to or changesystem structure located

Who decides far upstream on the inflowpipe do we look

Who decides how far down the outflowpipe are we concerned with

Who sets the rules that determine theparameters of the flows

Who sets the rules around goal setting

Who determines the consequences ofnot closing the gap

Who can change the system structure

What interventions are possible to increasethe ability of the system to self-organise?

What decisions and actions can peoplemake for themselves?

The State

of the

System

inflows outflows

perceived state

discrepancy

goal

S G l


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System Goals

Changing the goals changes almosteverything else. It changes the point ofthe system,. What it is there to do, thepurpose of turning up to work every day.

When goals are in conflict or unclear itmakes life difficult, confusing and often

very de-motivating. Espousing one goalwhile acting on another can develop verynegative cultures within organisations

The State

of the

System

inflows outflows

perceived state

discrepancy

goal

The Mindset Out of Which the System


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The Mindset Out of Which the SystemArises

The concept of a public health system.Regardless of what we change, there is anidea in the minds of the NZ public about whata public health system is. Whatever therules are, the funding levels provided, thegoals we set they will all be pushed upagainst the accepted idea of a public healthsystem.

Another paradigm, held by many is the ideathat the quality of our health system isdetermined by the quality of the hospital inour community.

Changing paradigms is difficult - one has to

keep pointing to the anomalies and failureswithin the paradigm, assure people about thevalue of the new one and put people whounderstand and accept the new paradigm inpositions of power and public visibility

The State

of the

System

inflows outflows

perceived state

discrepancy

goal

T di Mi d t


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Transcending Mindsets:

This is about going beyond paradigms andideology. It is about realising that noparadigm is true. Nothing works all the time.At best the good stuff works some time in

some places.

Freeing yourself of paradigms allows you tosee each now situation anew, able to choosewhatever path meets the needs

MinSpecs


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MinSpecs -

Creative progress towards a difficult goal can emerge from a few, flexible, simple

rules, or so called minimum specifications.

However, current organisational thinking is built largely on the assumptions thatplans for progress must provide the best way, completely specified in greatdetail, and consistently implemented in that same level of detail across theboard.

This thinking, often reflected in such things as national service frameworks ordetailed guidelines with newly specified standards, fails to take advantage of thenatural creativity embedded in the organisation, and fails to allow for theinevitable unpredictability of events.

Minimum specifications typically provide four things that create an environment inwhich innovative, complex behaviours can emerge:

Direction pointing

Boundaries

Resources,

Permissions.

Paul PlsekBMJ 2001

Minspecs as supporters of generative


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p pp glearning

Direction

pointing

A good enough vision

Points towards desired functional attributes, the way things wouldneed to work to achieve our outcomes

Boundaries Minimum set of rules needed to achieve outcome

Minimum needed constraints on creativity

Challenge each proposed rule by asking: "Can we imagine asituation where we get our desired outcome even though this rule isviolated?"

Resources The resources that are available

Any conditions on resources

Permissions Positive, enablers

Negative, prohibitions

Minspecs: Sustainable Services Straw


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pMan

Directionpointing

(-ve) No creeping, slowly emerging, not recognised service failures (+ve) A system of ongoing self assessment & proactive response to riskthat maintains safe sustainable services

Boundaries Focus on x services/service types/organisations? People assess risk in a systematic way Creates a safe environment to explore risk supportslearning/constructive challenge

Uses multiple perspectives to understand riskPromotes clinical network leadership across districts Acts to minimise uncertainty and fear within wider stakeholders Actions reflected in District accountability requirements

Resources A whole system risk assessment framework Support to engage & facilitate clinical networks Resources for external review if needed

Support to facilitate structural and facilities change if needed

Permissions DHBs can require others to be involved in support of safe services Cannot rely on private for sustainability without approval

Further Information


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Further Information

http://www.synergia.co.nz/page/dynamic-decision-support
http://www.synergia.co.nz/page/dynamic-decision-supporthttp://www.synergia.co.nz/page/dynamic-decision-support

moh clinical advisors_091209

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