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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
The Feedback View of Planning & ProcessImprovement
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goals
situation decisions
problem
sideeffects
decisions
by others
goals of
othersproblem asperceived by
others
results
The Feedback View of Planning & ProcessImprovement
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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
20
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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Framework for Understanding &Changing Complex Systems
21
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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Framework for Understanding &Changing Complex Systems
22
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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Framework for Understanding &Changing Complex Systems
23
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
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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.itm8/3/2019 MoH Clinical Advisors_091209
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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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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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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