Professor Brenda Zimmerman,

Director of Health Industry Management Program

Schulich School of Business,

September 23, 2014

Engaging with Complexity

Thrive! A Plan for a Healthier Nova Scotia

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Why do strategic plans tend to fall short of expectations?

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There Are Several Types of Problems

pSimpleMaking Soup

Right “recipe” essential

Gives same results every time

pComplicatedSending a Rocket to the 

Moon

“Formulae” needed

Experience built over time and can be repeated with success

pComplex

Raising a Child

No “right” recipes or protocols Outside factors influence Experience 

helps, but doesn’t guarantees success

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Throwing a Rock or a Bird?

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y = x2 – b

f = ma

?“attractor pattern”

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Complicated and Complex Systems

Complicated (machine-like)– Metaphor: Send a rocket to the moon– Reliance on installation and mechanical replication of technically

correct solutions designed by experts.

Complex (organic)– Metaphor: Raising a child– Keys: appreciation of uniqueness, interaction, being adaptable,

& staying tuned in to what is happening. Looking for the attractor patterns

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6http://www.youtube.com/watch?v=Miwb92eZaJg

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Dave Snowden – BD party lessons “We manage emergence of beneficial coherence

within attractors, within boundaries.”

How? We observe & stimulate the patterns of activity

called an attractor. When we see beneficial attractors – we attempt to

stabilize and amplify them When we see negative attractors – we attempt to

dampen or destroy them

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Understanding Change in Complex Social Systems

Behavior of the system can be largely explained by understanding “attractors.”

Relationships and coordination among parts can be more important than the parts themselves.

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Creating Attraction for Change

The concept of “resistance to change” is negative and emotionally draining

We need to stop speaking of “us” and “them”

Complex adaptive systems can be understood through attractor patterns

How can I make my change more naturally attractive to others?

When you encounter resistance, ask yourself… “What is it that *I* do not understand here?”

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Know When Your Challenges Are In the Zone of Complexity

CertaintyClose to Far from

Clo

se to Simple

Plan, control

Chaos

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Simple &

complicatedPlan, control CertaintyClose to Far from

Clo

se to

ChaoticSeek Patterns

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CertaintyClose to Far from

Clo

se to

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Workout one on SCC Take a stuck problem you have. One that keeps

rearing its head.

Use two peers to interview you about this. Their job is to get the facts and probe deeper but NOT to advice or share their own experiences.

Where is the issue on the SCC grid? What strategies have you been trying to date? What

is working? What isn’t working?

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“Things that never happened before, happen all the time”

Kathleen Sutcliffe, PhD

So what??We need to be skillful at expecting, seeing andresponding to surprise. This is both for individuals

and the collective.

Key to adaptability

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Lessons From Biology Living systems - follow simple “rules” or minimum specifications that create complex adaptability

“Boids”, ants, democracy & chess

Champions for Change: Leading a Backbone Organization for Collective

Impact

16April 2013 Champions for Change: Leading a Backbone Organization for Collective

Impact

Insert flamingos….

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Example: Reynolds’ Flocking Rules

Maintain a minimum distance from other boids and objects

Match speed of neighbouring boids Move toward the center of mass of flock-mates in

your area

Complex “flocking” emerges!

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Exploring Min Specs/ Simple Rules

What are the rules that are currently affecting action? (inductive analysis)

What are the minimum set of rules to shape action in the future? (deductive analysis)

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ALCOA – “prevent all injuries”

Safety is a precondition not a priority(if priority – can say “can’t afford to be better”)

Report all injuries within 24 hours(“capital offense” – failure has consequence)

Share lessons learned(financial incentive to learn and share)

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Priority vs. Precondition

Paul O’Neill – ED of Pittsburg Health Authority (ex CEO of Alcoa and also ex Secretary of Commerce)

“When “safety” is a priority rather than a precondition, won’t have “0” accidents.”

Preconditions aren’t negotiable

“Capital offense” to not report accidents

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Patient Safety – example Missouri Baptist hospital

Fix what you can Tell what you fixed Report what you cannot

ALL employees know this and it is reinforced through both compensation and evaluation

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Checklist vs. Min Specs/Simple Rules

Min Specs/Simple Rules Need to adapt

quickly to changing circumstances Set boundaries of

acceptable behaviour Leave room for

flexibility or creativity Coherence Adaptability

Checklist Lay out clear task Optimal process

known apriori Steps to optimal

process known and articulated Consistency Efficiency

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… Picking up on yesterday’s remarks

“Why is our health not a sacred value in Canada?”

… “should be a priority”…. Minister Glavine

Beyond priority to precondition

If it is a sacred value it will influence every decision.

It would be a “minimum specification”.

“Governance for Health” - Hancock

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Imagine what it would mean if Nova Scotia adopted human development as a pre-condition. Then the economy could be a priority

as it would be filtered through the lens of human development. Priorities can change year by year

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Min Specs/Simple Rules – allow for swarming

They give enough of a sense of direction without over-specifying

Local solutions can be discovered (at the “edge” rather than center)

Following same rules – can result in different solutions – Creates coherence rather than

consistency– Allows for constant adaptation &

innovation

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“… Human systems grow toward

what they persistently

ask questions about”

(Cooperrider and Whitney 1999, 10).

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The Brazil Complex Problem

How do you respond to an AIDS epidemic in a developing country? No money for expensive drugs

– problems of affordability of drugs A very iffy health care system

– problems of treatment High levels of illiteracy

– problems of compliance even if there were drugs High levels of poverty and hunger

– problems of nutritional needs for drugs And… it is a sexually transmitted disease

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Questions Posed by World Bank “What will drug costs be for the infected

population?”

“What resources are needed to manage drug therapies for illiterate patients?”

“What resources are needed to assure compliance with drug associated nutrition in this population?”

“What are the resources needed for an effective prevention program?”

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World Bank Responds to AIDS as Complicated

Meaningful solutions require sophisticated, integrated national health care systems We cannot provide treatment to all when

the drug costs are so high We cannot afford resources to manage

treatment compliance With our limited resources, we should

focus more on prevention than treatment It will therefore take a long time for the

problem to work itself through

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Brazil Implicitly Recognized the Complexity

Were unwilling to accept the answers of the World Bank

Hence – had to change the questions…– Changing the questions changes the

focus, changes what is “analyzed”, changes what is seen as possible/impossible

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The Brazil Questions Assume Complexity

“What will drug costs be for our infected population?”

“What resources are needed to manage drug therapies for illiterate patients?”

“How can we reduce costs so that we can provide treatment to all who need it?”

“What methods of communication will work to convey the drug therapy routine to a patient – even a homeless, illiterate patient?”

World Bank Questions Brazil Questions

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The Brazil Questions

“What resources are needed to assure compliance with drug associated nutrition in this population?”

“What are the resources needed for an effective prevention program?”

“If food is an issue, how can we ensure greater compliance by linking up with charities/food banks/ churches etc.?”

“How can we achieve our prevention goals while treating all of those currently infected?”

World Bank Questions Brazil Questions

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Brazil saw the value in the relationships as the key to change

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The Brazil Conclusions

Meaningful solutions require sophisticated, integrated national health care systems

We cannot provide treatment to all when the drug costs are so high

We cannot afford resources to manage treatment compliance

With limited resources, focus more on prevention than treatment

It will therefore take a long time for the problem to work itself through

Find ways to use the resources we have to respond to the problem

Provide drugs to all by finding ways to reduce drug costs

Use our informal system to train people to care for themselves

Prevention will be part of the treatment

Seek short and long term results

World Bank Conclusions Brazil Conclusions

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The Brazil Responses

A stable container: Brazil built on existing infrastructure (natural network existed)– A somewhat shaky health system of

hospitals and clinics– Added to by 600 NGOs, churches

(hubs)

Free drugs to all AIDS patients: faced down drug companies in pursuit of national interest

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The Brazil Responses - cont’d

Patients managed their own drugs– Illiterate people were taught by local “trustworthy” folks (hubs were sought)

Free treatment spread prevention ideas– No labeling of those affected– Prevention information readily

available

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Brazil --- epilogue to the case

For over 20 years maintained their HIV prevalence to 0.3% of the population

But with complexity, success is never a destination. Things change, contexts change and what worked at one time will not work at another time.

Today prevalence is climbing in youth (15-24 year olds) -- dramatic increase in number of cases

WHY?? What has changed?

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Brazil in 2014

Christian following has changed – In 1970 5% of Christians in Brazil were Evangelical– In 2013 grew to 22% -- and trending up

-- And so??

With a low prevalence rate for HIV, young people were starting to feel immune – “It was a problem of the past”

Starting to ask new questions… -facing up to changed context

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When In The Zone Of...

Simple/Complicated

Plan then act- Attention during strategic

planning process key

Aim for consistency

– Best practice– Predictions– BUY-IN to the plan

Engineering Resilience

Complexity

“Act-learn” at the same time -(“iterative approach to strategy”)–Lots of attentiveness as you act

Aim for “coherence”(“global integration but local relevance)”–Emergent outcomes shaped by min specs (or simple rules)–OWNERSHIP of the approaches–Ultra-sensitivity to enviroEcological Resilience

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ENGINEERING RESILIENCE: Bouncing back to

the status quo

ECOLOGICAL RESILIENCE: Adaptation and deep

change throughcreative destruction which allows the system to continuallylearn from surprises

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Buy–In vs Ownership*Buy-In: Someone else has developed the

idea, made the decision, designed an action plan and then asks and needs the staff to implement it.

Ownership: Front line staff develops the idea, makes the decisions, designs the action plan and acts on it.

* Buy-in is the opposite of ownership and a danger signal that tells you that your development and implementation process are missing the essential ingredient of involving everyone who needs to be.

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Workout 2 – go back to your stuck problem

Are you aiming for buy-in or ownership?

Are you looking for consistency or coherence?

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When In The Zone Of...

Simple/Complicated– Plan then act

– Aim for consistency– Buy-In – Limit type of action (best

practice)– “Blueprints”– Project Management– Inquiry – problem

solving, convergent, data

Complexity– “Act-learn” at the same

time (tight feedback loops)– Aim for “coherence”– Ownership– Multiple actions– Min specs/simple rules– Generative thinking AND

Generative relationships– Inquiry – appreciative

inquiry, divergent, “wicked”

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“Stop trying to change reality by attempting to eliminate complexity.”

David Whyte

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Time is too short and

things are too bad

for pessimism.Dee Hock

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REFERENCES for future reading www.plexusinstitute.com - Excellent resources (books,

articles, and cases).

For more articles, books from Brenda Zimmerman:

– www.change-ability.ca --- some articles from Brenda Zimmerman and colleagues

– Westley, Frances, Brenda Zimmerman and Michael Quinn Patton, “Getting to Maybe: How the World is Changed”, Random House Canada, 2006

– Zimmerman, Brenda, Lindberg, Curt and Plsek, Paul. (1998). Edgeware: Lessons From Complexity Science for Health Care Leaders. Dallas, TX: VHA Inc. (This book can also be found on the Plexus Institute website under Resources – Edgeware)

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