SYSTEMS TOOLS FOR COMPLEX HEALTH SYSTEMS: A GUIDE TO CREATING CAUSAL LOOP DIAGRAMS

Transcription

1 SYSTEMS TOOLS FOR COMPLEX HEALTH SYSTEMS: A GUIDE TO CREATING CAUSAL LOOP DIAGRAMS

2 Session One 2 Five sessions 1. An introduction to Systems Thinking 2. Developing a Rich Picture 3. Creating Interrelationship Digraphs 4. Surfacing Causal Loop Diagrams 5. Applying Systems Thinking Tools

3 SESSION ONE INTRODUCTION TO SYSTEMS THINKING

4 Session One 4 Five sessions 1. An introduction to Systems Thinking 2. Developing a Rich Picture 3. Creating Interrelationship Digraphs 4. Surfacing Causal Loop Diagrams 5. Applying Systems Thinking Tools

5 Session One 5 Session outline The complexity of health systems Thinking about systems What is systems thinking? How can systems thinking help us address health system challenges? Introducing systems thinking tools

6 Session One 6 Session outline The complexity of health systems Thinking about systems What is systems thinking? How can systems thinking help us address health system challenges? Introducing systems thinking tools

7 Session One 7 Working in health systems... What is our current reality? How has this changed over time?

8 Session One 8 Current reality for health systems practitioners Prior context Discipline-based expertise (e.g., epidemiology) Disease-focused initiatives Disease-focused teams and units Donors/agencies working in parallel Donor-driven programs Current context Focus on Health system strengthening Inter- and multi-disciplinary teamwork Collaborative partnerships and joint planning Complex flows of funding, information and communication channels Increased use of technology Country-owned sustainable national health strategies

9 How do we understand our reality? Systems and Structure Events and Symptoms Patterns Tasks Crises Trends What is happening now? How do patterns play out over time and space? What are the drivers and deep structures? How are they related? Unwritten Rules Reward Systems Political dynamics Hargreaves M, 2010 Session One 9

10 Hargreaves M, 2010 Session One 10 How do we respond to our reality? Systems and Structure Events and Symptoms Patterns Tasks Crises Trends Fire-fighting Anticipating Designing Unwritten Rules Reward Systems Political dynamics

11 Session One 11 Session outline The complexity of health systems Thinking about systems What is systems thinking? How can systems thinking help us address health system challenges? Introducing systems thinking tools

12 Session One 12 Elements of a system Components/ Variables Interconnections Function

13 Session One 13 What is a system? System: an assembly of components connected together in an organized way Components are affected by being in the system and are changed if they leave it Assembly of components does something Assembly has been identified by someone as being of interest

14 Session One 14 What is a system? The central concept system embodies the idea of a set of elements connected together which form a whole, this showing properties which are properties of the whole, rather than properties of its component parts. (Checkland, 1981)

15 Session One 15 Thinking about systems A system is more than the sum of its parts. How a system behaves and performs is determined by its components, the relationships amongst these components and resultant structure of the system. System behavior reveals itself as a series of events over time.

16 Session One 16 Thinking about systems Distinguish between systems based on: degree of certainty about the link between cause and effect amongst variables in the system and degree of agreement as to the best course of action in a situation in order to produce a consistent outcome

17 Degree of agreement Thinking about systems Low Complex systems Random systems High Simple systems High Degree of certainty Low Mills A, 2010 Session One 17

18 Session One 18 General types of systems Simple (puzzle) Complicated (problem) Complex (mess)

19 Simple (puzzle) systems Following a recipe The recipe is essential Recipes are tested to assure replicability of later efforts No particular expertise required; knowing how to cook increases success Recipe notes the quantity and nature of parts needed Recipes produce standard products Certainty of same results every time Freedman, Session One 19

20 Freedman, Session One 20 Complicated (problem) systems Sending a rocket to the moon Formulae are critical and necessary Sending one rocket increases assurance that next will be ok High level of expertise in many specialized fields + coordination Separate into parts and then coordinate Rockets similar in critical ways High degree of certainty of outcome

21 Freedman, Session One 21 Complex (mess) systems Raising a Child Formulae have only a limited application Raising one child gives no assurance of success with the next Expertise can help but is not sufficient - relationships are key Can t separate parts from the whole Every child is unique Uncertainty of outcome remains

22 Session One 22 Simple, complicated or complex? Collaborating with partners? Implementing a supply chain system? Strengthening adherence to anti- retrovirals?

23 Session One 23 What is a Complex Adaptive System? A complex adaptive system is a collection of individual actors with freedom to act in ways that are often not predictable, and whose actions are interconnected, so that one agent's actions changes the context for other agents (Plesk 2001)

24 Session One 24 Health systems are complex systems Observance of health systems including findings from failed interventions tells us that a health system is a complex adaptive system BUT Methods for addressing health system problems are designed as though the health system is merely complicated

25 Session One 25 Session outline The complexity of health systems Thinking about systems What is systems thinking? How can systems thinking help us address health system challenges? Introducing systems thinking tools

26 Session One 26 What is systems thinking? Systems thinking is a discipline for seeing wholes, recognizing patterns and interrelationships, and learning how to structure those interrelationships in more effective, efficient ways. (Senge & Lannon-Kim 1991)

27 Session One 27 What is systems thinking? It is a way of thinking in approaching problems and in designing solutions that appreciates the very nature of complex [adaptive] systems as: dynamic, constantly changing, governed by history and by feedback, where the role and influence of stakeholders and context is critical, and where new policies and actions (of different stakeholders) often generate counterintuitive and unpredictable effects, sometimes long after policies have been implemented policy resistance. (Adam 2012)

28 Allen W, 2013 Session One 28 What is systems thinking? It is a way of thinking in approaching problems and in designing solutions that allows the identification of solutions that simultaneously address different problem areas and leverage improvement throughout the system.

29 Systems Thinking moves from this. Events and Symptoms Patterns Tasks Crises Trends What is happening now? How do patterns play out over time and space? Systems and Structure What are the drivers and deep structures? How are they related? Unwritten Rules Reward Systems Political dynamics Hargreaves M, 2010 Session One 29

30 to making sense of the dynamics Events and Symptoms Patterns Tasks Crises Trends What is happening now? How do patterns play out over time and space? Systems and Structure What are the drivers and deep structures? How are they related? Hargreaves M, 2010 Session One 30

31 Session One 31 Session outline The complexity of health systems Thinking about systems What is systems thinking? How can systems thinking help us address health system challenges? Introducing systems thinking tools

32 Session One 32 Health systems are complex systems Applying systems thinking to health system helps to: anticipate synergies mitigate negative emergent behaviours, policy resistance and unintended consequences when designing changes in the health system evaluating these interventions

33 Session One 33 How can Systems Thinking help to understand health systems? Practitioners need to: SEE differently THINK differently ACT differently

34 Session One 34 SEE differently

35 World Session Health Organization. One Expanding our vision of health systems From Understanding individual health systems building blocks To Understanding the relationships amongst building blocks

36 Session One 36 Expanding our vision of health systems From: Patients Towards people: who are consumers, taxpayers, citizens and coproducers of health and who interact with each other and their environment in complex, adaptive ways

37 Session One 37 Expanding our vision of health systems From a sole focus on health outcomes Towards emergent properties that serve to strengthen the health system including: Equity Trust Responsiveness Social and fair financing protection Efficiency

38 Session One 38 Expanding our vision of health systems From technical interventions Towards understanding implementation within an enabling environment

39 Session One 39 THINK differently

40 Session One 40 Think differently We cannot solve our problems with the same thinking we used when we created them. (Albert Einstein)

41 Edson R, 2008 Session One 41 Think differently Systems thinking is an ordered, methodological approach to understanding problem situations and identifying solutions to these problems. It takes into account both the forest and the trees through a process of synthesis, analysis and inquiry.

42 (Russell Ackoff, 1995) Session One 42 Think differently Without Systems Thinking We risk doing the wrong things with greater and greater efficiency rather than establishing what is the right thing to be doing. It is better to do the right thing imperfectly than to keep doing the wrong thing better and better.

43 Session One 43 Think differently Without Systems Thinking We are at risk of committing a Type III Error - the right answer for the wrong question (Schwartz 1999) In other words we have the perfect solution for a problem that has not been adequately understood

44 Session One 44 ACT differently

45 Adam Session T, 2012 One 45 Act differently We need new ways of thinking and of working in order to accommodate the complexity of the challenges in and urgent need for health system innovation and change. (Herbert and Best, 2011)

46 Act differently Accept that systems thinking is about dealing with the inevitable lack of comprehensiveness, and is not the means to achieve comprehensiveness (Midgley & Richardson, 2007) Session One 46 Midgley G, 2007

47 Session One 47 Act differently We need systems thinking tools that will assist us to: Challenge assumptions Make sense of the complexity Model a situation over time Identify appropriate leverage points for intervention Mitigate policy resistance Enable collaboration and sharing

48 Session One 48 Act differently Systems thinking tools enable three functions: Synthesis: putting together, assessing the system as a whole in its environment/context e.g., Rich Picture, Interrelationship Digraph Analysis: (combined with synthesis) understanding the detail and how the components fit together within a context e.g. Systems Map, Causal Loop Diagrams Inquiry: developing robust interventions through a systemic investigation e.g. Systems Dynamic Modeling, Scenario Planning

49 Session One 49 Systems thinking tools Synthesis Understand Whole System Context Determine Boundaries Inquiry Identify Leverage Points Develop Interventions through Systemic Investigation Analysis Understand System Itself within Context Surface & Challenge Assumptions

50 Session One 50 Session Outline The complexity of health systems Thinking about systems What is systems thinking? How can systems thinking help us address health system challenges? Introducing (a few) systems thinking tools

51 Session One 51 Useful systems thinking tools Rich Pictures Inter-relationship diagraphs Systems maps (causal loop diagrams) Systems dynamic modeling Agent based modeling Network analysis Scenario development

52 Session One 52 What we will do Create and use our own causal loop diagrams To end up here

53 Session One 53 We need to first Define the boundaries of our system seek to understand the big picture Identify the elements/variables in our system Understand how these variables might change over time Surface and test our assumptions (consider how our mental models affect our understanding of the current reality) To do all of the above we develop a RICH PICTURE

54 Rich picture Session One 54

55 Session One 55 Then we will Explore how these elements/variables relate to one another Resist coming to a quick conclusion and once again surface and test our assumptions Identify the major drivers and outcomes in our system To do this we develop an INTERRELATIONSHIP DIGRAPH

56 Interrelationship Digraph Time Until Effective Care (Third Delay) Level of Function of Referral System Quality of Health Services Size of Health Workforce Availability of Medical Equipment, Supplies & Drugs Prioritization of (Maternal) Health in Domestic Policy Level of Infrastructure Level of Corruption Presence of Conflict Government Financial Resources Amount of International Funding Session One 56

57 Session One 57 And only then do we surface a CAUSAL LOOP DIAGRAM Informed by our Rich Picture, Interrelationship Digraphs Considering both short and long-term consequences Understanding the system structure to identify possible leverage actions

58 Session One 58 We use this causal loop diagram to: Understand the system structure giving rise to the system behavior Find where unintended consequences (policy resistance) emerge Explore consequences of proposed action Recognize impact of time delays when exploring relationships Identify possible leverage points for actions

59 Session One 59 Always remembering that All models are wrong, some are useful (Attributed to George Box)

60 Session One 60 References Hargreaves M, Parsons B, and Moore M. Evaluating Complex Systems Initiatives. Professional development workshop presented for the National Institutes of Health Evaluation Set-Aside Program, Evaluation Office, Division of Program Coordination, Planning and Strategic Initiatives, Bethesda, MD, February 25 26, Checkland P. (1981). Systems Thinking Systems Practice. Chichester: John Wiley. Mills A. Complexity science. An Introduction (and invitation) for actuaries. Society of Actuaries Freedman, ODI presentation, Exploring the science and remains. complexity of aid policy and practice, London, July Plsek P, Greenhalgh T. Complexity science. The challenge of complexity in health care. BMJ. 2001;323: Senge P, Lannon-Kim C. The Systems Thinker Newsletter. 1991; 2(5). Adam T, de Savigny D. Systems thinking for strengthening health systems in LMICs: need for a paradigm shift Health Policy and Planning 2012;27:iv1 iv3 Allen W. sparksforchange. Complicated or complex knowing the difference is important. March 3, World Health Organization. Everybody s Business: Strengthening health systems to improve health outcomes WHO s Framework for Action. Geneva: WHO, 2007, page 3. Edson R. Systems Thinking. Applied. A Primer Accessed December Midgley G, Richardson KA (ed.) Systems Thinking for Community Involvement in Policy Analysis Systems thinking for community involvement in policy analysis E:CO Issue Vol. 9 Nos pp Foresight Tackling obesities: future choices

61 Session One 61 Thank you Presentation developed by Helen de Pinho MBBCh, MBA, FCPH assisted by Anna M. Larsen BS, MPH Averting Maternal Death and Disability Program (AMDD) Heilbrunn Department of Population and Family Health Mailman School of Public Health This work was coordinated by the Alliance for Health Policy Columbia and Systems University Research, the World Health Organization, with the aid of a grant from the International Development Research Centre, February Ottawa, 2015 Canada. February 2015