Taming a Wicked Issue: Building a Generative Team to Improve Access and Flow
Improving quality treatment and patient experience depends on the access they have to excellent care and the flow they experience moving through the medical system. HSD helps this team improve both.
“Take a method and try it. If it fails, admit it frankly and try another. But above all, try something.”
—Franklin Roosevelt
One of the ways I like to describe the functionality of Human Systems Dynamics (HSD)1 to those new to the methodology is to joke that the tools are a great way to understand the formation of the universe! Scientists are constantly exploring how it is possible for something to grow in complexity while becoming increasingly disordered at the same time. Working as an Innovation, Planning and Transformation Leader within Fraser Health, one of Canada’s largest health authorities, there are times when it feels like the work of moving patients through the system is like trying to unlock the secrets of the universe.
When you think about access and flow, people in healthcare usually think about getting patients home sooner. However, at the heart of this work is the inextricable link between quality treatment and patient experience. Accessing the right care, in the right place, at the right time, for the best patient outcomes is at the heart of what we do. To describe this as a complex process is an understatement. Consideration of access and flow touches every aspect of health care. It involves an interminable number of care providers doing their parts efficiently, day after day, with no control over the number of patients arriving at any given moment. From arrival to admission; from diagnostics to treatment; from discharge to home or services in community; so many moving pieces can affect this process. Add a global pandemic, and we find ourselves thrust from complexity to chaos and back.
Complex systems are made-up of various parts and elements that repeatedly and collectively interact, while feeding back to the behaviour of individual parts2. A complex system can survive the removal of an element or part by adapting to the change. For example, in a large healthcare system, the removal of a nurse or physician will not shut down the system because it can adapt and compensate. Whereas chaotic systems refer to situations of disorder and randomness, with very few interacting sub-components. When dealing with a global pandemic, the early stages reflected an initial period of randomness. Once adaptive actions were launched and assessed for impact, we were able to return to more ‘familiar’ states of complexity.
To understand these various notions of complexity, I reference the Cynefin framework3 renowned as the conceptual structure to aid decision making. In this context, we tried to adapt this to ‘sense make’ within our world of healthcare as per the examples below.
This begs the question: “How, in such challenging times, are we actually seeing improvements to problems that once seemed unsolvable within our health authority?4” What patterns did we shift because of the pandemic that have resulted in the health authority being able to sustain site access at or below 90% occupancy5 while maintaining operational surgical slates?
Following the first months of the COVID-19 pandemic response, a number of opportunities were identified to improve access and care delivery. With an aim to sustain site occupancy at or below 90% regionally, objectives and key results (OKRs) were refined to ensure the continued focus on quality of care and patient experience. (See Appendix 1). These OKRs focused on four areas:
- Eliminating overcrowding in Emergency to improve quality and patient safety
- Decreasing length of hospital stay to improve patient safety and reduce overcrowding
- Improving the integration of partnerships supporting access and flow across the health authority
- Achieving 7 day a week discharge planning and services across all sites for timely patient access
For the purposes of this blog, I will focus specifically on the use of HSD tools to build a team that supports systemic changes post-recovery plan and facilitates the integration of partnerships supporting access and flow across the health authority (Objective 3).
A key learning from the first wave of the pandemic was that for access and flow to become a mainstreamed priority, you need dedicated support. A newly formed team was established to build a permanent regional structure to support access and flow at all 12 sites6. This group consisted of two Executive Sponsors representing the administrative and physician perspective: a dedicated Executive Director of Access and Flow, working in partnership with an Executive Medical Director. To provide clinical expertise and a direct link to frontline staff, a Regional Quality and Access Clinical Nurse Educator and Clinical Nurse Specialist were added. A Systems Optimization Managing Consultant joined to provide the data and analytics to drive evidence-based Adaptive Action cycles. Finally, to bring integrated strategic change and project management expertise, members of the Innovation, Planning and Transformation team were included.
One of the first things this team had to do was acknowledge the complexity of the task ahead and identify the patterns that did not serve the organization in the past. The first step in our journey was simple, yet liberating:
Acknowledge that in states of complexity and chaos, we don’t know what we don’t know.
Our first meeting as a core team opened with the Landscape Diagram as a connection exercise in order to understand where we think we stood as a system. On the X-axis, the group reflected on their personal certainty about the direction we needed to take to meet our objectives. On the Y-axis, they reflected on how cohesive the group was in terms of moving forward in that direction. Each member placed a star on the diagram (see illustration below) nearest to the axes which demonstrated where they personally were in terms of their certainty about what we needed to do to achieve our OKRs, and how certain they felt the group was in terms of the approaches to delivering that mandate. My aim in introducing this tool was to illustrate that by bringing together this new and inter-professional group of experts, we could explore together our understanding of how certain or uncertain we were in terms of what we were trying to achieve, and where we needed to be to get there. It also illustrated where our work stood in terms of the level of emergent or unstable characteristics.
The Landscape Diagram7 became an integral starting point for us to accept together:
- That we are doing complex work in a state of chaos
- That it is ok to move from various states such as complexity and chaos
- That, in alignment with agile methodologies, there are no errors, but learning experiences from which we refine or launch new Adaptive Action cycles
- That if our work slipped into complicated or simple, we were no longer being innovative
- That the work we do will never be simple and structured, because, well – entropy!
Entropy anecdotes aside, you can see the variation in perspectives from the placement of our stars. This experience freed us to understand and explore ‘the what’, while building our vision from a place where we acknowledged we were building the ship while sailing it. Our ‘so what’ become the development of our mission, vision and values that would underpin our work going forward:
Mission Statement: A description of what we do and whom we serve
We empower our many partners to find innovative and effective solutions in providing patients with timely access to the quality care they deserve.
Vision Statement: A description of our desired future impact on the organization / stretch goal
Leading the country in supporting patients in their healthcare journeys.
Values: A description of what we stand for
Collaboration – Creating and strengthening relationships to work with a diverse group of providers to understand and find solutions
Trust – A multidisciplinary team providing consistent and reliable best evidence and support for our many partners
Vision – Thinking about and planning for the future with imagination, expertise and wisdom
The landscape diagram was especially helpful to look for best ‘fit in the moment’ given the fluctuations from unstable to emergent, to focus on the differences that mattered, and to amplify new or useful connections in an emergency context. As a result, innovative planning responses formed.
Our Next Adaptive Action: Establish a Permanent Regional Structure and Coordination Centre to Support Flow
Our next Adaptive Action cycle evolved into the creation of a new regional structure to support access and flow and keep the work forefront during the pandemic (See Appendix 2). This structure utilized a coordination centre model that would allow for quick escalation of systemic barriers to flow. At the frontline level, daily coordination meetings with site leadership enhanced collaboration and accountability among sites. Based on the patterns observed at the daily check-ins, we refined our organization’s objectives and key results related to quality and access (Appendix 1) to reflect the focus and work-streams that we believed would be the best fit this moment in time. (These are regularly reviewed, based on live informatics systems to serve as evidence-based platforms from which to monitor improvement and Adaptive Action cycles). Our regular check-ins inspired new Adaptive Action cycles based on patterns in identified systemic barriers to flow. These included a lack of 7-day-per-week discharge services. Putting structures in place to support the latter has resulted in steady increases in discharges from June (257 daily, on average) to (274 daily, on average) by September 2020.
We are also observing sites making valiant efforts on a daily basis to support each other to provide space for patients and to meet their discharge targets. Since the access and flow coordination centre was launched, there is a consistent afternoon update that speaks to the region exceeding its discharge targets on a daily basis. We have also had consistent success in reducing our occupancy rates. When comparing mid-October 2019 with mid-October 2020, we reduced our occupancy from 96% to 88% (despite the pandemic and fully operational surgical slates). This pattern has been repeated since August this year.
Growing Super-Stars: Using the Star Model to Build a Dedicated and Generative Team
According to the agile manifesto, self-organizing teams encourage great designs. Combine this with skilled and motivated team members who have been given decision-making power, and the result is a deeper connection of coalitions necessary to sustain the permanent regional structure. This has led to improvements in individual accountability towards removing barriers to flow, increased sharing of innovations at a site and regional level, and an overall improvement in the delivery of quality patient experiences.
A generative team and its corresponding culture identifies and evolves ideas and relationships in psychologically safe ways. This includes building relationships through collective inquiry, dialogue, active listening and continuous learning and innovation. Whether it was by luck, or grand design, the team that came together naturally embodied these principles. In order to get to, and stay in this place, the principles of the STAR model were adapted in our mission, visions, values and rebranding process. (Appendix 4)
The STAR diagram represents four conditions that reflect the nature of the interactions and work of the team that comes together. In this case, we utilized the principle to set our shared expectations and commitments as our new team formed. Our common purpose was to support Fraser Health to meet the goals set out in the objectives and key results – with an ultimate aim to deliver quality patient care while sustaining 90% occupancy regionally. Given the combination of expertise brought by the Executive Director, Executive Medical Director, Clinical Nurse Educator, Clinical Nurse Specialist and change and innovation specialists, the team was able to regularly connect (both virtually and in person) to assemble ideas and create disruption to support forward momentum and change. This is a reflection of the same / different component which allowed us to regularly refine or dissolve our preferred work streams, engage stakeholders at all levels of leadership across sites through roadshows to elicit ideas and feedback and to come together to accomplish varied, yet connect tasks.
The principles of ‘talking and listening’ are embodied in our shared values of collaboration and trust. All team members come together to contribute, without prejudice of clinical experience or otherwise, to the direction of this work. An inherent simple rule underscored this relationship: ‘Value each other’s contributions’ - for we all bring something brilliant to the table.
In this pandemic / emergency context, ‘authentic work teams’ and ‘reason for being’ become inextricably linked. Given that the challenges and opportunities form the most compelling motivators of all – quality patient outcomes and experience – the team’s raison d’etre and mandate is clear, resulting in the greatest motivator of all.
As we continue to go forward and engage with others, we will be quietly setting these conditions to build those relationships, assess our progress, and adapt when those relationships exhibit tension. Based on our learning so far and based on a series of engagements with physician and clinical leadership across the system, our next Adaptive Action will be identifying the areas of focus that will allow for the greatest impact across the region.
Some early indications point to:
- Building organization-wide educational opportunities concerning access and flow
- Building innovative tools to support clinicians in this work
- Enhancing culture and structures to support continuous quality improvement and learning
- Providing the organizational strategic direction concerning access and flow in partnership
For now, we have seen early successes in how we have refined our structures and processes to maximize collaboration between sites to keep patients, families and communities safe.
1 HSD creates opportunities out of chaos and invites you to see patterns in complexity to look at problems in new or useful ways. https://www.hsdinstitute.org/
2 A Simple Guide to Chaos and Complexity, Rickles, Hawe and Shiell https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2465602/
3 https://en.wikipedia.org/wiki/Cynefin_framework
5 When comparing August 2019 with August 2020, we reduced our occupancy from 97%- 91% regionally. Likewise, when comparing September 2019 with September 2020, we have reduced our occupancy from 97% to 88% regionally.
6 See Appendix 3
7 Image of Landscape Diagram from: https://www.hsdinstitute.org/resources/Plan_Across_Your_Landscape.html
8 https://www.smartsheet.com/comprehensive-guide-values-principles-agile-manifesto