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Dr Kambiz Maani presented this overview of systems thinking and how it relates to health.
Systems thinking is one of the five disciplines of a "learning organisation", a concept popularised by Peter Senge.
Maani broke down the term "systems thinking" into its component parts "system" and "thinking". He emphasised the need for new ways of thinking and offered some definitions of the term "system".
Systems thinking can be defined as a language for understanding change, uncertainty and complexity and for creating harmony of thoughts and actions.
Maani considered why systems thinking is required, citing such factors as the increasing interdependence and complexity of the world, the need for leadership and decision-making at all levels of work and the need for shared vision and alignment of thoughts and action. He also cited the need for a common language for understanding uncertainty and complexity. These issues exist internationally and within and outside the health sector.
| Maani set out nine principles of systems: | |
| 1. | Cause and effect are often not close in time and space. Quick results may be misleading. The time between decisions and results may be much longer than expected and may show itself in a very different place. |
| 2. | Today’s problems are often caused by yesterday’s solutions (linked to principle 1). |
| 3. | All actions have feedback. There is a false expectation that the world is linear. Actions can produce results that impact back on action taken. |
| 4. | There is often talk of either "this" or "that" but there is likely to be a number of issues in between (AND vs OR rather than either/or). The tendency to accept one and reject the other is shallow and ignores multiple possibilities. |
| 5. | Results are not proportional to effort. We expect them to be proportional to effort because we expect the world to be linear. |
| 6. | We contribute to our own problems through our assumptions, values, beliefs, and unintended consequences of our actions. The system itself generates a lot of its own problems. |
| 7. | A system is as good as its weakest link - there is often a focus on "star performers" at the expense of ignoring the weaker parts. |
| 8. | There is more than what we can "see". Soft measures, such as staff morale, commitment and respect for leadership, are powerful indicators of performance. |
| 9. | The structure of systems determines its behaviour - there is a lot of interest in changing behaviour but this will not happen if attention is not paid to the structure driving the change. |
Maani presented four levels of "seeing reality" in a pyramid diagram (refer slide 12). "Events", such as news, form the top of the pyramid, "patterns of behaviour", which change over time, are at the next level down and below these are "structures", which describe how things relate to each other. "Mental models", another of the five disciplines of Senge’s "learning organisation", are at the base of the pyramid and offer the most fundamental leverage for change. Systems thinking provides the tools for achieving this.
The balance of the presentation focused on systems thinking, one of the five disciplines of a learning organisation (refer slide 16), and the related discipline of organisational learning.
Organisations fail because they do not learn fast enough and adapt fast enough. It has been proposed that the rate at which individuals and organisations learn may become the only sustainable competitive advantage.
Individual learning is not necessarily organisational learning.
Maani reviewed the core principles of learning, as put forward by Senge:
• Learning starts with ignorance.
• Making mistakes is fundamental to learning.
• Thinking is the foundation of learning.
• Learning requires action.
• Learning requires theory (why things work the way they do).
• Management’s job is to focus on relationships.
• Quality of relationship affects quality of learning.
• Learning must be connected to what people really care about.
• Learning requires engaging the full person, spirit, mind and body.
There are lots of mechanisms in business that prevent learning, for example, the first two principles above are hard concepts to sell in organisations where there is a habit of disguising error. In addition, organisations, where there is often a culture of doing versus thinking, tend to leave little time for thinking, and management, rather than focusing on relationships, tends to focus on "things".
Many studies show that managers regularly and consistently make wrong decisions. Maani noted that to expect managers not to make mistakes is wrong. There is a need to learn and to treat mistakes as learning.
Maani presented some health systems models. He presented a UK case demonstrating the main feedback loops emerging from a case study in UK community care (refer slide 22). The causal loop diagram showed the links between all relevant variables and how demand on the separate budgets for community care and hospital care was affected by decisions in many different parts of the system and could not really be separated out.
A similar diagram showing the two main loops involved in the UK-based management of short-term psychiatric patients demonstrated the value of the diagrams to determine the potential effects of proposed changes in policy (refer slides 23 and 24).
Maani then presented a New Zealand case study that considered the determinants of quality in health care, as described by staff and by policy makers (refer slides 28 and 29). Despite the same question being provided to both groups, very different variables were identified as well as different relationships, and different language was used. This exercise demonstrated the dissimilar mental models of the participants.
[View Kambiz Maani’s presentation Systems Thinking-From Complexity to Elegant Simplicity]
