Lehigh Valley Hospital & Health Network Reframing Questions Using Complexity Science Principles for Practice Organizations William L. Miller, MD, MA Lehigh Valley Hospital & Health Network Allentown, PA, USA October 20, 2007 Building upon the complexity music already laid down, my comments will address three key points: What might an appropriate research strategy be? What is an important lens for looking? Suggest eight new/reframed questions

PARTICIPATORY FRACTAL RESEARCH STRATEGY: Jazz Simulation Research Self-similarity across scales (& I add parallel processes at same scale also) – Have research strategy MIRROR the system studied Therefore: Collaborative research model that focuses on motivation & capacity (leadership, relationships, reflection) Models key properties of CAS (emergence, self-organization, nonlinearity, co-evolution) Exemplifies research design as a verb (emergence, improvisation) & thus, ethically, needs to be participatory How it works: Selected data immersion (selected by “field folk” based on experience & team based on theory) Identified patterns & themes Small group explores these in-depth Large group feedback Literature & other data sources (think of these as the fitness landscape) & negative case analysis Large group refinement Next cycle

SCALE Importance of looking at the world and practice organizations through the lens of scale. Five scales are pictured here for my own practice at Lehigh Valley - The larger Lehigh Valley bioregion - The Allentown community within the Lehigh Valley - The LVHHN health care system in Allentown - The Family Health Center within the LVHHN system = the Practice scale - The clinical encounter within the FHC Within the practice scale, need to look for: - the identifiable segments or containers - the coupling and connections - the patterns - the distributions - the learning (look at conversations and for significant differences) But must also look for those same things across and between the scales with a special eye for fractals or self-similarity

Wicked Questionable Metaphors Food Dinosaurs Worms Music Ghosts Stones & Ripples Zoo Laws Here are metaphors to help you remember the eight new or reframed questions based on complexity principles

The Wicked Questions How is primary care like food on the fitness landscape? (Robustness) Why are some practices dinosaurs? (Resilience) What role do worms play in the emergence of a healthy tall oak tree? (Healing Landscapes) How does the practice make music? (Practice Jazz & Self-Organization) What is self-organized around these robust areas related to health? What new is emerging where traditional primary care practices aren’t functioning well? Is a practice office always the best way to do primary care? And why are some thriving rodents? What are the motivations? What are the capacities (leadership, relationships, reflections, sensemaking skills, connectedness to the fitness landscape)? What conversations are occurring (i.e. what is the contact architecture)? What is the role of the practice in facilitating the emergence of healing? This is about improvisation. How do practices learn? What do they know? How well do they play, especially with surprise?

More Wickedness Where are the ghosts? (Lyapunov & Sensitivity to Initial Conditions) Can you identify thrown stones and follow the ripples? (Interdependencies) How interesting is the zoo? (Diversity & Variability - Emergence) What power laws are operating? (Non-linearity) 5. Persistence of self-organization when there is much loose coupling and multiple feedback loops. 6. Look both within scale and across scales 7. This is about identifying appropriate variation. This is about adaptability. 8. Examples: - Length of stay – can’t use averages since the distribution isn’t a “normal” one – 80% of LOS # is based on 20% of the outlier patients - Referred admissions from family docs – 80% of admissions come from 20% of the docs - 80% of a practice’s attention is devoted to 20% of their patients - 80% of employee challenges in a practice are related to only 20% of the employees Process and outcome are merged into the larger mission of a better life together! Another way of saying this as a question: What helps us participate and thrive in the presence of great uncertainty?