the importance of relational strategies in microsystem ... · batalden pb, & stoltz pk. (1993)....
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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)
from decision-making to sensemaking b
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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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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)
be
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the
tech
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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.