Terry Hill MPH. St. Louis County Health and. Human Services Conference,. 2012.
Using Systems Thinking to. Understand Family &. Organizational Dynamics ...
Using Systems Thinking to Understand Family & Organizational Dynamics
David X. Swenson PhD LP Terry Hill MPH St. Louis County Health and Human Services Conference, 2012
Agenda • What is a system? • Why systems thinking? • Tools & Techniques
• When & How to use systems mapping • Individual & Family system examples • Organizational & leadership examples
• Considerations for current HHS
Familiar Systems
“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 that form cycles. • Systems have boundaries that include some things and exclude others • Cycles or subsystems are organized as part of larger systems or hierarchies. • Mechanisms in the system tend to maintain them; they resist change • A system 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 systems exchanges with its environment in a manner that enables it to adapt; not to adapt risks 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…
Some solutions are counterintuitive…
Good intentions and hard work may not be sufficient....
Lack of systems thinking may be counterproductive Expected Outcome
Poor grades
Actual Outcome
Poor grades
Criticize child for poor grades Child’s behavior improves
Wants to defy and frustrate parent
Pressure by adults
Criticize the child
Past criticism
Child becomes angry & recalls past criticism
Low esteem
Too threated to react directly so is passive
Past abuse
Preoccupied, anxious thinking
What we expect is not always what we get….
Fishbone or Ishikawa Diagram for Resistance to Innovation
Force-Field Analysis
Systems Approach to Force Field Analysis for a Community Gardening Program
http://www.idrc.ca/events-swaminathan/ev-85414-201-1-DO_TOPIC.html
India/China
native species
Mexico
Mynah Turtle Dove
Lantana camara Plant
+
Lantana Camara– A case example of good intentions No. of birds
army worm population
+
Seeds
Berries
+ Larvae Eradication of Lantana makes room for even more invasive species
Grassland
Sugarcane
cattle grazing Agromyzid Fly Financial stability
India/China
native species
Mexico
+ _
Mynah Turtle Dove
Lantana camara Plant
+
+
Seeds
No. of birds
army worm population
_
Berries
+ Larvae Eradication of Lantana makes room for even more invasive species
Grassland
Sugarcane
cattle grazing Agromyzid Fly Financial stability
India/China
native species
Mexico
Mynah Turtle Dove
Lantana camara Plant
_
No. of birds
_
Seeds
army worm population
Berries
_
_ Larvae
Eradication of Lantana makes room for even more invasive species
+
Grassland
Sugarcane
cattle grazing
Agromyzid Fly Financial stability
India/China
native species
Mexico
_ Lantana camara Plant
_
+
Seeds
Mynah Turtle Dove
No. of birds
_
army worm population
Berries
_
_ +
Eradication of Lantana makes room for even more invasive species
Larvae
+
Grassland
Sugarcane
cattle grazing
Agromyzid Fly Financial stability
India/China
native species
Mexico
Mynah Turtle Dove
Lantana camara Plant
_ Seeds
Berries
Army worm population
No. of birds
_
_ Larvae Eradication of Lantana makes room for even more invasive species
+
Grassland
Sugarcane
cattle grazing
Agromyzid Fly Financial stability
India/China
native species
Mexico
Mynah Turtle Dove
Lantana camara Plant
+ army worm population
No. of birds
Seeds
Berries
Larvae Eradication of Lantana makes room for even more invasive species
_
_
_
Grassland
Sugarcane
_ Cattle grazing
_
Agromyzid Fly
_
Financial stability
India/China
native species
Mexico
Mynah Turtle Dove
Lantana camara Plant
No. of birds
army worm population
Seeds
Berries
Larvae Eradication of Lantana makes room for even more invasive species
Grasslands
Sugarcane
cattle grazing Agromyzid Fly Financial instability
Causal Loop Mapping • 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
Systems Thinking: Reinforcing connections between ADHD & Conduct Out of seat, bother others
Hyperactivity
ADHD
Impulsive: act before thinking Inattention, poor concentration
Make mistakes
Get in trouble Discipline
Misread social cues
Poor working memory, slow processing
Unpredictable relating
Difficulty learning, get behind
Nonattendance
Withdrawal
Act out
Feel it’s unfair Peer avoidance rejection
Repeated failure
Embarrassment, frustration, discouragement
Resentment
Default to delinquent peers Defiance
Sample Family System Dynamics: It’s all tied together– treat the system! 1
Father’s8 subsystem of 2 thoughts, feelings, 7 3 experiences that lead 4 to6strictness 5
Son’s behavior issues
Father’s Strict
Truancy
Parental conflict
Verbal abuse
Mother’s leniency
ADHD
Frustration with school
Son observes
Poor academic performance
1
Mother’s subsystem of thoughts, feelings, experiences that lead to leniency 8
2
7
3
6
4
5
Selfjustification
Physical abuse
Withdrawal by each
Angry about abuse
Hypersensitive, reactive Fighting with peers
Depressed, preoccupied about situation
Poor concentration at school
Defiant with teacher
Referred for discipline
Case: HHS organization response to economic downturn
• 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
+
Change Drivers
+
Prolonged economic downturn
+
Political pressure Increased reliance on county & local resources
Individual & family stress
+ Referrals
Level of funding
_
Service availability
+ Programming Consolidation Staffing Evidence-based Early retirements Accountability No replacements Triage priorities Part time Strategic alliances Staff layoffs Grant writing Productivity monitoring Technology
+ +
_
_
+ Need for services
+
Competition for scarce funds
Reputation
+
Work overload Reduced quality Staff fatigue Illness Errors Absenteeism Service delays Turnover
_
Systems Mapping Model for Strategic Intervention Identify significant events & their sequence Are there spinoffs that will produce unexpected consequences?
8
2
7 What can be done to reduce the barrier?
What leverage is available at each node?
1
3 6
4 5
What nodes present the greatest resistance or barrier to change?
How feasible is the leverage for each node?
Economic stress
Reduced funding
Low salaries
Decline in services & programs
Rapid shift from paper to electronic record
Intake interviews w/ computer notetaking
Insufficient recruitment efforts
Inexperienced new staff
Staff go to competition
Stress; Client need for services
Training/ skill lag
Turnover; staff loss
Staff dissatisfaction with inattention, slow skills, slow technology
Resist change, complain, low morale
Poor agency reputation
Challenge of Electronic Case Notes
Client dissatisfaction w/ inattention; complaints or not return
Resources
How to Tell the Story from a Loop • Start anywhere. Pick the element, for instance, of most immediate concern.
Service Quality
Staffing Levels
• 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.....
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. The easy way out usually leads back in, and faster is slower. 5. Cause and effect are not closely related in time and space. 6. 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
American Health Outcomes
• Overtreatment
• Patient safety breakdowns • Pharmaceutical errors • 60 million uninsured • Economic drain • Poor public health outcomes
We need to change our ways of thinking about issues in HHS “Every system is perfectly designed to produce the outcomes it is producing” --Peter Senge “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
Form Follows Financing: The current health business model
Based on volume – the more you do, the more money you make
New Health System Based on VALUE Quality + Service Patient Value = 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
When is Systems Thinking Appropriate? • 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
Some Limitations of the Systems Approach • Systems usually involve a high level of complexity, sometimes beyond the feasibility of modeling • Tolerance of ambiguity and preference for complexity are personality features and some people may dislike a systems approach
• A system map is dependent on the factors that are identified; too often there are unknown variables, although they may emerge later as awareness increases • Events or nodes on a systems map are usually significant events. It may be that very small and relatively unnoticeable events are key factors as well. • As larger system constraints become clear, change may be less feasible (although that may save wasted effort, and still leads to considering alternatives)
Systems Thinking Habits
• Seek to understand the big picture • Identify the circular nature of complex causeeffect 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”
Lake Superior Systems Thinking Group • Grass roots-based multidisciplinary community members • Learn and share ideas about systems thinking • Apply systems thinking to current HHS issues, with emphasis on rural healthcare
• Invited guests to present on current issues • Form your own Systems Thinking Group
Team Norms tolerating or supporting OT
Motivation for rewards contribution, commitment, exemplary performance, bonus, time off, etc. Willing to work overtime Overtime
Poor planning
Organizational culture emphasizing high work loads, multitasking, and high pressure
Lower reputation
Inaccurate time estimation; Unclear, emerging, changing requirements
Systems Model of Overtime
Delays
“all nighters” “Death March”
Poor eating habits; Insufficient sleep; Inactivity, postural strain, headaches
Fatigue More mistakes, bugs, lower quality
Lower defect removal rate for release
Work/home relationship imbalance
Caffeine loading; sleep medication
Poor alertness, attention, concentration, memory
Team member conflicts
Increased irritability, frustration, depression, low energy
Some Systems Examples
Systems map for stress management
