The science of large systems change - NSW Agency for ... · The science of large systems change: Innovation from within Rick Iedema Professor, Director Centre for Health Communication

The science of

large systems

change:

Innovation from

within Rick Iedema

Professor, Director

Centre for Health Communication University of Technology Sydney

The Science Of Large Systems Change Research Think Tank

Monday 28th October 2013, Australian Technology Park

Main points

What is happening

• Service complexity shifts

organisational centre of gravity

from the top to the frontline

• ‘Frontline’ harbours

knowledge about practice that

is most up-to-date and acute

• ‘Frontline adaptiveness’

operates through relationships

capable of and committed to

(rapid) adaptation and

response

What this means: priorities

• Relationships [Erskine et al]

• Stability (end rotations and acting roles)

• Continuity of accountability

and responsibility (limit audit creep)

• Frontline that understands

and is committed to

managing local complexity

• Functional change (reduce

contextual perturbation)

• Focus on the realities and

affordances of existing

practice

Michigan Keystone project: CLAB prevention checklist into 100 ICUs

Atul Gawande

• Rigourous execution of

checklist process

• ‘Dressage’ approach to

improvement

– adoption of prescribed

technique

• Compliance

Charles Bosk et al

• Checklist proposal adapted

to existing processes,

relationships, interests and

understandings

• Political view of

improvement

– strategies & tactics

– compromises, learning

• Social adaptive process

Gawande A. (2011) Checklist Manifesto. London: Profile Books.

Bosk C et al. (2009) The art of medicine: Reality check for checklists. Lancet

374(2009):444-45.

‘the numerical supremacy

syndrome’

“Is [this preference for numbers]

indicative of the distance that we

create [and maintain] between

who we are, what we do, and

how we talk about these things?”

Data

Iedema R, Braithwaite J, Sorensen R

(2003) The reification of numbers:

statistics and the distance between

self, work and others. British Medical

Journal 326:771.

‘The story-telling problem’

• “If you ask a world class tennis player how he hits a top spin

forehand they will always say this, ‘Right at the moment of impact, I

roll my wrist’.

• Well, [the coach] took video tapes of world class tennis players

hitting top spin forehands and … noticed that no one ever rolled their

wrist when they hit the ball.

• Yet all these guys are going around the country giving seminars

teaching young kids how to hit a top spin forehand and saying, …

you gotta roll your wrist just like that’.

• They had no idea.”

Gladwell M. (2004) Plenary presentation. Pop!Tech Conference 2004. Camden, Maine

(http://timothycomeau.info/29/).

Stories and data may alert us to issues, but they do not

explain how to change practice.

Practice observation using video:

What do we see?

Video reflexivity: storing improvement impulse

‘in the body’

FUTURE: What

happened next

SYSTEM: What is

pervasive and

constraining about this

scene

CONTEXT:

What else

is going on

PAST: What happened

leading up to this

HABIT: How are we

collectively implicated

in what we do

Towards a pedagogy for

complexity Learning for stability

• Fact & rule memorisation

• Authority resides elsewhere

• Representational know-

ledge: numbers, reasoning

• Execution routines

• Measurement and

monitoring from a distance:

fixed benchmarks

• Cognition: ‘what I know

and how I apply it’

Learning for complexity

• Knowledge design

• Authority resides in us

• Experiential knowledge:

visualisation, emotion

• Actors’ inter-dependence

• Evaluation of local,

contextualised

practice

• Practice: ‘what we do and what its effects are’

Global spread of video feedback • Australia:

– UWS (Prof Wendy Hu, medical workplace based assessment)

– UTS (Prof Carolyn Homer, Birth unit design)

– Freemantle Hospital (Dr E Stewart-Wynne, ward round evaluation)

– Flinders University (Dr Aileen Collier)

• Europe:

– Worthing Hospital (UK, Dr Gordon Caldwell – ward round redesign)

– Utrecht Hospital and 6 affiliated hospitals (Prof Cor Kalkman – post-

operative processes)

– Maastricht Hospital (Dr Jessica Mesman, NICU sterility processes)

• USA

– Kaiser Permanente (Dr Estee Neuwirth and colleagues)

– Indiana University School of Medicine (Department of Paediatrics) and

Women’s Deaconness Hospital, Newburgh Indiana, USA (Dr Ken

Hermann & Dr Katherine Carroll)

– Mayo Clinic (from March 2014: Dr Katherine Carroll)

– eoi: Armstrong Institute, Johns Hopkins

So … what is the relevance of local

reflexivity for large systems change?

• ‘the small embodies the large’

• less structure change; more ‘receptive attentivity’ to

– here-and-now practice

– our imbrication in the systems, habits, and identities that

define current practice (Dunne 2011)

• maximum adaptive capacity where there is maximum

complexity - the frontline

• pre-condition: more stable, more responsive and more

responsible relationships -> better systems

References Iedema R, Mesman J, Carroll K. (2013) Visualising

health care improvement: Innovation from within.

Oxford UK: Radcliffe.

Iedema, R., Merrick, E., Kerridge, R., Herkes, R., Lee, B.,

Anscombe, M., Rajbhandari, D., Lucey, M., & White, L.

(2009). ‘Handover - Enabling Learning in Communication for

Safety’ (HELiCS): A Report on Achievements at Two

Hospital Sites. Medical Journal of Australia, 190(11), S133-

S136.

Iedema, R., Merrick, E., Rajbhandari, D., Gardo, A., Stirling, A.,

& Herkes, R. (2009) Viewing the taken-for-granted from

under a different aspect: a video-based method in pursuit of

patient safety. International Journal for Multiple Research

Approaches, 3(3): 290-301.

Carroll K, Iedema R, Kerridge R. (2008) Reshaping ICU ward

round practices using video reflexive ethnography.

Qualitative Health Research 2008;18(3):380-90

Iedema, R., D. Long, R. Forsyth, K. Carroll (2006). Visibilizing

clinical work: Video enthography in the contemporary

hospital. Health Sociology Review 15(2): 156-168.

1. Key people leading the change (strategic or blunt end)

2. Continuity of key personnel

3. Focus on clinical-management relationships

4. Clear goals and priorities

5. A supportive organisational culture and cooperative

networks

6. Distributed leaders(hip) ‘from board to ward’

7. Engagement of all professions

8. Nurturing of followership as much as of leadership

Erskine J, Hunter DJ, Small A, et al. Leadership and transformational change in healthcare

organisations: A qualitative analysis of the North East Transformation System. Journal of Health

Services Management Research 2013;26(1):29-37.

“Key large system change

success factors”

“Key large system change

success factors” 1. Key people leading the change (strategic or blunt end)

2. Continuity of key personnel

3. Focus on clinical-management relationships

4. Clear goals and priorities

5. A supportive organisational culture and cooperative

networks

6. Distributed leaders(hip) at all levels ‘from board to ward’

7. Engagement of all professions

8. Nurturing of followership as much as of leadership

Erskine J, Hunter DJ, Small A, et al. Leadership and transformational change in healthcare

organisations: A qualitative analysis of the North East Transformation System. Journal of Health

Services Management Research 2013;26(1):29-37