Thank you for sharing this very interesting chapter Matthew – it does rather resonate – especially the “maverick at the edge of the organisation” phrase. Our understanding of complex adaptive systems (CAS) is growing and we know that exploring the “edge of chaos” is where the future innovations will be found and this implies “prodding the tender spots” and seeing what happens as Dave Snowdon might describe it. These are the “elephant in the room” questions that are inherently uncomfortable and the usual emotional reactions are “ignore the message” and “shoot the messenger” because, to use the Chris Argyris phrase “the undiscussables are undiscussable”. This is the built-in negative feed back loop or defence mechanism that stabilises the current paradigm and that also blocks innovation. Ever has it been so according to Thomas Kuhn who wrote “Structure of Scientific Revolutions” and coined the phrase “paradigm shift”. Unfortunately, those who promote improvement can get stuck in the same trap and fail to walk their own talk and to continuously challenge their own assumptions .. i.e. push themselves to the edge of chaos. And it is interesting to note that innovators such as W Edwards Deming never stopped evolving their own learning – while they were alive and I’m sure would be dismayed to see their last iteration treated like a Bible. It is also interesting to observe that a new discipline is emerging as our understanding of complex adaptive systems deepens … that is called complex adaptive systems engineering (CASE) and health care would seem to be a worthy place to try it out. Perhaps in the most chaotic bits such as emergency care and primary care that to date have resisted conventional improvement approaches?
Thank you too Matthew, perfect timing for me and capturing some of my current learning and experience of improving the results in our systems. I have two ‘edges’ that I’ve been thinking about right now. The first relates to QI methodologies and the big question about where/when we should and shouldn’t apply the scientific method to what we do. We keep applying reductionist approaches to defining problems and designing interventions in our complex systems. I think we need some new thinking on that, pick up where Deming left off as you say Simon. The second is the sole application of the ‘systems leadership’ approach to multi-agency/organisation endeavours. To the obvious boundaries. What about the boundaries within organisations? The boundary, for example, between professions, between cultures. The hierarchical model of leadership is dead no matter where you choose to place your boundaries.
Also, with you Simon on applying some new thinking to emergency care and primary care – if they’re not complex problems, they’ll do until a complex problem comes along! Maybe this is the space for an applied Q capability building across boundaries piece?
Great to read your insightful comments. I hope you both can join Gareth Evans’ zoom call on Friday: he’ll be sharing one of the systems thinking/complexity approaches that has got a bit further with practical tools and frameworks – Human Systems Dynamics.
Also, Etienne Wenger has said that he can do a session about ‘Systems Convening’ later in the year (needs to finish his current book, over the summer, first). I think the book after that is actually going to be a handbook on Systems Convening – just what the NHS needs imho.
I also find Prof Mary Uhl-Bien’s ‘Adaptive spaces’ framework for working with complexity in healthcare and elsewhere particularly helpful. It described pretty much perfectly the path of Hexitime (the first national NHS Timebank) from idea to launch.
Hi Matthew,
Thanks for all these signposts … sadly I am already committed on Friday so I can’t join the Zoom. I have read some of Etienne’s work so am looking forward to a new book. Adaptive spaces resonates with me so I’ll need to look at that because one of the ways that I have successfully applied complexity science in practice is in the arena of “emergence” and “self-organisation”. In one of the first awareness raiser workshops that I run the delegates are given the pragmatic challenge of redesigning a chaotic outpatient clinic – but I don’t provide a recipe of how to do it – I just provide the tools and say that it is possible. What then happens is fascinating to watch. The microsystem design teams (about 7 people is the ideal size) self-organise and the counter-intuitive solution just emerges from their collective actions. It has never failed yet – and the delegates are always very surprised (and delighted). If they were sceptical about improvement by diagnosis-and-design before they are certainly not afterwards!
Hi Simon – so each team has a bunch of potential tools they could potentially use, but nothing more than that?
It’s fascinating that Wenger has seen that there’s a cross-boundary, complexity-aware role that is above the level of the Communities of Practice he usually focuses on.
Hi Matthew,
Not a bunch of tools – just one tool – and one that was invented about 100 years ago.
The challenge is to use the tool to solve the clinic design problem and how to do that is counter-intuitive because of the unconscious assumptions that the participants are using are creating a fog of confusion.
This is why so many NHS clinics are chaotic and have been so for a long time, but the chaos is avoidable.
Just me saying that “it is possible to solve with what you have on the table” removes the “impossibility” assumption and focuses the team on finding what they cannot yet see. Sometimes they need a nudge/hint if they get stuck and that is usually done using a Socratic Question.
The solution is an emergent phenomenon of the complex adaptive system and is tangible evidence that they have unlearned their limiting belief(s).
I developed this emergent learning approach because I found trying to explain how to solve the problem doesn’t work … because it is counter-intuitive. Demonstration and explanation operate at the conscious level and if there are limiting beliefs operating out of awareness the result is more confusion and frustration. The answer has to be ‘discovered’ (or technically re-discovered because the solution is well known outside the NHS). And the effect is profound because the fog of confusion evaporates, clarity of insight is established and there is an OMG emotional reaction. What was impossible is now obvious.
All I did was “design” (i.e. engineer) the context for the “magic” to happen.
Ask Hesham Abdalla … he has seen it twice … and Walsall are running one of these workshops next week.
The idea of systems convening certainly resonates in public health and to some extent it’s helpful to use as a lens for my own practice. I’m currently part way through an MSc in Systems thinking in practice through OU and very thoughtful about the extent of its application – how to translate some of the theory into practice – and more importantly engage others in seeing the benefits of that! Also interested in how systems ideas and theories translate into improvement. Perhaps it’s about where we do that – ie do we spend enough time trying to understand a system before deciding what needs to be improved? Do we need to maintain a tension between systems (holistic) approaches and improvement (systematic) approaches?
Really interested to hear others’ thoughts.
Simon, I’m curious to know – are you able to say what the tool is that you refer to in your magical workshop?
Hi Emma,
The “magical” tool is a big strip of squared paper, coloured pens and some coloured card and is based on the original work of Henry Laurence Gantt who died in 1919 (i.e 100 years ago). Ask Hesham Abdalla … he has seen it in action several times and I believe has used it at Walsall for re-designing their Ante Natal Clinic to reduce queues, chaos and patient waiting. PS. There is no such thing as magic … or rather the magic disappears when the magician reveals how the ‘impossible’ was made possible. 😉
With regards,
Simon
Hi Emma,
I’ve got to say that the clearest big picture model I’ve seen of why we need systems/complexity thinking is Prof Mary Uhl-Bien’s: https://youtu.be/miEcPzx3_FI (the video blurb explains her model, and she doesn’t talk for long in the video, 20 or 25 mins).
What model do you find most helpful for explaining it to others?
Thank you for sharing this very interesting chapter Matthew – it does rather resonate – especially the “maverick at the edge of the organisation” phrase. Our understanding of complex adaptive systems (CAS) is growing and we know that exploring the “edge of chaos” is where the future innovations will be found and this implies “prodding the tender spots” and seeing what happens as Dave Snowdon might describe it. These are the “elephant in the room” questions that are inherently uncomfortable and the usual emotional reactions are “ignore the message” and “shoot the messenger” because, to use the Chris Argyris phrase “the undiscussables are undiscussable”. This is the built-in negative feed back loop or defence mechanism that stabilises the current paradigm and that also blocks innovation. Ever has it been so according to Thomas Kuhn who wrote “Structure of Scientific Revolutions” and coined the phrase “paradigm shift”. Unfortunately, those who promote improvement can get stuck in the same trap and fail to walk their own talk and to continuously challenge their own assumptions .. i.e. push themselves to the edge of chaos. And it is interesting to note that innovators such as W Edwards Deming never stopped evolving their own learning – while they were alive and I’m sure would be dismayed to see their last iteration treated like a Bible. It is also interesting to observe that a new discipline is emerging as our understanding of complex adaptive systems deepens … that is called complex adaptive systems engineering (CASE) and health care would seem to be a worthy place to try it out. Perhaps in the most chaotic bits such as emergency care and primary care that to date have resisted conventional improvement approaches?
Thank you too Matthew, perfect timing for me and capturing some of my current learning and experience of improving the results in our systems. I have two ‘edges’ that I’ve been thinking about right now. The first relates to QI methodologies and the big question about where/when we should and shouldn’t apply the scientific method to what we do. We keep applying reductionist approaches to defining problems and designing interventions in our complex systems. I think we need some new thinking on that, pick up where Deming left off as you say Simon. The second is the sole application of the ‘systems leadership’ approach to multi-agency/organisation endeavours. To the obvious boundaries. What about the boundaries within organisations? The boundary, for example, between professions, between cultures. The hierarchical model of leadership is dead no matter where you choose to place your boundaries.
Also, with you Simon on applying some new thinking to emergency care and primary care – if they’re not complex problems, they’ll do until a complex problem comes along! Maybe this is the space for an applied Q capability building across boundaries piece?
Hi Simon and Liz.
Great to read your insightful comments. I hope you both can join Gareth Evans’ zoom call on Friday: he’ll be sharing one of the systems thinking/complexity approaches that has got a bit further with practical tools and frameworks – Human Systems Dynamics.
Also, Etienne Wenger has said that he can do a session about ‘Systems Convening’ later in the year (needs to finish his current book, over the summer, first). I think the book after that is actually going to be a handbook on Systems Convening – just what the NHS needs imho.
I also find Prof Mary Uhl-Bien’s ‘Adaptive spaces’ framework for working with complexity in healthcare and elsewhere particularly helpful. It described pretty much perfectly the path of Hexitime (the first national NHS Timebank) from idea to launch.
Hi Matthew,
Thanks for all these signposts … sadly I am already committed on Friday so I can’t join the Zoom. I have read some of Etienne’s work so am looking forward to a new book. Adaptive spaces resonates with me so I’ll need to look at that because one of the ways that I have successfully applied complexity science in practice is in the arena of “emergence” and “self-organisation”. In one of the first awareness raiser workshops that I run the delegates are given the pragmatic challenge of redesigning a chaotic outpatient clinic – but I don’t provide a recipe of how to do it – I just provide the tools and say that it is possible. What then happens is fascinating to watch. The microsystem design teams (about 7 people is the ideal size) self-organise and the counter-intuitive solution just emerges from their collective actions. It has never failed yet – and the delegates are always very surprised (and delighted). If they were sceptical about improvement by diagnosis-and-design before they are certainly not afterwards!
Hi Simon – so each team has a bunch of potential tools they could potentially use, but nothing more than that?
It’s fascinating that Wenger has seen that there’s a cross-boundary, complexity-aware role that is above the level of the Communities of Practice he usually focuses on.
Do you ever include ‘Relational Coordination’ work, like the Sheffield Microsystems folks do? They started with the full online survey, but now just do the manual f2f version: http://www.liberatingstructures.com/relational-coordination/
This page has some links to read more about Uhl-Bien’s framework: https://q.health.org.uk/event/how-to-support-innovation-in-the-nhs-with-a-little-help-from-complexity-science-zoom-webinar-with-prof-mary-uhl-bien/
Michael Arena even wrote a whole book on it, called Adaptive Space – though did do justice to the entire model, focused more on the networks aspect.
Hi Matthew,
Not a bunch of tools – just one tool – and one that was invented about 100 years ago.
The challenge is to use the tool to solve the clinic design problem and how to do that is counter-intuitive because of the unconscious assumptions that the participants are using are creating a fog of confusion.
This is why so many NHS clinics are chaotic and have been so for a long time, but the chaos is avoidable.
Just me saying that “it is possible to solve with what you have on the table” removes the “impossibility” assumption and focuses the team on finding what they cannot yet see. Sometimes they need a nudge/hint if they get stuck and that is usually done using a Socratic Question.
The solution is an emergent phenomenon of the complex adaptive system and is tangible evidence that they have unlearned their limiting belief(s).
I developed this emergent learning approach because I found trying to explain how to solve the problem doesn’t work … because it is counter-intuitive. Demonstration and explanation operate at the conscious level and if there are limiting beliefs operating out of awareness the result is more confusion and frustration. The answer has to be ‘discovered’ (or technically re-discovered because the solution is well known outside the NHS). And the effect is profound because the fog of confusion evaporates, clarity of insight is established and there is an OMG emotional reaction. What was impossible is now obvious.
All I did was “design” (i.e. engineer) the context for the “magic” to happen.
Ask Hesham Abdalla … he has seen it twice … and Walsall are running one of these workshops next week.
Hi all
The idea of systems convening certainly resonates in public health and to some extent it’s helpful to use as a lens for my own practice. I’m currently part way through an MSc in Systems thinking in practice through OU and very thoughtful about the extent of its application – how to translate some of the theory into practice – and more importantly engage others in seeing the benefits of that! Also interested in how systems ideas and theories translate into improvement. Perhaps it’s about where we do that – ie do we spend enough time trying to understand a system before deciding what needs to be improved? Do we need to maintain a tension between systems (holistic) approaches and improvement (systematic) approaches?
Really interested to hear others’ thoughts.
Simon, I’m curious to know – are you able to say what the tool is that you refer to in your magical workshop?
Hi Emma,
The “magical” tool is a big strip of squared paper, coloured pens and some coloured card and is based on the original work of Henry Laurence Gantt who died in 1919 (i.e 100 years ago). Ask Hesham Abdalla … he has seen it in action several times and I believe has used it at Walsall for re-designing their Ante Natal Clinic to reduce queues, chaos and patient waiting. PS. There is no such thing as magic … or rather the magic disappears when the magician reveals how the ‘impossible’ was made possible. 😉
With regards,
Simon
Hi Emma,
I’ve got to say that the clearest big picture model I’ve seen of why we need systems/complexity thinking is Prof Mary Uhl-Bien’s: https://youtu.be/miEcPzx3_FI (the video blurb explains her model, and she doesn’t talk for long in the video, 20 or 25 mins).
What model do you find most helpful for explaining it to others?