Complexity Science

&

Implementation

VHA Cyberseminar

December 6, 2012
What is your familiarity wit

complexity science?

1. Just heard of it2. Some passing familiarity from the lite

3. Know it moderately well / familiar wi

literature

4. Have used the framework in my own 
Objectives

Discuss the insights that complexity scieprovides for implementation science:• Presence of uncertainty• Focus on rel i at onal i f n rastructure &

interdependencies

• Importance of sensemaking, improvis

learning
Challenges Challenges in implementat

implementat

• Difficulties scaling i t n erventions across m

systems

• Unpredictable diffusion of knowledge th

organizations

• U dn erstanding how the local cont t ex i f

n 

implementation efforts

• Tension between “local” and “generaliza
Complexity Science
Uncertainty Uncertainty is inherent

inherent

Patient Science S

?
Interdependencies

Relationships Processes Aff
Interdependencies

Relationships

The individuals

in the system

and how they

relate

Processes

The ways we

work

e.g. care

pathways

Self

‐organization

Aff

The 

at o

e.g

pl

Sensemaking, Improvising

& Learnin
Self‐organization
Complexity Science
Navigating interdependenc

& uncertainties

• Relationships form the basis for effect

action in uncertain uncertain environments environments

• Relationships – the basis for:

– Sensemaking– Learning
Relationship characterist

Relationship DefinitioncharacteristicTrust Willingness to be vulnerable to othersDiversity I l nc uding different perspectives and diff

thinking

Respect Valuing the opinion of others

Honest interactions

Heedfulness Awareness of how each person’s roles im

rest of the team

Mindfulness Openness to new ideas and free discuss

Social / Task Relatedness Relatedness Balance Balance of both work and social‐related related Rich / LeanCommunication

Use of in‐person communication for sendifficult issues
Relationship impact

• Linked to outcomes in:

– Surgical teams– Medical teams

– Nursing homes

– Primary care– Intensive care
Physician team relationship

outcomes of hospitalized pat

Team Number 1 2 3a 3b 4a 4b 5 6 

Relationship

score

0 5 7 2 2 3 5 7 

scoreLength of stay(days)

5.6 7.2 3 4 3.6 3.8 3.5 2.6 

Complicationrate (%)

25 32.3 19 UR 20.6 UR 21.9 9.8 
Physician team relationship

outcomes of hospitalized pat

Team Number 1 2 3a 3b 4a 4b 5 6 

Relationship

score

0 5 7 2 2 3 5 7 

scoreLength of stay(days)

5.6 7.2 3 4 3.6 3.8 3.5 2.6 

Complicationrate (%)

25 32.3 19 UR 20.6 UR 21.9 9.8 
Sensemaking
Sensemaking

• “a diagnostic process directed at cons

plausible interpretations of ambiguou

that are sufficient to sustain action”

• Reflection, conversation and briefing /

debriefing
Surgical mortality

Study of differences between hospitals with low a

surgical mortality
Improvising
–

Improvising

• Applying scientific knowledge and clin

experience in novel ways

– Reliant on knowledge

Reliant Reliant on relationships relationships
Learning
Learning

• Changing your mental model
Speaking Speaking up in the O R. 

• Surgical teams where team members 

up” learned more quickly

• Surgical outcomes better
Learning Learning in primary primary car

I am frequently taught new things by other people in this clinic

I learn a lot about how to do my job by talking with the people i

When we have a problem problem in this clinic, we tend to examine examine it ca

ca

we can come to an understanding of the problem and why it oc

In this clinic, we frequently learn about new things together as a 

I learn how to do things in this clinic by sharing knowledge with 

members

Reciprocal learning significantly associated w

clinic ability to implement the chronic care 
Tying these together together
Bloodstream infections

• Mi hi c gan ICU project  reduced rates of 

venous catheter infections to 0

– Checklists implemented by project teams

• Reframed as a “social process”

Dix
Leveraging Leveraging local patterns patterns o

relationships to enable

sensemaking, improvising

and learning

will lead to more successfu

implementation efforts
Relationships

• Shared understanding of goals to encour

more mindful and heedful process

– Participatory Participatory elements elements built into the interve

interve

allowing intervention to be shaped

• Promote relationships among people wh

collaboration is critical to intervention su

• Creation Creation of complimentary complimentary interconnect

interconnect

between individuals
Intervention attributes that m

impact the role of relationsh

• Degree of uncertainty• Patient control over the process

• Degree of work‐sharing sharing required required

• Pace of evolution of disease process
Three sites in Kenya

Weekly SMS texts asking individuals in the first 

“How are you?”

s of

ion

Local group had input into the implementation 

Regular meetings of patients and staff

High degree of local input

95% adherence in 61.5% of intervention group, 

Lower levels of viremia

S i ett ng

InterventionKey attributeimplementat

Outcomes

HIV Adherence
Sensemaking Sensemaking, Improvising Improvising & Le

Le

• Make these activities explicit

• Time & space for conversations conversations & refl

refl

• Allow the intervention to be shaped a

unf ld o s
Operating room team brie fing / d beriefin

18% reduction surgical mortality among 

teams vs 7%

Medical Medical Team Training Training

••
Acknowledgements

Many thanks to my colleagues whose w

reflected in this

presentation:

• Jackie Pugh• H ll o

y

L h an

ham

• Reuben McDaniel• Michael Parchman• Shannon Provost
Thank you!!

Leykum@uthscsa.edu

Luci.Leykum@va.gov