Objectives
1) Describe the current state of health outcomes2) Define complexity science3) Describe healthcare as a complex adaptive system4) Introduce implementation science5) Describe the Cynefin framework for decision makin

Schneider, MD, FACP, Doron

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Population Health and Complexity Science.  A Leadership Primer  Doron Schneider, MD FACPVice President, Population Health ServicesTandigm Health.Objectives 1) Describe the current state of health outcomes 2) Define complexity science3) Describe healthcare as a complex adaptive system4) Introduce implementation science 5) Describe the Cynefin framework for decision makingDoron Schneider, MDOur collective goal…. Quadruple Aim.  Doron Schneider, MDAre We Making Progress? Doron Schneider, MDSpending as share of GDP https://www.oecd.org/health/health-spending-set-to-outpace-gdp-growth-to-2030.htmDoron Schneider, MDObesity TrendsDoron Schneider, MDBurnouthttps://www.ama-assn.org/practice-management/physician-health/report-reveals-severity-burnout-specialty Doron Schneider, MDUnsafe Care –Affects Quadruple Aim• 1999: TEIH:  44-98 K deaths a year• 2016:  BMJ:   Approx 250 KMedical error—the third leading cause of death in the US. Makary et alBMJ 2016;353:i2139Patient Safety…  Have we made progress in 20 years?Doron Schneider, MDWe Need New Ways of Thinking…..Last 20 years• Scientific approach• Rules• Regulations• Management centric(diminished role of Physicians)What is needed • New types of research approach• Soft sciences (and soft scientists)• Qualitative research• Anthropology, Sociology, Ethnography• Stories• Focusing on what makes things go righthttps://hub.jhu.edu/2019/12/03/still-not-safe-sutcliffe/Doron Schneider, MDWe must increase our understanding of systems and complexityDoron Schneider, MDPopulation Health and Wicked Problems• Exact causal mechanisms  are obscured and difficult to address• Effective solutions/interventions are not known• Policies have not been effective.• Traditional population health methods and thinking are inadequate to use to solve. • Examples – obesity, diabetes, substance abuse, falls Doron Schneider, MDTraditional Problem Solving – and Solutioning• Has focused on linear thinking• Belief • Causes are known and understood.• Most important ‘contributing causes’ can be identified• Interventions to address ‘root causes’ can be developed• Interventions can be implemented and….• Improvement would unfold!• This thinking is• Simplistic, reductionist and……. WRONG!(often)Doron Schneider, MDChanging Paradigms of Understanding Care (and Accidents)From Linear Thinking To Some Systems theory Reason, James (1990-04-12). "The Contribution of Latent Human Failures to the Breakdown of Complex Systems". Philosophical Transactions of the Royal Society of London. Series B, Biological Sciences. 327 (1241): 475–484. Doron Schneider, MDComplexity Theory – Outcomes (Including Safety) is a Property of the System – Emergence Doron Schneider, MDHealthcare is a Complex Adaptive System (CAS)“a collection of individual agents with freedom to act in ways that are not always totally predictable, and whose actions are interconnected such that one agent’s actions change the context for other agents”Plsek PE, Greenhalgh T. The challenge of complexity in health care. Br Med J. 2001;323:625–8.Agents:  person, molecule, species,nursing unit, organization, etc etcDoron Schneider, MDOur Healthcare System(s)Doron Schneider, MDComplexity Science• Helps in the study of systems (and their behavior/outcomes) that are only partially understood by traditional scientific insights.Examples of complex systems• Stock markets, forests, immune systems, termites colonies, weather• Human body, hospitals…..Leaders who understand complexity science – approach leadership in an entirely different way…Doron Schneider, MDOur collective experience…..Strategic plans – fail to produce intended results                 (assumptions of future conditions that were wrong)Policies – that don’t produce intended resultsInterventions – don’t succeed (despite a lot of effort!)FrustrationDoron Schneider, MDTraditional vs Complexity ScienceTraditional Science• Built on Newtonian ideas• Dominant metaphor is the machine• Can be explained as the sum of its parts• Parts are affected by simple predictable forces/laws• If you understand the forces you can control and predict the output• Parts don’t have ‘choice’ or self determinationComplexity Science• No single theory or idea• Study of complex adaptive systems• Look at the relationships between parts• The whole is greater than the sum of its parts!• Highly interdisciplinary – biologists, anthropologists, economists, sociologist, management theorists• Trying to understand living, adaptable, changeable systems Doron Schneider, MDWe need to change majors!Physics• Rigor• Immutable• Based on equations, simple models and lawsBiology• Messy, unpredictable, disorderly, unstable• Always changing• No equations and simple modelsMove from studying how organizations should behave to understanding how they actually behaveDoron Schneider, MDComplex Adaptive SystemsDependent on History / Initial ConditionsEvolution of whole greater than sum of parts[[[[[[Time and Space]]]]]]]Doron Schneider, MDCompression of Time.  Is your network……Enabling immediate interactions with ‘agents’ for self organizationUsing slow, planned meetings with centralized control?Doron Schneider, MDDifferent Outcomes:   Doron Schneider, MDHospitalsNursing Units Staff Each Complex Adaptive System is nested in another Complex Adaptive System!Pearl:   Study the macro and microDoron Schneider, MDNetworkRegionsOffices Staff Each Complex Adaptive System is nested in another Complex Adaptive System!Pearl:   Study the macro and microDoron Schneider, MDTo really understand complexity(and your systems)• Move from quantitative to…• Qualitative methods  (Soft Research Methodology - SRM) • Ethnography / Sociology / Psychology• Case studies• Case comparison / time series analysis• Social surveys• Simulation and network analysis• Soft Systems MethodologyByrne DS. Complexity theory and the social sciences: an introduction. New York, NY: Routledge; 1998.Agents are Interacting:Use Mixed MethodsDoron Schneider, MDSocial Network Analysishttps://imperiumadinfinitum.wordpress.com/2017/04/23/social-network-theory-basics/Doron Schneider, MDSocial Network AnalysisHelps you understand….• Strength of relationships between agents• Why certain ideas/beliefs are widely shared (or not)• Why certain implementations are successful (or not)• Why certain innovations succeed and are spread (or not)!Doron Schneider, MDhttps://www.kingcounty.gov/audience/employees/benefits/your-benefits/medical-plans/kingcare-select/multicare.aspx Doron Schneider, MDSo you have a problem..Doron Schneider, MDAnd you think you have a solution…..• You select an ‘approach’ to fix your problem.• A tactic/tool/technique is developed – with hope for positive impact• Implementation must occur in many microsystems (PCP offices, Nursing units  etc)Not So Easy• Implementation Science: microsystems are not machines.• Unlike a machine – a part can’t be easily added, swapped out, or eliminated to fix the problem• A framework for understanding is requiredImplementation Science and ComplexityDoron Schneider, MDConsolidated Framework for Implementation Researchhttps://cfirguide.org/Doron Schneider, MDT1  - Sustainability of healthcare innovations (SUSHI): Long term effects of two implemented surgical care programmes (protocol)VL  - 12  - 10.1186/1472-6963-12-423  BMC health services researchDoron Schneider, MDBraithwaite, J., Churruca, K., Long, J.C. et al. When complexity science meets implementation science: a theoretical and empirical analysis of systems change. BMC Med 16, 63 (2018). https://doi.org/10.1186/s12916-018-1057-zDoron Schneider, MDBraithwaite, J., Churruca, K., Long, J.C. et al. When complexity science meets implementation science: a theoretical and empirical analysis of systems change. BMC Med 16, 63 (2018). https://doi.org/10.1186/s12916-018-1057-zDoron Schneider, MDDo we thing our idea is really going to change the system and lead to improvement?• Each person is an independently acting agent• Has own attitudes, knowledge beliefs• Each agent changes based on interactions with others• Interactions are internal to the microsystem – and are affected by how the microsystem interacts with other microsystems.• Its complex….• Leaders must understand the realities on the ground!Doron Schneider, MDLeadership and a new way of thinking…..https://ollelindholm.com/personal-mission-statement/ Doron Schneider, MDHealthcare is not a machinehttps://commons.wikimedia.org/wiki/File:PSM_V39_D312_A_gilling_machine.jpghttps://www.industryweek.com/operations/media-gallery/21966444/bright-red-robots-a-glimpse-inside-the-tesla-plant-slideshow/slideshowDoron Schneider, MDWe have moved away from the linear production line - to complexityDoron Schneider, MDPopulation Health –Our Systems Are Not All The SameNetwork A Network BDoron Schneider, MDComplexity Theory:  Why “Change” is Hard• Systems are more than the sum of their parts.• The parts (agents/participants) – work through relationship building, networking and making sense of their own surroundings.• Agents – do not behave in linear ways ad do not respond in a 1:1 fashion to interventions.• Participants self organize, co-evolve and adapt dynamically• Participants respond haphazardly to rules from above – but they create, or already have culturally, their own…   • If put under pressure – they are often resilient and impervious to change!• Change ‘emerges’ from new interactions – that are dependent on previous interactions.Doron Schneider, MDPath Dependence and Trust• Interactions today are dramatically affected (? Determined) by interactions of the past• Leaders who build ‘trust’ between parties today are more likely to have the results they desire in the futureDoron Schneider, MDSo What Framework Can Todays Leader Use to Address Problems?Doron Schneider, MDIntroducing ….   The Cynefin FrameworkSnowden, Boone. HBR Nov 2007Cynefin framework….   Four types of problems/ scenarios• Simple and Complicated• Ordered universe where cause and effect relationship are perceivable and the right answers are determined by facts• Fact based management• Complex and Chaotic• Unordered and no apparent cause and effect relationship• The way forward is determined on the basis of recognizing emerging patterns• Pattern-based managementDoron Schneider, MDLeadership Action Patterns –Should depend on the nature of the problem.• Simple: Sense, Categorize, Respond (Best practice)• Complicated: Sense, Analyze, Respond (Good practice)• Complex: Probe, Sense, Respond (Emergent Practice)• Chaos: Act, Sense, Respond (Novel Practice)Doron Schneider, MDSimpleDoron Schneider, MDSimple Problems• Best practices:  focuses on efficiency and ‘process’ (production line)• Best solved through “command and control” style of leadership• Solutions are obviousFractured arm:  SurgeryDoron Schneider, MDSimple Problems:  Leader Skills and Competencies• The leader can answer the 5 Ws:   Who, What  When, Where, Why• Sort the issue into the correct category• Respond with tried and true procedures• Delegate and give instructions – and communicate clearly• Correct use of technical vocabulary to reduce ambiguityDoron Schneider, MDComplicated ProblemsDoron Schneider, MDComplicated Problems• Leaders need to sense , analyze and respond• Expert opinion (gained) often required.   Networking• Deep knowledge and experience are key• Put forward a design, build and implement new structure or process• Problem solving and change is incrementalDon’t let the perfect be the enemy of the good….Doron Schneider, MDComplicated Problems: Johari Window Doron Schneider, MDComplexProblemsDoron Schneider, MDLeadership/Management in Complex System• Perceived patterns can be perceived by not predicated• Leaders are confronted by a range of potential futures – with a range defined by  a limited number of key variable• Critically important is the growth of the leaders networking• A leader should patiently allow the path forward to reveal itself instead of imposing a course of action.• A leaders should probe to make the patterns more visible before taking action.• Allows for creativity, new business models and innovation.    FAIL FAST, LEARN FAST and SAFE FAIL.Doron Schneider, MDThe New Requirements: Adaptive Leadership• Older thinking• People that are being led are assembled as mindless machine extensions performing impersonal processes. Very mechanical.• Attention focused only on activities, job descriptions that are detailed and constraining, roles are rigid, policies are oriented towards control of what people can’t do• New thinking:  Adaptive leadership • Attention focuses on value added outcomes.  Job descriptions are broad to allow flexibility, roles are fluid and attitude is to encourage people to take a “can do” mindset to find solutions (discretionary effort) Doron Schneider, MDAdaptive Leadership• Allows for individuals to feel responsible and active player in the organization• Leads to motivation and commitment for the work• Can trigger and lead to peak performance• Allows for discretionary effort to be added Doron Schneider, MDLeaders Need to Encourage Design Thinking• Open discussions where people generate innovative ideas to help leaders in decisions and strategies are welcome.• Dissent and diversity is encouraged • Leaders monitor for emergence because outcomes are unpredictable• User specifications or requirements are not fully understood and defined up front.Doron Schneider, MDDoron Schneider, MDvConversational Leadership:  An Approach for Complexity https://thesystemsthinker.com/conversational-leadership-thinking-together-for-a-change/Complexity• Listen and observe for emergingpatterns, ideas• Schoen – Reflective Practitioner• Edgar Schein – Humble Inquiry• Search for Epoche:  the suspension of judgment and refraining from a conclusion prematurelyDoron Schneider, MDhttps://en.wikipedia.org/wiki/Mechanical_waveModels of Leadership For ComplexityOODA Loop Adaptive Leadership ModelSolutions can not be imposed.  They emerge Doron Schneider, MDIf we are to really improve population health….Go LookDoron Schneider, MDUnderstand the Workhttps://participatorymedicine.org/epatients/wp-content/uploads/sites/3/2012/11/HSS-comparison-weighted.pdfDoron Schneider, MDDo We Control or do We Influence?Doron Schneider, MDGoing to the Gemba• Do we understand the people who are doing the work• Their attitudes, beliefs, understanding of the why?  Their interactions with others. The culture• Do we understand the processes.• How much variation s there?  How much is dependent on the person, the conditions on the ground.If we don’t – we may think we have simple problem – when in fact it may be complex!Doron Schneider, MDThe Difference:  Complicated  vs Complex• Complicated matters, as technical problems, have solutions in the current know-how through the organization’s current structures, procedures, and ways of doing things.  (how do we optimally care for the GI bleed patient in the ER)Complex adaptive challenges can only be addressed through changes in  people’s  priorities, beliefs, habits and loyalties. • Complex challenges forces us to move beyond authoritative expertise to mobilize discovery.Doron Schneider, MDChaotic Doron Schneider, MDChaos: Leader Best Practices• Only a “super hero” can fix the problem• Rapid, decisive action is required to • reduce the turbulence, • sense where there is stability• transform from chaos to complexity so that patterns an be discerned • Allows leaders to impel innovation and novel practiceLeaders should select a reliable manager or crisis management team and allow them to do things differently.   If you wait for the crisis to be over – the chance for innovation is gone.Doron Schneider, MDChaosLanding every plane in the US within minutes Doron Schneider, MDIn the Center:  Disordered• Order seekers:   Try to create or enforce rules• Experts:  try to seek and conduct additional research to accumulate new data• Politicians seek to expand and increase the effectiveness of their network• Dictators – seeing it as chaos – seek absolute control.People seem to pull issues towards the context they feel most empowered by their capabilities and perspectives.Doron Schneider, MDDoron Schneider, MDLeadership Has a Problem .  Now What?• Identify what quadrant a particular issue currently resides in• Change leadership style/tactics based on the quadrant• Prepare the organization for the different quadrants and how to transition between each• Emotional intelligence to move easily between quadrants Doron Schneider, MDQuestions:Does your network leadership…..• Go to the frontlines to understand the context• Use deliberative design to share best practice• Encourage self organization• Implement tactics using implementation science• Use a leadership framework like Cynefin• Use a generative approach• Recognize the solutions come from groups• Built excellent feedback loops to fail forward fast.• Think they think they have more control than they do!• Think that ‘causes’ of problems can all be written down?Doron Schneider, MDLeadership StylesComplex Adaptive Systems• Are open, responsive • Offer alternatives• Collaborative, co-participative• Connected• Adaptable• Acknowledge paradoxes• Engaged, continuously emerging• Value persons• Reduce rules• Help others• ListenersTraditional Systems• Controlling• Repeat the past• Are in-charge• Autonomous• Self preserving• Resist change / bury contradictions• Disengaged (nothing ever changes)• Value Positions• Set rules• Make decisions• Knowers https://amee.org/getattachment/AMEE-Initiatives/ESME-Courses/AMEE-ESME-Online-Courses/Leadership-Online/ESME-LME-Resources/Applying-Complexity-Science-to-Health-and-Healthcare.pdf Doron Schneider, MDQuestions?CFIRMacroMicroCynefinCASChaosAEIOUDoron Schneider, MD

Population Health and Complexity Science: A Leadership Primer

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Population Health and Complexity Science: A Leadership Primer

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