Systems, complexity and improvement Christian Plessen North Zealand Hospital Hillerød Denmark Christian Plessen, MD, PhD, North Zealand Hospital

Systems, complexity and improvement

Christian PlessenNorth Zealand Hospital

HillerødDenmark

Christian Plessen, MD, PhD, North Zealand Hospital

Reasons for failure

1. Culture not taken into account

2. Complexity not taken into account


Culture

Culture = ”the ways of thinking, behaving and believing that members of a social unit have in common”

Source: Rousseau, D 1988 Int Rev Ind Org Psychol


Marc Bard:

“Culture eats strategy for lunch over and over again”

What does he mean?


Culture

Talk with your neighbour and write down some quotes on culture in your organisation!




Gareth Morgan

Talk with your neighbour!

• Find en example from one work place!

• List artifacts and espoused values in two colums!

• Look for tensions/discrepancies!


Uncovering underlying assumptions (E. Schein)

”Obervable” elements that describe your organisation

• Patient cannot find their way in the hospital

Espoused values

• ”XX is a patient centered health care organisation”

Look for tensions/discrepancies to uncover deepest level!


Decreasing safety

Legal

Expected safe space of action as defined by professional standards

Culture and safety

Source: Modified from Amalberti R, 2001 Saf Sci


Legal

Market demand

Technology

Individual and sociale concerns

Safety regulations & good practices, certification, accreditation standards


Culture and safety

Decreasing safety



Legal

Illegal-normalReal life standards

Market demand

Technology



Usual space of action


Culture and safety

Decreasing safety



Legal


Illegal-IllegalMarket demand

Technology



Accident

Acceptable under extreme conditions



Culture and safetyVe

ry u

nsaf

e

Decreasing safety



Legal


Illegal-IllegalMarket demand

Technology



Accident

Acceptable under extreme conditions



Culture and safetyVe

ry u

nsaf

e

Decreasing safety



Idealized types of safety culture

Safety is a waste of

time

Acting on events

Systems to deal with problems

Constantly identifying risk

Patological Reactive Calculative Proactive Generative

Safety integrated

everywhere

Westrum , R 1991Christian Plessen, MD, PhD, North Zealand Hospital

A true story• Two colleagues are ill on medical ward 08Y one day in November. Also one of the doctors has

influenza. Floor nurse K, usually working with administrative tasks, helps out with looking after patients in team 1. Everybody is a little late with their work. The daily chek-in at 09.00 was delayed until 09.10 and only half of the staff attended because thy were so busy looking after their patients. At 10.00, K receives a call that about a transfer of patient from intensive care. He has just recovered a complicated pneumonia and will need a couple of days before discharge. The patient is fine on 2L of oxygen and will be on the ward at 11.00. The rounds in K’s team are somewhat unstructured because she has to answer phone calls to the ward and she just received a message from S. that she will not be able to do her night shift the same day. At 11.00, the patient from intensive care arrives and is placed in room 10 before K has a chance to talk to him. When she gets there at 11.10 ,the patient is cyanotic and she finds that there is no equipment for oxygen and suction in the room and the oxygen bottle that the patient used during transfer was empty. K runs to get the equipment on her way the wife of another patient stops her and asks for help because her husband has aspirated a tablet. When K arrives at this room, she finds a cyanotic patient who is not breathing. She needs a minute or two to get the suction equipment going, because it is placed on the wrong side of the bed. Finally, she manages to remove the tablets and the patient gets better right away. K goes to the ward central to inform her colleague P who is responsible for this patient. When she arrives at the ward central, she remembers that she actually wanted to find the suction and oxygen equipment for the first patient….

• Thoughts?Christian Plessen, MD, PhD, North Zealand Hospital

A true story cont.• Two days later, K meets attending H on the corridor and asks how patient, who was

transferred from intensive care, was doing. H tells her that the patient had a pulmonary embolism and that he was recovering.

• H wants to know why K asks. K wants to know if the pulmonary embolism can be realted to the temporary lack of oxygen the patient experienced after transfer from the intensive care. H asks why she wants to know about this. The K tells him the episode and that the patient was without oxygen for up to 20 mins.

• Thoughts?


A true story cont. 2• In the following weekly meeting, the teams talks about the use of the Early

Warning Score as a method to detect deterioration of vital signs and to ensure safe transfers. An young doctor asks why we have to do all this scoring and documentation and why the team talks about the topic so often.

• The discussion moves on to human factors in patient safety. H asks K to tell her story about the suction and oxygen equipment. K gives a detailer account about what happened and about her feelings and preoccupations afterwards.

• She talks about the old problem of oxygen and suction equipment that shoul be checked every day. Nurse A asks who actually is responsible for that equipment There is no answer to that question. K says that this will be changed.

• Thoughts?


Leaders’ responsibility in safety1) Psychological safety

Ensure that speaking up is not associated with being perceived as ignorant, incompetent,

critical or disruptive (leaders must create an environment where no one is hesitant to voice a

concern and caregivers know that they will be treated with respect when they do)

2) Organisational fairness

Ensure that caregivers know that they are accountable for being capable, conscientious and

not engaging in unsafe behaviour, but are not held accountable for system failures

3) A learning system

engaged leaders hear patients and front-line caregivers’ concerns regarding defects that

interfere with the delivery of safe care, and promote improvement to increase safety and

reduce waste. Leaders are the keepers and guardians of these attitudinal norms and the

learning system.Leonard & Frankel How can leaders influence a safety culture? Health Foundation 2012



Leading Large Scale Change – a practical guide. NHS 2013


Agenda for today

• Introduction: a list, a story and a concept

• Why improvement efforts often fail

– Culture

– Systems

– Complexity

• Tools and leadership


Systems

• Ackhoff on system

• What did you learn about systems from Ackhoffs talk?


https://www.youtube.com/watch?v=OqEeIG8aPPk&feature=kp

Patient & individual caregiver

Clinical microsystem

MacroOrganization

System

Individual self-care system

MacroOrganization

System

A system view on health care

Batalden, CECS 117


Source: Jönköping, Sweden


What we observe is not nature itself, but nature exposed to our method of questioning.

Werner Heisenberg

Batalden, CECS 117



NeuroMED AFST,

TS, PVK Mette

JytteMichael

Per

GryAnnette

Mette

Mette


Gyn/ObsPVK

OrthoKAD, HØJ RISK,

TS

ITAMAT, RESP, CVK, PVK,

TS

OPKIR

Kard/EndoPVK, AMI, HJ

INSUF

ØNH OPKIR ØNH

PVKKIRMED AFST, TS, PVK, SEPSIS,

CVK

ServiceTS

NefroCVK, KAD

NeuroMED AFST,

TS, PVK

KIR DAGKIR

BØRNMED AFST

LiAKAD, TS, PVK,

CVK, MED AFS, HØJ RISK

BDEPVK

AMASEPSIS,

MED AFST, PVK



Living, adaptive systems

• Structure

• Processes

• Patterns

After Capra, Plsek

Batalden, CECS 117


Living, adaptive systems

• Structure: the physical embodiment of its pattern of organisation

• Patterns: the configuration of relationsships that gives a system

its essential characteristics

• Processes: the activities that go on in structures and that link the

structure and the patternsFritjof Capra, The Web of Life

Batalden, CECS 117


Intensiv Kirurgi Ledelse Medicin Sengeafdeling

Mortalitets-analyser

Patientsikker-hedsrunder”Spors

and bundles”


Bundles and departments


Bundles and departments


A process

Batalden, CECS 117


https://www.youtube.com/watch?v=8NPzLBSBzPI

Some common traps when thinking of health care as a ”system”

• Not recognizing the different levels of systems at work in health care

• Assuming that because we present systems in one way that these same systems cannot simultaneously be represented as deterministic, probabilistic, and chaotic

• Seeking only insight and understanding, avoiding taking action

Batalden, CECS 117


The essence of the discipline of systems thinking lies in a shift of mind towards…

• Seeing interralationships rather than linear cause – effect chains

• Seeing processes rather than snapshotsPeter Senge


Patients and doctors are part of the same system.

L.J. HendersonNEJM, 1936

Batalden, CECS 117


Agenda for today



– Culture

– Systems

– Complexity



Traditional view of organisations

• Organisation = machine

• Hierarchical and functional

• Planning and doing seperated

• Looing for one solution


Simpel Complicated Complex

Repair a bike Fly to the moon Raise a child

Take an ECG Cardiac bypass Smoking cessation

Kilde: Zimmerman B


Talk with your neighbour and find two examples!


Complexity

Stacey RD 1996. Strategic management and organizational dynamics, London: Pitmann Publishing


Characteristics of complex adaptive systems

• Adaptive elements

• Nonlinear cause/effect

• Emergent

behavior/novelty

• Sensitive dependance

on initial conditions

• Not predictable in detail

• Inherent order

• Context and

”embeddedness”

• Co-evolution

• Simple rules

After PlsekBatalden, CECS 117





Kilde: Kelly K. Edgeware


Clockware Swarmware

Rational Creative

Standardized Experimental

Repeatable Trying

Controlled Free

Measured Autonomous

Knowledge based At the edge of knowledge/experience

Kilde: Kelly K. Edgeware


"Some people really want to stop controlling, but are afraid. Everywhere things are changing, creating high degrees of uncertainty and anxiety. And the more anxious you are, the more in control you need to be. Making all this even worse, we've bought into the myth that leaders have all the answers. Managers who accept this myth have their levels of anxiety ratcheted up again. ...If complexity theory can begin freeing managers from this myth of control, I think you'll see people a whole lot more comfortable."

Linda RuschVice President of Patient CareHunterdon Medical CenterNew Jersey

Kontrol


Kontrol"The tendency of people in positions of power is to believe that they can control and they believe in the power of 'let us figure it out.' 'Let's hire the experts, let us sit in a room, figure it out and then it'll happen.' That is a common theme and it's one that I just don't believe in."

James TaylorPresident and CEOUniversity of Louisville HospitalLouisville, Kentucky


"In the past, when managers have tried to implement change, they'd find themselves wasting energy fighting off resistors who felt threatened. Complexity science suggests that we can create small, non-threatening changes that attract people, instead of implementing large-scale change that excites resistance. We work with the attractors."

Mary Anne Keyes, R.N.Vice President, Patient CareMuhlenberg Regional Mediacal CenterPlainfield, NJ

Attractors


If we want to work with a system to influence its direction – a normal desire as we work with human interactions – the place for us to work is deep in the dynamics of the system where [its] identity is taking form.

Wheatley and Kellnor-Rogers, 1996

Batalden, CECS 117


[Living] Systems do not accept direction, only provocation. …[systems] leave us with no choice but to become interested experimenters, sending pulses into the system to see what it notices.

Wheatley and Kellnor-Rogers, 1996

Batalden, CECS 117


Pakke

Proc Res

KAD 1097 816 849 475 19 27 0 532 270 86 646 63 50 339 92 121 92 122 997 0 580 0 762 0 0 869 182

PVK 1185 951 951 751 19 0 114 83 124 467 89 226 90 262 89 27 81 122 82 59 8 83 125 0 139 0 192 76 232 0 0 30 493

CVK 997 997 0 141 421 482 67 269 961 71 1040 616 121 122 766 0 391 0 38 434 934

Tryksår

Revurd

282 42 19 97 39 10 77 33 0 190 89 67 88 239 80 16 82 55 63 57 67 79 100 83 80 0 149 0 163 169 0 0 198 58 67 58 15

80 236

9/10

6/9

76

AMIEle-menter

Mortalitet

Principper for monitorering:

- Resultatmål monitoreres altid- Stabil proces = median 95 % i 6 måneder- Ved stabil proces på 95 %

# Audit på alle patienter en given dag: x 1 pr. måned i 2014

1/10

76

10/10

0

8/9

93 88

8/10 10/10

0

PVK: 30 dageCVK: 300 dageTryksår: 100 dage ml. grad 2Sepsis: < 5

: x 1 hver 3. måned i 2015VAP: 300 dage

Ikke påbegyndt Ikke besluttet

9/10 10/10

KNEB1B2

ØNH 0631

Orto 1551

6/10

80

9/10 1/10

10/1010/10

For-klaringer

Kirurgipakke

EWS - opfølgning

0 0

00

10/109/10

Højrisikomedicin

/Opiater

Sepsis

EWS - "Total"

Ventilatorpneu-moni (VAP)

11 patienter i april med svær sepsis/septisk chok på ITA

5/5

10/10 8/9

5/9 10/1010/10

Medicinaf - ud. 00

0

9/10 9/10EWS - basisobs. 0

9/107/10

4/10

90 40

4/10

78

0

9/10

50

9/10

080 0 90

69

10/10

0

10/10 9/10

00

9/10

9/10

10/10

64

90

KIR 0151

AKbase 1

ONK A8

ONK 0861

AK base 2

KIR 0141

AK FS

KIR 0161

BØRN

80

GYN 0121

OBS 0131

Neuro 0871

0

Rel

/ ak

t ind

80 80

Dag

e m

elle

m

00

Neuro 0671

Juni 2-14

Medicinaf. - ind.

OBS 0142

00

LIA 0655

LIA 0651

IMA0633

Orto 0152

KNE 0842

ITA0531

Opv

ågni

ng

0

LIAB7B8

Orto 0661

0

NeuroRehabA1A3

70

0

0

0

0

9694

700

0

7080

10/10

464290

KIRB5B6

0

0

10/10

9/10

73

1541

1521

90

9080

0632

0

KNE 0641 15

31

Ingen ny data pr. 26. juni (0 %)

- Monitorering på alle pakker indtil processer er stabile

Arket er baseret på data fra de forgående to uger. Der kan være data tidligere, som ikke er med her.Mål pr pakkeKAD: 100 dage

95-100 % af proces-målet / resultat nået



Indikator på vej

Ikke relevant

80

10/10


Nine Principles for leadership of complex settings

• View your system through the lens of complexity • Build a good-enough vision • When life is far from certain, lead with clockware and

swarmware in tandem • Tune your place to the edge • Uncover and work with paradox and tension • Go for multiple actions at the fringes, let direction arise • Listen to the shadow system • Grow complex systems by chunking • Mix cooperation with competition

Adapted From: Edgeware: Lessons From Complexity Science for Health Care Leaders, by Brenda Zimmerman, Curt Lindberg, and Paul Plsek, 1998, Dallas, TX: VHA Inc.


Læring i netverk


M1S3 Data i afdelingen 60

Stop pressure ulcers!


Source: Plsek


Kilde: Eugene C. Nelson, DSc, MPH, Institute for Healthcare Improvement, Dartmouth Medical School & Dartmouth-Hitchcock Medical Center, presented at ISQua, LondonOctober 23, 2006


Agenda for today



– Culture

– Systems

– Complexity



Driver


Safe care & developmen

t of a proactive culture of safety at

North Zealand Hospital

Will & energy for improvement

Organising for patient safety

Improvement capability

Coaching of teams at point of care

Infrastructure for data

Leadership of patient safety

Attention to microsystems & transitions

Prioritising of ‘real’ problems

Clinical leadership

Vision & strategy

Set of methods & tools

Improvement teams & spors

Space for learning & reflection

Appreciation of each others’ work

Research in safety & QI

Position in Region & Denmark

Constancy of purpose

Collaboration across units & disciplines

Exchange with peers in DK & abroad

Developing a culture for

quality improvemen

t

Desk

Reality

Plan Plan PlanDiscuss Accept

Implement

Implementation - traditionel approach

Reinertsen, Bisognano & Pugh (2008)


Desk

Reality

Plan

Test and modify

Accept

ImplementTest and modify

Implementation by adapting to local context

Reinertsen, Bisognano & Pugh (2008)

Test and modify


Small scale testing

1 3 5


P

DS

A

How do we know that we achieve it?

What do we want to achieve?

Which changes do we want try?


Teaching top leaders PDSA’s• Task: Improve patient experience at the hospital!• Process:

– CEO explaines on leadership seminar– Pre-printed PDSA forms with questions– Time to read, discuss, reflect during seminar– Test period

• Report back to CMO on the following questions!– How long did the test take?– What have you learned?– What is your plan?


Ron Moens arguments for MFI• Roots are with profound knowledge, especially with theory of knowledge

• Is useful as a roadmap for small, simple projects as well large-system projects

• Is useful for process or system design or redesign

• Is useful for product or service design or redesign

• Is applicable to all types and levels of organizations

• Facilitates the use of teamwork to make improvements

• Provides a framework for the application of statistical methods

• Encourages planning to be based on theory

• Emphasizes and encourages the iterative learning process

• Allows project plans to adapt as learning occurs

• Provides a simple way to empower people in the organization to take action


Data



Source: Ackoff

Information

Knowledge

Wisdom

Data

Connectedness

Understanding

Human interaction/intervention



Forslag: Håndhygiejne

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PatientSikkert Sygehus dashboard Direktion NOH Hillerød 02.07.2014

Laveste HSMR nogensinde :-)

Uændret

OBS: Ugemålinger: median ligger nu > 80%!

65

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2011-1 2011-3 2012-1 2012-3 2013-1 2013-3

HSMR Hillerød

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Medicinafstemning ved udskrivelse (%)

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Hospitalserhvervede tryksår Hillerød Hospital

Antal tryksår Median Antalgrad 2

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Skadede patienter per 1000 udskrivelserGTT



18 cm2


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18.000 cm2


Documents

Systems, complexity and improvement Christian Plessen North Zealand Hospital Hillerød Denmark Christian Plessen, MD, PhD, North Zealand Hospital