Systems Science & Team Science

Systems Science & Team Science Abundance, Joy & Transformation

Kurt C. Stange, MD, PhD Professor of Family Medicine & Community Health,

Epidemiology & Biostatistics, Oncology and Sociology Case Western Reserve University

American Cancer Society Clinical Research Professor Editor, Annals of Family Medicine www.AnnFamMed.org

Promoting Health Across Boundaries www.PHAB.us NCI Division of Cancer Control & Population Sciences via IPA

Systems Science

If you…

Sometimes feel that your research paradigm and theory don’t fit the complexity of the way the world actually works.

If you…

Find that your methods sometimes constrain your thinking more than enlighten it.

If you…

Find that measures of central tendency mask important factors in your research.

If you…

Study phenomena in which the whole is more than the sum of the parts.

If you…

Are tired of looking under the lamppost when the interesting stuff is in the darkness.

If you…

Discover the potentially transformative challenge, abundance and joy in complexity.

Rogers EM. Diffusion of Innovations. 4th ed. New York, NY: The Free Press; 1995.

Rogers Diffusion of Innovations

Rogers EM. Diffusion of Innovations. 4th ed. New York, NY: The Free Press; 1995.

Knowledge Persuasion Decision Implementation Confirmation

Accept

Reject

Five Stages in the Decision Innovation Process

Rogers EM. Diffusion of Innovations. 4th ed. New York, NY: The Free Press; 1995.

Five Stages in the Decision Innovation Process

Knowledge Persuasion Decision Implementation Confirmation

Accept

Reject

Solberg LI. Improving Medical Practice: A Conceptual Framework. Ann Fam Med 2007 5:251-256.

Implementing Innovations in Medical Practice

Change Process Capacity

Care Process Content

Quality Improvement Priority

Facilitators

Barriers

X

Facilitators

Barriers

X

Facilitators

Barriers

=

Solberg LI. Improving Medical Practice: A Conceptual Framework Ann Fam Med 2007 5:251-256.

Change Process Capability

Care Process Content

Quality Improvement Priority X X

Facilitators Facilitators Facilitators

Barriers Barriers Barriers

=

Implementing Innovations in Medical Practice

Simple/Complicated • Homogeneous • Linear • Deterministic • Static • Independent • No feedback • No adaptation or self-

organization • No connection between

levels or other systems

Complex Systems • Heterogeneous • Non-linear • Stochastic • Dynamic • Interdependent • Feedback • Adaptation & self-

organization • Emergence

Simple vs. Complex Systems

Table 9-1. Brownson, Colditz & Proctor. D&I Research in Health.

Systems: a set of interacting or interdependent components forming an integrated whole

Systems Science: An interdisciplinary field that studies the nature of complex systems in nature, society, and science.

Systems / Science

en.wikipedia.org/wiki/System_Science

Some Complex Systems D&I Frameworks

Expanded Chronic Care Model

Barr VJ, Robinson S, Marin-Link B, Underhill L, Dotts A, Ravensdale D, Salivaras S. The expanded Chronic Care Model: an integration of concepts and strategies from population health promotion and the Chronic Care Model. Hosp. Q. 2003;7:73-82.

• Relative advantage in effectiveness • Compatibility with intended users’ values, norms, needs • Low complexity – as perceived by key stakeholders • Trialability –user can experiment on a limited basis • Observability of the benefits visible to the user • Potential for reinvention and spread through informal,

decentralized, horizontal social networks.” • Fuzzy boundaries Complex interventions with an

irreducible core and a ‘soft’ periphery of organizational structures and systems that aid implementation.

• Risk ratios benefits for powerbase outweigh risks. • Task relevance for key mission and functions. • Technical support that augments existing approaches • Tacit knowledge is less important than explicit

knowledge for implementation.

Features of Easily Adopted Innovations

Adapted from Greenhalgh et al. Milbank Q. 2004

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External inf luences on changeoption landscape

Motiv ation, Innov ation &Independence

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6

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Evaluating & exercising choices for change

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Motivation ofkey stakeholders

Resourcesfor change

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Cohen D, McDaniel RR, Crabtree BF, et al. A practice change model for quality improvement in primary care practice. J Healthc Manag, 2004; 49:155-170.

An Ecological (Panarchy) Framework

Gunderson LH, Holling CS, eds. Panarchy: understanding transformations in human and natural systems. Washington, DC: Island Press; 2002.

Stange KC. Making sense of health care transformation as adaptive-renewal cycles. Ann Fam Med, 2009; 7: 484-487.

A D&I Line Investigation that stumbled onto a systems

science approach

DOPCDirect Observation of Primary Care (NCI, RWJF: 1994-97)

SCOPESupporting Colorectal Cancer Outcomes through Participatory Enhancements(NCI: 2005-2011)

P&CDPrevention & Competing Demands in Primary Care (AHRQ: 1996-99)

Observational StudiesSTEP-UPStudy To Enhance Prevention by Understanding Practice (NCI: 1997-2000)

ULTRAUsing Learning Teams for Reflective Adaptation (NHLBI: 2002-07)

Intervention Studies

EPOCHSEnhancing Practice Outcomes through Community and Healthcare Systems (NCI: 2004-11)

TMTeachable Moments for Health Behavior Change (NCI: 2004-2009)

IMPACTInsights from Multimethod Practice Assessment of Change over Time (NCI: 2001-2004)

1. Discover and characterize essential features of healthcare innovations that have promise to transform primary health care and improve health.

2. Identify the contextual factors that enable these innovations to develop and flourish.

3. Analyze the implications of these discoveries for important healthcare problems, such as improving cancer control and implementing the patient-centered medical home.

4. Foster communities of knowledge by interactively communicating discoveries about innovations and their enabling contextual factors.

Aims for the next (unfunded) study in the line: Practice/System/Community Innovations &

Context for Health Care Transformation

Aims for a grant proposal to the National Cancer Institute

•

Title

…

Initial Hypotheses

Current Portfolio of Potential Innovators

Emerging Portfolio of Innovators

Existing Data•Prior studies•Public domain

New Data•Interview•Observation•Other sources(Site visits)

Case Study Reports

Scholarly Output•Scientific papers•Presentations•Web tools

Comparative Case Study Reports

2Sampling

3Data Collection

and Coding

7Additional Sampling

4Analysis

5 Sharing

9Cross-cutting

Analyses

12Additional

Interpretive Analyses

Study Design

11

1

13 14

15

10Sharing

A

B C

D

EF

G

Reports on Related Topics

HI

Innovation

Enabling Environmental and Contextual

Factors

Understanding of

6

8Analyses

Reflection & Feedback from:

Case Members(Web & Site Visits)

Collaborators & Consultants

(Web & Annual Retreats)

Invited Participants (Web)

Public (Web)

A Complex & Systemic Study Design

From a subsequent (just funded) study in the line: Paradox of Primary Care

Primary care is associated with: • Poor quality of care for individual diseases, but • Better quality at population level • Similar whole-person functional health • Better population health • Lower resource use and cost • Less inequality in healthcare & health Stange KC, Ferrer RL. The paradox of primary care. Ann Fam Med. 2009;7(4):100-103.

26

Principles of Primary Care (Hypotheses) • Accesibility as 1st contact

with health care • Accountability for large

majority of healthcare needs (comprehensiveness)

• Coordination & integration of care across settings, acute & chronic illnesses, mental health & prevention

• Sustained partnership – relationships over time in a family & community context

Donaldson MS, Yordy KD, Lohr KN, Vanselow NA, eds. Primary Care: America's Health in a New Era. Washington D.C.: National Academy Press; 1996.

Stange KC, Nutting PA, Miller WL, et al. Defining and measuring the Patient-Centered Medical Home. J Gen Intern Med. 2010; 25(6): 601-612.

• [Insert movie of a model run]

Agent-Based Model of the Paradox

The Network on Inequality, Complexity, and Health (NICH). OBSSR 7/1/10-6/30/14. Group Model Building to Engage Patient & Clinician Wisdom to Design Primary Care. Patient-Centered Outcomes Research Institute (PCORI) 7/1/12 – 6/30/14.

• “Systems science methodologies provide a way to address complex problems, while taking into account the big picture and context of such problems.” e.g. – Agent-based models – System dynamics models – Social network analysis

• Systems Science and Health in the Behavioral and Social Sciences (R01 and R21) http://grants.nih.gov/grants/guide/pa-files/PAR-11-314.html (R01) http://grants.nih.gov/grants/guide/pa-files/PAR-11-315.html (R21)

OBSSR and Systems Science

OBSSR. System Science. http://obssr.od.nih.gov/scientific_areas/methodology/systems_science/index.aspx Institute on Systems Science & Health. http://obssr.od.nih.gov/training_and_education/issh/index.html

• Work narrowly but raise your gaze periodically to put reductionist work in a larger context

• Pay attention to and report context • Multimethod approaches • Participatory approaches • Pursue an evolving line of investigation • Simulation modeling • Develop relationships; move from M→I→T

Acting Differently Based on Systems Understanding

• Holmes BJ, Finegood DT, Riley BL, Best A. (2012). Systems thinking in dissemination and implementation research. In R. Brownson, G. Colditz, & E. Proctor (Eds.), Dissemination and Implementation Research in Health: Translating Science to Practice. Oxford University Press.

• Luke, D. A. (2012). Viewing dissemination & implementation research through a network lens. In R. Brownson, G. Colditz, & E. Proctor (Eds.), Dissemination and Implementation Research in Health: Translating Science to Practice. Oxford University Press.

• Scott J. Leischow and Bobby Milstein. Systems Thinking and Modeling for Public Health Practice. American Journal of Public Health: March 2006, Vol. 96, No. 3, pp. 403-405. http://ajph.aphapublications.org/doi/full/10.2105/AJPH.2005.082842

• Meadow, DH, with Wright D. Thinking in Systems. A Primer. White River Junction, VT: Chelsea Green Publishing, 2008.

• Kernick D. Complexity and Healthcare Organization: A View from the Street. Oxford: Radcliffe Medical Press, 2004.

Reading

• Galea, Sandro et al. 2009 “Causal thinking and complex system approaches in epidemiology” International Journal of Epidemiology 39:97–106. http://obssr.od.nih.gov/issh/2010/files/track_abmt/galea_causal_thinking_2010.pdf

• Sterman, John. 2006. “Learning from Evidence in a Complex World.” American Journal of Public Health 96:505–14. http://obssr.od.nih.gov/issh/2010/files/track_abmt/AmericanJournalofPublicHealth_2006_Sterman.pdf

• Mabry PL, Olster DH, Morgan GD, Abrams DB. Interdisciplinarity and systems science to improve population health: a view from the NIH Office of Behavioral and Social Sciences Research. Am. J. Prev. Med. Aug 2008;35(2 Suppl):S211-224. www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=18619402

• Miller WL, McDaniel RR, Jr., Crabtree BF, Stange KC. Practice jazz: understanding variation in family practices using complexity science. J. Fam. Pract. 2001;50(10):872-878. www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=11674890

• Plsek PE, Greenhalgh T. Complexity science: the challenge of complexity in health care. BMJ. 2001;323(7313):625-628. www.ncbi.nlm.nih.gov/pmc/articles/PMC1121189/pdf/625.pdf

Reading

Team Science

Collaborative Group Process: Developing Cross-Disciplinary Research Teams

William L. Miller, MD, MA Benjamin F. Crabtree, PhD Carlos R. Jaén, MD, PhD

Paul A. Nutting, MD, MSPH Robin S. Gotler, MA

Kurt C. Stange, MD, PhD

Center for Research in Family Practice and Primary Care Supported by a Center Grant from the

American Academy of Family Physicians

What’s Coming (presentation & extra slides)

• The need for collaboration • A typology of the collaborative process • Consider your experiences • The 6 stages of collaboration • Barriers • 6 ingredients for successful collaboration • Leadership to foster collaboration • Examples

When an Individual Approach is Too Limiting

• Knowledge, understanding, perspective • Energy • Resources • Opportunities • Fun

To Answer D&I Research Questions

• Meaning • Multiple perspectives • Multiple methods • Multiple sites and settings • Diverse expertise • Need for integration

Stange KC, Miller WL, McWhinney IR. Developing the knowledge base of family practice. Fam Med. 2001;33:286-297.

Collaboration can create

abundance by sharing scarcity.

Crabtree BF, Miller WL, Adison RB, Gilchrist VJ, Kuzel A. Exploring Collaborative Research in Primary Care. Thousand Oaks, California: Sage Publications; 1994.

A Typology of Collaboration

• Multidisciplinary • Interdisciplinary • Transdisciplinary

Rosenfield PL. The potential of transdisciplinary research for sustaining and extending linkages between the health and social sciences. Soc. Sci. Med. Dec 1992;35(11):1343-1357. Stange KC. The Journal of Participatory Medicine: setting its sights on a community of practice. J Participat Med. 2009;(Oct):Launch Issue. http://jopm.org/index.php/jpm/article/view/34/30 Stokols D, Misra S, Moser RP, Hall KL, Taylor BK. The ecology of team science: understanding contextual influences on transdisciplinary collaboration. Am J Prev Med. 2008;35(2 Suppl):S96-115. Stokols D, Hall KL, Taylor BK, Moser RP. The science of team science: overview of the field and introduction to the supplement. Am. J. Prev. Med. Aug 2008;35(2 Suppl):S77-89. Crabtree BF, Miller WL, Adison RB, Gilchrist VJ, Kuzel A. Exploring Collaborative Research in Primary Care. Thousand Oaks, California: Sage Publications; 1994.

Multidisciplinary Research • Multiple disciplines

• Each contributes their piece to solving a problem

• Like an edited book or separate presentations by multiple experts

Interdisciplinary Research

• A conversation between and among disciplines

• Working together on solving a common problem

• Like a collaborative health care team

Transdisciplinary Research

• A sustained conversation across and beyond disciplinary boundaries

• Creates a new shared language

• Such as the emergence of D&I research

Think about your experience • In research

• In practice

• In other life experiences

A Typology of Collaboration • Multidisciplinary

• Interdisciplinary

• Transdisciplinary

6 Stages of Collaboration

• Acceptance / validation • Shared expectations

• Declaring group process • Action consensus

• Common space • Sustained common action

Bonus!!! Extra Slides (These won’t be presented)

Acceptance / Validation

• Affirmative listening

• Participants reveal their disciplinary expertise

• Participants sense acknowledgment and appreciation by others

Shared Expectations • Each person shares their specific agenda for

the problem at hand • Multiple agendas are understood within a

group-defined common task • Participants comfortably remain within a

disciplinary tradition, using their own language • Pseudocommunity

• Multidisciplinary stage

Declaring Group Process • Openly acknowledging differences

• Expressing a desire for deeper understanding that moves beyond jargon, values & assumptions

• Working to overcome task-avoidant unexpressed differences and fears of misunderstanding – Flight or fight – Pairing – Dependence

Action Consensus • Agreement on an organizational framework

– For staying on task – For maintaining group work

• Example frameworks – Using the leader’s framework – Using a model developed by the dominant discipline – Traditional methodological strategies

• Members begin using the language of other disciplines

• Interdisciplinary stage

Shared Common Space • Unpacking / emptying communication

barriers – Prejudices – Hidden expectations – Preconceptions – Need to fix, solve, control

• Living with tension, disagreement, public self-revelation

• Work of creating true community

Sustained Common Action

• Remaining in / expanding shared common space

• True community

• Creation of a newly agreed-upon language

• Transdisciplinary stage

6 Stages of Collaboration • Acceptance / validation • Shared expectations

• Declaring group process • Action consensus

• Common space • Sustained common action

Shared Expectations Acceptance

Group

Process

Claimed

Common

Space

Sustained Common

Action

Action

Consensus

Interdisciplinary

Transdisciplinary

Barriers to Collaborative Process • Rhetorical stones

– Power heaping – Shaming – Jargon hurling

• Powerful hegemony – Rationality vs. / and – Wonder, confession gratitude, receptivity to gift & mystery

• Tension between pragmatism and reflection • Tension between individual & systems focus

Tactics for Advancing the Process

• Brainstorming

• Humor

• Storytelling

• Silence and time out for play

The Actual Process • Non-linear

• Blurring and blending of levels

• Back and forth between levels

• Destabilized by time pressure

• Enhanced by flexibility, tact, patience and persistence

Dangers of Collaborative Research Relationships

• Sloppiness from training down

• Suppression of individuality

• Cultism

• Political nature of groups

• Minimizing these requires self-reflection and challenging

6 Ingredients for Successful Collaborations

• Linkage perspective

• Local context and action

• Problem-focused but appreciative

• Appropriate methods

• Critical multiplism

• Coordination by a generalist researcher

Linkage Perspective

• Vertical

• Horizontal

• Time

• Academic - practitioner - public - policy

Local Action • Personal contacts and context

• Scale for collaboration

• Local knowledge grounds search for universal knowledge

• Theory and generalizable knowledge comes from the comparison and convergence of multiple local knowledges over time

Problem-Focused & Appreciative • Locally relevant problems and

questions

• Relevant shared goals

• Task orientation AND focus on group process

• Appreciative Inquiry that values the positive and creates space for stories

Appropriate Methods

• Fit the methods to the question

• Expand the team as needed

• Mixed methods over time for complex questions

Critical Multiplism

• Multiple ways of knowing are necessary for scientific inquiry

• Multiple triangulation – Data – Theory – Investigator – Methods

Generalist Researcher • Theoretical pluralism • Methodological pluralism • Practice-based • Community-oriented • Translator • Negotiator • Facilitator, seed planter, coordinator, conductor,

witness, organizer, consensus-builder, problem-focuser, builder of creative tension between task orientation & group process

Leadership for Collaborative Research

• Whole system – Top down – Bottom-up

Thomas P, Griffiths F, Kai J, O'Dwyer A. Networks for research in primary health care. BMJ. 2001;322:588-590.

Leadership for Collaborative Research

• In the face of change and uncertainty – Animation

• Provide initial direction • Encourages updating • Facilitates respectful interaction - trust, trustworthiness

– Improvisation • A hunch held lightly is a direction to be followed, not a

decision to be defended – Lightness

• “I don’t know” – Authentication

• Sensemaking – Learning

Weick KE. Leadership as the legitimation of doubt. In Bennis W, Spreitzer GM, Cummings TG, (eds). The Future of Leadership. San Francisco: Jossey-Bass, 2001.

Examples • Center for Research in Family Medicine and

Primary Care* • Cancer Center • Practice-based research • Community participatory research • Prescription for Health • The Annals of Family Medicine

* Stange KC, et al. The Direct Observation of Primary Care Study: Insights from the process of conducting multimethod, transdisciplinary research in community family practice. J Fam Pract. 2001;50:345-352.

* Crabtree BF, Miller WL, Gilchrist VL, Jaén CR, Stange KC. Common space: Living a collaborative research conversation. 1999 NAPCRG Plenary Presentation, San Diego. [Audio tape available for $5 from NAPCRG.]

Examples

Stages & Ingredients for Collaboration

6 Stages • Acceptance / validation • Shared expectations

• Declaring group process

• Action consensus

• Common space • Sustained common

action

6 Ingredients • Linkage perspective • Local context & action • Problem-focused,

appreciative • Appropriate methods • Critical multiplism • Coordination by

a generalist researcher

A Typology of Collaboration • Multidisciplinary

• Interdisciplinary

• Transdisciplinary

Sustained Common Action

Common Space

Action Consensus

Group Process Claimed

Acceptance Validation

Shared Expectations

Group

Levels of Collaborative Research

Base case – Set-up

Run 157 tics

Specialists more effective for people with single diseases

Primary care more effective for people with multiple diseases

Over time, specialist treatment effectiveness increases.

PC Range decreased to 0.5 175 tics: ↓ Paradox in health; ↓Specialty

PC Turnover ↑in 2 Poorest Neighborhoods

Competing Demands Theory • Many worthwhile services compete with

each other for time on the agenda of primary care patient visits.

• When primary care clinicians are not doing one activity under scrutiny (e.g. preventive services), they may be doing something else that is more compelling.

Jaén CR, Stange KC, Nutting PA. The competing demands of primary care: A model for the delivery of clinical preventive services. J Fam Pract. 1994; 38:166-171.

Stange KC, Fedirko T, Zyzanski SJ, Jaén CR. How do family physicians prioritize delivery of multiple preventive services? J Fam Pract. 1994; 38:231-237.

Theory of Competing Opportunities

• Integrated, prioritized care within an ongoing personal relationship • Breadth of care • Depth of knowledge of the patient, family and

community over time • Bridging of the boundaries between health and

illness • Guiding access to more narrowly focused care

Stange KC, Jaén CR, Flocke SA, Miller WL, Crabtree BF. The

value of a family physician. J Fam Pract, 1998; 46:363-368.

Primary Care Practices are Complex Adaptive Systems

• Complex behavior emerges from relationships among agents • Simple rules • Recurrent patterns • Co-evolution • Dependence on initial conditions • Non-linearity • Strategies for intervention

• Joining • Transforming • Learning

Miller WL, Crabtree BF, McDaniel RA, Stange KC. Understanding primary care practice: A complexity model of change. J Fam Pract, 1998; 46:369-376. Miller WL, McDaniel RA, Crabtree BF, Stange KC. Practice Jazz: Understanding variation in family practices using complexity science. J Fam Pract, 2001; 50:872-878.

Using Complexity Science to Inform a Reflective Practice Improvement Process

• Understanding practices’ vision and mission is useful in guiding change

• Creating tie and space for learning & reflection helps organizations to adapt & plan change

• Tension & discomfort are essential & normal during change

• Diverse perspectives foster adaptability & new insights for positive change

• Sustainable change requires supportive leadership Stroebel CK, McDaniel RR Jr, Crabtree BF, Miller WL, Nutting PA, Stange KC. Using complexity science to inform a reflective practice improvement process. Jt Comm J Qual Patient Saf, 2005. 31:438-446.

Facilitating Practice Change • The edge of chaos

– Innovators (live on the edge) – Outside forces move toward the edge – QI intervention moves toward the edge

• Change is difficult to predict • Tailor facilitation to malleable moments • Motivated change agents

– Work with the already motivated – Increase motivation by

• Linking to values or other needs • Peer comparison feedback

• Once motivated, address instrumental needs Ruhe MC, Weyer, SM, Zronek S, Wilkinson A, Wilkinson PS, Stange KC.

Facilitating practice change: Lessons from the STEP-UP clinical trial. Prev Med. 2005; 40(6): 729-734

Evolution of Practice Change Models • Office systems approaches • Value-focused intervention • Complexity science models

– Initial conditions, emergent opportunities, attractors – Relative importance of critical initial & emergent conditions – Importance of interrelationships between critical domains – Dynamic nature of multi-level relationships over time

Stange KC, Ruhe MC, Weyer SM et al. Practice change models: Insights from Multimethod

Practice Assessment of Change over Time (IMPACT). Prev Med. 2005; 40(6): 729-734 Cohen D, McDaniels R, Crabtree BF, et al. A practice change model for quality improvement in

primary care practice. 2004; J Healthcare Manage. 2004; 49:155-168. Stroebel CK, McDaniel RR, Crabtree BF, Miller WL, Nutting P, Stange KC. Using complexity science

to inform a reflective practice for improvement in primary care. Jt Comm J Qual Saf, 2005; 31:438-446.

Litaker D, Tomolo A, Liberatore V, Stange KC, Aron D. Using complexity theory to build interventions that improve health care delivery in primary care. J Gen Int Med, 2006; 21 Suppl 2:S30-4.

In Both Systems & Team Science • Look for fit

– Model – Method – Stakeholders

• Think & act beyond indentifying & overcoming barriers. Be open to: – Emergence – Team – ‘The creativity & fun of adaptive designs’ – Abundance

• Think & act – both/and – Numbers & narratives – A priori hypotheses & emerging insights – Internal & external validity – Task & relationship – Why & what & how