This document discusses using systems thinking approaches to understand and improve outcomes. It provides an example of using systems analysis to address high asthma readmission rates among Medicaid youth. The example shows mapping the current process and identifying two key causes - environmental triggers and inconsistent medication use. It then discusses digging deeper to understand the root causes through tools like fishbone diagrams. The document emphasizes that defining the problem by understanding the full system is crucial before developing solutions and that improvement requires seeing how all the pieces work together as a whole.

1. Seeing the System
PC1: Improvement Science Basics
Monday, March 2, 2015

2. The Improvement Journey
2
Problem
P D
S A
Understand
the
problem
See the
system
Set an aim
Develop a
theory of
improvement
Test
changes
Spread
changes
Identify
measures

3. Atul Gawande
TED Talk: How do we heal medicine?
3

4. We Need to Improve Systems
“We are rewarding cowboys…but it’s pit crews we need.”
“…Get all of the different pieces…to come together into a whole.”
4

5. 5
A different assumption
Every system is perfectly
designed to get exactly the
results that it gets

6. 6
Asthma
Asthma is the #1 source of
hospital admissions &
hospital stays for children
and youth Black children are 2x more
likely to be hospitalized
and 4x more likely to die
14.4 million school
days are missed
because of Asthma
Asthma
Chronic disease that
affects more than 9 million
children
$20 Billion in healthcare
costs annually

7. An improvement case
7
Why?
1,500 hospital
admissions due
to Asthma per year

8. Understanding the problem
8
Medicaid Youth:
23% return to the ED
within 90 days
Non-Medicaid Youth:
12-15% return to the
ED within 90-days
Gap in Asthma
Outcomes
Why?
Cause #1: Contact with
environmental triggers
(tobacco smoke, dust
mites, mold, rodents and
cockroaches)
Why?

9. Environmental
triggers are noted
in the child’s
record
9
Doctor has an
initial consultation
with the family
Environmental
triggers are noted
in the child’s
record
Agency follows
up and removes
trigger
Child arrives at
the ED or clinic
Why?
Doctor has an
initial consultation
with the family
Why?

10. Understanding the problem
10
Medacaid Youth:
23% return to the ED
within 90 days
Non-medacaid Youth:
12-15% return to the
ED within 90-days
Gap in Asthma
Outcomes
Why?
Cause #1: Contact with
environmental triggers
(tobacco smoke, dust
mites, mold, rodents and
cockroaches)
Why?
Cause #2: Inconsistent
medication use
Why?

11. Start
administration
Parents pick up
meds from the
pharmacy
11
Doctor
prescribes meds
Parents pick up
meds from the
pharmacy
Start
administration
Why?Why?

12. Understanding the problem
13
Medicaid Youth:
23% return to the ED
within 90 days
Non-medicaid Youth:
12-15% return to the
ED within 90-days
Gap in Asthma
Outcomes
Cause #1: Contact with
environmental triggers
(tobacco smoke, dust
mites, mold, rodents and
cockroaches)
Why?
Cause #2: Inconsistent
medication use
Why?
Re-engineer
the system

13. Reengineering the System
14
Medicaid Youth:
16% return to the ED
within 90 days
Non-medicaid Youth:
12-15% return to the
ED within 90-days
Gap in Asthma
Outcomes

14. Table Discussion
Reflect on the Gawande video and the
Cincinnati Children’s case:
–What is striking about their approach to
improvement?
–How is this similar or different than what
is currently occurring in educational
improvement?
–How does it complement current efforts?

15. Systems Thinking
 Beliefs about the causes of the current outcomes
– An assumption: People want to do a good job and take pride
in their work.
16

16. Improvement is About Systems
“At the heart of a scientifically grounded theory for
improving healthcare is the premise that quality
is a system property, and that, therefore, what
primarily determines the level of performance is
the design of a healthcare system, not simply the
will, native skill, or attitude of the people who work
in that system.”
D Berwick,“Improvement, trust, and the healthcare workforce,”
Qual Saf Health Care 2003;12(Suppl 1):i2-i6

17. Systems Thinking
 Beliefs about the causes of the current outcomes
– An assumption: People want to do a good job and take pride
in their work.
 Skills: Seeing the system
– An interdependent group of items, people, and processes
with a common aim
18

18. Tools for Seeing the System
 Measures:
– “When you are a specialist you can’t see the end result very well.
You have to become really interested in data, unsexy as that sounds.”
Gawande
 Visualizing processes:
– Process Maps
19

19. Viewing Processes:
BTEN Feedback Management Process
20
Principal
assigns BT to
Case Manager
and Support
Provider
Principal has
initial
conference with
BT to identify
focus area
BT ready for
observation?
BT meets
indicator
of
success?
Every
two
weeks
NO
NO
YES
YES
Case Manager
has follow-up
conference
with BT
Case
Manager
observes
BT
Case Manager
has post-
observation
Conference
with BT
Support
provider
works
with BT
Support
provider
works
with BT
Case Manager
and BT
determine
next focus
area
Principal
assesses BT
performance
Principal, Case
Manager,
Support
Provider meet
regularly to
communicate
about BT’s
progress
Within
48 hrs.

20. Tools for Seeing the System
 Measures:
– “When you are a specialist you can’t see the end result very well.
You have to become really interested in data, unsexy as that sounds.”
Gawande
 Visualizing processes:
– Process Maps
– Linkage of Processes
21

21. Developing
calendar
Determining
activities
Designing
curriculum Interfacing
with
community
Talking with
previous or
subsequent
schools
Getting
feedback from
teachers
Interfacing
with alumni
Working with
parents or
present
students
Recruiting
students for
specific
programs
Running
Headstart
Admitting
students
Orientating
new students
Selecting
classes
Scheduling
classes
Teaching
courses
Conducting
labs
Tutoring
students
Giving exams
Grading
Promoting
students
Counseling
Assessing
student’s needs
Evaluating
teachers
Attending
professional
meetings
Developing
teachers
Conducting
faculty meetings
Training new
teachers
Hiring teachers
Recruiting
teachers
Setting
requirements
for teachers
Setting pay
scale for
teachers
Providing food
services for
students
Providing
school supplies
Conducting
activities
Managing
facility and
grounds
Fund raising
Dealing with
school board
Complying
with state
Setting rules
and
regulations
Disciplining
students
Accounting
Providing
health services
to students
Products:
• Curriculum
• Exams
• Newsletter
Suppliers:
• Parents
• Previous schools
Input:
• Children
Customers:
• New schools
• Society
Outcome:
• Children with
knowledge
Sample Linkage of Processes

22. The Power of Understanding Systems
Peter Senge, 1990: The Fifth Discipline
The disciplines of seeing interrelationships gradually
undermines older attitudes of blame and guilt. We begin to see that
all of us are trapped in structures, structures embedded both in our
ways of thinking and in the interpersonal and social milieus in which
we live. Our knee-jerk tendencies to find fault with one another
gradually fade, leaving a much deeper appreciation of the forces
within which we all operate.
This does not imply that people are simply victims of the
systems that dictate their behavior. Often, the structures are of our
own creation. But this has little meaning until those structures are
seen. For most of us, the structures within which we operate are
invisible. We are neither victims nor culprits but human beings
controlled by forces we have not yet learned how to perceive.

23. “If I had 20 days to solve a problem,
I would take 19 to define it.”
- Albert Einstein

24. Understanding the problem
25
Medacaid Youth:
23% return to the ED
within 90 days
Non-medacaid Youth:
12-15% return to the
ED within 90-days
Gap in Asthma
Outcomes
Why?
Cause #1: Contact with
environmental triggers
(tobacco smoke, dust
mites, mold, rodents and
cockroaches)
Why?
Cause #2: Inconsistent
medication use
Why?

25. What is a Causal Systems Analysis (CSA)?
CSA is an improvement process that helps you
identify the initiating causes of a problem.
Tool: Ishikawa Fishbone
or “Cause-and-Effect” Diagram
26

26. 27
BRANCH:
CATEGORY
BRANCH:
CATEGORY
BRANCH:
CATEGORY
BRANCH:
CATEGORY
PROBLEM
STATEMENT
BONE: CAUSE
BONE: CAUSE
BONE: CAUSE
BONE: CAUSE

27. The Problem:
New teacher support and retention

28. 1987-1988

29. 2007-2008

30. 31
WEAK RELATIONSHIP
WITH PRINCIPAL
INADEQUATE
FEEDBACK
INEFFECTIVE RECRUITING, HIRING
& PLACEMENT SYSTEMS
LACK OF PROFESSIONAL
COMMUNITY
INEFFECTIVE PROFESSIONAL
DEVELOPMENT
TURNOVER RATES
FOR NEW TEACHERS
ARE HIGH AND NEW
TEACHERS ARE NOT
EFFECTIVE FAST
ENOUGH
POOR WORKING
CONDITIONS

31. 32
WEAK RELATIONSHIP
WITH PRINCIPAL
INADEQUATE
FEEDBACK
INEFFECTIVE RECRUITING, HIRING
& PLACEMENT SYSTEMS
LACK OF PROFESSIONAL
COMMUNITY
INEFFECTIVE PROFESSIONAL
DEVELOPMENT
TURNOVER RATES
FOR NEW TEACHERS
ARE HIGH AND NEW
TEACHERS ARE NOT
EFFECTIVE FAST
ENOUGH
POOR WORKING
CONDITIONS

32. Activity: Identifying Root Causes
Imagine you are a school leadership team.
Choose one “category” that’s not feedback
Brainstorm some potential causes.
For a couple of causes, ask “why?” again and again
to dig deeper.
–Stop when you feel that you’ve gotten to a root
cause – write it on your fishbone.
–If you get to something you can’t influence, step
back to the cause before.
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33. 34
Examples
Teachers are receiving inadequate feedback.
Why?
There’s not enough time to
give feedback.
Why?
Administrators are too busy
with building management and
student discipline.
Why?
There are only two
administrators in the building.
Why?
The instructional coach is
not being deployed.
Why?
The instructional coach is often
assigned to cover classes.
The process to request
substitutes is not working
efficiently.
Why?

34. Activity: Identifying Root Causes
Imagine you are a school leadership team.
Choose one “category” that’s not feedback
Brainstorm some potential causes.
For a couple of causes, ask “why?” again and again
to dig deeper.
–Stop when you feel that you’ve gotten to a root
cause – write it on your fishbone.
–If you get to something you can’t influence, step
back to the cause before.
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35. Poll Everywhere
What is one root cause
your team identified?
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Go to pollev.com/cfsummit
or text cfsummit to 22333

36. Tips for Crafting a Fishbone Diagram
INTERROGATEYOUR SYSTEM
Always ask “why” to dig deeper.
Be open-minded about what you discover.
STAY USER-CENTERED
Talk to users to understand their experience.
See the system from different points of view.
USE DATAWHEN POSSIBLE
Measure the gap you’re trying to close.
Test causes against data.
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37. Closing
Two key assumptions of improvement work:
–See the system causing current outcomes
–Understand the problem before jumping to
solutions
Useful throughout the improvement journey:
particularly important at the beginning, but you
may return to them regularly.
There are tools that can help you, but really they
are skills to invest in.
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