1. Workshop 5 Systems Thinking Business case Next steps
Quality Improvement Development for NHSScotland Organisational Development Leads
Workshop 5
Systems Thinking
Business case
Next steps

2. Agenda Systems thinking and complexity Business case for change
QI – the next steps for change

3. Objectives
Understand the importance of systems thinking as it applies to healthcare
Introduce 4 elements of systems thinking and how they can be applied to quality improvement

4. Analytical Take apart Understand the parts, how they work
Child with a toy
Study subjects at school/university
Photo: bgottsab

5. Quantum theory Chaos theory
Future state of world is unknowable
Small differences in conditions can lead to dramatically different outcomes
Systems are complex
photo by Hamed Saber

6. What is a system?
A collection of people and/or parts which interact with each other to function as a whole
Tree
Tropical rainforest
Cardiovascular system
Human body
Cities and Megacities

7. Complicated versus complex
Snowflake
Elaborate patterns
Large number of elements with minimal interaction
Not an open system; no feedback loops
Cannot adapt to its environment

8. Complicated versus complex
Human brain
Elaborate pattern
Large amount of elements interacting with each other within its structure
Many and varied feedback loops
Continual adaptation to flow of information/energy
Dynamic interactions

9. Adaptive Dynamic agents – acting and reacting Interpretative
Non-linear
Tightly linked
Governed by feedback
Constantly evolving with changing environment

10. Examples of complex adaptive systems

11. Exercise Everyone stand up Select 2 people in the room as references
Now move equidistant to these 2 people

12. Venn Diagrams  Six circles
Interconnectedness of health systems
Venn Diagrams  Six circles
Governance
Medicines & Technology
Information
People
Human Resources
Finance
Service Delivery
Adapted from Systems Thinking for Health Systems, WHO

13. Healthcare Organisations as Complex Adaptive Systems
Self-organisation
Constantly changing
Tightly linked
Governed by feedback
Non-linear
De-centralised
History dependent
Robust

14. People’s Mental Models
System view
Events
Influence
+ve effect
System structure
Mental models
-ve effect
Materials
Flows
Unwritten Rules
Written Rules
Emotions
Control Mechanisms
People’s Mental Models
Values and
Beliefs
Procedures/ Policies

15. Systems exercise Work in pairs Think about when you started a new job
How did you learn about what tasks you had to carry out?
How did you learn about the system structure (written rules, procedures, etc)?
How did you learn about the mental models?
10 minutes

16. Analytical Thinking Hospital System
…governs our approach to understanding our environment
Hospital System HR
Pharmacy
Finance
Theatres
A&E 16

17. Analytic versus systems thinking
Analytic Thinking
Take apart
Try to understand what the parts do
Assemble your understanding of the parts into an understanding of the whole
Systems Thinking
Determine what it’s a part of
Try to understand the behaviour of the whole
See the functional interdependencies of the parts with respect to the whole
Whole =
Product of Part Interactions
Whole =
Sum of Parts
Adapted from J Dubuc ROI Creations, 17

18. Systems thinking elements
Organising
Networks
Knowledge
Dynamics

19. Systems organising Managing and leading a system
Rules that govern the system and set direction through vision and leadership
Prohibitions through boundary setting
Permissions through setting incentives and providing resources

20. Effective leadership for complex systems
Vision
Self-awareness
Empathy
Values
Integrity
Characteristics
Creativity
Listening
Influencing
Enabling
Collaborative working
Skills & competencies
National issues
External environment
Internal environment
Human behaviour
Knowledge
Adapted Empey, Peskett & Lees, 2002

21. Leadership questions to consider
Are the senior leadership team visible and sharing the vision about how quality improvement will improve services for patients, staff and the organisations involved?
Do we have an effective and regular communications plan for all staff and patients? Can they follow progress and contribute?
Who are our clinical leaders at all levels of the organisation? Do they have the skills and support to design and champion this work?
What support, skills and training might service managers need to develop and implement the changes operationally?

22. Leadership exercise Work in pairs Identify a project
What knowledge, skills and characteristics did the leader display?
How were the vision and the rules communicated
10 minutes

23. Systems thinking elements
Organising
Networks
Knowledge
Dynamics

24. System networks
Understanding agents and managing agents within the system
Understanding and managing system stakeholders
Understanding the web of interconnectedness

25. Systems thinking elements
Organising
Networks
Knowledge
Dynamics

26. Systems dynamics Modelling and understanding dynamic change
Analysing structure and mental models and how that influences behaviour of system

27. Systems dynamics: +ve relationship
Quality
Customer satisfaction

28. Systems dynamics: -ve relationship
Price
Perceived value

29. Systems dynamics: feedback loops
Health S
Employee
Performance
Reinforcing
Energy
Level S O B R
Hours
Worked S
Ambition
Manager’s
Supportive
Behaviour S
Family commitments
Response from colleagues

31. Examples of feedback loops

32. Systems dynamics exercise
Work in teams
Consider the training model
What are the dynamic factors at play?
15 minutes
Knowledge
Training
Service improvement

33. Systems thinking elements
Organising
Networks
Knowledge
Dynamics

34. Systems knowledge
Managing content and infrastructure for explicit and tacit knowledge transfer
Support continual training, learning and practice
Using feedback, chains of data, information and evidence for guiding decisions

35. 6 practices of organisations that learn and adapt to complex systems
Understand, communicate the “main thing” that is central to success
Create alignment around the main thing by giving everyone a “line of sight”
Utilise multiple perspectives to gain a systems understanding
Defer to expertise
Maintain fluid communications across permeable boundaries
Support continual training, learning and practice

36. 10 steps to systems thinking approach: Intervention design
Convene stakeholders
Collectively brainstorm
Conceptualise effects
Adapt and redesign

37. 10 steps to systems thinking approach: Evaluation design
What are we trying to accomplish?
How will we know that change is an improvement?
What change can we make that will result in an improvement?
Determine indicators
Choose methods
Select design
Develop plan and timeline
Set budget
Source funding

38. Questions ? ? ?

39. Developing a business case
Executive summary
Background
Evidence for change:-
Best practice
Baseline data
ROI
Outline of idea
Project plan
Team

40. Workshop
Objective = To develop a national strategy for supporting quality improvement skills across the workforce
How can the OD agenda and QI agenda work in partnership?

41. Group 1 – Systems Organising
Values, goals
Boundaries
Incentives
Resources

42. Group 2: Systems Networks
Who are the stakeholders in OD and QI networks?
What are the connections (formal and informal)?
What is the quality of the relationships (critical)?
How can exchange be optimised?

43. Group 3: Systems Dynamics
What are the structures in place for the dissemination of learning?
How to combine the OD and QI agenda

44. Group 4: Systems Knowledge
How is knowledge explicitly and implicitly disseminated?
What skills, knowledge and behaviour do we want to encourage?
What new ideas for achieving this?

45. Feedback