How 3D Problem-Solving Models Transform Healthcare | E. 80

The Healthcare Leadership Experience

To improve outcomes, we have to improve systems. David Dibble explores a systems plan to fix the systems problems in healthcare, with Jim Cagliostro.

Episode Introduction

David explains the law of dissipating structures, how systems, not people, produce 94% of outcomes, and why reorder is a ‘’flight towards chaos.’’ He also explains why the C-suite and frontline employees are different systems in healthcare, highlights the importance of a ‘’pull’’ strategy, and shares why systems improvement means everybody wins.

Show Topics

• Systems, not people, produce 94% of outcomes

• Understanding the law of dissipated structures

• Covid exposed the fragility of systems in healthcare

• Overcoming resistance to change in the C-suite

• 3D change management uses a ‘’pull’’ strategy

• The ‘’golden triad’’ of change agents

• You can’t solve problems with the same thinking used to create them

02:39 Systems, not people, produce 94% of outcomes

David said the work of W. Edwards Deming, and Illya Prigogine was his inspiration for working in systems.

‘’When I first ran into his work I went, oh my gosh. I mean, this whole notion that systems were producing 94% of outcomes and not people, I mean, that was news to me. I had always, like everybody else, assumed that, well, if we just got the people to behave differently we would get the results that we wanted, and it turned out that was not actually the way things work. So I learned about the power of systems. And then at the same time I ran into the work of a brilliant man named Ilya Prigogine, and he had won a Nobel Prize in 1977 for his law of dissipated structures. And so I ended up taking Deming's work and Prigogine's work, and maybe a few other bits and pieces out there, and looking at how I could implement that work in my own business. And it turned out to be a real boon for us. We had, at the time, I think about a thousand competitors nationwide, and after we implemented this systems improvement model in my own business, we probably rose into the top 15 in quality, technology, service. So all of a sudden our business was better.’’

05:59 Understanding the law of dissipated structures

David outlined the steps of dissipated structures which lead to ‘’reorder’’ and natural system change.

‘’Well, we are actually experiencing (in healthcare) what happens when the law of dissipated structures is at work anywhere in the universe. And the law of dissipated structures is actually very simple, but it's incredibly powerful and we don't get to vote on it, it's basically doing what it does. And what it does is it dictates that all systems will resist change when the environment is calling out for them to change. So we normally think of resistance to change as not a good thing, but it turns out it's actually necessary to create systematic change. So it resists change, and in that resistance to change it creates more complexity within the system. That complexity requires more energy coming into the system than the system can dissipate. Now, this stresses the system, and stress causes dysfunction in the system, and as the system continues to resist change, eventually it becomes so stressed that it can't contain the stress energy anymore and it enters what Prigogine called reorder, and reorder is basically a flight toward chaos. And of course, a flight to chaos means that we can't even identify it as a system anymore, but the energy is still there from the original system, and now it begins, slowly, generally over time, to come back together into a completely new system. And that completely new system is operating at a higher level of functionality in the changed environment, and is, again, stable in the changed environment, until it again begins to resist change again as the environment changes and goes through the process again.’’

09:51 Covid exposed the fragility of healthcare

David said the law of dissipated structures is at work in healthcare right now.

‘’I think the thing that's most important for what I would call mainstream healthcare, these are the big medical centers and everything that's attached to the big medical centers and the center of the macro system, is that the law of dissipated structures is at work in your organization right now, top to bottom. It is most evident in care delivery, and particularly since COVID, because what COVID did is it exposed the fragility and the already stressed care delivery systems, particularly in acute care settings. And what that did, COVID literally pushed some of those acute care settings into reorder. And the thing that is, I think, really important is that stress in systems is passed on to the people who work in those systems, and it's passed on to them both physically and mentally. And so we start looking at what's happened to staff, exhaustion, and then on the mental side we've got burnout and PTSD, and all sorts of things that are basically driving them off the job. And I think people, management and leadership in healthcare, should be very aware of what is happening down on the care delivery level, because that care delivery level is literally producing those numbers that are so important to leadership. They're producing the revenue numbers, they're producing the cost numbers, they're producing the margins, and unless we go down and we start improving those systems and start saving staff from these toxic systems down there, it's definitely going to affect those numbers that leadership and management are focused on.’’

13:49 Overcoming resistance to change in the C-suite

David explained why focusing on the numbers is the way to communicate with the C-suite.

‘’So when you talk to the people in leadership, I talk to them about the things that are important to them. I talk to them about profits and, okay, how do you really maximize profits? … So you can go in and you can say, "Well, let's talk a little bit about how can we maximize profitability, and how can we create huge ROIs for doing something, and how can we do it with the least possible risk to you," And this is important, "and you not really having to change much of what you're doing." You know how it is up there, it's like, oh my God, they've already tried so many of these things. The programs came in, even Deming, you can't implement it and sustain it in healthcare, and then it was Total Quality Management and Six Sigma and Lean and Lean Sigma and Toyota. None of them can you implement and sustain in healthcare, because all of those programs are not really programs, they're management models… let's say, at the top, you have to change your management model, and that has just never happened. It's just not going to happen. So in speaking to the people in the C-suite, I would talk about the things that are important to them, I would talk about the numbers. In talking to the people that are actually delivering the care, I would talk about what's important to them. I would say, "Okay, we're going to be looking at improving the quality of care, improving safety, taking the stress out of the job, reducing burnout, reducing turnover, addressing shortages." I would also talk to the people at the top about addressing shortages, I mean that's, I think, a potential existential problem for everybody.’’

17:32 3D change management uses a ‘’pull’’ strategy

David said a pull strategy is 100% voluntary, fixing systems and people at the same time.

‘’I think one of the things that's really important too is the implementation strategy. If you look at pretty much all of the systems improvement programs that healthcare has attempted to implement, they all use a top-down push strategy. So the top buys into the program at least and says, yeah, we're going to implement, I'll make it a lean, and we're going to have whatever we need to do, but basically we're going to push it down into the organization. And eventually it's going to be pushed onto staff, and staff is going to be told, "You're going to do this." …and so now we get the pushback. And so what staff does is they know, they just wait it out, it'll be another flavor of the month, this too shall pass, and eventually the energy that was on getting this new program going starts to fade and things go back to pretty much the way they were. So whatever it is that we implement has to reverse that, and you have to use a pull strategy. So for instance, when we implement 3D change management, it all uses a pull, it's 100% voluntary, top to bottom. Nobody is asked to do anything they don't want to do. And the other thing is that in the implementation of the model, it must be healing to the people who implement it. In other words, you've got to give them their voice. You've got to actually work on the things that are important to them. They have to see that they can be successful in making a difference, and that all is healing. And so the idea that not only are we fixing the systems, we're fixing the people too at the same time.’’

21:20 The ‘’golden triad’’ of change agents in healthcare

David explained how just three can successfully succeed change.

‘’So we've made it so inexpensive that you can pretty much find the budget to get started pretty much anywhere. So it has to be really inexpensive. The ROIs, you've got to point out what is the return going to be for this? And then finally, you have to get a commitment from them not to kill the program before it can show success, which is generally within 90 days. So if we just have that from the top, we're in good shape. Now the bottom, all you need to do is you need to seed it. Now, it's better if you can go beyond seeding, but to seed it into a hospital, and you really only need three change agents to be trained, you need a change agent nurse, a change agent physician, and a change agent from admin, and titles don't matter, but just someone who cares about other people and wants to help and wants to do good, and that, we call it the golden triad. We can train those three people and literally seed it into pretty much any healthcare system, and we can start the work and the work will grow organically. You don't have to do a thing. The success is where it's been seeded, they'll talk about it in the hallways, and that sort of thing, and the next thing you know there'll be other departments saying, well, when do we get to do this? So it's a totally different way, and notice it's all a pull strategy. We're not going into a department and saying, "Okay, you're going to have to do this now." I think this is the setup that allows for a 3D, whether it's problem solving, change management, or systems redesign, to be successful.’’

25:06 ‘’You can’t solve problems with the same thinking used to create them’’

David explained why implementing changes means being willing to expand your mindset.

‘’I think if you were looking at legacy programs, and stuff like that, yes, it is overwhelming for everybody, but I do not think this is overwhelming. I think it's just a matter of being willing to open your mind a little bit to another possibility that's completely different than everything else that we have looked at. I would call it from legacy mindsets. I mean, Einstein said, "You can't solve problems with the same thinking used to create them," and I think that we have quite a bit of that at the top in healthcare, and it's not a bad thing, we're all in the same boat. The mind naturally filters anything unlike itself. It's a dissipated structure. It's there in the same thing as the systems. And so it's not bad, but if we really want to look at expanding and taking the overwhelm away and getting started, then I think we have to expand our mindsets a little bit to include, it's not overwhelming and it's actually fairly straightforward.’’

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You’ll also hear:

If we want to improve outcomes, we’ve got to improve the systems. ‘’It turns out that the physical universe, from the macro, which might be a cluster of galaxies in deep space, to the quantum level, is all systems and subsystems, and in nature, 100% of all the outcomes that we experience are a function of those systems and subsystems.’’

Thinking differently about the C-suite, the ‘’profit maximization system.’’ ‘’Their job is basically to maximize profits and make sure that the financials are good. Now, the people in care delivery aren't really interested in that that much. They're different systems.’’

Why team players are vital for success: ‘’If you don’t care about others and if you're not a team player, you can't do this work.’’

The law of dissipative structures is not waiting around. ‘’…the thing to remember too is, there's a little bit of a ticking clock on all of this….and at some point the law of dissipative structures is going to have its way unless we intervene, particularly at the care delivery level for healthcare.’’

Leadership tips: Why we all need to take time out to reflect and expand our awareness. ‘’But in order to go beyond what's already there, I think we need those moments of reflection, in particular around what are the things we do on automatic that just have not been working.’’

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