Thinking Thinking Wholelistically:Wholelistically:

Systems Thinking-- Systems Thinking-- Human & Organizational Human & Organizational

Cognition, Actions, Cognition, Actions, Events and Events and

BehaviorBehavior Another way of thinking in diagnosing & Another way of thinking in diagnosing &

solving problemssolving problems

JP Bishop, ABD, CPTJP Bishop, ABD, CPT

A Screw in My Sandwich???A Screw in My Sandwich???

A Real Life Story from a customer who purchased a sandwich at A Real Life Story from a customer who purchased a sandwich at Arby’s on October 30, 2006.Arby’s on October 30, 2006.

Screw

What is Systems Thinking?What is Systems Thinking? Crosses disciplinesCrosses disciplines Multiple perspectivesMultiple perspectives

Studies the structure, properties, and Studies the structure, properties, and characteristics of systems, focusing on how characteristics of systems, focusing on how systems interact and effect each other and/or systems interact and effect each other and/or the environment, and/or how systems, in the environment, and/or how systems, in turn, are effected by the environmentturn, are effected by the environment

Way of understanding reality that emphasizes Way of understanding reality that emphasizes the relationships among a system's parts, the relationships among a system's parts, rather than the parts themselvesrather than the parts themselves

Many DisciplinesMany Disciplines Employs many theoretical perspectives and Employs many theoretical perspectives and

borrows fromborrows from– OntologyOntology– Philosophy of sciencePhilosophy of science– PhysicsPhysics– BiologyBiology– EngineeringEngineering

Uses concepts from these theoretical bases and Uses concepts from these theoretical bases and applies toapplies to– SociologySociology– GeographyGeography– Political sciencePolitical science– Management scienceManagement science– Economics, etcEconomics, etc

Ludwig Von BertalanffeyLudwig Von BertalanffeyAustrian BiologistAustrian Biologist

A system is an entity which maintains its existencethrough the mutual interaction of its parts.

•Scientists operated on the idea that all systems were closed systems (i.e. did not interact with their environments)

•Von Bertalanffey proposed that systems are open systems which led to the General Systems Theory which factored in effects of the environment on the system

Defining Characteristics of Defining Characteristics of Systems ThinkingSystems Thinking

Every system has a purpose within a larger system

All of a system's parts must be present for the system to carry out its purpose optimally

A system's parts must be arranged in a specific way for the system to carry out its purpose

Systems change in response to feedback Systems maintain their stability by making

adjustments based on feedback

Feedback LoopFeedback Loop

Process

Input

InputInput

InputInput

OutputOutput

OutputOutput

OutputOutput

OutputOutput

Types of Systems- Isolated Types of Systems- Isolated SystemSystem

Isolated systemIsolated system– A physical system that does A physical system that does

not interact with its not interact with its surroundingssurroundings

In i.e. thermodynamics it In i.e. thermodynamics it obeys a number of obeys a number of conservation lawsconservation laws

– Its total energy and mass Its total energy and mass stay constantstay constant

They cannot enter or They cannot enter or exit but only move exit but only move around insidearound inside

– ““A system in which the only A system in which the only forces which contribute to the forces which contribute to the momentum change of an momentum change of an individual object are the forces individual object are the forces acting between the objects acting between the objects themselves can be considered themselves can be considered an isolated system”an isolated system”

– In real life, totally isolated In real life, totally isolated systems do not exist; systems do not exist; HOWEVER, real systems have HOWEVER, real systems have behaved this way for behaved this way for exceptionally long times!!!exceptionally long times!!!

Types of Systems- Closed Types of Systems- Closed SystemSystem

Definition from thermodynamicsDefinition from thermodynamics– ““A system that can exchange heat and A system that can exchange heat and

work but not matter”work but not matter”– # of particles as well as total energy fixed by

boundary conditions Tends toward equilibrium and increases in entropy

Practical example:Practical example:– Closed system toll roadClosed system toll road

Take ticket when you get on, pay at the endTake ticket when you get on, pay at the end– Toll calculated by distance traveledToll calculated by distance traveled

Types of Systems- Open Types of Systems- Open SystemSystem

Open systems draw some sort of Open systems draw some sort of energy from the environmentenergy from the environment– Matter and energy can flow into and out Matter and energy can flow into and out

from the systemfrom the system– Capable of self-maintenance based on Capable of self-maintenance based on

throughput from the environmentthroughput from the environment

Advantages of Systems Advantages of Systems ThinkingThinking

More effective problem solvingMore effective problem solving More effective leadershipMore effective leadership More effective communicationsMore effective communications More effective planningMore effective planning More effective organizational More effective organizational

developmentdevelopment Avoiding Founder's SyndromeAvoiding Founder's Syndrome

Differences Differences

AnalysisAnalysis Systems ThinkingSystems Thinking

Systems Thinking & Problem Systems Thinking & Problem SolvingSolving

Problem Solving and the Problem Solving and the Root Cause AnalysisRoot Cause Analysis

Industry likes using Root Cause Analysis for Industry likes using Root Cause Analysis for accident investigationsaccident investigations

Root Cause Analysis also good for Root Cause Analysis also good for uncovering repeat errors, underlying uncovering repeat errors, underlying problems, and which can be solvedproblems, and which can be solved

95% of the problems are caused by process 95% of the problems are caused by process failures and 5% by personnel failuresfailures and 5% by personnel failures– Based on asking “Why?”Based on asking “Why?”– Decision tree logic- working backwards to the Decision tree logic- working backwards to the

origins of the causeorigins of the cause

Danvers, MA Chemical Plant Danvers, MA Chemical Plant ExplosionExplosion

4/5 Steps in the Root Cause 4/5 Steps in the Root Cause Analysis ProcessAnalysis Process

1.1. Collect dataCollect data– First need to entirely understand an eventFirst need to entirely understand an event– Majority of time spent in analyzing event is to Majority of time spent in analyzing event is to

gather data gather data 2.2. Chart causal factorsChart causal factors

Provides structure for organizing contributing Provides structure for organizing contributing factors/ eventsfactors/ events

Identifies gaps and inefficienciesIdentifies gaps and inefficiencies3.3. Root cause identificationRoot cause identification4.4. Sometimes steps 4 AND 5: Sometimes steps 4 AND 5:

Recommendation generation and Recommendation generation and implementationimplementation

CausalCausalChartChart

Causal Chart 2Causal Chart 2

Fishbone TechniqueFishbone Technique

Fishbone Diagram Problem Fishbone Diagram Problem SolvingSolving

Invented by Dr. Kaoru Invented by Dr. Kaoru Ishikawa, a Japanese Ishikawa, a Japanese quality control quality control statisticianstatistician

How constructed:How constructed:– The 4 M’s: The 4 M’s:

Methods, Methods, Machines, Machines, Materials, Materials, Manpower Manpower

– The 4 P’s: The 4 P’s: Place, Place,

Procedure, Procedure, People, Policies People, Policies

– The 4 S’s: The 4 S’s: Surroundings, Surroundings,

Suppliers, Suppliers, Systems, SkillsSystems, Skills

Brainstorm ideas to identify factors within Brainstorm ideas to identify factors within each categoryeach category– ““What are the ________ issues causing What are the ________ issues causing

_____”_____” Repeat this procedure with each factor Repeat this procedure with each factor

under the category to produce sub-factors. under the category to produce sub-factors. Continue asking, "Why is this happening?" Continue asking, "Why is this happening?" and put additional segments each factor and put additional segments each factor and subsequently under each sub-factorand subsequently under each sub-factor

Continue until you no longer get useful Continue until you no longer get useful information as you ask, "Why is that information as you ask, "Why is that happening?"happening?"

Analyze the results of the fishbone after Analyze the results of the fishbone after team members agree that an adequate team members agree that an adequate amount of detail has been provided under amount of detail has been provided under each major categoryeach major category– Do this by looking for those items that Do this by looking for those items that

appear in more than one category appear in more than one category – These become the 'most likely causes"These become the 'most likely causes"

For those items identified as the "most For those items identified as the "most likely causes", the team should reach likely causes", the team should reach consensus on listing those items in priority consensus on listing those items in priority order with the first item being the most order with the first item being the most probable" causeprobable" cause

Fishbone DiagramFishbone Diagram

Interrelationship DiagramInterrelationship Diagram

Current Reality TreeCurrent Reality Tree

Root Cause LimitationsRoot Cause Limitations Hindsight biasHindsight bias Brainstorming activity- if the team does not recognize a failure Brainstorming activity- if the team does not recognize a failure

mode then it does not get includedmode then it does not get included Time consumingTime consuming Unknown unknowns- might miss a failure mode if it is not Unknown unknowns- might miss a failure mode if it is not

recognizedrecognized Taking on too large scopeTaking on too large scope Not including operatorsNot including operators Not including customersNot including customers Becomes a consuming job- takes too longBecomes a consuming job- takes too long Not including one or more ; people, method, equipment, materials, Not including one or more ; people, method, equipment, materials,

EnvironmentEnvironment Not getting into details- superficial look at process onlyNot getting into details- superficial look at process only Confusing root cause with failure modeConfusing root cause with failure mode Not looking at each productNot looking at each product Assuming detection controls are better than they areAssuming detection controls are better than they are Assuming detection controls apply when they don’tAssuming detection controls apply when they don’t

Cognition & Ways of Cognition & Ways of ThinkingThinking

Thinking systemically and Thinking systemically and systematically changes the way you systematically changes the way you approach problemsapproach problems

Advantage:Advantage:– See the “big picture”See the “big picture”– Get to the root causeGet to the root cause

Disadvantage:Disadvantage:– TimeTime– CostCost– Not a quick fixNot a quick fix

Scenario # 1Scenario # 1 The Plant Manager walked into the plant The Plant Manager walked into the plant

and found oil on the floor and found oil on the floor He called the Supervisor over and told him He called the Supervisor over and told him

to have maintenance clean up the oil to have maintenance clean up the oil The next day while the Plant Manager was The next day while the Plant Manager was

in the same area of the plant he found oil in the same area of the plant he found oil on the floor again and he subsequently on the floor again and he subsequently raked the Supervisor over the coals for not raked the Supervisor over the coals for not following his directions from the day before following his directions from the day before

His parting words were:His parting words were:– ““Either get the oil cleaned up or I’ll find Either get the oil cleaned up or I’ll find

someone who will!”someone who will!”

Scenario # 2Scenario # 2 The Plant Manager walked into the plant and found oil on the floorThe Plant Manager walked into the plant and found oil on the floor He called the Supervisor over and asked him why there was oil on the floorHe called the Supervisor over and asked him why there was oil on the floor The Supervisor indicated that it was due to a leaky gasket in the pipe joint aboveThe Supervisor indicated that it was due to a leaky gasket in the pipe joint above The Plant Manager then asked when the gasket had been replaced and the The Plant Manager then asked when the gasket had been replaced and the

Supervisor said that each one seemed to leakSupervisor said that each one seemed to leak The Supervisor also indicated that Maintenance had been talking to Purchasing The Supervisor also indicated that Maintenance had been talking to Purchasing

about the gaskets because it seemed they were all badabout the gaskets because it seemed they were all bad The Plant Manager then went to talk with Purchasing about the situation with the The Plant Manager then went to talk with Purchasing about the situation with the

gasketsgaskets The Purchasing Manager indicated that they had in fact received a bad batch of The Purchasing Manager indicated that they had in fact received a bad batch of

gaskets from the suppliergaskets from the supplier The Purchasing Manager also indicated that they had been trying for the past 2 The Purchasing Manager also indicated that they had been trying for the past 2

months to try to get the supplier to make good on the last order of 5,000 months to try to get the supplier to make good on the last order of 5,000 gaskets that all seemed to be badgaskets that all seemed to be bad

The Plant Manager then asked the Purchasing Manager why they had purchased The Plant Manager then asked the Purchasing Manager why they had purchased from this supplier if they were so disreputable and the Purchasing Manager said from this supplier if they were so disreputable and the Purchasing Manager said because they were the lowest bidder when quotes were received from various because they were the lowest bidder when quotes were received from various supplierssuppliers

The Plant Manager then asked the Purchasing Manager why they went with the The Plant Manager then asked the Purchasing Manager why they went with the lowest bidder and he indicated that was the direction he had received from the lowest bidder and he indicated that was the direction he had received from the VP of FinanceVP of Finance

The Plant Manager then went to talk to the VP of Finance about the situationThe Plant Manager then went to talk to the VP of Finance about the situation When the Plant Manager asked the VP of Finance why Purchasing had been When the Plant Manager asked the VP of Finance why Purchasing had been

directed to always take the lowest bidder the VP of Finance said, "Because you directed to always take the lowest bidder the VP of Finance said, "Because you indicated that we had to be as cost conscious as possible!" and purchasing from indicated that we had to be as cost conscious as possible!" and purchasing from the lowest bidder saves us lots of moneythe lowest bidder saves us lots of money

The Plant Manger was horrified when he realized that he was the reason there The Plant Manger was horrified when he realized that he was the reason there was oil on the plant floor. was oil on the plant floor. Bingo!Bingo!

Most Influential Systems Most Influential Systems Theory linked to Theory linked to organizations…organizations… Peter Senge (MIT)Peter Senge (MIT)

– Survival learning = adaptive learningSurvival learning = adaptive learning– Innovation = generative learningInnovation = generative learning

In order for organizations to learn they must master 5 In order for organizations to learn they must master 5 disciplinesdisciplines– Systems thinkingSystems thinking– Personal masteryPersonal mastery– Mental modelsMental models– Building shared visionBuilding shared vision– Team learningTeam learning

Senge adds to this recognition that people are agents, able Senge adds to this recognition that people are agents, able to act upon the structures and systems of which they are a to act upon the structures and systems of which they are a part. All the disciplines are, in this way, “concerned with a part. All the disciplines are, in this way, “concerned with a shift of mind from seeing parts to seeing wholes, from shift of mind from seeing parts to seeing wholes, from seeing people as helpless reactors to seeing them as active seeing people as helpless reactors to seeing them as active participants in shaping their reality, from reacting to the participants in shaping their reality, from reacting to the present to creating the future” (Senge, 1990, p. 69). present to creating the future” (Senge, 1990, p. 69).

The The Book Book That That

Started Started It All It All 19901990

Great Systems ThinkersGreat Systems Thinkers 1950s1950s

– Von BertalanffeyVon Bertalanffey, Austrian born biologist known as one of the founders , Austrian born biologist known as one of the founders of General Systems Theoryof General Systems Theory

– Anatol RapoportAnatol Rapoport, Russian-born American mathematical Jewish , Russian-born American mathematical Jewish psychologist, one of the founders of General Systems Theory, game psychologist, one of the founders of General Systems Theory, game theory and semantics, and psychological conlficttheory and semantics, and psychological conlfict

– Kenneth E. BouldingKenneth E. Boulding, (British) unbounded theorist, advocate of , (British) unbounded theorist, advocate of normative economics, normative economics,

– William Ross AshbyWilliam Ross Ashby, English psychiatrist and pioneer in study of , English psychiatrist and pioneer in study of complex systems, Ashby’s Law of Requisite Variety, principles of a self-complex systems, Ashby’s Law of Requisite Variety, principles of a self-organizing systemorganizing system

Variety absorbs Variety, defines the minimum number of states necessary Variety absorbs Variety, defines the minimum number of states necessary for a controller to control a system of a given number of states for a controller to control a system of a given number of states

– Margaret MeadMargaret Mead, cultural anthropologist, positive and negative feedback , cultural anthropologist, positive and negative feedback into the social sciencesinto the social sciences

– Gregory BatesonGregory Bateson, British anthropologist and social scientist, , British anthropologist and social scientist, cybernetics (study of communication and control involving feedback cybernetics (study of communication and control involving feedback loops to social systems)loops to social systems)

– Jay ForresterJay Forrester, MIT (pioneered the field of system dynamics -- analysis of , MIT (pioneered the field of system dynamics -- analysis of the behavior of systems)the behavior of systems)

LaterLater– Peter SengePeter Senge, MIT, (learning organizations), MIT, (learning organizations)

Stephen HawkingStephen Hawking Expanded systems thinking to the global Expanded systems thinking to the global

platform by introducing the 'Chaos Theory' platform by introducing the 'Chaos Theory' that claims the 'interconnectedness of all that claims the 'interconnectedness of all things'--- (i.e. the beating of a butterfly’s things'--- (i.e. the beating of a butterfly’s wings in Asia can affect the course of wings in Asia can affect the course of Atlantic hurricanes)Atlantic hurricanes)

Quantum Theory, origins of the universe, Quantum Theory, origins of the universe, imagery of timeimagery of time

How Systems Thinking How Systems Thinking Changes BehaviorChanges Behavior

Problem/ Cause investigationsProblem/ Cause investigations– TenerifeTenerife– TMITMI

Management failuresManagement failures– EnronEnron– Bering BankBering Bank

Process weaknessesProcess weaknesses Organizational structuresOrganizational structures

Performance Improvement Performance Improvement ModelModel

Performance Analysis

Cause Analysis Intervention Selection

Desired Performance

State Organization

Process

IndividualActual Performance

State

GAPGAP

Target GroupIntrapersonalInterpersonal

IntragroupIntergroup

Intervention TypeTraining/Learning

ConsultativeTechno-Structural

Process

Intervention Selection

Change ManagementEvaluate Results

Types of InterventionsTypes of Interventions

Training/ learningTraining/ learning– Knowledge and skillsKnowledge and skills

ConsultativeConsultative– Support and feedbackSupport and feedback– Results and consequencesResults and consequences– Employee selectionEmployee selection

Techno-structuralTechno-structural– Rewards and incentivesRewards and incentives– Equipment and toolsEquipment and tools– Organizational structureOrganizational structure

ProcessProcess– Job/process designJob/process design– Goal and strategic Goal and strategic

planningplanning

SummarySummary

ReferencesReferences Aronson, D. (1996-8). Overview of systems thinking. Aronson, D. (1996-8). Overview of systems thinking.

Retrieved 11/22/06 from Retrieved 11/22/06 from http://http://www.thinking.net/Systems_Thinking/OverviewSTArticle.pdfwww.thinking.net/Systems_Thinking/OverviewSTArticle.pdf

Heylighen, F. (1998). Basic concepts of the systems Heylighen, F. (1998). Basic concepts of the systems approach. Brussels: Principia Cybernetica Web. Retrieved approach. Brussels: Principia Cybernetica Web. Retrieved 11/21/06 from 11/21/06 from http://pespmc1.vub.ac.be/SYSAPPR.htmlhttp://pespmc1.vub.ac.be/SYSAPPR.html

McNamara, C. (1999). Systems thinking. Authenticity McNamara, C. (1999). Systems thinking. Authenticity Consulting LLC. Retrieved 11/23/06 from Consulting LLC. Retrieved 11/23/06 from http://www.managementhelp.org/systems/systems.htmhttp://www.managementhelp.org/systems/systems.htm

Senge. P. (1990). Senge. P. (1990). The fifth discipline. The fifth discipline. NY:NY: Doubleday.Doubleday.