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TRANSCRIPT
The science of
large systems
change:
Innovation from
within Rick Iedema
Professor, Director
Centre for Health Communication University of Technology Sydney
The Science Of Large Systems Change Research Think Tank
Monday 28th October 2013, Australian Technology Park
Main points
What is happening
• Service complexity shifts
organisational centre of gravity
from the top to the frontline
• ‘Frontline’ harbours
knowledge about practice that
is most up-to-date and acute
• ‘Frontline adaptiveness’
operates through relationships
capable of and committed to
(rapid) adaptation and
response
What this means: priorities
• Relationships [Erskine et al]
• Stability (end rotations and acting roles)
• Continuity of accountability
and responsibility (limit audit creep)
• Frontline that understands
and is committed to
managing local complexity
• Functional change (reduce
contextual perturbation)
• Focus on the realities and
affordances of existing
practice
Michigan Keystone project: CLAB prevention checklist into 100 ICUs
Atul Gawande
• Rigourous execution of
checklist process
• ‘Dressage’ approach to
improvement
– adoption of prescribed
technique
• Compliance
Charles Bosk et al
• Checklist proposal adapted
to existing processes,
relationships, interests and
understandings
• Political view of
improvement
– strategies & tactics
– compromises, learning
• Social adaptive process
Gawande A. (2011) Checklist Manifesto. London: Profile Books.
Bosk C et al. (2009) The art of medicine: Reality check for checklists. Lancet
374(2009):444-45.
‘the numerical supremacy
syndrome’
“Is [this preference for numbers]
indicative of the distance that we
create [and maintain] between
who we are, what we do, and
how we talk about these things?”
Data
Iedema R, Braithwaite J, Sorensen R
(2003) The reification of numbers:
statistics and the distance between
self, work and others. British Medical
Journal 326:771.
‘The story-telling problem’
• “If you ask a world class tennis player how he hits a top spin
forehand they will always say this, ‘Right at the moment of impact, I
roll my wrist’.
• Well, [the coach] took video tapes of world class tennis players
hitting top spin forehands and … noticed that no one ever rolled their
wrist when they hit the ball.
• Yet all these guys are going around the country giving seminars
teaching young kids how to hit a top spin forehand and saying, …
you gotta roll your wrist just like that’.
• They had no idea.”
Gladwell M. (2004) Plenary presentation. Pop!Tech Conference 2004. Camden, Maine
(http://timothycomeau.info/29/).
Stories and data may alert us to issues, but they do not
explain how to change practice.
Practice observation using video:
What do we see?
Video reflexivity: storing improvement impulse
‘in the body’
FUTURE: What
happened next
SYSTEM: What is
pervasive and
constraining about this
scene
CONTEXT:
What else
is going on
PAST: What happened
leading up to this
HABIT: How are we
collectively implicated
in what we do
Towards a pedagogy for
complexity Learning for stability
• Fact & rule memorisation
• Authority resides elsewhere
• Representational know-
ledge: numbers, reasoning
• Execution routines
• Measurement and
monitoring from a distance:
fixed benchmarks
• Cognition: ‘what I know
and how I apply it’
Learning for complexity
• Knowledge design
• Authority resides in us
• Experiential knowledge:
visualisation, emotion
• Actors’ inter-dependence
• Evaluation of local,
contextualised
practice
• Practice: ‘what we do and what its effects are’
Global spread of video feedback • Australia:
– UWS (Prof Wendy Hu, medical workplace based assessment)
– UTS (Prof Carolyn Homer, Birth unit design)
– Freemantle Hospital (Dr E Stewart-Wynne, ward round evaluation)
– Flinders University (Dr Aileen Collier)
• Europe:
– Worthing Hospital (UK, Dr Gordon Caldwell – ward round redesign)
– Utrecht Hospital and 6 affiliated hospitals (Prof Cor Kalkman – post-
operative processes)
– Maastricht Hospital (Dr Jessica Mesman, NICU sterility processes)
• USA
– Kaiser Permanente (Dr Estee Neuwirth and colleagues)
– Indiana University School of Medicine (Department of Paediatrics) and
Women’s Deaconness Hospital, Newburgh Indiana, USA (Dr Ken
Hermann & Dr Katherine Carroll)
– Mayo Clinic (from March 2014: Dr Katherine Carroll)
– eoi: Armstrong Institute, Johns Hopkins
So … what is the relevance of local
reflexivity for large systems change?
• ‘the small embodies the large’
• less structure change; more ‘receptive attentivity’ to
– here-and-now practice
– our imbrication in the systems, habits, and identities that
define current practice (Dunne 2011)
• maximum adaptive capacity where there is maximum
complexity - the frontline
• pre-condition: more stable, more responsive and more
responsible relationships -> better systems
References Iedema R, Mesman J, Carroll K. (2013) Visualising
health care improvement: Innovation from within.
Oxford UK: Radcliffe.
Iedema, R., Merrick, E., Kerridge, R., Herkes, R., Lee, B.,
Anscombe, M., Rajbhandari, D., Lucey, M., & White, L.
(2009). ‘Handover - Enabling Learning in Communication for
Safety’ (HELiCS): A Report on Achievements at Two
Hospital Sites. Medical Journal of Australia, 190(11), S133-
S136.
Iedema, R., Merrick, E., Rajbhandari, D., Gardo, A., Stirling, A.,
& Herkes, R. (2009) Viewing the taken-for-granted from
under a different aspect: a video-based method in pursuit of
patient safety. International Journal for Multiple Research
Approaches, 3(3): 290-301.
Carroll K, Iedema R, Kerridge R. (2008) Reshaping ICU ward
round practices using video reflexive ethnography.
Qualitative Health Research 2008;18(3):380-90
Iedema, R., D. Long, R. Forsyth, K. Carroll (2006). Visibilizing
clinical work: Video enthography in the contemporary
hospital. Health Sociology Review 15(2): 156-168.
1. Key people leading the change (strategic or blunt end)
2. Continuity of key personnel
3. Focus on clinical-management relationships
4. Clear goals and priorities
5. A supportive organisational culture and cooperative
networks
6. Distributed leaders(hip) ‘from board to ward’
7. Engagement of all professions
8. Nurturing of followership as much as of leadership
Erskine J, Hunter DJ, Small A, et al. Leadership and transformational change in healthcare
organisations: A qualitative analysis of the North East Transformation System. Journal of Health
Services Management Research 2013;26(1):29-37.
“Key large system change
success factors”
“Key large system change
success factors” 1. Key people leading the change (strategic or blunt end)
2. Continuity of key personnel
3. Focus on clinical-management relationships
4. Clear goals and priorities
5. A supportive organisational culture and cooperative
networks
6. Distributed leaders(hip) at all levels ‘from board to ward’
7. Engagement of all professions
8. Nurturing of followership as much as of leadership
Erskine J, Hunter DJ, Small A, et al. Leadership and transformational change in healthcare
organisations: A qualitative analysis of the North East Transformation System. Journal of Health
Services Management Research 2013;26(1):29-37