Whole systems approaches

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Whole systems approaches

• Steve Onyett
• Senior Development Consultant- CSIP SW/
• Visiting Professor- UWE
• ICN Conference. July 19th 2006

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Complex
Complicated
Simple
From - Plsek, P. Complexity, culture and large
systems change presentation
Source Brenda Zimmerman, PhD
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Questions? (after Chapman, 2004)

• Are we spending too much time trying to apply
  complicated solutions to complex problems?
• What approach would we adopt if we accepted that
  systems cannot be controlled nor its behaviour
  predicted?

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Build collective understanding of what working in
complex systems really means

• small changes can have big effects
• ..and big changes very little effect
• tolerance of flexibility, uncertainty and
  emergence
• avoiding reliance on push and exhortation

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Working with complexity values

• Multiple approaches that make effective use of
  experience, experimentation, freedom to innovate
  and working at the edge of knowledge and
  experience.
• Allowing solutions to emerge by
• Encouraging rich interaction, removing barriers
  and oppressive controls
• giving space and time,
• not overspecifying means
• focussing bottom-up rather than top down

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• When it comes to understanding organisational
  existence from the perspective of human action,
  the is no better clue to a systems overall
  well-being than its guiding image of the future
• Srivastva and Cooperrider, 1999

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Four Column Matrix
Strategic Goals
System Level Measures
National Targets
Projects
Develop transformational goals that connect with
the values that brought people into healthcare in
the first place
Develop system level measures that track progress
against these goals
Show how externally set targets sit within the
context of the strategic goals to build ownership
to delivery
Align project level goals with the strategic
goals of the system to create a sense of purpose
and channel energy
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Establish a system-level vision for improvement
with ambition and commitment.

• Leaders need to commit personally to the vision.
  This means taking a stand and framing the
  objectives as promises to users and the people
  that support them.

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Aims framed as promises to users
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Aims framed as promises to users
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Have the right team leading right

• The most common reason for failure of large
  systems to change is the failure of the senior
  leadership team to function as an effective team
  with the right balance of skills, healthy
  relationships, and deep personal commitment to
  the achievement of the goals
• (Reinertsen et al, 2004, p.3).
• What is the cross-community leadership team that
  you need to get the job done?
• How will it achieve the required horizontal and
  vertical integration of vision and activity?

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Have the right team leading right

• The leadership team needs to sign up to a
  framework for improvement that build on strengths
  and the meaning that people attach both to their
  dreams and current roles.

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Have the right team leading right

• And selecting local project areas as learning
  opportunities for the whole system
• With authority to grant formal permission for
  people to operate outside their normal roles and
  work places

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Trusting Relationships
Shared Vision
Conflicting Needs
Shared Values
Pressures/Stress
Integrity
Change/Uncertainty/Dishonesty
Clear Communications
UnclearCommunications
Reliable Information
Complex/Poor Data
Familiarity
Lack of Time / Prior Experience
Distrusting Relationships
Source Richard Lauve, MD (VHA Inc.)
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Constructive and defensive cultures in mental
health services

• Constructive cultures are those characterized by
  organizational norms of supportiveness and a
  focus on individuals they encourage interactions
  with people and approaches to tasks that will
  enable staff to meet their higher-order
  satisfaction needs.
• Defensive cultures are characterized by norms of
  conformity and submissivenessencourage or
  implicitly require interaction with people in
  ways that will not threaten personal security
• Aarons and Sawitzky, 2006

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• Scary graphic coming up on the inter-team
  relationships described in the MH Policy
  Implementation Guides

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In-patient services
Continuing care
Assertive community treatment
Early intervention team
Police
Child and Adolescent MH Team
Crisis resolution/Home treatment team
Inter team relation-ships
Criminal justice system
Approved social workers
Services for homeless people
CMHT/ Primary care liaison team
Psychology
Acute medical services
Forensic services
KEY Direct referral route Referral may be out
of hours
Self referral
Primary Health Care Team
Non-statutory agencies
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A system is best understood by walking it

• Mental health communities will also have to take
  care that they do not think about service
  elements in isolation. All elements have to
  interact as a system, so that the service user
  experiences continuity during their pathway
  through care,with each element offering added
  value. MHPIG
• This is what process mapping illuminates
• ..and care coordination should deliver at the
  individual level.

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Learning from the business world- intellectual
capital is the prize!

• Interest in bringing together knowledge
  management and cross-functional team working that
  evolves into communities of practice.
• The climate we create as leaders has a major
  impact on our ability to share knowledge across
  time and space
• Bob Buckman of Buckman Laboratories.

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From Mohamed, Stankovsky and Murray (2004)
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Learning from the business world- intellectual
capital is the prize!

• Management and leadership play a critical role
  in establishing the multi-level context needed
  for the effective assimilation of KM practices..
  Two elements overcoming resistance to change,
  and dismantling barriers to communication, both
  across the organisation and between different
  levels of management
• Mohamed, Stankovsky and Murray (2004)

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Working with your stakeholders- what is their

• Readiness to change?
• Confidence to change?
• Judgement of the importance of change?

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Respectfully consider these cells and provide
information to inform
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Local whole systems development

• These days, what managers desperately need is to
  stop and think, to step back and reflect
  thoughtfully on their experience. events or
  happenings, become experience only after they
  have been reflected on thoughtfully
• Jonathan Gosling.
• The Five Minds of a Manager. Harvard Business
  Review. 2003

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The effective teamworking and leadership programme

• 7 day action learning based programme
• For 21 people dependent on each other to achieve
  positive outcomes for a defined group of users
  (including the users and their supports).
• Includes whole group work on improving team
  effectiveness.
• Originally funded by Leadership Centre and rolled
  out by CSIP Development Centres

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Key features

• Working across boundaries
• Leadership linked to improvement and the task in
  hand
• An emphasis on clarifying shared objectives and
  values
• Developing a shared experience of the users
  perspective
• Using tried-and-tested models for improvement
  those based on clinical know-how- e.g. solutions
  focus, motivational interviewing

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Does it work? To quote

• Overwhelmingly, participants response to the
  day-by-day experience of their development
  programmes was positive. Throughout the course
  their comments indicated that they valued the
  opportunity to interact with other team members
  away from the work environment, enjoyed both
  networking and the chance to meet new people, and
  find out more about them. participants selected
  action learning sets as being particularly
  useful. They found these covered real issues and
  problems, had connections with their practice,
  and enabled them to come away with definite
  action plans (Rees and Shapiro, 2005).

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Senior leadership development within complex
local systems

• Local whole systems leadership for improvement
  programme based on ETL principles
• Supported by the National MH Partnership
• And the social inclusion programme with new
  secondment
• Link to person centred approaches
• NMHP seeking support for their members
  applications for Foundation Trust status.
• 4 sites proposed initially
• Recruiting a Development and Delivery Team

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