Opening presentation at the first meeting on CQI in Public Health in Ontario, held at the Dalla Lana School of Public Health at the University of Toronto. Practitioners from across the province gathered to learn more about quality assurance measures, metrics, theories and ideas. This presentation provides a simple overview of systems thinking as it might apply to CQI in public health. This simple overview looks at the nature of systems, how they apply to CQI, how design thinking and developmental design can aid public health in creating relevant, appropriate means of quality assessment in its work.

1. Systems Perspectives on CQI
and Public Health
Cameron D. Norman PhD CE
Principal CENSE Research + Design
Adjunct Professor, Dalla Lana School of Public Health, University of Toronto
@cdnorman
September 20, 2013
Presentation to the First Meeting to Advance CQI in Public Health in Ontario
Toronto, ON

2. CQI in Public Health
CQI is a commitment to systems change to execute a
continuous flow of improvements that meets or exceeds
the expectations of the customer (communities) and
generally includes a link to the organization’s strategic
plan and goals
- Randolf & Lea (2012) cited in Law, Graham, Bridge & Ross (2013): A Primer on
Quality in Public Health

3. Thinking in Systems
• In complex systems the aim is to attend to attractors (e.g., policies, programs,
ideas), which create patterns of activity, and amplify those that are producing
beneficial outcomes and dampen those that are not.
• The initial decisions within a complex system can create a path dependency and
guide further activities that follow. It is critical to be mindful of these paths to
realize that they can be changed (e.g., first person to walk across a park after the
snow creates the first pathway. The likelihood that someone will choose to walk
in an established path grows with each successive person that chooses to follow
that initial path).
• Be mindful – attentive, aware, non-judgemental – about the paths chosen and
the dynamics going on within the system to determine how the patterns of
activities resulting from those choices influence the process and outcomes
related to the work. Making these paths / decisions visible allows for active, not
just reactive influence.

4. Thinking in Systems
• Systems thinking is about where you stand in the system; your perspective on the system
and place within it can help set the boundaries
• Boundaries in social systems are partly determined by the edge of where new information
no longer makes a discernible difference to the key purpose and strategic operations (i.e.,
where are the differences that make a difference?)
• Understanding what type of system you are operating in will determine the type of metrics
and approaches needed to assess and promote quality within the system
• There are three types of systems that occur in nature:
• Chaotic: Lack of appreciable order and often does not last long
• Ordered: Linear relationships that are clearly defined between objects, their impact on
each other and the boundaries of the system
• Complex: Dynamic, evolving and non-linear relations within flexible and adaptive
boundaries
• See Dave Snowden’s video on the nature of systems using the example of
organizing a children’s party: http://youtu.be/Miwb92eZaJg

5. • Every one of these holds a legitimate position while defining the systems boundaries
differently. Public health is the same way. What quality means in each of these cases is
partly dependent on what matters in each system, which is not always the same.
• Further, systems can be embedded within one another as the above photos
demonstrate. They can have overlapping processes and foundations, but operate at
different scales to different effects at those scales.

6. CQI in Public Health: LEANing in or out?
Linearity in systems
Example: The LEAN Production Method
LEAN was based on the work of the Toyota
Production System which was designed to
effectively and efficiently produce cars at the rate
of demand.
It is predicated on increased efficiency, decreased
waste, and eliminating errors. However, when you
are in a complex system and deal with
relationships, what is waste? What is an efficient
conversation? What is a fully optimized innovation
space – and how would you it if you saw it?
When you expect the same thing – and can predict
that same thing time and again – this is a
reasonable assertion. Yet much of what public
health does operates outside that realm or at its
periphery.

7. Problematic Questions for Context?
Are these the right questions for this
system (example?)
What is an effective tree?
What is the best practice for a tree?
What is a fully optimized tree?

8. Path Dependency
• Complex systems are highly sensitive to initial conditions. Thus, the choices
organizations make to start their QI work can disproportionately shape the work that
comes after it.
• Structuring a mindful process of attending to activities on a regular basis and linking
that with the intentional actions/mission of the organization can help illuminate path
dependencies when they are forming.
• It is difficult to change measures and methods mid-stream once things are in place, so
processes of self-reflection, monitoring, and organizational leadership committed to
continuous quality improvement of the QI system itself is required for system-level
success.

9. Design Thinking: A Developmental
Approach to Quality
• Design thinking is a set of methods, tools and approaches to mostly complex
problems that aids in problem determination, problem definition, and solution
exploration. It is a creative, iterative and evaluative approach to developing, trialing,
assessing and implementing innovations.
• Design thinking brings together brainstorming, visualization, user-centredness,
empathy, and abductive reasoning to a developmental process of generating
workable and re-workable options for programs, policies and actions within a set of
conditions (and constraints). It can be practiced by designers and non-designers
alike.
• Helps generate workable solutions within systems and often uses systems
thinking to guide the framing and evaluation of solutions

10. System Strategy
• Making sense of systems requires that you have a clear sense of purposiveness for
the system. It is imperative to have a clear sense of what the public health
organization / system is about and what it is set out to accomplish. Doing so helps
define what signals are relevant and how much attention to place on them in
monitoring, evaluation, sensemaking and design
• By expressing the intentions behind the system appropriate quality markers can be
developed in harmony with the systems’ type(s): chaotic, complex, ordered
• A stated intention and purpose aids in clarifying the goals for the system and
facilitates the implementation of appropriate quality assessment approaches that fit that
system.

11. Visual Thinking +"
System Mapping
• The language across different stakeholders in the system may be different; visualizing the
system provides a common frame of reference to discuss divergent and convergent
perspectives
• Mapping a system visually through any method – drawing, digital rendering, sticky notes,
cut-outs, computer model or others – provides a means of seeing relationships and
connections that are often impossible to make as a group when using abstract language
• Visualization can serve as a means of prototyping, surfacing and testing assumptions
about relationships, validating existing models, and as a means of exploration and idea
generation

12. Sample Visualization
Methods & Models
• System Dynamics Models: e.g., Homer, J. B., & Hirsch, G. B. (2006). System Dynamics
Modeling for Public Health : Background and Opportunities. American Journal of Public
Health, 96(3), 452–458.
• Concept Mapping: e.g., Trochim, W. M. K. (1989). Concept Mapping - Soft Science or
Hard Art. Evaluation and Program Planning, 12(1), 87–110.
• Gigamapping: e.g., Sevaldson, B. (2010). Discussions & Movements in Design
Research: A systems approach to practice research in design. FORMakedemisk, 3(1), 8–
35.
• Influence Mapping / Causal Loop Diagrams: (see system dynamic models for examples)
• Organizational charts

13. Sensemaking
• Collective sensemaking can take place across an organization, in teams or by experts,
but almost always with some participation and deep engagement with stakeholders
• Serves as a means of integrating systems thinking, design thinking and evaluation
together by examining the feedback from prototypes with the stated purposes and goals
of the organization with patterns of activity observed within the system.
• An activity done by those with connection to the work being looked at. In complex
systems those who have experience with the work generate the most reliable and
abundant information for decision making. Thus front-line staff are best to assess that
work, managers to assess the workings of the teams/staff, senior managers with overall
unit managerial performance and so forth.

14. Take Home: Messages
• CQI depends on seeing quality as embedded in and a product of
systems
• Systems are defined by where you stand in relation to them
and how variation operates within it
• Where you stand determines your metrics for quality
• Your metrics feed your improvement and (re)define quality by
influencing where you stand

15. Take Home: Strategies
• Pay attention / pay intention
• Map your system to intentions, people, settings, contexts based on
what you see
• Collect relevant, timely, useful data based on the context of your
operations and strategy (build on what you map)
• Engage in collective sense-making of the data
• Design & redesign your programs

16. Benefits: (Re)Defining Quality as a Systems Design Issue
• Clarification of organizational strategy; Greater alignment with
vision, mission and implementation
• Attunement to what is known and unknown; not just
evaluation, but idea generation
• Increased receptor capacity for learning, adaptation and
resilience across the organization
• Better organizational intelligence (stronger, more reliable
feedback loops)

17. Benefits: (Re)Defining Quality as a Systems Design Issue
• Placing emphasis on sensemaking within the system - not
just analytics – allows for seeing emergent phenomena
• High levels of employee engagement and enthusiasm
across the organization
• Evaluates strategy, execution and organizational design
simultaneously

18. Cameron D. Norman PhD CE
www.cense.ca
cdnorman@cense.ca
Blog: censemaking.com
@cdnorman
For More Information
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19. Photo Credits
2
0
• All images are original or used under license* to the author; do not use without
permission of original creator where relevant
• * IStockPhoto, Shutterstock and Creative Commons