Systems Thinking for Implement

Research & Practice

VA QUERI Series

July 7, 2009

Jennifer Terpstra, MPH Luci Leykum, MD, Doctoral Student, UBC Investigator, VERD
Objectives

1. Explain the need for alternative appr

to implementation

2. Define systems‐based approaches

3. Explore potential application of syste

thinking for implementation researc

practice

4. Discuss alternative approaches for

implementation in healthcare system
Why do we need new

approaches to implementat
Overview of the Problem

 Difficulty translating “best practice” i

routine practice

 Inconsistency of intervention effectiv

across time and settings

 Many of our approaches inherently a

linearity and predictability
However...

 Healthcare problems are context spe

 Healthcare settings are rarely linear a

predictable systems

 We need a new approach that is cons

with the fundamental nature of the sy
A Paradigm Shift

Towards a More Complex Understan

of Causality and Change
Different Types of Scienc

MODE I

• Focus is knowledge

generation

• Basic to applied research

• Scientist as expert• Researcher driven

• High internal validity

MODE 

• Focus on prob

solving

• Co‐creation of

knowledge

• Context depen• Stakeholder d• High external 

Denis JL et al. In Lemieux-Charles L & Champagne F. Using KnowledgHealth Care, U of T Press, 2004
THE IMPLEMENTATION

PROCESSDecision-making devolved 

to front line teams

Hands-on approach by 

leaders and managers

Human resource issues,

especially training 

Dedicated resourcesInternal communicationExternal collaborationReinvention/development

THE OSocio-IncentiInter-o

norm-

Enviro

SYSTEM READINESS FOR INNOVATIONTension for changeInnovation-system fitPower balancesAssessment of implicationsDedicated time / resourcesMonitoring and feedback

THE INRelativCompaLow coTrialabObservPotentRiskTask is

THE ADOPTERNeeds MotivationValues and goalsSkills Learning style Social networks

Greenhalgh Greenhalgh, Trisha, et al. , Trisha, et al. Diffusion in service Diffusion in service organizations. organizations. Milbank Milbank Quarterly Quarterly 2004;82:581 2004;82:581-629

A Whole Systems Approa
What are systems‐base

approaches,

and how do do they add to 

understanding of health c

systems?

Systems Thinking

 Systems are bounded entities with

interdependent parts, where the who

greater than the sum of the parts

 Systems are nested Holism – Understand the whole by lo

for emergent patterns resulting from

interactions of different system parts
Stacey Matrix

•Simple systems•Complicated sys•Complex system•Complex AdaptiSystems•Chaotic systems

Zimmerman, Lindberg, & Plsek (2001). Edgware: insights from science for health care leaders.
Complex Systems

 Characterized by interactions that are:

– Non linear– Not deterministic

 Complex systems approach can be applied 

physical, biological, or social systems

 Application to organizations often called “c

adaptive systems”
Analogy of a Complex Syst
The Characteristics

of

Complex Systems
Learning

Current approaches:

– People with specific licenses, skills, etc., are

interchangeable

– “Pushing” knowledge is an effective strateg

Complex systems perspective:

– Individuals have a fund of organizational kn

that makes them valuable

Implication:

– Improving individuals’ ability to learn may b

effective way of improving a clinical system
Relationships / Interconnec

Current approaches:

– Focus on role definition, individual skill s

– “everyone does her or his own job”

Complex systems perspective:

– The patterns of relationships are import

Implication:

– Interventions that focus on interconnect

be more effective than those that focus 

individuals
Co‐evolution

Current approaches:

– All clinical settings are the same

Complex system perspective:

– Each system is at a unique point

– Each system co‐evolves with its external

environment

Implication:

– interventions may not be easily translate
Self‐organization

Current approaches:

– Organization can be dictated from outsid

– Hierarchical command and control is pos

Complex system implications:

– Organization cannot be imposed from ab

individuals must be active participants in 

– Control is distributed amongst system ag

Implications:

– Bottom‐up approaches may be more suc
Emergence

Current approach:

– Strategic management based on study o

individual parts

– Uncertainly can be reduced to zero thro

planning and role‐definition

Complex systems perspective:

– The whole is greater than the sum of the 

– Patterns can be seen at the macro level, 

micro level
Emergence

Implications:

– Because uncertainty and surprise are inh

strategies that improve individuals’ abilit

“make sense” of what is going on may b

successful

– It may be difficult to interpret the interv

effects
Non‐linearity & Time La

Current approaches:

– The effects of interventions should be th

over time

Complex system perspective:

– Inputs and outputs are not proportiona

predictable!

– Uncertainly and surprise are inherent
Feedback Loops

Current approaches:

– Events unfold in a linear process

Complex system perspective:

– A circular relationship‐ an influence is bo

and an effect

• Reinforcing (positive) loops• Self‐correcting (negative loops) (eg. Thermo
Nonlinearity & Feedback Lo

Implications:

– Identify feedback loops to guide change

– The same action can have different effec

time, depending on the state of the syst

– Difficult to predict outcomes and imposs

identify single causative factor
Examples of complex syste

approaches in the healthc

literature
Paul Plsek

Crossing the Quality Chas

• Clinical microsystems are interconnec

organizing, naturally adaptive, potent

unpredictable

• BMJ series:

– Complexity Science: the challenge of com

healthcare

• Plsek & Greenhalgh 2001

– Complexity Science: complexity, leaders

management in healthcare organization

• Plsek & Wilson 2001
Work in primary care

• Application of CAS to primary care develop

Crabtree, Miller, Nutting, Stange, McDanie

– “Practice Jazz”

Miller et al, J Fam Practice 50(10) 2001

– “Using Complexity theory to build intervention

improve health care delivery in primary care”

Likater et al JGIM 21 2006
Work in primary care

• Observations on the following key att

of primary care systems:

– Relationships

• Talia et al, Family Practice Management 13(1) 2006; 

Annals of Fam Med 6(4) 2008

– “Knowledge management”

• Orzano et al, Health Care Mgmt Review 33(1) 2008

– Surprise

• McDaniel et al, Health Care Mgmt Review 28(3) 2003
NECSI

• Work in healthcare has looked at prob

scale

– Mismatch between simple, large‐scale a

and the complex treatment of individual 

– Mismatch between complexity of patien

situations and current reductionist appro

– Bar‐Yam et al. Am J Public Health 2006

– Bar‐Yam et al. NECSI Technical Report 20
Multimethod Assessment Pr

Reflective Adaptive Proce

• How to more effectively create change

/ im

processes in primary care practices?

•

5 principles:

– Articulate

a vision and mission

– Create time

/ space for learning and reflection

– Tension and discomfort is normal and essentia

– Improvement teams must include

a variety of p

with different perspectives

– Supportive leadership must facilitate the proce

Stroebel et al, Joint Comm J Qual and Pt S
Association between CAS 

outcomes in chronic disea

• Systematic review of organizational

interventions to improve outcomes fo

patients with type 2 diabetes

• Sets of investigators independently ra

– Consistency of intervention with CAS pri

– Outcome effectiveness

Leykum et al, Implementatio
Association between CAS 

outcomes in chronic disea

Leykum et al, Implementation Sc
Role of Conversations

• Based on work in 5 studies*

• Reframe change as not a problem of r

transfer, but of local sensemaking and 

• Conversation concepts:

– Collaboration– Meaning‐making– Improvisation

• Use of conversation to promote these 

* DOPC, P&CD, STEP-UP

Jordan et al. Implementatio
Working in complex syste
Practice Facilitation

• Individuals who assist change efforts• Goal is to help practice to achieve sys

level changes

• Relevance to Systems theory:

– Help promote relationships– Explicitly create time for reflection & con

– Work within local context

– Allows solutions to emerge

Nagykaldi et al, JABFM 
Participatory Action Resea

• Design in which researchers and parti

are partners in implementing change

• Cyclical, iterative process that focuses 

understanding impact of change

• Relevance to Systems theory:

– Context specific– Builds relationships– Reflection part of the process

– Self organization promoted, solutions em
Social Network Analysis

Christakis & Fowler (2007) N Engl J Med 357:4,370.
System Dynamics Modelin

Hovmand, P et al. (2008). Science meets p

Overview of main feedback mechanisms in a model of the implemorganizational performance 
Agent‐Based Model of HIV S
In summary ‐ A Paradigm Sh

Reductionist Lens Complexity S

Metaphor is a... Machine Brain (ie. living sChange by ... Plan & control Change by learn

adaptation

Identify... Cause & effect relationships PatternsStudy approach Reduce to parts and study

independently

Identify interact

loops

Look at the... Micro level,

Study single component

Macro (whole sy

monitor pattern

Validity emphasis Internal validity‐ control

context

External validity

Context is a inte

Intervention goals Standardization of parts Adaptation to loResearcher role External & objective Shared developm

collaboration
Thank you!