SESSION 2 - Complexity - Barbour
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  • June 2009 Slugging: grew out of nothing; created to address the long commutes which are bypassable only in the HOV lane. No supervisor, no schedule, no ticket and NO FEE. Rules: Agree on destination; no further interaction unless initiated by driver (no eating, talking, cell phones, etc.) Stock Market is classic example of ‘nesting CAS within other CAS NYC food distribution – no “CEO” to control the food that comes in, where it goes and how much is to be re-ordered. Forest – more nesting; somewhat blurry boundaries Hospital – Here we HAVE a CEO!! Does that make it better? Does that stop ‘self-organization’?
  • June 2009 Zone 1: Rational decision-making Use components and boundaries Prioritize using critical issues Plan, measure, adjust, reward Zone 2 Certainty > Agreement compromise, negotiation (political tools) Agreement > Certainty ideology, judgment (role for experts) Zone 3: Reflection Minimum specifications ‘ Wicked’ questions Metaphor and Language Generative relationships Lifecycle to ecocycle etc.
  • June 2009 In the life of steel making, the highest and most refined and sought after were those who made the finest rolled sheet steel for autos and the like. The making of rebars is coarse and rough and doesn’t require a lot of finesse – this type of manufacture is relegated to the bottom of the totem pole. The large integrated steel makers have not been sitting still; in recent years they have streamlined their processes (from 9 hours per ton to 3 hours per ton), pruned inefficient plants (reduced personnel from 93,000 to 23,000), and put in $15 Billion in R&D and improvements. They deliver high quality steel with a 30% margin and have realized real gain in their profits and stock price. Linear thinking would push for continued movement along the previous track: continued quality improvements and increased efficiency. And then, in the 1970s, along come the “mini-mills”. At small cost they set up trivial technology to begin producing the commodity products now shunned by the big companies – they began making rebar. Their technology was not so expensive and they represented a 20% cost advantage over the Major mills; they got the business and began to expand and make Other bars, then structural steel. They, however, remained small and responsive to the immediate commodity market where they could offer a price advantage. By the 1990s, the mini-mills had captured over 40% of the steel market and are continuing to grow while the major mills continue to make high quality sheet steel for their customers who are sticking with them – for now.
  • June 2009 Community = defined as the cohort with same or very similar resources and responsibilities. Getting beyond that ‘community’ makes comparisons invalid (this is why imported ‘best practices’ rarely work.) Situational awareness = “ecological survey” not using linear approaches like dec trees or systems like KM that identify and focus on the 5% outliers. PDs ask AH questions like ”are trucks clean or dirty?” “who says it is their job to prevent infection?” They also listen to the language (“WHO did this?” v. WHAT happened?”) Patterned Responses include acting on the most likely (the 70-80%) (Pareto Principle); keeping their vocabulary terse and their categories limited (Minimum Rules). They use a model that connects the high level measures to the worker level and they recognize threats and failures early and avoid continuing down wrong paths. They are action oriented (Ready-Fire-Aim) and they tend to hold people accountable (not blamable). Their resources include detailed references on how to do common and important tasks.
  • Four hundred years ago, Francis Bacon warned that our minds are wired to deceive us. "Beware the fallacies into which undisciplined thinkers most easily fall--they are the real distorting prisms of human nature." Chief among them: "Assuming more order than exists in chaotic nature." The problem, Nassim explains in The Black Swan , is that we place too much weight on the odds that past events will repeat (diligently trying to follow the path of the "millionaire next door," when unrepeatable chance is a better explanation). Instead, the really important events are rare and unpredictable. He calls them Black Swans, which is a reference to a 17th century philosophical thought experiment. In Europe all anyone had ever seen were white swans; indeed, "all swans are white" had long been used as the standard example of a scientific truth. So what was the chance of seeing a black one? Impossible to calculate, or at least they were until 1697, when explorers found Cygnus atratus in Australia. Taleb explains that conventional social scientists use induction to collect data, which is then plotted on the good old Gaussian bell curve. With characteristic silliness, Taleb dubs the land of the bell curve "Mediocristan" - and informs us that it is the natural habitat of the white swan. He contrasts Mediocristan with "Extremistan" - where chaos reigns, the wholly unexpected happens, power laws and fractal geometry apply and the bell curve does not. Taleb's fictional/metaphorical 'stans' share something with the 'stans' of the real world: very ill-defined borders. Indeed, one can never tell whether one is in the relatively safe territory of Mediocristan or if one has wandered into the lawless tribal regions of Extremistan. The bell curve can only help you in Mediocristan, but you have no way of knowing whether you have strayed into Extremistan - beyond the bell curve's jurisdiction. This means that bell curves are of no reliable use, anywhere. The Drunkard’s Walk explains the mathematics behind the Butterfly Effect through the understanding of the Law of Large Numbers and the corresponding law of small numbers. . . The randomness of unforeseeable events (?Black Swans) cannot be avoided and, in fact, account for much more of what constitutes an individuals path in life (as opposed to ‘career planning’ ) Nobel Laureate Max Born: “Chance is a more fundamental concept than causality.”
  • The Black Swan theory discloses a critical extension of the problem of induction logic. The theory operates on fact that most real-world distributions are not ‘normal’ they exhibit kurtosis and skew and carry an unknown (but very small) possibility of a major occurrence that is completely unpredictable. Concept of ‘orderly randomness’ underlies the concepts of Game Theory – but really only deal with ‘known unknowns’ – the Black Swan is a true ‘unknown unknown’ – and once the Black Swan intrudes, consequent events are linked and would have been unpredictable before the Black Swan (e.g., the impact on the railroad industry by the Interstate Highway system, prediction of the iPod when ARPANET was being developed, etc.) Publisher: Random House; 1 edition (April 17, 2007) Language: English ISBN-10: 1400063515 ISBN-13: 978-1400063512
  • Critical Decision Making for Medical Executives: Keys to Improving Healthcare Delivery December 2009June 2009 June 2009 Another way to uncover paradox is to ask “wicked questions.” These are questions that have no obvious answers, but expose our assumptions. For example, in an organization that was trying to build a more-enabled environment, one leader asked, “Are we really ready to put responsibility for the work on the shoulders of the people who do the work?” Perhaps you can sense the discomfort in such a question. But challenging the sacred cows is an activity that can put you at the edge of chaos, and begin to reveal the hidden assumptions. "Clearly leadership has to do with the sustaining of creative tension in organizations. Creative tension is derived through strategic imbalance, which occurs when operating at the limits of organizational consensus or the boundaries of the organization. Innovation takes place on the edges of the organization where the potential for far-from-equilibrium conditions is optimal.“ –Zimmerman Leaders need to define success for the organization – only then can every person in the organization adapt that vision to themselves; further, when they ‘get there’ it will be evident to them and they will feel successful even if the leader is not right there to pat them on the back. You can most easily do these things if you view the organization thru a ‘complexity lens’ – that does not mean ‘seeing all the complexity’, rather it means to recognize the interactions and the working relationships for their biologic nature as opposed to a machine-like concept of the functioning of the organization. Minimum requirements are hard to determine and set (we all have a tendency to lengthen the list with a lot of ‘niceties’); sticking to the true basics will free the employees to develop many different ways to get the job done. Think of Battle Bots. When you do act, use multiple actions and vary between swarmware and clockware – give yourself and the organization the best possible chance to find a way that works. Often solutions come in ‘chinks’, small pieces that work in one area. Keep these and try to build on them. Creative tension often pushes us toward success; use the “either-and” rule Reflection is, therefore, a key skill for anyone in a CAS. Good leaders in a CAS lead not by telling people what to do, but by being open to experimentation, followed by thoughtful and honest reflection on what happens. Sometimes that input comes from the shadow system rather than thru face-to-face feedback. We are emphasizing teamwork – and the cooperation that underlies such effectiveness. But it is acceptable to recognize individual effort, too. That’s the idea of the MVP on the World Championship team, right?
  • June 2009 Zone 1: Rational decision-making Use components and boundaries Prioritize using critical issues Plan, measure, adjust, reward Zone 2 Certainty > Agreement compromise, negotiation (political tools) Agreement > Certainty ideology, judgment (role for experts) Zone 3: Reflection Minimum specifications ‘ Wicked’ questions Metaphor and Language Generative relationships Lifecycle to ecocycle etc.

Transcript

  • 1. Session 2: CompleXity, Surprise,Innovation & Deviance inDecision-making for Health CareSystems Galen Barbour, MD FACP, FACHE Director, Health Services Administration Uniformed Services University
  • 2. QuestionsWhy doesn’t strategic planning work?Why do decisions work sometimes and sometimes not?Why aren’t ‘best practices’ importable? 2-2
  • 3. Objectives1. Appreciate Newtonian thinking and the elements of the ‘linear world’.• Contrast Linearity with: - the implications of Complexity Science - the concept of Positive Deviance (and why ‘best practices’ are so hard to import) - the framework of Disruptive Innovation (and application to the national health care debate) - the ubiquity of randomness and the reality of the Black Swan phenomenon - the relationship to Uncertainty and Surprise• Develop problem solving approaches for non- linear situations. 2-3
  • 4. A Short History of Physics 300 BC: Aristotle: Observation & Deduction; 1700 AD: Newton, Galileo, et al: Exp & Induction: A body persists its state of rest or of uniform motion unless acted upon by an external unbalanced force. Force equals mass times acceleration (F = ma). To every action there is an equal and opposite reaction. Aristotelian and Newtonian thought generated a verylinear way of seeing the world: “this (always) follows that” 2-4
  • 5. A Short History of Physics300 BC: Aristotle: Observation & Deduction;1700 AD: Newton, Galileo, et al: Exp & Induction: A body persists its state of rest or of uniform motion unless acted upon by an external unbalanced force. Force equals mass times acceleration (F = ma). To every action there is an equal and opposite reaction.1950 AD: Planck, Rutherford, Bohr, Einstein: Observation,Experimentation and Analytic Theory Quantum theory 2-5
  • 6. The Quantum World • Is non-linear • Is unpredictable (but leaves tracks) • Encompasses innumerable possibilities (not ‘mutations’) • Studies of the quantum world led to appreciation of complexity 2-6
  • 7. The ConundrumNewton’s Laws ‘explain’ the macro world and make sense formost issues.When we apply Newtonian thinking, we are seeing the world in amechanical and quite linear way. (and that works for the mostpart)When something unexpected intrudes, we are unprepared. Wetend to think there is a ‘mechanical’ or ‘linear’ aspect that we didn’tmeasure or consider. We must be ignorant or negligent.Truth is, “Variation Happens” and we would be better if we knewhow to deal with it.Variation = complexity. 2-7
  • 8. A Complex System 2-8
  • 9. Understanding of Complexity Initially, a theoretical construct explaining time and space Later identified at micro-levels in biology Now recognized at every level of existence as ‘the’ (or a partial) explanation for heretoforepuzzling phenomena. Derivative studies on SWARM INTELLIGENCE and NETWORKS and STRING THEORY have added additional insight. 2-9
  • 10. Examples of CASs • DC/NOVA slug lines • Stock market • NYC food distribution • Forest • Hospital Each system “succeeds” by adapting to its changing environment. 2-10
  • 11. Characteristics of CASs• diversity • novelty; prog. adaptations• adaptability • capacity to change• interdependency • linkages• • scalar embedded nature • “butterfly” effect• nonlinear • past context• history-dependent • not machinery• ‘biologic’ • many “both-and” rather• paradoxical than “either-or” 2-11
  • 12. Implications of Complexity1. Inter-related processes form systems – with Order, Chaos and Complexity within the system.2. Systems that are complex show signs of self- organization – they adapt to external forces and other causes for change.3. We are surrounded by complexity – but we still approach each situation as if it is Simple and Linear. 2-12
  • 13. C oLeve l of Syste m h Turb ulen ce s a High Low Low High Level of Immediate Necessity 2-13
  • 14. simple Zone 1Routine, expected issues – Staffing – Budgeting – Information Management – Marketing 2-14
  • 15. Zone 1 simple ToolsRational decision-making – Use components and boundaries – Prioritize using critical issues – Plan, measure, adjust, reward – Linear approaches work well here 2-15
  • 16. complicated Zone 2• Events not as predictable; more uncertainty exists about the future• Labor negotiations• Opening new services• Developing an incentive system 2-16
  • 17. Zone 2 complicated 1 Tools 21. Certainty > Agreement, compromise, negotiation (political tools)2. Agreement > Certainty, ideology, judgment (role for experts) 2-17
  • 18. complex Zone 3Complexity increased by an order of magnitude Different tools needed• Dramatic legislative changes• Re-design of health care delivery systems• Mergers (systems, departments, etc.) 2-18
  • 19. complex Zone 3 ToolsWe need to recognize the situation as‘non-linear’ (e.g., a ‘mystery’ not a‘puzzle’) before we can begin to think ofusing ‘non-linear’ tools.Applying linear thought and problem-solving to complex situations is highlyunlikely to work. 2-19
  • 20. Zone 3 complex Tools• Reflection• Minimum specifications• ‘Wicked’ questions• Metaphor• Generative relationships• Lifecycle to ecocycle• etc. (See: Edgeware: insights from complexity science for health care leaders. B Zimmerman, P Plsek, C Lindberg Critical Decision Making for Medical 2-20
  • 21. Comparison of Approaches Simple Complicated Complex• Planning is quite • Multiple plans with • ‘Plan’ is very generaldetailed (e.g., a interaction (more questions thanrecipe, blueprint) answers) • Outcomes are big and• Clear, measurable complicated • Uncertainty is kingoutcome • Reliance is on the • Use Minimum• Measurement, goals experts specificationsand targets • Heroes win, villains • Embrace the• Accountability at a cause trouble or prohibit paradoxes withpersonal level. success. optimism. 2-21
  • 22. ComplicatedModern medicine has created knowledge andpractice patterns that are very complicated: • Emergency response to chest pain • Sudden onset stroke (“brain attack”) • Cardiac bypass surgery • Organ transplantationHow can we reduce ‘errors’ and ‘ineptitude’? 2-22
  • 23. LinearLinear thinking can (at times) mislead people into thinkingthey are in one business when they are really in another.1920s-1950s: Railroad Executives pushed for more track andmore powerful engines for the “Railroad Business”1940s-1970s: Trucking companies moved in to the smallmarkets not served by railroads and began to expand in the“Transportation Business”1960s – 1980s American railroads nearly went bankrupt (andsome actually did). 2-23
  • 24. mer g ing custo in n n o demand ai ati Most st v S u no InPerformance n io v at no In e tiv up D isr er gc ustom demandin Least Time 2-24
  • 25. Integrated Steelmakers Sheet steel Structural steelPerformance Mini-mills Other bars and rods Rebar Time 2-25
  • 26. “Disruptions”Characteristics of these successful “disruptions”:2. Breaks with ‘linear’ thinking3. Starts with simple technology and functionality4. Operates ‘under the system’ by starting in ‘rebar’ markets with minimal regulatory barriers5. Is cheaper; allows less costly people to meet the needs of an emerging market.6. Initially competes against non-consumption; later meets more demanding needs without customers having to change their ways. 2-26
  • 27. Disruptions and Health Care We have the technology to disrupt - the hospital business model - the physician’s practice business model - the reimbursement system - the care of chronic illness according to The Innovators Prescription: A Disruptive Solution for Health Care - Clay Christensen 2-27
  • 28. “usual” “D” “B” Performers Performers LOW HIGH PositivePerformers Deviants Performers 2-28
  • 29. Deviance Positive Deviance = Best outcomes in the ‘community’. Positive Deviants = Recognizable within the community Use two key approaches 1. Acute situational awareness Not decision tree or knowledge management Modified Analytical Hierarchy 2. Patterned responses Commitment, end-in-mind, action-oriented, measure threats & progress, operate on evidence basis 2-29
  • 30. Positive Deviance Principles of disbursing Positive Deviance2. Help ‘community’ identify the PDs3. Obtain their involvement thru intrinsic motivation and professionalism4. Engage others thru Practice -> Attitude -> Knowledge (this is ‘backwards’ to the usual way of ‘teaching’)The Power of Positive Deviance: How Unlikely Innovators Solve the Worlds Toughest Problems Pascale, Sternin & Sternin Vietnam diet http://www.fastcompany.com/magazine/41/sternin.html MRSA reduction http://www.plexusinstitute.org/news-events/show_news.cfm?id=1 2-30
  • 31. Puzzles versus Mysteries Puzzle: problem or enigma; pieces must be fit together in a logical (i.e., linear) way to come to the right conclusion. Mystery: occurrences or relationships that are difficult to make clear; often have secret or hidden qualities that need explanation (i.e. red herring, misdirection, unexpected events, etc.)
  • 32. What About Uncertainty And SurpriseVariation is unpredictable & uncertain(perhaps anticipated). Black Swan theory: The Black Swan: The Impact of the Highly Improbable. Nassim Nicholas Taleb 2-32
  • 33. What About Uncertainty and SurpriseVariation is unpredictable & uncertain(perhaps anticipated). Black Swan theory: The Black Swan: The Impact of the Highly Improbable. Nassim Nicholas Taleb 2-33
  • 34. What About Uncertainty and SurpriseVariation is unpredictable & uncertainTools that deal with variation improve the ability to deal withuncertainty.Surprise is the culmination of uncertainty – the actual event asopposed to the threat.Answers (solutions) may come from CAS, or from PD ormaybe from DI . . .-- but NOT likely from a linear approach or such an approachshould have predicted the event . . . 2-34
  • 35. ToolsSome ‘tools’ to use in dealing with complex situations:• Look thru the Complexity Lens• Be sure you are asking the Right Question• Set only Minimum requirements• Use Metaphor (biologic not machine-like)• Initiate Multiple actions (swarmware)• Do some Chunking (bit development like UNIX)• Allow Tension and Paradox (Generative relations)• Ask Wicked Questions• Tune to the edge• Don’t shy away from being Wrong• Reflect & Listen to the Shadow System• Mix competition and cooperation 2-35
  • 36. Leve l of Turb ulen ce tion nova ti ve I n D isrup t i ve dap are) ex A ew C ompl s (Edg d M etho Co mp rom Po i se s it iv eD Ex Sw ev Str pe ar r i an at egi tO m cP pi Int ce High l an ni el l Low nin o n ige g, e nc t al e Low High Level of Necessity 2-36
  • 37. Reference List for Complexity et al:• Edgeware: Zimmerman, Plsek, Lindberg• The Innovators Prescription: Christensen• The Power of Positive Deviance: Pascale, Sternin, Sternin• The Black Swan: Taleb• The Drunkard’s Walk: Mlodinow• The Checklist Manifesto: Gawande• The Perfect Swarm: Fisher• Being Wrong: Schulz 2-38