session 2 - complexity - barbour

Session 2: CompleXity, Surprise, Innovation & Deviance in Decision-making for Health Care Systems

Galen Barbour, MD FACP, FACHEDirector, Health Services AdministrationUniformed Services University

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Questions

Why doesn’t strategic planning work?

Why do decisions work sometimes and sometimes not?

Why aren’t ‘best practices’ importable?

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1. Appreciate Newtonian thinking and the elements of the ‘linear world’.

• Contrast Linearity with: - the implications of Complexity Science

- the concept of Positive Deviance (and why ‘best practices’ are so hard to import)

- the framework of Disruptive Innovation (and application to the national health care debate)

- the ubiquity of randomness and the reality of the Black Swan phenomenon

- the relationship to Uncertainty and Surprise

• Develop problem solving approaches for non-linear situations.

Objectives

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A Short History of Physics

300 BC: Aristotle: Observation & Deduction;

1700 AD: Newton, Galileo, et al: Exp & Induction:

A body persists its state of rest or of uniform motion unless acted upon by an external unbalanced force.

Force equals mass times acceleration (F = ma).

To every action there is an equal and opposite reaction.

Aristotelian and Newtonian thought generated a very

linear way of seeing the world:

“this (always) follows that”

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A Short History of Physics

300 BC: Aristotle: Observation & Deduction;

1700 AD: Newton, Galileo, et al: Exp & Induction:

A body persists its state of rest or of uniform motion unless acted upon by an external unbalanced force.

Force equals mass times acceleration (F = ma).

To every action there is an equal and opposite reaction.

1950 AD: Planck, Rutherford, Bohr, Einstein: Observation, Experimentation and Analytic Theory

Quantum theory

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• Is non-linear• Is unpredictable (but leaves tracks)• Encompasses innumerable possibilities

(not ‘mutations’)• Studies of the quantum world led to

appreciation of complexity

The Quantum World

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The ConundrumNewton’s Laws ‘explain’ the macro world and make sense for most issues.

When we apply Newtonian thinking, we are seeing the world in a mechanical and quite linear way. (and that works for the most part)

When something unexpected intrudes, we are unprepared. We tend to think there is a ‘mechanical’ or ‘linear’ aspect that we didn’t measure or consider. We must be ignorant or negligent.

Truth is, “Variation Happens” and we would be better if we knew how to deal with it.

Variation = complexity.

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A Complex System

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Understanding of Complexity

Initially, a theoretical construct explaining time and space

Later identified at micro-levels in biology Now recognized at every level of existence as ‘the’

(or a partial) explanation for heretofore puzzling phenomena. Derivative studies on SWARM INTELLIGENCE and

NETWORKS and STRING THEORY have added additional insight.

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Examples of CASs

• DC/NOVA slug lines• Stock market• NYC food distribution• Forest• HospitalHospital

Each system “succeeds” by adapting to its changing environment.

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Characteristics of CASs

• diversity• adaptability• interdependency• embedded nature• nonlinear• history-dependent• ‘biologic’• paradoxical

• novelty; prog. adaptations• capacity to change• linkages• scalar• “butterfly” effect• past context• not machinery• many “both-and” rather

than “either-or”

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1. Inter-related processes form systems – with Order, Chaos and Complexity within the system.

2. Systems that are complex show signs of self-organization – they adapt to external forces and other causes for change.

3. We are surrounded by complexity – but we still approach each situation as if it is Simple and Linear.

Implications of Complexity

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Level of Immediate Necessity

C h

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Routine, expected issues– Staffing– Budgeting– Information Management– Marketing

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Zone 1simple

Rational decision-making– Use components and boundaries– Prioritize using critical issues– Plan, measure, adjust, reward

– Linear approaches work well here

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Zone 1Tools

simple

• Events not as predictable; more uncertainty exists about the future

• Labor negotiations• Opening new services• Developing an incentive system

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Zone 2complicated

1. Certainty > Agreement, compromise, negotiation (political tools)

2. Agreement > Certainty, ideology, judgment (role for experts)

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complicatedZone 2Tools 1

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Complexity increased by an order of magnitude Different tools needed

• Dramatic legislative changes• Re-design of health care delivery systems• Mergers (systems, departments, etc.)

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Zone 3complex

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We need to recognize the situation as ‘non-linear’ (e.g., a ‘mystery’ not a ‘puzzle’) before we can begin to think of using ‘non-linear’ tools.

Applying linear thought and problem-solving to complex situations is highly unlikely to work.

complexZone 3Tools

• Reflection• Minimum specifications• ‘Wicked’ questions• Metaphor• Generative relationships• Lifecycle to ecocycle• etc. (See: Edgeware: insights from complexity science for

health care leaders. B Zimmerman, P Plsek, C Lindberg

2-20Critical Decision Making for Medical Executives: Keys to Improving Healthcare Delivery

complexZone 3

Tools

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Comparison of Approaches

Simple Complicated Complex

• Planning is quite detailed (e.g., a recipe, blueprint)

• Clear, measurable outcome

• Measurement, goals and targets

• Accountability at a personal level.

• Multiple plans with interaction

• Outcomes are big and complicated

• Reliance is on the experts

• Heroes win, villains cause trouble or prohibit success.

• ‘Plan’ is very general (more questions than answers)

• Uncertainty is king

• Use Minimum specifications

• Embrace the paradoxes with optimism.

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Complicated

Modern medicine has created knowledge and practice patterns that are very complicated:

• Emergency response to chest pain

• Sudden onset stroke (“brain attack”)

• Cardiac bypass surgery

• Organ transplantation

How can we reduce ‘errors’ and ‘ineptitude’?

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Linear thinking can (at times) mislead people into thinking they are in one business when they are really in another.

1920s-1950s: Railroad Executives pushed for more track and more powerful engines for the “Railroad Business”

1940s-1970s: Trucking companies moved in to the small markets not served by railroads and began to expand in the “Transportation Business”

1960s – 1980s American railroads nearly went bankrupt (and some actually did).

Linear

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Pe

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Time

Least demanding customer

Most demanding customer

Disrup

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Sustai

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Innova

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Per

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Time

Rebar

Integrated Steelmakers

Mini-millsMini-mills

Sheet steel

Structural steel

Other bars and rods

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Characteristics of these successful “disruptions”:

2. Breaks with ‘linear’ thinking

3. Starts with simple technology and functionality

4. Operates ‘under the system’ by starting in ‘rebar’ markets with minimal regulatory barriers

5. Is cheaper; allows less costly people to meet the needs of an emerging market.

6. Initially competes against non-consumption; later meets more demanding needs without customers having to change their ways.

“Disruptions”

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Disruptions and Health Care

We have the technology to disrupt - the hospital business model - the physician’s practice business model - the reimbursement system - the care of chronic illness

according to The Innovators Prescription: A Disruptive Solution for Health Care

- Clay Christensen

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“usual”

“B”Performers

“D”Performers

LOWPerformers

HIGHPerformersPositive Deviants

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Positive Deviance = Best outcomes in the ‘community’.

Positive Deviants = Recognizable within the community

Use two key approaches

1. Acute situational awareness

Not decision tree or knowledge management Modified Analytical Hierarchy

2. Patterned responses

Commitment, end-in-mind, action-oriented, measure threats & progress, operate on evidence basis

Deviance

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Principles of disbursing Positive Deviance

2. Help ‘community’ identify the PDs

3. Obtain their involvement thru intrinsic motivation and professionalism

4. Engage others thru Practice -> Attitude -> Knowledge (this is ‘backwards’ to the usual way of ‘teaching’)

The Power of Positive Deviance: How Unlikely Innovators Solve the World's Toughest Problems Pascale, Sternin & Sternin

Vietnam diethttp://www.fastcompany.com/magazine/41/sternin.html

MRSA reduction

http://www.plexusinstitute.org/news-events/show_news.cfm?id=1665

Positive Deviance

Puzzle: problem or enigma; pieces must be fit together in a logical (i.e., linear) way to come to the right conclusion.

Puzzles versus Mysteries

Mystery: occurrences or relationships that are difficult to make clear; often have secret or hidden qualities that need explanation (i.e. red herring, misdirection, unexpected events, etc.)

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What About Uncertainty And Surprise

Variation is unpredictable & uncertain(perhaps anticipated).

Black Swan theory: The Black Swan: The Impact of the Highly Improbable. Nassim Nicholas Taleb

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Variation is unpredictable & uncertain(perhaps anticipated).

Black Swan theory: The Black Swan: The Impact of the Highly Improbable. Nassim Nicholas Taleb

What About Uncertainty and Surprise

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Variation is unpredictable & uncertain

Tools that deal with variation improve the ability to deal with uncertainty.

Surprise is the culmination of uncertainty – the actual event as opposed to the threat.

Answers (solutions) may come from CAS, or from PD or maybe from DI . . .

-- but NOT likely from a linear approach or such an approach should have predicted the event . . .

What About Uncertainty and Surprise

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Some ‘tools’ to use in dealing with complex situations:• Look thru the Complexity Lens• Be sure you are asking the Right Question• Set only Minimum requirements• Use Metaphor (biologic not machine-like)• Initiate Multiple actions (swarmware)• Do some Chunking (bit development like UNIX)• Allow Tension and Paradox (Generative relations)• Ask Wicked Questions • Tune to the edge• Don’t shy away from being Wrong • Reflect & Listen to the Shadow System• Mix competition and cooperation

Tools

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Low High

Level of Necessity

Strategic Planning, et al

Compromise

Expert Opinion

Disruptive Innovation

Complex Adaptive

Methods (Edgeware)

Positive D

eviance

Swarm Intelligence

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Reference List for Complexity et al:• Edgeware: Zimmerman, Plsek, Lindberg

• The Innovators Prescription: Christensen

• The Power of Positive Deviance: Pascale, Sternin, Sternin

• The Black Swan: Taleb

• The Drunkard’s Walk: Mlodinow

• The Checklist Manifesto: Gawande

• The Perfect Swarm: Fisher

• Being Wrong: Schulz