**Transcript of Cyberseminar**

**QUERI Enhancing Implementation Science**

**Advanced Program Session 5- Insights from Complexity Science for Implementation Science**

**Presenter Luci Leykum**

**December 6, 2012**

Molly:As we are approaching the top of the hour I would like to introduce our speaker now. We have Dr. Luci Leykum presenting for us today. She is an investigator at Verdict in the South Texas Veteran’s Healthcare System. She is also an Associate Professor of Medicine at South Texas Veteran’s Healthcare System and University of Texas Health Science Center at San Antonio. Luci are you ready to share your screen now?

Dr. Luci Leykum:Okay. Well thank you everybody. I appreciate your joining the cyberseminar today. As Molly mentioned we are going to talk about complexity science and implementation. And to get started I wanted to just start with a question just for all of you to see what your familiarity with complexity science. There are some options for answers there.

Molly:Thank you Dr. Leykum. I have launched the poll so the question is: What is your familiarity with complexity science? Please select one answer. The first option is, just heard of it. The second option is, some passing familiarity from the literature. The third option is, know it moderately well, familiar with the literature or; have used the framework in my own work. We have had about almost 70% of our audience answer at this point, so we will give everybody just a few more seconds to get their responses in. Okay, it looks like the responses have slowed down so I am going to go ahead, close the poll at this time, and share the results. It looks like 50% of our audience has just heard of it, one-third of the audience has some passing familiarity from the literature, 3% of the audience knows it moderately well and 13% have used the framework in their own work. So thank you to our audience members and we are back to you Luci.

Dr. Luci Leykum:Okay. Great. So we have a mix of folks on the call today and my goal is really to talk about complexity science but with a focus on the insights from complexity science that can help us from the perspective of implementing new interventions. There is a lot that we could talk about with complexity but I am going to focus in on a few things.

One is the presence of uncertainty. We will talk a lot about that. The second is a focus on relational infrastructure and interdependencies. One of the things that we will talk about is that we think a lot about processes and process improvement in healthcare and I want to reframe how you think about that a little bit in terms of relationships and interdependencies. Finally, we are going to talk a bit about sense making, improvising and learning as social activities that are grounded in this relational infrastructure and can help people to navigate the complex systems in which we work.

So with that background, let me put it in the context of implementation and some challenges that we still have. So first, we still have difficulty what works in one setting and applying it successfully in other settings. Even when we are working within a single organization, the diffusion of new knowledge is difficult and often unpredictable. We recognize that understanding the local context is important and more and more tools are being developed to help us think about and assess the local context but we still do not have enough of an understanding of the local context to be more consistently effective in implementation efforts. Lastly I think this ties into the fact that we still have some difficulty thinking about or determining what elements of an intervention or generalizable and what really are just more relevant in that local context.

So getting back to complexity science, I want to talk a little bit about some particular characteristics of complexity and I am hoping that this diagram of the interconnected nodes will help illustrate what I want to emphasize. So complex systems are nested and they are interdependent. Therefore, if you think about the small clinical units in which we work like a nursing unit in the hospital or a clinic or a radiology department, there are a lot of people that work within each of these units. However, the boundaries are porous so you have people interacting with each other and within each of these units but then outside of each of the units. As they do that, these units are starting to influence each other and they are starting to coevolve with each other. So for example if there is a change in the processes in the radiology department that is going to lead to other reciprocal changes in the primary care clinic or in the hospital.

So from a complexity science perspective we would think of each of these little units as these clinical microsystems that are nested in this larger system, which in turn may be nested in even larger systems. But again the key thing here is that these little systems are all influencing each other and they have porous boundaries with people moving in and out.

Then another key aspect of the complex systems is their nonlinear dynamics. So the system dynamics in complex systems unfold over time in a way that the outputs are not necessarily proportional to the inputs that have gone into the system. So we may make what we think is a really trivial change but then it ends up having a huge impact or we do something that we think is going to have a really large impact that does not have much impact at all. I think about this every time for example, we change a template or we do an upgrade to our electronic health system health records and we see all the things that happen that we did not expect because of how interdependent all of what we do is on each other.

So because of these nonlinear dynamics the precise prediction of outputs based on inputs is really on a practical level impossible. So we have uncertainty in the system and the uncertainty comes from three different areas. So one is the patient. We cannot predict the trajectory of a patient; even if we have some certainty about what we think is going on, we are not necessarily going to be able to predict where the patient is going to go. So for example, I am a hospitalist, so I take care of patients in the hospital and we have patients that fall with some frequency. Most of our patients that fall we have identified as being high-risk for falls but we do have patients that fall that we did not anticipate them; we thought that they were moderate or even low-risk. So we do not always know what is going to happen with our individual patients.

The next is that there are some limits to the science. So there is only so much of what we know about how to treat certain things or what to do in certain situations and this may be even more true when we look at subpopulations of patients.

Then finally we have got this system level uncertainty due to these nonlinearities and the way that each of the building blocks in the system are influencing each other that we just talked about in the last slide.

So we have to deal with this uncertainty as we deliver clinical care. One thing that we often do when we do not know what to do, when things are uncertain, is that we talk to other people. And we do this all the time clinically. I think it is relevant also when we think about these larger systems issues like implementations. 

So I want to reframe how we think about what is happening in healthcare systems in terms of interdependencies rather than just processes. So when we think about interdependencies we highlight the relationship infrastructure among the people in the system. We still have the processes so these are the way we work. So for example if we have care pathways in place and we have guidelines that we use in certain situations. We also have what has been called affordances or the resources we have at our disposal and how we choose to use them. For example we might have a certain physical plant infrastructure or we might have certain electronic health records in one health system that we do not have in another. And how we use them is part of these interdependencies in the system.

Here is another way of thinking about them. We have our relationships. We have our processes. We have all our resources and we have this pattern of self-organization that emerges from them. I am going to talk a little bit more about self-organization on the next slide but it is basically the way that people come together; the patterns to which they come together to do the work that has to be done. From that pattern of self-organization we start to get these social activities; sense making, improvising and learning. These are going to be what actually helps us deal effectively with all the uncertainties that we encounter. These uncertainties again could be on many different levels so it could be in patient care. It could be related to implementation because any time we introduce a new intervention or a new approach into the system we are creating uncertainty. We do not know exactly what the impact of what that, in the way of doing things, is going to be. So we are going to rely on these social activities, the sense making, improvising and learning to help us to navigate that new situation.

So here is self-organization. I want us to talk a little bit more about it because it is the process through which these local interactions get apprised to these patterns of organization. This is a picture of a flock of birds as you can tell and it is the prototypical example of this. So we cannot necessarily predict behavior of the flock by looking at the behavior of an individual bird. There is no clear leader that is directing the flock but we get this flocking behavior that ends up being organized and ends up accomplishing something. So similarly in complex systems and in healthcare systems we get this patterns of self-organization that are rooted in how people are actually getting the work done kind of on the ground. 

These patterns can be very difficult to change because they really are rooted in the constraints that people are dealing with or the work processes that people are dealing with every day. These local patterns and these local constraints actually may not be recognized at higher system levels so it can be hard to change them from above. So you might look at an organizational chart and think based on that and based on people’s job descriptions and roles that certain people do certain things and that you can influence the system by changing this role or changing that role. But the reality on the ground in the system is that that pattern of how people are actually organized to do the work is a bit different and that makes it hard to change.

So I wanted to use this kind of diagram to just give you a sense of what I am talking about; I am trying to put all these things together. So we have this outer ring of complexity or uncertainty and that is our context. That is the environment in which we are working. Then we have these interdependencies within that system and again that is the processes, it is the relationships and it is the affordances. Then from that, we get the self-organization and the social activities emerge from them. We are going to talk about the sense making, the learning and the improvising.

So I want to start by focusing on the relationships. The relationships are really going to be the basis for effective action in uncertain environments because it is how people relate to each other that is going to influence all these social activities. The relationships, there has been quite a bit of work on relationships in healthcare. 

Here is one framework from Lanham et al from 2009 and these were seven characteristics of relationships that were developed in primary care settings. You can see trust which is defined as a willingness to be vulnerable to other people. So for example saying I do not know could be an example of willingness to be vulnerable. Diversity or including different perspectives. Respect, valuing the opinions of others. Heedfulness is an awareness of how each person’s role impacts the rest of the team. So when you think about okay if I do something different how does that influence everyone else. Mindfulness is an openness to new ideas. Social and task relatedness is having both types of interactions or either type of interaction among people in the system. Then rich/lean communication; the idea here is that the method of communication should match the type of information that you are trying to communicate. So if you are trying to discuss something such as difficult issues you have to get some information out about that, that is probably more suited to in-person communication rather than something that is more lean like electronic communication.

So from an implementation perspective these characteristics can provide some insight. So it is important to acknowledge that you do not know all of the implications of a new approach to things. Getting a diversity of insights into a new process can be helpful before it is implemented and as the implementation unfolds. I think this analogous or similar to the idea of a participatory action approach for example. Being aware of how a new intervention is going to impact people’s roles and may change how things are done in unexpected ways is important and those things speak to the heedfulness and the mindfulness. Then as I mentioned marrying the type of communications with the type of information that needs to be conveyed is important. I think we have a tendency to think about this in terms of being kind of a leadership or a management issue but it really does not necessarily have to be.

I am going to talk a little later about some work that we have done observing physician teams in the hospital but I wanted to share some stories from those teams as we discuss this slide. So one of the teams that we observed and this a group of inpatient physician teams; an attending physician, residents, interns and medical students. On one of these teams that we observed, one of the interns was a new intern who had not trained or gone to medical school in our hospital and was really struggling with just keeping it all together, staying organized, keeping on top of the workload. Without anybody really intending for this to occur or asking the medical students to do this, they could see what was happening with this intern who was having trouble and they started only taking her patients so that they provided some extra support to her. When she was presenting her patients they would have CPRS open so that if there was information that she did not have that they could have it there ready for her. So that is an example of heedfulness on the part of the students and they are thinking about how they could be helpful and influence the situation in a way that was not at all top down.

We saw another team where the attending did a lot of kind of day to day patient management and she did not do a lot of general teaching and the resident on that team really stepped up and started doing more teaching and did it slowly at first and would just kind of interject and bring in smaller examples. But then that grew over time as it became part of the team dynamic. And again, he was not the leader of the team but he was able to have a big role in how those team dynamics unfolded over time.

When we look at relationship impact in healthcare settings there is a lot of different examples. And we are going to talk about some of these in surgical teams, medical teams, nursing homes, primary care and intensive care. A lot of the literature in intensive care talks about teams, that is kind of the language that is used rather than relationships. But I think a lot of the ideas and contexts are similar. 

That study of the physician teams that I mentioned, here is some more data from that. Each of those numbers along the top that says team number is a different month that we observed the team. The A and B refer to half months where the attending changed. As we observed these teams, we looked for behaviors that we felt reflected each of those relationship characteristics I told you about and you can see that there was a big variation. So some teams we really felt like we saw behaviors where all of these relationship characteristics were reflected and in other teams, we felt like we did not see any at all. Then we looked at the length for stay for patients admitted to these teams and we started looking at the complication needs. These data are taking us longer just because we have to adjust them. So that UR refers to under review. But you can see for teams that we felt like exhibited more behaviors consistent with effective relationships the length of stay was lower, the complication rates were lower for those that we have. Then for teams where we really did not see those signs of effective relationships, the length of stay was higher and the complication rate was higher. Now if you look at team 2, that was kind of an interesting team because it had more relationship characteristics but the outcomes were among the worst that we have looked at so far. When we look at the details of the types of relationship characteristics that we were seeing, the ones that we felt that we did not see a lot of were trust and mindfulness. So it may be that trust and mindfulness are particularly important in terms of fostering effective relationships in healthcare settings.

Now I want to turn a little bit to sense making. So sense making has been defined as a diagnostic process directed at constructing plausible interpretations of ambiguous cues that are sufficient to sustain action. So basically, you are looking around, you are seeing what is happening, you are seeing all this information in the environment and you are trying to put it together in a way that is going to enable you to act. We do this all the time as we take care of patients. In fact, a lot of us would think about this as being analogous to kind of a medical decision-making process where we are taking or putting all this information from the patient, the laboratory studies, the history together to come up with a working hypothesis and a diagnostic and treatment plan. But I think that we can think about sense making as being even bigger than that. So we are not just treating somebody’s diabetes but we are understanding that diabetes in the context of the patient’s life. It is more than just what medication are you going to use. So we also do this when we are trying to figure out how to make things happen in the system. So when we implement something new, people need to make sense of it. So why are we doing this new thing? What is the goal? Hopefully, through that process, they will start to get to the next question of, okay well how can we get there even more effectively. So hopefully you are starting to get a sense of why the relationship infrastructure is so critical because it is going to influence how people relate to each other which is going to influence how they make sense of what is happening.

The other thing that I think is very important when thinking about sense making is being very explicit about the types of activities that can foster people making sense of what is going on. Some examples of this include; reflection, conversation, briefing and debriefing. So being explicit about building these types of activities into an implementation for example I think is really important.

I wanted to give you this kind of clinical example of sense making. This example relates to surgical mortality. This was a study of differences between hospitals with low and high surgical mortality. So what the authors did was they looked at Medicare data and they found hospitals that had a low mortality rate and you can see on that left set of bars, 3% mortality versus 8% mortality. This was risk adjusted and they limited it to certain diagnoses. So they were doing as much of an apples to apples comparison as they could. The authors expected that in higher mortality hospitals patients would be more likely to have complications and it would be those complications that in fact were responsible for the higher mortality rate. But in fact what they found was the opposite. So when they looked in these hospitals the complication rates in high and low mortality hospitals were not significantly different. But what they felt like they saw was a difference in the ability of the providers to recognize the complication early and act effectively to treat the complication. So they called this idea failure to rescue. So in hospitals with high mortality there was a failure on the part of the providers to recognize what is going on and act effectively to counteract it. To me that sounded really like sense making.

I want to talk a little bit about improvising or what we do when we do not know what to do. I have a picture of the jazz band here because I think the jazz band is the kind of the prototypical example that people think of with improvising. What is important about improvising is it is not really just flying by the seat of our pants or just winging it. It really is starting from a platform of knowledge and using that knowledge and applying it in new ways. So in the jazz band analogy these are accomplished musicians who work together and are able to react to each other and come up with melodies. Similarly in healthcare we have providers who have a knowledge base who when they do not know what to do can put that knowledge together in different ways to come up with a plan. So improvising is relying on knowledge. And again, it is relying on the relationship infrastructure because people have to figure this out together. The reference there that is at the bottom of the page is a study of improvising in healthcare and Kalen [PH] McKenna interviewed physicians across six or seven different specialties and asked them about examples of improvising. Across all specialities people were able to give examples of how in routine care they were improvising on a day to day basis.

Next, I want to talk about learning. So learning is different from sense making in the sense with learning you are changing your mental model. So there is kind of a sense making may in fact lead to learning but it may not always lead to learning. Much of what we are doing in healthcare or what maybe we should be doing in healthcare is active learning as we are taking care of patients. As we are trying new things to improve how we are taking care of patients. And again, that relational infrastructure is critical in terms of being the basis from which engaged people in the system are able to analyze and evaluate what is going on in a way that they can learn from it. I wanted to mention this study as an example of this. 

So this was published by Amy Edmundson in 2003 and it is called “Speaking up in the Operating Room”. She studied 16 cardiothoracic surgical teams that were implementing a new minimally invasive technique. She was looking at how quickly they learned the techniques and how effectively they learned the technique in terms of the surgical outcomes from the patients. What she found was that the surgical teams where all the members of the team spoke up learned more quickly and their outcomes were better. What this means is that everyone on the team, the scrub nurse, the scrub tech, everybody contributed to this process of learning the new intervention. It was not just a situation where only the surgeon was speaking and everybody else reacted. These were teams where anybody would speak and the team could react to that. This was the framework that she used in the paper which is a little different from the one that I am using for the talk but you can see that some of the things are still related to what we are discussing in terms of the relationship characteristics and making sense and learning. They used the term psychological safety in this study so on the teams where people felt comfortable speaking up there was psychological safety. But we could also describe this in terms of trust, respect and again mindfulness. So teams that exhibit these characteristics are able to implement this new surgical technique more quickly and more effectively.

Going in another direction, learning in primary care. So, we had done a study looking at learning in primary care settings in both VA and non-VA settings in South Texas and some people on the research team had developed a survey of learning. We gave out that survey in a number of clinics and when we did the factor analysis, there were these five items that came out and you can see what they are. But they are talking about, I am taught new things by other people in the clinic. I learn how to do my job by talking with the people in the clinic. When we have a problem we examine it carefully so we can come to an understanding of the problem and why it occurred. We learn things together as a group. I learn how to do things in this clinic by sharing knowledge. So you see, in these items people are really talking about what we thought, we called, a reciprocal learning process. So people are talking to each other in the clinic. They are coming together and they are building on what they are doing in a way that is helping them to learn. The reciprocal learning score was significantly associated with the clinic ability to implement the chronic are model. So again, just like in the operating rooms, we have people in the clinic coming together and talking to each other about what is going on in a way that allows them to act more effectively and learn.

So I want to tie these all together and again we have got these relationships leading to sense making, improvising and learning which in turn can lead to more effective healthcare teams, improved patient outcomes, and improved implementation efforts. And as part of tying this all together I wanted to talk about bloodstream infections and the Michigan ICU project which I am sure probably all of you have heard of but this initiative to reduce central line infections by using standard protocols and checklists to always do the same process to insert the central line in a sterile way. So this was implemented in ICUs throughout Michigan and it was very successful. They effectively reduced rates of central line infections almost to zero. But when this intervention started being applied in different areas the outcomes were not always the same and they were not always as good. So the people that were involved in that original work reflected on what was different about what they did versus maybe some of these later implementation efforts. They really reframed what they had done as a social process.

So rather than thinking about their intervention as just a checklist they reframed it as an opportunity for all the people working in the ICU to come together and have a conversation. So as they were developing this intervention and as they were developing the checklist, people were talking to each other. People who would not necessarily have talked to each other before about what they were doing and why are you doing this and have you thought about doing it this other way, were now having those conversations. They felt like what they had actually done with this intervention was not just have a checklist that they implemented but that they actually changed and improved the relational infrastructure in these intensive care units.

So to bring this back together I would phrase this as, if we can take advantage of these relationships and improve these relationships in a way that helps people to make better sense, to improvise and learn we are going to have more successful implementation efforts. So how can we do this?

Well, coming back to the relationships a bit, having a shared understanding of the goals helps to encourage more mindfulness and heedfulness among people in the system. So when everybody is engaged in shaping the intervention and there is this participatory approach, that intervention is going to be shaped in a way that is going to make it more effective. Promoting relationships among the people whose collaboration is critical to the intervention success is really important. If that is not explicitly part of the effort then it is going to be harder to do. Then the idea that we are creating complimentary interconnections between individuals. So rather than trying to put an intervention into place that is going to either disrupt or just not sync with this local pattern of self-organization that we have. How can we design interventions or implement interventions in a way that actually takes advantage of them or is complimentary to them?

It may be that the attributes of the intervention and the context in which you want to intervene are going to influence the role of relationships and shaping the intervention. I do not really have definitive data to share on this yet but this is something that we have been thinking about as we are looking at the results of all these studies across different settings again; from the hospitals to the primary clinic to the nursing home. And we think about the different ways that relationships seem to influence care delivery across these different settings. So I am just going to put these out there as just things that we are thinking about right now that may be relevant for implementation science.

The degree of uncertainty in the intervention may be very important when you think about how important the relationships are to the success of the intervention. So if there is an intervention that is going to introduce more uncertainty it is going to be more disruptive. It is going to change how people do things more then you really have to focus more on the relationships as part of that intervention.

Thinking about, what is the role of the patient in the process and how much control does the patient have over the process? So that might be really different in a primary care setting where you are trying to improve glycemic control versus an ICU setting where the patient may have very little control over what is going on in that very acute period. That may influence what relationships you are going to focus on and what relationships with the patient that you want to focus on. The degree of work sharing that is required either within units or between units or microsystems again is going to be really important to how you are going to think about what is going to be the impact on the relationships. How can I use the relationships to actually compliment the work?

There was a study that was done in the University of Chicago that looked at quality improvement interventions and they did a social network analysis of each of the physician leaders for those QI teams. Then they looked over time to see, okay which interventions either had the greatest impact or were actually still in place some time later and network of the lead physician and the degree to which they were involved in the work and other areas influenced the outcomes of those projects. I think it is a similar idea here. So how do reach across boundaries with your project? How do you need to reach other people? What network are you going to take advantage of to do that?

The last thing that I wanted to mention is what is the pace of evolution of the disease process you are trying to work on here? Which is maybe related to what is the degree of patient control is over the process. But if you are trying to do something in a setting where it is an acute care setting and the disease progression is very rapid, there may be inherently more uncertainty in that system. You are going to have to rely even more on the relational infrastructure to make changes in that system. That may be different from the way you have to think about the relational infrastructure and how it is going to influence an intervention done in a primary care center or a nursing home setting or another outpatient setting.

To get to this relationship idea I wanted to give you this example of HIV adherence. This was a study done, it’s three sites in Kenya and the issue here was that the investigators wanted to improve the adherence to antiretroviral treatment because the degree of adherence is related to the degree of viremic control. What they did in these three sites was they did weekly secure messaging texts between nurses in the clinic and the individuals with HIV in the first year of their treatment and they would just ask them, how are you. That would start a little text interaction and depending on how the patient replied, they could do a number of things. They could say, okay, talk to you next week or they could say, oh, do we need to talk about that further or do you want to come into the clinic. And if there was no response, they would more actively try to reach out to that person.

As they were implementing this intervention in these three sites the local group in each of the three sites had input into how they implemented it. They had regular meetings of both some of the patients that were involved in the study and the staff and they felt that they had a very high degree of local input at each site into how this intervention was going to be implemented. So who was going to do the text messaging? Who was going to do the follow-up call and how they were going to respond? So that looked a little different in each site. When they looked at the outcomes they achieved 95% adherence in a significantly greater proportion of patients in the intervention group than in the control group. Again, they had lower levels of viremia.

One of the interesting stories that they told from this study was that it turned out that there was some political instability at the time of the study. The patients started using the secure health messaging from the capabilities that they had from the study to start communicating with each other and the clinic so they could say, are you open or so and so cannot get to the clinic. They would start relaying messages on behalf of other patients that could not get in. So that this text network ended up helping them to still maintain a robust delivery system for the antiretroviral even though there was a political instability taking place.

Now I want to turn a little bit to the sense making, the improvising and the learning in implementation. The key thing I wanted to communicate here is the need to really make these activities explicit; to really consider time and space for conversations and reflection. If you allow this to occur as part of your implementation, it will allow the intervention to be shaped as it unfolds in a way that is more likely to be successful. As an example of this, I wanted to use the VA initiative. So you guys might be familiar with medical team training. This was an initiative undertaken in a number of VAs where initially teams had some training and they started this process of operating room team briefing and debriefing. What would happen is the entire surgical team would come together before a case and they would just talk about it. So what do we need to anticipate? What kind of things might go wrong here? What do we need to look out for? So getting the whole team prepared for what is going to happen. And then after the surgery they would debrief. So how did it actually go? What did not go as we expected? What could we have done differently? What did we learn from this? I think of the debriefing as really being an opportunity for both sense making and potentially learning depending on exactly what the issues were. 

When they looked at surgical mortality among teams that had been involved in the medical team training and did these briefings and debriefings, there was an 18% reduction in surgical mortality among those teams compared with only 7% among teams who did not do the medical team training. While there was some structure or some intention around the briefing and debriefing about, what is our purpose here, it is really the team who’s briefing and debriefing and talking about what they need to talk about.

So that wraps up what I wanted to say about relationships, sense making, improvising and learning. I did want to thank my many colleagues whose work is reflected in this presentation and all my colleagues in San Antonio, some of who are listening despite me asking them not to. With that I would like to thank you all and open it up for questions.

Molly:The first question: Can you please provide the citation for the learning model with the active/passive learning components and the percentage retained?

Dr. Luci Leykum:Sure. So my email address is up on the screen. Hopefully you can see them and please feel free to email me at either of those email addresses and I am happy to send whatever citations from any of the sites.

Molly:Thank you. We do also have several people requesting the slides and wondering if this session will be recorded or has been recorded. Yes. In the reminder email that you used to enter today’s session there is a hyperlink leading to the slides or you can always email cyberseminar@va.gov. We did record today’s session. It will be posted in our online archive catalogue within the next 48 hours.

There is another question asking for citations. So I just assume they should also contact you off-line. 

Dr. Luci Leykum:Yes. That would be great.

Molly:Okay. Excellent. A couple of comments came in saying thank you for the excellent presentation. Very helpful. Thank you to that.

Can you speak a little bit more about strategies for describing and planning for these processes and a grant application that is gives some clear structure so that the processes do not sound just like fluff?

Dr. Luci Leykum:I will try, although I cannot say that I have been completely successful myself yet in this. But I would say that the idea of a participatory action research or a participatory action approach to research is actually there is quite a literature around that and it is well described and utilized in other social sciences. So I think if you try and ground your approach in that kind of language, I think that might be one way to go. Another that I have tried to use is really just to explain the concepts and for me the sense making is particularly important. Carl Whike [PH] has written quite a lot about sense making and quite a lot about specific strategies for sense making or specific actions that are part of sense making. So that is the way I try and frame the sense making in terms of a grant application. Is that helpful enough?

Molly:Thank you for that response. If they would like further clarification, they are more than welcome to write in again. We have a couple more comments just saying thank you for bringing this area of thinking into the series. It is important for implementation science and very important that communication and relationships be included in this science.

Another question: Can you talk a little bit more about affordances and constraints in regards to complexity?

Dr. Luci Leykum:Yes. So okay, I have to admit, affordances are something that is kind of new to me too. One of the PhD students, Shannon Provost that I mentioned in the previous slides has really brought that to our attention. But the idea is that there is this group of things that you have at your disposal. You can use those things in different ways. So one of the examples that is in this literature is a hole in a tree. So for an owl it is a place to sleep. For a squirrel it is a place to put nuts. So in our environment we have different things at our disposal and we can use them in different ways. Those things in the environment may be both opportunities and constraints. So they could be opportunities for us to use but they also really are going to constrain what we do. So for example, I think the physical environment has a huge influence on the way that we interact. When we did Jackie Pugh’s study and this was primary care clinics in the VA there really look like there are differences in the relationships in clinics where there is more, what she is calling, interstitial space; kind of a hallway where just the providers and the staff are where they have an opportunity to interact outside the patient care areas for example. So I think those are examples of things that are in the environment that people are interacting with and that are going to shape the way that they relate to each other and also shape the processes that they use to do the work.

Molly:Thank you for that reply. That is the last pending question we have at this time. Would you like to give any concluding...I spoke too soon. We do have a couple of more people saying that they will email you offline for references.

Dr. Luci Leykum:Okay. Good.

Molly:Would you like to give any concluding comments?

Dr. Luci Leykum:Thank you all again. Hopefully this was really some food for thought and some inspiration as you are working on your own projects. I am really happy to hear from anyone and send any references.

Molly:Excellent. Well I would like to thank you for lending your expertise to the field and also thank our attendees for joining us today. That does conclude todays HSR&D cyberseminar. Everyone have a wonderful day.

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