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the importance of relational strategies in

microsystem improvement

beyond the technical

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Without overthinking, generate a list of:

common strategies, methods, tools, approaches

used in your organization to support improvement

The essential flaw of [quality improvement methodology] is that, when

implemented, it tends to reinforce the mechanistic and hierarchical models that are consistent with the mental maps of

most managers Chris Argyris,

Flawed Advice and the Management Trap

Read more at: http://www.slideshare.net/HelenBevan/signed-sealed-delivered-leading-improvement-in-a-new-era and http://www.slideshare.net/jurgenappelo/management-30-workout

From H. Bevan and G. Henriks

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two kinds of knowledge

professional knowledge

• subject

• discipline

• values

improvement knowledge

• system

• variation

• psychology

• theory of knowledge

patient by patient

improvement of healthcare

systematic

improvement of processes

and systems +

continuous improvement of health care

Adapted from Batalden & Stoltz (1993)

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improvement knowledge

Deming

knowledge

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“Left side – Right side” © Zach Baranowski available at http://www.flickr.com/photos/zbaranowski_photography/6926052984/

TECHNICAL systems • mapping • fishbone

variation • measurement

knowledge • plan-do-study-act

psychology • commitment maps • force-field analysis

RELATIONAL systems • sympathy • complexity

variation • narrative

knowledge • sensemaking

psychology • curiosity • reflective practice

RELATIONAL STRATEGIES: SYSTEMS THINKING

http://www.flickr.com/photos/josefstuefer/9500503/

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understanding of a system: sympathy

recognize that “we are part of the system”

Anderson & Johnson (1997)

relate to the system and those in the system

• what is your role?

• how do your actions or inactions affect the ability to

change?

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understanding of a system: complexity

1) use the lens of complexity: interdependence &

individuality

2) provide minimum specifications: simple rules

3) lead with clockware & swarmware in tandem:

standardization & experimentation

4) tune to the edge: ‘just enough’ information flow, diversity,

connectivity, power differential, & anxiety

Adapted from Zimmerman, Lindberg, Plsek (2008)

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understanding of a system: complexity

5) work with paradox: wicked questions

6) go for multiple actions rather than consensus

7) listen to the shadow system: it’s where the creativity lives

8) grow by chunking: link simple systems that work well

9) mix cooperation with competition

Adapted from Zimmerman, Lindberg, Plsek (2008)

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Example: scope overlap in physicians

Technological advances have made it possible for radiologists and cardiologists to reshape damaged arteries, something that used to require the skills of a vascular surgeon.

In most places, a senior administrator would be put in the unenviable position of representing the system's interests, while serving as negotiator and referee among these powerful constituencies.

Atlantic Health Systems took a CAS Approach…

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Example: scope overlap in physicians A CAS approach instead involves

1) "convening a group with representatives of all three specialties" (increasing diversity, connections among agents, and anxiety);

2) giving them honest information about the system's resources and requirements (increasing information flow and tuning the power differential);

3) "asking them to develop a plan" (in the end, decreasing diversity and power differential); and

4) "telling them that the system won't invest in the procedure until they have come up with such a plan" (increasing power differential and anxiety). This approach led to many, creative, successful, collaborative relationships with physician groups at a time when many health care organizations report nothing but contention. Plesk P, Lindberg C, Zimmerman B. Some Emerging Principles for Managing in Complez Adapative Systems (1997). Accessed May 26, 2014 at: http://www.plexusinstitute.org/page/edgeware/?

RELATIONAL STRATEGIES: VARIATION

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who has heard…

“if you can’t measure it,

you can’t manage it”

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Deming

It is wrong to suppose that if you can’t

measure it, you can’t manage it –

a costly myth.

The New Economics (1994)

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Deming

The most important things cannot be

measured.

The most important things are

unknown or unknowable.

Out of the Crisis (1994)

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variation: the power of narrative

patience and trust are essential for preparing to

listen to stories… “we should listen with three

ears: two on our head and one in our heart”

Archibald (1997)

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RELATIONAL STRATEGIES: THEORY OF KNOWLEDGE

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organizational sensemaking is interactive, social, shared

“knowledge is not something people possess in their

heads but rather something they do together”

Weick (2009)

theory of knowledge: sensemaking

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If I make a decision it is a possession. I take pride in it, I

tend to defend it and not listen to those who question it.

If I make sense, then this is more dynamic, and I listen

and I can change it.

A decision is something you polish.

Sensemaking is a direction for the next period.

Gleason (1995) cited in Berwick (2004)

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When bewildered people ask, “what’s the story?” the

crucial thing is to get them moving, observing, updating,

and arguing about feasibility and plausibility. A powerful

means to do this is for the leader to answer the question

by saying, “I don’t know what the story is, but let’s find out”

Weick (2009)

leader’s role in sensemaking

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RELATIONAL STRATEGIES: PSYCHOLOGY OF CHANGE

“monarch lifecycle 13 of 20” and “newly emerged monarch butterfly” © Sid Mosdell available at http://www.flickr.com/photos/sidm/with/4813040967/

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psychology: curiosity

Continually inquire into the “unchanged present.”

Living systems adapt & respond to their internal and

external contexts. They resist intentional change partly

because there are competing commitments and

assumptions which effectively hold the unchanged present

in place…

Batalden (2011)

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psychology: reflective practice

Adapted from Senge, Kleiner, Roberts, Ross, & Smith (1994)

levels of understanding

Action Mode Time Orientation Way of Perceiving Questions you would

ask

Events react! present witness event what is the fastest way to react to this event

now?

Patterns adapt! measure or track

patterns of events

what kinds of trends or patterns of events

seem to be occurring?

Structure create

change! future

systems thinking tools

what structures are in place that are causing

these patterns?

System Thinking Basics, Anderson and Johnson, 1997

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what about mental models?

left-hand column

ladder of inference

johari window

Action Mode Time Orientation Way of Perceiving Questions you would

ask

Mental Models

reflect! past-present-

future reflection tools

what is my role in this? why are things the way

they are?

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Argyris (1990) in Senge, Kleiner, Roberts, Ross, & Smith (1994)

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Johari window

Luft (1984) from Luft and Ingham (1955)

known

by self

unknown

by self

known by others

OPEN BLIND

unknown by others

HIDDEN UNKNOWN

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Chapman (2003)

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al “ruthlessly compassionate partners

who will tell the truth”

Senge, Kleiner, Roberts, Ross, & Smith (1994)

seek out

“Left side – Right side” © Zach Baranowski available at http://www.flickr.com/photos/zbaranowski_photography/6926052984/

TECHNICAL systems • mapping • fishbone

variation • measurement

knowledge • plan-do-study-act

psychology • commitment maps • force-field analysis

RELATIONAL systems • sympathy • complexity

variation • narrative

knowledge • sensemaking

psychology • curiosity • reflective practice

integrating the technical and relational

promise-making

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promise-making

For society and interdependent work to function,

we must make promises to each other

Batalden (2011)

based on Arendt (2005)

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promise-making

type of promise helpful knowledge/preparation

to self: about

professional work

clarity about personal values, meaning

of work

to patient: about

system performance

knowledge of performance, sufficient for

prediction…

to patient: about

one’s own role in the system

knowledge of the way personal

performance contributes to the results

experienced by the patient

to colleagues: about

one’s own work

knowledge of the way one’s own work

connects to the work of others and vice

versa

Batalden (2011)

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promise-making

type of promise helpful knowledge/preparation

to self: about

professional work

clarity about personal values, meaning

of work

to patient: about

system performance

knowledge of performance, sufficient for

prediction…

to patient: about

one’s own role in the system

knowledge of the way personal

performance contributes to the results

experienced by the patient

to colleagues: about

one’s own work

knowledge of the way one’s own work

connects to the work of others and vice

versa

Batalden (2011)

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promise-making

type of promise helpful knowledge/preparation

to self: about

professional work

clarity about personal values, meaning

of work

to patient: about

system performance

knowledge of performance, sufficient for

prediction…

to patient: about

one’s own role in the system

knowledge of the way personal

performance contributes to the results

experienced by the patient

to colleagues: about

one’s own work

knowledge of the way one’s own work

connects to the work of others and vice

versa

Batalden (2011)

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promise-making

type of promise helpful knowledge/preparation

to self: about

professional work

clarity about personal values, meaning

of work

to patient: about

system performance

knowledge of performance, sufficient for

prediction…

to patient: about

one’s own role in the system

knowledge of the way personal

performance contributes to the results

experienced by the patient

to colleagues: about

one’s own work

knowledge of the way one’s own work

connects to the work of others and vice

versa

Batalden (2011)

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works cited & consulted Anderson V, Johnson L. (1997). Systems thinking basics. Waltham, MA: Pegasus Communications.

Archibald J. (1997). Coyote learns to make a storybasket : the place of First Nations stories in education

(doctoral dissertation). Retrieved from http://summit.sfu.ca/item/7275.

Arendt H. (1958). The Human Condition. Chicago, IL: Chicago University Press

Batalden PB (2011). Leading the Improvement of Health Care: A One-Page Book. Unpublished manuscript,

based on lecture available at: http://www.youtube.com/playlist?list=PLB534E7ED26273C53

Batalden PB, & Stoltz PK. (1993). A framework for the continual improvement of health care: building and

applying professional and improvement knowledge to test changes in daily work. The Joint Commission

journal on quality improvement, 19(10), 424.

Berwick DM. (2004). Escape fire: designs for the future of health care. San Francisco, CA: Jossey-Bass.

Chapman A (2003). Retrieved from: www.businessballs.com/johariwindowmodel.html.

Deming WE. (1994). The new economics: for industry, government, education. Cambridge, MA: MIT press.

Deming WE. (2000). Out of the Crisis. Cambridge, MA: MIT press.

Luft J. (1984). “The Johari Window: a graphic model of awareness in interpersonal relations”. Group

Processes: an introduction to group dynamics. Palo Alto, CA: Mayfield Publishing Co.

Senge P, Kleiner A, Roberts C, Ross R, & Smith, B. (1994). The Fifth Discipline Fieldbook. New York, NY:

Doubleday.

Weick, KE. (2009). Making Sense of the Organization (Vol. 2) The Impermanent Organization. West Sussex,

UK: John Wiley & Sons Ltd.

Womak J, Jones D, & Roos. (1990). The machine that changed the world. New York, NY: Rawson Associates.

Zimmerman BJ, Lindberg C, and Plsek PE. (1998). Edgeware: Insights from Complexity Science for Health

Care Leaders. Dallas, TX: VHA Publishing.