Systems Thinking in Public Health for Continuous Quality Improvement

Systems Perspectives on CQI and Public Health Cameron D. Norman PhD CE Principal CENSE Research + Design Adjunct Professor, Dalla Lana School of Public Health, University of Toronto

@cdnorman September 20, 2013

Presentation to the First Meeting to Advance CQI in Public Health in Ontario Toronto, ON

CQI in Public Health

CQI is a commitment to systems change to execute a continuous flow of improvements that meets or exceeds the expectations of the customer (communities) and generally includes a link to the organization’s strategic plan and goals

- Randolf & Lea (2012) cited in Law, Graham, Bridge & Ross (2013): A Primer on Quality in Public Health

Thinking in Systems

•  In complex systems the aim is to attend to attractors (e.g., policies, programs, ideas), which create patterns of activity, and amplify those that are producing beneficial outcomes and dampen those that are not.

•  The initial decisions within a complex system can create a path dependency and guide further activities that follow. It is critical to be mindful of these paths to realize that they can be changed (e.g., first person to walk across a park after the snow creates the first pathway. The likelihood that someone will choose to walk in an established path grows with each successive person that chooses to follow that initial path).

•  Be mindful – attentive, aware, non-judgemental – about the paths chosen and the dynamics going on within the system to determine how the patterns of activities resulting from those choices influence the process and outcomes related to the work. Making these paths / decisions visible allows for active, not just reactive influence.

Thinking in Systems

•  Systems thinking is about where you stand in the system; your perspective on the system and place within it can help set the boundaries •  Boundaries in social systems are partly determined by the edge of where new information no longer makes a discernible difference to the key purpose and strategic operations (i.e., where are the differences that make a difference?) •  Understanding what type of system you are operating in will determine the type of metrics and approaches needed to assess and promote quality within the system •  There are three types of systems that occur in nature:

• Chaotic: Lack of appreciable order and often does not last long • Ordered: Linear relationships that are clearly defined between objects, their impact on each other and the boundaries of the system • Complex: Dynamic, evolving and non-linear relations within flexible and adaptive boundaries

•  See Dave Snowden’s video on the nature of systems using the example of organizing a children’s party: http://youtu.be/Miwb92eZaJg

• Every one of these holds a legitimate position while defining the systems boundaries differently. Public health is the same way. What quality means in each of these cases is partly dependent on what matters in each system, which is not always the same. •  Further, systems can be embedded within one another as the above photos demonstrate. They can have overlapping processes and foundations, but operate at different scales to different effects at those scales.

CQI in Public Health: LEANing in or out?

Linearity in systems Example: The LEAN Production Method LEAN was based on the work of the Toyota

Production System which was designed to effectively and efficiently produce cars at the rate of demand.

It is predicated on increased efficiency, decreased waste, and eliminating errors. However, when you are in a complex system and deal with relationships, what is waste? What is an efficient conversation? What is a fully optimized innovation space – and how would you it if you saw it?

When you expect the same thing – and can predict that same thing time and again – this is a reasonable assertion. Yet much of what public health does operates outside that realm or at its periphery.

Problematic Questions for Context? Are these the right questions for this system (example?)

What is an effective tree?

What is the best practice for a tree?

What is a fully optimized tree?

Path Dependency

•  Complex systems are highly sensitive to initial conditions. Thus, the choices organizations make to start their QI work can disproportionately shape the work that comes after it. •  Structuring a mindful process of attending to activities on a regular basis and linking that with the intentional actions/mission of the organization can help illuminate path dependencies when they are forming. •  It is difficult to change measures and methods mid-stream once things are in place, so processes of self-reflection, monitoring, and organizational leadership committed to continuous quality improvement of the QI system itself is required for system-level success.

Design Thinking: A Developmental Approach to Quality

•  Design thinking is a set of methods, tools and approaches to mostly complex problems that aids in problem determination, problem definition, and solution exploration. It is a creative, iterative and evaluative approach to developing, trialing, assessing and implementing innovations. •  Design thinking brings together brainstorming, visualization, user-centredness, empathy, and abductive reasoning to a developmental process of generating workable and re-workable options for programs, policies and actions within a set of conditions (and constraints). It can be practiced by designers and non-designers alike. •  Helps generate workable solutions within systems and often uses systems thinking to guide the framing and evaluation of solutions

System Strategy

•  Making sense of systems requires that you have a clear sense of purposiveness for the system. It is imperative to have a clear sense of what the public health organization / system is about and what it is set out to accomplish. Doing so helps define what signals are relevant and how much attention to place on them in monitoring, evaluation, sensemaking and design •  By expressing the intentions behind the system appropriate quality markers can be developed in harmony with the systems’ type(s): chaotic, complex, ordered •  A stated intention and purpose aids in clarifying the goals for the system and facilitates the implementation of appropriate quality assessment approaches that fit that system.

Visual Thinking +" System Mapping

• The language across different stakeholders in the system may be different; visualizing the system provides a common frame of reference to discuss divergent and convergent perspectives •  Mapping a system visually through any method – drawing, digital rendering, sticky notes, cut-outs, computer model or others – provides a means of seeing relationships and connections that are often impossible to make as a group when using abstract language •  Visualization can serve as a means of prototyping, surfacing and testing assumptions about relationships, validating existing models, and as a means of exploration and idea generation

Sample Visualization Methods & Models

•  System Dynamics Models: e.g., Homer, J. B., & Hirsch, G. B. (2006). System Dynamics Modeling for Public Health : Background and Opportunities. American Journal of Public Health, 96(3), 452–458. •  Concept Mapping: e.g., Trochim, W. M. K. (1989). Concept Mapping - Soft Science or Hard Art. Evaluation and Program Planning, 12(1), 87–110. •  Gigamapping: e.g., Sevaldson, B. (2010). Discussions & Movements in Design Research: A systems approach to practice research in design. FORMakedemisk, 3(1), 8–35. •  Influence Mapping / Causal Loop Diagrams: (see system dynamic models for examples) •  Organizational charts

Sensemaking

• Collective sensemaking can take place across an organization, in teams or by experts, but almost always with some participation and deep engagement with stakeholders •  Serves as a means of integrating systems thinking, design thinking and evaluation together by examining the feedback from prototypes with the stated purposes and goals of the organization with patterns of activity observed within the system. •  An activity done by those with connection to the work being looked at. In complex systems those who have experience with the work generate the most reliable and abundant information for decision making. Thus front-line staff are best to assess that work, managers to assess the workings of the teams/staff, senior managers with overall unit managerial performance and so forth.

Take Home: Messages

•  CQI depends on seeing quality as embedded in and a product of systems

•  Systems are defined by where you stand in relation to them

and how variation operates within it

• Where you stand determines your metrics for quality

•  Your metrics feed your improvement and (re)define quality by influencing where you stand

Take Home: Strategies

•  Pay attention / pay intention

• Map your system to intentions, people, settings, contexts based on what you see

•  Collect relevant, timely, useful data based on the context of your operations and strategy (build on what you map)

•  Engage in collective sense-making of the data

•  Design & redesign your programs

Benefits: (Re)Defining Quality as a Systems Design Issue

• Clarification of organizational strategy; Greater alignment with vision, mission and implementation

• Attunement to what is known and unknown; not just evaluation, but idea generation

•  Increased receptor capacity for learning, adaptation and resilience across the organization

• Better organizational intelligence (stronger, more reliable feedback loops)

Benefits: (Re)Defining Quality as a Systems Design Issue

• Placing emphasis on sensemaking within the system - not just analytics – allows for seeing emergent phenomena

• High levels of employee engagement and enthusiasm across the organization

• Evaluates strategy, execution and organizational design simultaneously

Cameron D. Norman PhD CE  

www.cense.ca

[email protected]

Blog: censemaking.com

@cdnorman

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