Cynefin and Healthcare

In an effort to introduce you to the Cynefin framework, let me introduce you to the field I work in, Healthcare and one of the places I work.. an Emergency Department.

Emergency Departments

Emergency Departments (ED or Emergency Rooms (ER) as they are known in the US) are not known to be calmest, most peaceful of places. They are not the easiest places to work, but I sense they are amongst the most challenging and rewarding.

They are the front doors of the health service, always open, never closed, offering a 24/7 service to anyone and everyone who attends with anything they feel is an Emergency.
While the ED is at the interface between the primary, community and the hospital elements of the health service, as an organised unit they are a relatively new phenomenon, though some suggest they are a microcosm of the wider healthcare system.

The speciality of Emergency Medicine developed after army medical doctors returned to the US from the wars of Korea and Vietnam in the 1960s, 1970s and has spread steadily since then.
The Emergency Departments at Leeds Teaching Hospitals NHS Trust, based on 2 sites see over 200,000 patients per year.
Over the last years the NHS has significantly changed the way we coordinate the flow in the department, as we now need to ensure 95% of patients are cared for between arrival and discharge- in under 4 hours. So what was a challenging environment and the bottleneck in the system is now a much more efficient environment, particularly from a patients perspective.

Let me now explore how I see Emergency Departments from my own perspective using the Cynefin framework…. looking at their simple, complicated, complex and chaotic features.
At any one time each/all of these may be at play.

Simple stuff

One could explain that Emergency Departments have a pretty simple function.. to assess and treat the sick and injured in a timely effective manner.
So patients arrive, are assessed and treated and they leave. Simple.
As one of our sites we see approximately, on average 300 patients at day.
300 x 365 days = approximately 109,500 per year. Simple.
Of the 300 patients we see per day, 95% (it was 98% for several years) need to be in and out within 4 hours. 5% are allowed “clinical exceptions” to the standard.
300 x 95%= 285 out of 300 need to be sorted in under 4 hours. Simple… at least from a mathematical point of view.
Aside from the simple maths….there are a variety of patient presentations that those of us trained in Emergency Medicine might consider relatively minor or “simple”.
E.g. If someone presents with a finger injury I’m pretty happy with the assessment of the problem and related treatment. As the anatomy and related pathology is pretty well known and well defined, so most cases are fairly simple to diagnose and treat (e.g. Mallet Finger Injury).

Complicated cases

Beyond the management of a single patient with a single isolated clinical problem, ED life of course quickly gets more challenging.
Imagine if you have to look after a patient with more than 1 clinical problem…
Lets take an illustrative case of a elderly diabetic patient who has collapsed and suffered head and hand injuries.
We need to assess the patient from several perspectives (the diabetic, the collapse, the head injury, etc..).. taking into account several potential problems and formulating a related plan that is in the best interests of that patient (who may have physical, mental and social needs). That can get complicated…. though medical school training trains us to be systematic and structured in our approach, so we sort it out, complicated though it may be.

It gets even more complicated if you need to get advice on an aspect of patient care from a specialist colleague. While you could expect that in that a single specialists opinion may provide clear-cut advice, it can often happen that if you ask 2 specialists for advice on the same clinical problem, that you may get 2 differing answers….
That is not in any way a poor reflection on those individuals, often simply a reflection of their prior experience, training and preferences, as well as differing mental models and frameworks for dealing with clinical problems.
So to get a clearer opinion on how to manage complicated patients you sometimes have to build a consensus opinion, which involves a dialogue between several minds.
Its often easier to agree with three minds in one place, triangulating problems to come to an agreed approach.
This approach to dealing with complicated problems is used successfully all the time at the front-line and is the basis of how clinical guidelines and protocols are developed.

Complex challenges… and simple rules

Beyond tackling complicated patients, things get more complex when we routinely have to juggle the care of multiple patients simultaneously. So as I mentioned as we see about 300 patients per day on the LGI ED site, as the senior doctor in the department, it is not uncommon to have 50/60 patients at any one time in the department, all of which you are nominally responsible for .
Overseeing the care of those patients is a pretty complex challenge at times, trying to ensure the quality and safety of the care involved, while under pressure to meet the Emergency Care standards we adhere to (i.e. the 95% standard I mentioned; 95% of patients should spend no more than 4 hours in the Emergency Department from arrival to discharge (home or hospital bed)).
In this regard the Emergency Department is a very good example of a complex system.

I should clarify that..
The Emergency Department;
-is made up of many parts,

-Has multiple interactions between those parts
-is impossible to understand completely
-is impossible to control completely
-can be controlled by harnessing some common patterns and letting the rest self organise.
-if not controlled properly can quickly turn to chaos..

so is the perfect example of a complex system.

What are those simple rules amidst the complexity you might ask?
Well what I can say is that I find myself asking the same key questions all the time, on every shift…e.g..
Is there any patients unstable in the resuscitation room?
Do they have an immediate A (Airway), B (Breathing) or C (Circulatory) problem that is life threatening?
If not..

Who is the next person who needs a decision made… usually in time order from when they arrived
If they are being admitted, is that really necessary?
What are this particular patients top 3 issues/problems?

If they are being discharged, are they safe to discharge? E.g. do they have someone at home?
If a patient is going home, I’ll always explain that one of 3 things should happen.
a) if they get worse, come back anytime ;
b) if their problem persists please see your GP ;
c) hopefully they will improve
Before leaving I make sure they are happy with our agreed plan and have no further questions.

On the edge of chaos;

Occasionally, the pressure and the complexity make it feel just a little bit chaotic at times.
It doesn’t take too much to tip such a complex system “on the edge of chaos” into chaos.

A power outage at one of our Emergency Department has done it. A number of potential “chemical incidents” in the city had the potential to do the same (though thankfully none were at all as bad as they could have been).
We are always aware of the potential for a ”Major Incident” in the Emergency Department to be declared at any time. The principles in preparing, keep it very very simple, keep calm and issue clear simple instructions such as..
“We are expecting a major incident, would anyone who is sitting in the waiting room and able to walk please consider leaving and returning if your case is non-urgent”. That can work..

Principles from Cynefin

As this article isn’t aimed exclusively at Emergency Physicians or Healthcare folk alone.. let me again clarify how the principles of the Cynefin framework help with tackling the variety of challenges that Emergency Departments can present….

Simple: Sense, Respond, Categorise (Best practice)

Complicated: Sense, Analyse, Respond (Good practice)

Complex: Probe, Sense, Respond (Emergent Practice)

Chaos: Act, Sense, Respond (Novel Practice)

I hope it has been useful to explore this Cynefin framework using the Emergency Department as a case in point. I should finish by saying I find the framework useful at the frontline..
Let me now explore the same framework and related principles in the very different world of business & management..

References

http://en.wikipedia.org/wiki/Emergency_medicine

Mark A, Snowden D (2006) “Researching Practice or Practicing Research: Innovating Methods in Healthcare – The Contribution of Cynefin”
http://www.cognitive-edge.com/articledetails.php?articleid=54

Smith M, Feied C (1999) “The Emergency Department as a Complex System” http://necsi.org/projects/yaneer/emergencydeptcx.pdf

Frectally speaking