David X. Swenson PhD LP Terry Hill MPH Brandon Olson, PhD St. Louis County Health and Human Services Conference, 2013

1. A Grassroots and Multidisciplinary Approach to Systems Thinking About Health and Human Service Issues David X. Swenson PhD LP Terry Hill MPH Brandon Olson, PhD St. Louis County Health and Human Services Conference, 2013

2. 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

3. 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

4. Familiar Systems

5. Team and Organizational Social Network Analysis Family-Provider System Ecomap Family Genogram

6. “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

7. 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

8. Mapping Complex Systems

10. What do you see? • Mud splatters • Satellite view of islands • Tile floor • Frosted window • Tired horse • Dog eating • Human face • Rorschach inkblot…

11. Good intentions and hard work may not be sufficient.... Revenge Effects: http://faculty.css.edu/dswenson/web/revenge.htm

12. Lack of systems thinking may be counterproductive Expected Outcome Actual Outcome Poor grades Criticize the child Past criticism Poor grades Child becomes angry & recalls past criticism Low esteem Criticize child for poor grades Wants to indirectly defy and challenge parent Child’s behavior improves Too threated to react directly so is passive Past Intimidation Preoccupied, anxious thinking interferes with study

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

14. Some solutions are counterintuitive…

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

16. Fishbone or Ishikawa Diagram for Identifying Resistance to Innovation

17. Systems Approach to Force Field Analysis for a Community Gardening Program http://www.idrc.ca/events-swaminathan/ev-85414-201-1-DO_TOPIC.html

18. 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

19. Systems Thinking: Reinforcing connections between ADHD & Conduct Out of seat, bother others Hyperactivity Get in trouble Make mistakes Impulsive: act before thinking Discipline Act out Feel it’s unfair ADHD Misread social cues Inattention, poor concentration Unpredictable relating Peer avoidance rejection Resentment Poor working memory, slow processing Difficulty learning, get behind Default to delinquent peers Repeated failure Non-attendance Embarrassment, frustration, discouragement Defiance Withdrawal

20. Sample Family System Dynamics: It’s all tied together– More than ADHD Father’s subsystem of thoughts, feelings, experiences that lead to strictness Son’s behavior issues Father’s Strict Truancy Parental conflict Frustration with school ADHD Verbal abuse Mother’s leniency Son observes Poor academic performance Physical abuse Angry about abuse Depressed, preoccupied about situation Referred for discipline Poor concentration at school Withdrawal by each Self- justification Hypersensitive, reactive Defiant with teacher Mother’s subsystem of thoughts, feelings, experiences that lead to leniency Fighting with peers

21. Case: Human service 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

22. + Political pressure Increased reliance on county & local resources Change Drivers Prolonged economic downturn + Competition for scarce funds + + _ Level of funding Individual & family stress + _ Service availability + Need for services + Staffing Early retirements No replacements Part time Staff layoffs Consolidate Programs Evidence-based Accountability Triage priorities Strategic alliances Grant writing Productivity monitoring Technology + Referrals Reputation + + Work overload Staff fatigue Illness Absenteeism Turnover • Reduced quality • Errors • Service delays _ +

23. Systems Mapping Model for Strategic Intervention Identify significant events & their sequence Are there spinoffs that will produce unexpected risks/consequences? What leverage is available at each node? How feasible is the leverage for each node? What can be done to reduce the barrier? What nodes present the greatest resistance or barrier to change?

24. How to Tell the Story from a Loop • 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.....

25. A Few Systems Principles • Today's problems come from yesterday's solutions. • The harder you push, the harder the system pushes back. • Behavior gets worse before it gets better. • Cause and effect are not closely related in time and space. • Small changes can produce big results-- the areas of highest leverage are often the least obvious. • Dividing an elephant in half does not produce two small elephants. • There is no blame.

26. The American Health Care System • High cost • Low quality • Inadequate access • Deteriorating population health

27. Systems Thinking Applied to Healthcare

28. American Health Outcomes • Overtreatment • Patient safety breakdowns • Pharmaceutical errors • 60 million uninsured • Economic drain • Poor public health outcomes

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

30. Form Follows Financing: The current health business model Based on volume : the more you do, the more money you make

31. The New Premise • Cost & population management • Risk management • Aligned organizations managing populations • High quality & value • Care coordination • Government • Private payers

32. New Health System Based on VALUE Quality + Service Cost Patient Value = • Value = Triple Aim • Better care • Better Health • Lower Cost

33. Paying for Value Continuum Measuring Reporting Pay for Performance Value-based purchasing (VBP)

34. Medicare Shared Savings Program • Creates accountable care organizations (ACOs) • Value Based Purchasing (VBP) Improve quality Improve patient experience Reduce cost = BONUS + +

35. VBP Demonstration Projects • Prospective payment system (PPS) hospitals • Critical access hospitals (CAHs) • Home health agencies • Nursing homes • Medical clinics

36. 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

37. 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

38. The River Metaphor & Illusion of Control “Control is mostly an illusion; we need awareness of the system in order to participate more fully”

39. 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

40. Survey of Perceptions of Systems Thinking 1= Strongly Disagree 2=Disagree 3=Neither Agree/Disagree 4=Agree 5= Strongly Agree

41. 1= Strongly Disagree 2=Disagree 3=Neither Agree/Disagree 4=Agree 5= Strongly Agree

42. 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

43. 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)

44. Q&A