Workshop presented at Sage Bionetworks, Elsevier, and the Puget Sound Design for Healthcare and Philadelphia Healthcare Experience Engineers events.

1. Systems Thinking for
Designing in Healthcare
Julie Guinn
@JulieAGuinn

2. Systems Thinking for
Designing in Healthcare
ACTIVITY!
Julie Guinn

3. Systems Thinking for
Designing in Healthcare
Julie Guinn
Activity inspiration: Tom Wujec, www.tomwujec.com

4. Systems Thinking for
Designing in Healthcare
Julie Guinn

5. Systems Thinking for
Designing in Healthcare
Julie Guinn

6. Systems Thinking for
Designing in Healthcare
?
Julie Guinn

7. Systems Thinking for
Designing in Healthcare
?
?
Julie Guinn

8. System
An interconnected set of
elements that is coherently
organized in a way that
achieves something.
Donella Meadows
Image source: http://donellameadows.org

9. Systems Thinking for
Designing in Healthcare
Elements
Connections
Purpose
System
An interconnected set of
elements that is coherently
organized in a way that
achieves something.
Julie Guinn

10. Systems Thinking for
Designing in Healthcare
System
Elements People, Objects, Organizations,
Concepts…
Connections
Purpose
Julie Guinn

11. Systems Thinking for
Designing in Healthcare
System
Elements
Connections
Purpose
People, Objects, Organizations,
Concepts…
Julie Guinn

12. Systems Thinking for
Designing in Healthcare
System
Elements
Relationships, Flows
of Materials or Information
Connections
Purpose
People, Objects, Organizations,
Concepts…
Julie Guinn

13. Systems Thinking for
Designing in Healthcare
System
Elements
Connections
Purpose Outcome or Achievement
Relationships, Flows
of Materials or Information
People, Objects, Organizations,
Concepts…
Julie Guinn

14. Systems Thinking for
Designing in Healthcare
Elements
Connections
Purpose Outcome or Achievement
Relationships, Flows
of Materials or Information
People, Objects, Organizations,
Concepts…
Boundary Spatial, Temporal, Purpose-driven
System
Julie Guinn

15. Systems Thinking for
Designing in Healthcare
Elements
Connections
Purpose Outcome or Achievement
Relationships, Flows
of Materials or Information
People, Objects, Organizations,
Concepts…
Boundary Spatial, Temporal, Purpose-driven
& Environment
System
Julie Guinn

16. Systems Thinking for
Designing in Healthcare
An interconnected set of
elements that is coherently
organized in a way that
achieves something.
Elements
Connections
Purpose
Boundary
& Environment
System
Julie Guinn

17. Systems Thinking for
Designing in Healthcare
Complex, Adaptive Socio-Technical System
Julie Guinn

18. Systems Thinking for
Designing in Healthcare
Elements
Connections
Purpose
Boundary
& Environment
Complex, Adaptive Socio-Technical System
Julie Guinn

19. Systems Thinking for
Designing in Healthcare
Multiple, potentially conflicting or incompatible
Highly interconnected & interdependent
Deeply nested subsystems with fuzzy borders
Large number of social, tech & environmentalElements
Connections
Purpose
Boundary
& Environment
Complex, Adaptive Socio-Technical System
Julie Guinn

20. Systems Thinking for
Designing in Healthcare
Multiple, potentially conflicting or incompatible
Highly interconnected & interdependent
Deeply nested subsystems with fuzzy borders
Large number of social, tech & environmental
Complex, Adaptive Socio-Technical System
Elements
Connections
Purpose
Boundary
& Environment
Julie Guinn

21. Systems Thinking for
Designing in Healthcare
Properties
Complex, Adaptive Socio-Technical System
Emergence
Non-Linearity
Adaptation
Self Organization
Julie Guinn

22. Systems Thinking for
Designing in Healthcare
Properties
Complex, Adaptive Socio-Technical System
Emergence
Non-Linearity
Adaptation
Self Organization
Design Implication
Holistic & inclusive perspective
Julie Guinn

23. Systems Thinking for
Designing in Healthcare
Properties
Complex, Adaptive Socio-Technical System
Emergence
Non-Linearity
Adaptation
Self Organization
Holistic & inclusive perspective
Iterative, customized interventions & observation
Design Implication
Julie Guinn

24. Systems Thinking for
Designing in Healthcare
Properties
Complex, Adaptive Socio-Technical System
Emergence
Non-Linearity
Adaptation
Self Organization
Holistic & inclusive perspective
Facilitative, participatory approach
Iterative, customized interventions & observation
Design Implication
Julie Guinn

25. Systems Thinking for
Designing in Healthcare
All of the above + patience
Facilitative, participatory approach
Iterative, customized interventions & observation
Properties
Complex, Adaptive Socio-Technical System
Emergence
Non-Linearity
Adaptation
Self Organization
Design Implication
Holistic & inclusive perspective
Julie Guinn

26. Wicked Problems
Horst Rittel
No agreement on what the problem is.
The definition depends perspective.
Multi-causal, many interdependencies.
Every wicked problem can be considered a
symptom of another problem.
Every wicked problem is essentially unique
Solutions can lead to unforeseen consequences.
Socially complex, requires changing behavior.
Multiple stakeholders, some unknown or invisible.
Seemingly intractable, characterized by chronic
policy failure.
Image source: Computational Design Lab, School of Architecture, CMU

27. Systems Thinking for
Designing in Healthcare
You design here
Image source: Humantific
.
Julie Guinn

28. Systems Thinking for
Designing in Healthcare
You design here
But your products
live (or die) hereImage source: Humantific
.
Julie Guinn

29. Much of the unfulfilled potential that our
research identified stems from the fact that our
clients do not routinely undertake a rigorous
systems analysis before they decide on the
problem to convert into an SBRI challenge.
Systems Thinking for
Designing in Healthcare
“
Quote source: https://innovateuk.blog.gov.uk/2017/07/31/think-like-a-system-act-like-an-entrepreneur/
.
Rowan Conway
Director of Innovation and Development
Royal Society for the Encouragement of Arts
Julie Guinn

30. Systems Thinking for
Designing in Healthcare
The RealityThe Brief
Julie Guinn

31. Systems Thinking for
Designing in Healthcare
The RealityThe Brief
Julie Guinn

32. Systems Thinking for
Designing in Healthcare
The RealityThe Brief
One drop-down menu!
Julie Guinn

33. Systems Thinking for
Designing in Healthcare
Systems grow and morph over time, quite
naturally. Even in environments that are strictly
controlled these systems end up being coupled
in ways that may not have been planned.
“
Colin Panisset
Director, Transformation and Delivery
Cevo Australia
Quote source: https://cevo.com.au/tools/devops/methods/2016/11/27/mapping-system-coupling.html
.
Julie Guinn

34. Systems Thinking for
Designing in Healthcare
Impractically complex
Technologically infeasible
Crosses system boundaries
The RealityThe Brief
Stuff you don’t want to realize
when you’re 4 weeks into a project
Julie Guinn

35. Systems Thinking for
Designing in Healthcare
Traditional user-centered design practices
are insufficiently powerful to solve
problems at this level of complexity.
“Root Cause
Narrow Personas
Ideal Solutions
Prototype Tests
Linear Journeys
Peter Jones
Author, Design for Care
Julie Guinn

36. Systems Thinking for
Designing in Healthcare
Root Cause
Narrow Personas
Ideal Solutions
Prototype Tests
Linear Journeys
Naming any persona as a user
privileges just one role in the
system. –Peter Jones
Systems happen all at once.
They are connected in many
directions simultaneously.
–Donella Meadows
There is a tension between user-
centered, empathy-based design
and systems thinking.
–Erika Hall
The aim is to improve the
situation rather than solve it.
–Russell Ackoff
Every wicked problem is a symptom of
another problem. There is always more
than one possible explanation.
–Horace Rittel
Prototyping is not appropriate for very
large, complex systems, where each user
will only understand a very small part.
–Susan Gasson
“
“
“
“
“
“
Julie Guinn

37. Systems Thinking for
Designing in Healthcare

38. If a problem is a mess then the aim is to find a
process for exploring the different perspectives
so as to establish sufficient common ground to
agree the first steps in addressing the issues.
Systems Thinking for
Designing in Healthcare
“
Peter Checkland
Author, Soft Systems Methodology in Action
Julie Guinn

39. 1. Rich Pictures
2. Systems Map
3. Relationship Map
4. Business Origami
5. Circles of Influence
6. Causal Loop Diagrams
7. Stock & Flow Diagrams
Systems Thinking for
Designing in Healthcare
Maps & Diagrams
Julie Guinn

40. Systems Thinking for
Designing in Healthcare
Image source: http://www.art-sciencefactory.com/complexity-map_feb09.html
Julie Guinn

41. Systems Thinking for
Designing in Healthcare
Image source: http://www.art-sciencefactory.com/complexity-map_feb09.html
Complexity Science
Systems Engineering
Operations Research
Social Science
Political Science
Computer Science
Julie Guinn

42. Systems Thinking for
Designing in Healthcare
Rich Pictures
Image source: http://www.mdpi.com/2073-4441/8/11/540
Julie Guinn

43. Systems Thinking for
Designing in Healthcare
Systems Maps
Image source: https://www.futurelearn.com/courses/systems-thinking-complexity/0/steps/20386
Julie Guinn

44. Systems Thinking for
Designing in Healthcare
Relationship Maps
Julie Guinn

45. Systems Thinking for
Designing in Healthcare
Relationship Maps
Julie Guinn

46. Systems Thinking for
Designing in Healthcare
Business Origami Sessions
Image source: Colin Bate, CanUX 2009, https://www.flickr.com/photos/rhuvok/4101726752
Method credit: Hitachi Design Center
Julie Guinn

47. Systems Thinking for
Designing in Healthcare
Circles of Influence Maps
Circle of Control
Take direct action
Circle of Concern
Monitor & respond to actions
Circle of Influence
Advocate or recommend actions
Method credit: Diana Larsen, FutureWorks Consulting, https://www.futureworksconsulting.com/blog/2010/07/26/circles-and-soup/
Julie Guinn

48. Systems Thinking for
Designing in Healthcare
Causal Loop Diagrams
Image source: https://dl.acm.org/citation.cfm?id=1517003
Image source: https://doi.org/10.1371/journal.pone.0129683
Julie Guinn

49. Systems Thinking for
Designing in Healthcare
Loops of Links
Image source: https://dl.acm.org/citation.cfm?id=1517003
Julie Guinn

50. Systems Thinking for
Designing in Healthcare
Positive Links
Elements change
in the same direction.
Negative Links
Elements change
in opposite directions.
Link Polarity
Julie Guinn

51. Systems Thinking for
Designing in Healthcare
Balancing Loops
Maintain a system in a stable state
Types of Causal Loops
Reinforcing Loops
Accelerate change within a system
(in a positive or negative direction)
Image source:https://systemsthinkinglab.com/causal-loop-diagram/
Julie Guinn

52. Systems Thinking for
Designing in Healthcare
Systems Dynamics Diagrams
Causal Loops Stock & Flow
Julie Guinn

53. Systems Thinking for
Designing in Healthcare
(another)
ACTIVITY!
Julie Guinn

54. Systems Thinking for
Designing in Healthcare
Exploring System Forces
with
Interrelationship Diagraphs
Julie Guinn

55. 1. Rich Pictures
2. Systems Map
3. Relationship Map
4. Business Origami
5. Circles of Influence
6. Causal Loop Diagrams
7. Stock & Flow Diagrams
Systems Thinking for
Designing in Healthcare
Maps & Diagrams
Julie Guinn
DISCOVERING &
COMMUNICATING
ANALYZING &
INFLUENCING

56. 1. Rich Pictures
2. Systems Map
3. Relationship Map
4. Business Origami
5. Circles of Influence
6. Causal Loop Diagrams
7. Stock & Flow Diagrams
Systems Thinking for
Designing in Healthcare
Maps & Diagrams
Interrelationship Diagraph
Julie Guinn
DISCOVERING &
COMMUNICATING
ANALYZING &
INFLUENCING

57. Systems Thinking for Designing in Healthcare
Image source: https://www.conceptdraw.com/examples/interrelationship-diagram
Julie Guinn

58. Systems Thinking for
Designing in Healthcare
What forces influence the current level of
adoption of telehealth*
in the U.S.?
*Providing clinical care, including diagnosis and treatment of illnesses, and patient monitoring
and follow up through the use of information and communications technologies to patients
at remote locations.
Challenge
Julie Guinn

59. Systems Thinking for
Designing in Healthcare
U.S. health care system is plagued by rising cost and
limited access. Telemedicine offers great promise to extend
quality care at an affordable cost. However, adoption of
telemedicine among the various stakeholders of the
health care system has not been very encouraging.
Dantu, R., & Mahapatra, R. (2017). Adoption of Telemedicine - Challenges and Opportunities. AMCIS.
“
Julie Guinn

60. Systems Thinking for
Designing in Healthcare
1. Create Groups of 4-6 people
2. Brainstorm System Elements
3. Select Significant Forces
4. Diagram Interrelationships Between Forces
5. Identify System Drivers & Outcomes
Activity Overview
Julie Guinn

61. Systems Thinking for
Designing in Healthcare
What might influence the adoption of telehealth?
1. Brainstorm System Elements
• One influence per sticky note
• Consider people, institutions, laws, policies, norms, beliefs…
• Include both enablers and disablers
Julie Guinn

62. Systems Thinking for
Designing in Healthcare
Identify and name 6 system forces.
2. Select Significant Forces
• One force per sticky-note
• Forces are:
• Nouns
• Measurable or observable
• Can change over time
• Neutral or positive:
“Internet Access” rather than “Slow Internet Access”
“Care Quality” rather than “Good Care” or “Poor Care”
“Physician Attitude” or “Physician Enthusiasm” rather than “Physician Apathy”
Julie Guinn

63. Systems Thinking for
Designing in Healthcare
Share your 6 forces with your group.
3. Share
• Post forces on flip-chart paper
• Stack duplicates
Julie Guinn

64. Systems Thinking for
Designing in Healthcare
Select 6 significant forces & arrange in a circle.
4. Narrow
Julie Guinn

65. Systems Thinking for
Designing in Healthcare
5. Map Relationships
For each pair, ask:
Is there a strong relationship between these two forces?
• If so: Which one causes, creates, or influences the other?
• Draw an arrow pointing in the direction of influence
• Influence may only go one way, no bi-directional influences
• If not: Move on
Julie Guinn

66. Systems Thinking for
Designing in Healthcare
For each force, record:
• Incoming arrows
• Outgoing arrows
6. Count Relationships
Julie Guinn

67. Systems Thinking for
Designing in Healthcare
System Drivers
Forces with more outgoing
than incoming arrows
7. Label Drivers & Outcomes
System Outcomes
Forces with more incoming
than outgoing arrows
Julie Guinn

68. Systems Thinking for
Designing in Healthcare
SHARE OUT
Julie Guinn

69. Systems Thinking for
Designing in Healthcare
Thinking in Systems, Donella Meadows
Soft Systems Methodology in Action, Peter Checkland
Design for Care, Peter Jones
Resources
Systems Practice, Omidyar Group
Field Guide to Systemic Design, CoLab
Books PDFs
Julie Guinn

70. Thank you
Julie Guinn
@JulieAGuinn