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Thinking Wholelistically: Systems Thinking-- Human & OrganizationalCognition, Actions, Events and Behavior Another way of thinking in diagnosing & solving problems JP Bishop, ABD, CPT
A Screw in My Sandwich???A Real Life Story from a customer who purchased a sandwich at Arby’son October 30, 2006.
What is Systems Thinking? Crosses disciplines Multiple perspectives Studies the structure, properties, and characteristics of systems, focusing on how systems interact and effect each other and/or the environment, and/or how systems, in turn, are effected by the environment Way of understanding reality that emphasizes the relationships among a systems parts, rather than the parts themselves
Many Disciplines Employs many theoretical perspectives and borrows from – Ontology – Philosophy of science – Physics – Biology – Engineering Uses concepts from these theoretical bases and applies to – Sociology – Geography – Political science – Management science – Economics, etc
Ludwig Von Bertalanffey Austrian Biologist A system is an entity which maintains its existence through the mutual interaction of its parts.•Scientists operated on the idea that all systems were closed systems (i.e.did not interact with their environments)•Von Bertalanffey proposed that systems are open systems which led to theGeneral Systems Theory which factored in effects of the environment on thesystem
Defining Characteristics of Systems Thinking Every system has a purpose within a larger system All of a systems parts must be present for the system to carry out its purpose optimally A systems parts must be arranged in a specific way for the system to carry out its purpose Systems change in response to feedback Systems maintain their stability by making adjustments based on feedback
Types of Systems- Isolated System Isolated system – A physical system that does not interact with its surroundings In i.e. thermodynamics it obeys a number of conservation laws – Its total energy and mass stay constant They cannot enter or exit but only move around inside – “A system in which the only forces which contribute to the momentum change of an individual object are the forces acting between the objects themselves can be considered an isolated system” – In real life, totally isolated systems do not exist; HOWEVER, real systems have behaved this way for exceptionally long times!!!
Types of Systems- Closed System Definition from thermodynamics – “A system that can exchange heat and work but not matter” – # of particles as well as total energy fixed by boundary conditions Tends toward equilibrium and increases in entropy Practical example: – Closed system toll road Take ticket when you get on, pay at the end – Toll calculated by distance traveled
Types of Systems- Open System Open systems draw some sort of energy from the environment – Matter and energy can flow into and out from the system – Capable of self-maintenance based on throughput from the environment
Advantages of Systems Thinking More effective problem solving More effective leadership More effective communications More effective planning More effective organizational development Avoiding Founders Syndrome
Problem Solving and the Root Cause Analysis Industry likes using Root Cause Analysis for accident investigations Root Cause Analysis also good for uncovering repeat errors, underlying problems, and which can be solved 95% of the problems are caused by process failures and 5% by personnel failures – Based on asking “Why?” – Decision tree logic- working backwards to the origins of the cause
4/5 Steps in the Root Cause Analysis Process1. Collect data – First need to entirely understand an event – Majority of time spent in analyzing event is to gather data2. Chart causal factors Provides structure for organizing contributing factors/ events Identifies gaps and inefficiencies3. Root cause identification4. Sometimes steps 4 AND 5: Recommendation generation and implementation
Fishbone Diagram Problem Solving Invented by Dr. Kaoru Brainstorm ideas to identify factors within each Ishikawa, a Japanese category quality control statistician – “What are the ________ issues causing How constructed: _____” Repeat this procedure with each factor under the – The 4 M’s: category to produce sub-factors. Continue Methods, Machines asking, "Why is this happening?" and put , Materials, Manpo additional segments each factor and wer subsequently under each sub-factor – The 4 P’s: Continue until you no longer get useful information as you ask, "Why is that happening?" Place, Procedure, P Analyze the results of the fishbone after team eople, Policies members agree that an adequate amount of – The 4 S’s: detail has been provided under each major category Surroundings, Sup pliers, Systems, Ski – Do this by looking for those items that appear in more than one category lls – These become the most likely causes" For those items identified as the "most likely causes", the team should reach consensus on listing those items in priority order with the first item being the most probable" cause
Root Cause Limitations Hindsight bias Brainstorming activity- if the team does not recognize a failure mode then it does not get included Time consuming Unknown unknowns- might miss a failure mode if it is not recognized Taking on too large scope Not including operators Not including customers Becomes a consuming job- takes too long Not including one or more ; people, method, equipment, materials, Environment Not getting into details- superficial look at process only Confusing root cause with failure mode Not looking at each product Assuming detection controls are better than they are Assuming detection controls apply when they don’t
Cognition & Ways of Thinking Thinking systemically and systematically changes the way you approach problems Advantage: – See the “big picture” – Get to the root cause Disadvantage: – Time – Cost – Not a quick fix
Scenario # 1 The Plant Manager walked into the plant and found oil on the floor He called the Supervisor over and told him to have maintenance clean up the oil The next day while the Plant Manager was in the same area of the plant he found oil on the floor again and he subsequently raked the Supervisor over the coals for not following his directions from the day before His parting words were: – “Either get the oil cleaned up or I’ll find someone who will!”
Scenario # 2 The Plant Manager walked into the plant and found oil on the floor He called the Supervisor over and asked him why there was oil on the floor The Supervisor indicated that it was due to a leaky gasket in the pipe joint above The Plant Manager then asked when the gasket had been replaced and the Supervisor said that each one seemed to leak The Supervisor also indicated that Maintenance had been talking to Purchasing about the gaskets because it seemed they were all bad The Plant Manager then went to talk with Purchasing about the situation with the gaskets The Purchasing Manager indicated that they had in fact received a bad batch of gaskets from the supplier The Purchasing Manager also indicated that they had been trying for the past 2 months to try to get the supplier to make good on the last order of 5,000 gaskets that all seemed to be bad The Plant Manager then asked the Purchasing Manager why they had purchased from this supplier if they were so disreputable and the Purchasing Manager said because they were the lowest bidder when quotes were received from various suppliers The Plant Manager then asked the Purchasing Manager why they went with the lowest bidder and he indicated that was the direction he had received from the VP of Finance The Plant Manager then went to talk to the VP of Finance about the situation When the Plant Manager asked the VP of Finance why Purchasing had been directed to always take the lowest bidder the VP of Finance said, "Because you indicated that we had to be as cost conscious as possible!" and purchasing from the lowest bidder saves us lots of money The Plant Manger was horrified when he realized that he was the reason there was oil on the plant floor. Bingo!
Most Influential SystemsTheory linked toorganizations… Peter Senge (MIT) – Survival learning = adaptive learning – Innovation = generative learning In order for organizations to learn they must master 5 disciplines – Systems thinking – Personal mastery – Mental models – Building shared vision – Team learning Senge adds to this recognition that people are agents, able to act upon the structures and systems of which they are a part. All the disciplines are, in this way, “concerned with a shift of mind from seeing parts to seeing wholes, from seeing people as helpless reactors to seeing them as active participants in shaping their reality, from reacting to the present to creating the future” (Senge, 1990, p. 69).
Great Systems Thinkers 1950s – Von Bertalanffey, Austrian born biologist known as one of the founders of General Systems Theory – Anatol Rapoport, Russian-born American mathematical Jewish psychologist, one of the founders of General Systems Theory, game theory and semantics, and psychological conlfict – Kenneth E. Boulding, (British) unbounded theorist, advocate of normative economics, – William Ross Ashby, English psychiatrist and pioneer in study of complex systems, Ashby’s Law of Requisite Variety, principles of a self-organizing system Variety absorbs Variety, defines the minimum number of states necessary for a controller to control a system of a given number of states – Margaret Mead, cultural anthropologist, positive and negative feedback into the social sciences – Gregory Bateson, British anthropologist and social scientist, cybernetics (study of communication and control involving feedback loops to social systems) – Jay Forrester, MIT (pioneered the field of system dynamics -- analysis of the behavior of systems) Later – Peter Senge, MIT, (learning organizations)
Stephen Hawking Expanded systems thinking to the global platform by introducing the Chaos Theory that claims the interconnectedness of all things--- (i.e. the beating of a butterfly’s wings in Asia can affect the course of Atlantic hurricanes) Quantum Theory, origins of the universe, imagery of time
How Systems Thinking Changes Behavior Problem/ Cause investigations – Tenerife – TMI Management failures – Enron – Bering Bank Process weaknesses Organizational structures
Performance Improvement ModelPerformance Analysis Cause Analysis Intervention Selection Desired Performance Target Group State Organization Intrapersonal Interpersonal Intragroup Intergroup GAP Process Intervention Type Training/Learning Consultative Individual Techno-Structural Actual Process Performance State Intervention Evaluate Results Change Management Selection
Types of Interventions Training/ learning – Knowledge and skills Consultative – Support and feedback – Results and consequences – Employee selection Techno-structural – Rewards and incentives – Equipment and tools – Organizational structure Process – Job/process design – Goal and strategic planning
References Aronson, D. (1996-8). Overview of systems thinking. Retrieved 11/22/06 from http://www.thinking.net/Systems_Thinking/OverviewSTArticle.pdf Heylighen, F. (1998). Basic concepts of the systems approach. Brussels: Principia Cybernetica Web. Retrieved 11/21/06 from http://pespmc1.vub.ac.be/SYSAPPR.html McNamara, C. (1999). Systems thinking. Authenticity Consulting LLC. Retrieved 11/23/06 from http://www.managementhelp.org/systems/systems.htm Senge. P. (1990). The fifth discipline. NY: Doubleday.