1. Session 2: CompleXity, Surprise,
Innovation & Deviance in
Decision-making for Health Care
Systems
Galen Barbour, MD FACP, FACHE
Director, Health Services Administration
Uniformed Services University

2. Questions
Why doesn’t strategic planning work?
Why do decisions work sometimes
and sometimes not?
Why aren’t ‘best practices’ importable?
2-2

3. Objectives
1. Appreciate Newtonian thinking and the elements
of the ‘linear world’.
• Contrast Linearity with:
- the implications of Complexity Science
- the concept of Positive Deviance (and why ‘best practices’
are so hard to import)
- the framework of Disruptive Innovation (and application to
the national health care debate)
- the ubiquity of randomness and the reality of the
Black Swan phenomenon
- the relationship to Uncertainty and Surprise
• Develop problem solving approaches for non-
linear situations.
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4. A Short History of Physics
300 BC: Aristotle: Observation & Deduction;
1700 AD: Newton, Galileo, et al: Exp & Induction:
A body persists its state of rest or of uniform motion unless
acted upon by an external unbalanced force.
Force equals mass times acceleration (F = ma).
To every action there is an equal and opposite reaction.
Aristotelian and Newtonian thought generated a very
linear way of seeing the world:
“this (always) follows that”
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5. A Short History of Physics
300 BC: Aristotle: Observation & Deduction;
1700 AD: Newton, Galileo, et al: Exp & Induction:
A body persists its state of rest or of uniform motion unless acted upon
by an external unbalanced force.
Force equals mass times acceleration (F = ma).
To every action there is an equal and opposite reaction.
1950 AD: Planck, Rutherford, Bohr, Einstein: Observation,
Experimentation and Analytic Theory
Quantum theory
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6. The Quantum World
• Is non-linear
• Is unpredictable (but leaves tracks)
• Encompasses innumerable possibilities
(not ‘mutations’)
• Studies of the quantum world led to
appreciation of complexity
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7. The Conundrum
Newton’s Laws ‘explain’ the macro world and make sense for
most issues.
When we apply Newtonian thinking, we are seeing the world in a
mechanical and quite linear way. (and that works for the most
part)
When something unexpected intrudes, we are unprepared. We
tend to think there is a ‘mechanical’ or ‘linear’ aspect that we didn’t
measure or consider. We must be ignorant or negligent.
Truth is, “Variation Happens” and we would be better if we knew
how to deal with it.
Variation = complexity.
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8. A Complex System
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9. Understanding of Complexity
Initially, a theoretical construct explaining time
and space
Later identified at micro-levels in biology
Now recognized at every level of existence as ‘the’
(or a partial) explanation for heretofore
puzzling phenomena.
Derivative studies on SWARM INTELLIGENCE and
NETWORKS and STRING THEORY have added
additional insight.
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10. Examples of CASs
• DC/NOVA slug lines
• Stock market
• NYC food distribution
• Forest
• Hospital
Each system “succeeds” by adapting to its
changing environment.
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11. Characteristics of CASs
• diversity • novelty; prog. adaptations
• adaptability • capacity to change
• interdependency • linkages
• • scalar
embedded nature
• “butterfly” effect
• nonlinear
• past context
• history-dependent
• not machinery
• ‘biologic’ • many “both-and” rather
• paradoxical than “either-or”
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12. Implications of Complexity
1. Inter-related processes form systems – with
Order, Chaos and Complexity within the
system.
2. Systems that are complex show signs of self-
organization – they adapt to external forces
and other causes for change.
3. We are surrounded by complexity – but we still
approach each situation as if it is Simple and
Linear.
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13. C
o
Leve l of Syste m
h
Turb ulen ce
s
a
High
Low
Low
High
Level of Immediate Necessity
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14. simple
Zone 1
Routine, expected issues
– Staffing
– Budgeting
– Information Management
– Marketing
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15. Zone 1 simple
Tools
Rational decision-making
– Use components and boundaries
– Prioritize using critical issues
– Plan, measure, adjust, reward
– Linear approaches work well here
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16. complicated
Zone 2
• Events not as predictable; more uncertainty
exists about the future
• Labor negotiations
• Opening new services
• Developing an incentive system
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17. Zone 2 complicated
1
Tools
2
1. Certainty > Agreement, compromise,
negotiation (political tools)
2. Agreement > Certainty, ideology, judgment
(role for experts)
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18. complex
Zone 3
Complexity increased by an order of magnitude
Different tools needed
• Dramatic legislative changes
• Re-design of health care delivery systems
• Mergers (systems, departments, etc.)
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19. complex
Zone 3
Tools
We need to recognize the situation as
‘non-linear’ (e.g., a ‘mystery’ not a
‘puzzle’) before we can begin to think of
using ‘non-linear’ tools.
Applying linear thought and problem-
solving to complex situations is highly
unlikely to work.
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20. Zone 3 complex
Tools
• Reflection
• Minimum specifications
• ‘Wicked’ questions
• Metaphor
• Generative relationships
• Lifecycle to ecocycle
• etc. (See: Edgeware: insights from complexity science for
health care leaders. B Zimmerman, P Plsek, C Lindberg
Critical Decision Making for Medical
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21. Comparison of Approaches
Simple Complicated Complex
• Planning is quite • Multiple plans with • ‘Plan’ is very general
detailed (e.g., a interaction (more questions than
recipe, blueprint) answers)
• Outcomes are big and
• Clear, measurable complicated • Uncertainty is king
outcome
• Reliance is on the • Use Minimum
• Measurement, goals experts specifications
and targets
• Heroes win, villains • Embrace the
• Accountability at a cause trouble or prohibit paradoxes with
personal level. success. optimism.
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22. Complicated
Modern medicine has created knowledge and
practice patterns that are very complicated:
• Emergency response to chest pain
• Sudden onset stroke (“brain attack”)
• Cardiac bypass surgery
• Organ transplantation
How can we reduce ‘errors’ and ‘ineptitude’?
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23. Linear
Linear thinking can (at times) mislead people into thinking
they are in one business when they are really in another.
1920s-1950s: Railroad Executives pushed for more track and
more powerful engines for the “Railroad Business”
1940s-1970s: Trucking companies moved in to the small
markets not served by railroads and began to expand in the
“Transportation Business”
1960s – 1980s American railroads nearly went bankrupt (and
some actually did).
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24. mer
g ing custo
in n
n o demand
ai ati Most
st v
S u no
In
Performance
n
io
v at
no
In
e
tiv
up
D isr
er
gc ustom
demandin
Least
Time
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25. Integrated Steelmakers
Sheet steel
Structural steel
Performance
Mini-mills
Other bars
and rods
Rebar
Time
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26. “Disruptions”
Characteristics of these successful “disruptions”:
2. Breaks with ‘linear’ thinking
3. Starts with simple technology and functionality
4. Operates ‘under the system’ by starting in ‘rebar’ markets
with minimal regulatory barriers
5. Is cheaper; allows less costly people to meet the needs of
an emerging market.
6. Initially competes against non-consumption; later meets
more demanding needs without customers having to
change their ways.
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27. Disruptions and Health Care
We have the technology to disrupt
- the hospital business model
- the physician’s practice business model
- the reimbursement system
- the care of chronic illness
according to The Innovators Prescription: A
Disruptive Solution for Health Care
- Clay Christensen
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28. “usual”
“D” “B”
Performers Performers
LOW HIGH
Positive
Performers Deviants
Performers
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29. Deviance
Positive Deviance = Best outcomes in the ‘community’.
Positive Deviants = Recognizable within the community
Use two key approaches
1. Acute situational awareness
Not decision tree or knowledge management
Modified Analytical Hierarchy
2. Patterned responses
Commitment, end-in-mind, action-oriented,
measure threats & progress, operate on evidence basis
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30. Positive Deviance
Principles of disbursing Positive Deviance
2. Help ‘community’ identify the PDs
3. Obtain their involvement thru intrinsic motivation and
professionalism
4. Engage others thru Practice -> Attitude -> Knowledge (this is
‘backwards’ to the usual way of ‘teaching’)
The Power of Positive Deviance: How Unlikely Innovators Solve the World's
Toughest Problems Pascale, Sternin & Sternin
Vietnam diet
http://www.fastcompany.com/magazine/41/sternin.html
MRSA reduction
http://www.plexusinstitute.org/news-events/show_news.cfm?id=1
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31. Puzzles versus Mysteries
Puzzle: problem or enigma; pieces must
be fit together in a logical (i.e., linear) way
to come to the right conclusion.
Mystery: occurrences or relationships that
are difficult to make clear; often have secret
or hidden qualities that need explanation
(i.e. red herring, misdirection, unexpected
events, etc.)

32. What About Uncertainty And Surprise
Variation is unpredictable & uncertain
(perhaps anticipated).
Black Swan theory:
The Black Swan: The Impact of the Highly Improbable. Nassim Nicholas Taleb
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33. What About Uncertainty and Surprise
Variation is unpredictable & uncertain
(perhaps anticipated).
Black Swan theory:
The Black Swan: The Impact of the Highly Improbable. Nassim Nicholas Taleb
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34. What About Uncertainty and Surprise
Variation is unpredictable & uncertain
Tools that deal with variation improve the ability to deal with
uncertainty.
Surprise is the culmination of uncertainty – the actual event as
opposed to the threat.
Answers (solutions) may come from CAS, or from PD or
maybe from DI . . .
-- but NOT likely from a linear approach or such an approach
should have predicted the event . . .
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35. Tools
Some ‘tools’ to use in dealing with complex situations:
• Look thru the Complexity Lens
• Be sure you are asking the Right Question
• Set only Minimum requirements
• Use Metaphor (biologic not machine-like)
• Initiate Multiple actions (swarmware)
• Do some Chunking (bit development like UNIX)
• Allow Tension and Paradox (Generative relations)
• Ask Wicked Questions
• Tune to the edge
• Don’t shy away from being Wrong
• Reflect & Listen to the Shadow System
• Mix competition and cooperation
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36. Leve l of Turb ulen ce
tion
nova
ti ve I n
D isrup
t i ve
dap are)
ex A ew
C ompl s (Edg
d
M etho
Co
mp
rom
Po
i se
s
it iv
eD
Ex Sw
ev
Str pe ar
r
i an
at egi tO m
cP pi Int
ce
High
l an ni el l
Low
nin o n ige
g, e nc
t al e
Low
High
Level of Necessity
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38. Reference List for Complexity et al:
• Edgeware: Zimmerman, Plsek, Lindberg
• The Innovators Prescription: Christensen
• The Power of Positive Deviance: Pascale, Sternin, Sternin
• The Black Swan: Taleb
• The Drunkard’s Walk: Mlodinow
• The Checklist Manifesto: Gawande
• The Perfect Swarm: Fisher
• Being Wrong: Schulz
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