0:00:01 – Announcer

You are listening to the National University Podcast.

0:00:10 – Kimberly King

Hello, I’m Kimberly King. Welcome to the National University Podcast, where we offer a holistic approach to student support, well-being and success- the whole human education. We put passion into practice by offering accessible, achievable higher education to lifelong learners. On today’s episode, we are talking about the systems thinking for healthcare leaders, and joining us is Dr. Mary McHugh.

Dr. McHugh got her BS in nursing at Wichita State and her master’s and doctorate in clinical nursing research at Michigan in Ann Arbor. She worked as a nurse and surgical and medical ICU before moving to coronary care ICU. She served as a staff nurse, charge nurse and unit manager in critical care units and as a psychotherapist doing group therapy, marriage counseling and suicide prevention in Ann Arbor’s Community Mental Health Center. She later served as the Director of Nursing Research in a large hospital, as a research statistician on several large-scale projects and has been co-investigator on various funded research projects.

Dr. McHugh has won several departmental and university teaching awards and has taught on the first online nursing course in the country in 1994. She later served as a consultant and committee member on healthcare issues, research methods and informatics to the Institute of Medicine and NIH. She’s been an assistant associate, a full professor with tenure at two universities in the Midwest before being recruited to California to serve as dean of nursing, from which she retired in 2020. She came out of retirement to assist National University with getting the nurse practitioner program approved by the Board of Registered Nursing and continues as its APD and Academic Program Director.

Thank you so much and we welcome her to the podcast today. Mary, how impressive. How are you?

0:02:15 – Doctor Mary McHugh

Thank you, I’m really pleased to be here.

0:02:19 – Kimberly King

Wonderful. Why don’t you fill our audience in a little bit on your mission and your work before we get to today’s show topic?

0:02:36 – Doctor Mary McHugh

Well, I would say my key mission as a professor is to turn out nurses who give the best possible care, and my topic today, systems thinking, comes into what I’ve told my doctoral students many times, is we need to change the way you think so that your thinking becomes more scientific, more structured, and more effective. And I would say my mission is to help students use their thinking capacity, their judgment, and their knowledge and skills of nursing to help as many patients as possible to improve and to be able to go back to their regular life and be successful in their lives. So that’s kind of what nurses do, is hopefully we help other people succeed in their lives through their health, and I’ve always loved nursing and I’ve been in it for a good many years now.

0:03:34 – Kimberly King

I love it, and I’m so glad that you came out of retirement for this, so thank you. I can’t wait to hear about it. Today, we are talking about systems thinking for health care leaders, and so, Mary, what is a system?

0:03:49 – Doctor Mary McHugh

Well, first and foremost, a system is an entity that is made up of many components that work together in cooperation to produce one or more outcomes, and the way systems work is according to a set of rules. Now, whether those be rules that are programmed into the system by people or, if you will, programmed by God into whatever is in nature, almost everything we see is part of a system, and, as a healthcare professional, I often use examples of body systems for my students so that they can kind of understand what a system is and why it’s important to use systems thinking in their work.

0:04:42 – Kimberly King

Well, that’s interesting. I like the full picture, broad view here. So what is systems thinking?

0:05:06 – Doctor Mary McHugh

Systems thinking is really a more successful approach to problem solving. And I first learned about it when I was learning at the University of Michigan in the business school, I was taking courses in structured systems analysis and what I learned is that systems thinking is different from other kinds of thinking. The way we grow up, thinking tends to be pretty linear. In other words, A goes into B and B goes into C, and then you get your result. But with systems thinking, what we have to learn is that systems are complex in most cases. Certainly, most of the systems we deal with in healthcare are complex, because the human body is almost unimaginably complex and it’s a whole system of feedback. For example, all of your hormones give messages to your tissues and your tissues give back messages to your hormones, which take them up to your brain in many cases, and there’s still many parts of our human system that we haven’t yet learned and we’re learning more and more about them. So we have to really change what we teach, because, for example, it used to be thought that cancer was a shameful thing and that you should hide it, and then for a long time, they were thinking oh well, cancer is probably basically the result of a virus, which still may be true, but what we’re discovering is that understanding the immune system is key to understanding cancer, because cancer actually is now thought to be a failure of the immune system, and we never knew that before. So we’re learning more and more every day about systems and how they work.

And systems thinking means that when you look at any part of your work where you may want to change something, you want to help a client change something, you want to give them a drug to treat a problem, there are likely to be unexpected consequences. There could be unintended consequences, which are usually bad outcomes. There are expected outcomes. For example, if I give a patient who’s got too much fluid and is starting to drown in his or her own fluids, if I give them something like Lasix to clear those fluids out, it can have the unintended consequence of causing that patient to have too little fluids and start having complications of dehydration. So when you think of systems, it’s really important to start thinking of interactions rather than just this causes this. Interactions and interconnectedness is the essence of systems thinking.

0:08:14 – Kimberly King

Those are really great examples, really from a health care point of view. So thank you for explaining that. What are the key characteristics?

0:08:24 – Doctor Mary McHugh

Well, probably we would start with the core characteristic is that in a system, every part of the system is interconnected with every other part of the system, and so we use the word perturb or perturbation. Perturb means to disturb something, and so if things are interconnected, that means if you perturb or disturb one part of a system, other parts are going to be affected, and they may be parts that you expected changes and they may be parts you didn’t. I mean, when you think about the Industrial Revolution, all people were thinking about was making more technology to make life better, safer, whatever for humans. They didn’t think about. Gee, if we start using all these fossil fuels, we might get atmospheric changes on our whole planet. Those were certainly unintended consequences. That’s probably one of the best- Another main characteristic of a system accomplishes a particular task of the system, which then lets the next part of the system know okay, this is done, I can start working. And when I start working, I need to tell the first part to quit working because I’ve got your product, so that it doesn’t produce too much. And one of the examples of that, is when you think about cancer, cancer is a disturbing of the system, such that the tissue that normally would have a message to stop growing doesn’t stop growing and it doesn’t- It loses that part of its DNA that tells it to stop growing, and so this is why cancer always arises from a particular type of tissue and that’s why you get so many different types of cancers. There are different types of tissue and one of the theories right now that is that when a virus attacks DNA in a part of your system, it damages the DNA that tells that cell to stop growing during tissue repair and regeneration. So it just keeps growing and growing and then it spreads to other parts of the body and keeps growing and growing, and that’s what a malignant cell can do. Another part of, another core principle or characteristic of the system is holism.

The whole is greater than the sum of its parts. You are not just the thyroid or thyroxin hormone that your thyroid produces. Kind of a cool example of that was back in the 1800s. They didn’t know what the thyroid did, and humans have a tendency to think if you don’t know what something does, it’s not very important. So people in areas that were far from the sea would get these great big nodules on their neck from the thyroid overgrowing because it wasn’t getting enough iodine and therefore it couldn’t produce enough thyroxine. So it got bigger and bigger trying to produce thyroxine. You know, the body thinking more thyroid cells will help.

And since they didn’t know what the thyroid did, some doctors would just take the whole thyroid out and those patients would do great for a few months and that’s all they followed them and one doctor saw a patient he’d operated on a year prior and that patient had become what they would call back then an imbecile, and that that’s a pejorative word now, but basically it meant that the patient turned into a person with severely compromised cognitive abilities. And he went and found all his other patients, or as many as he could, and every single one of them had lost their cognitive abilities. Because without thyroxine your brain is starved of critical substances, and it becomes damaged in such a way that you’re no longer able to think very clearly. And ultimately those people will die because also your metabolism slows down a lot, so they would gain a tremendous amount of weight. So those are unintended consequences, because they didn’t realize that the thyroid was part of an important whole and every part has its- you know, there is no part of your body that doesn’t have a role.

0:13:54 – Kimberly King

So it kind of. So. Now it really you’re really painting a clear picture of how these systems work. And so, because everything is connected, how, why should a professional use systems thinking?

0:14:04 – Doctor Mary McHugh

Well, a professional should use systems thinking, because if you don’t understand how the system works, you’re very likely to prescribe a therapy or some kind of a treatment that will cause other problems that you hadn’t anticipated, and certainly the thyroid example was a perfect example. Those people would have been a lot better off with a big goiter, which is a big swelling of the thyroid, then to lose all their cognitive abilities. And so, with systems thinking, what you really have to do is, before you jump in and make a change, you have to conduct what we call a structured systems analysis. Now, with a doctor or a nurse practitioner, that means they do a thorough system-by-system, head-to-toe body assessment, which is why your doctor is going to ask you about your breathing and your heart and your digestion and your sleep and all those. They’re trying to get a picture of how your system is functioning.

In business, before you want to make a change in a business process, you do more what we call a structured systems analysis, where you go in and you identify the components of the system, especially the hidden ones way deep inside, find out what each one of them does, so that if you need to make a change to make the system work better, you have a good idea of what might be directly affected, but what might be indirectly affected that you might not have expected. Therefore, the probability of your changes being successful increases. And it’s like any database decision making. You’re gathering data so you understand what the changes you’re going to make are most likely to do.

0:16:15 – Kimberly King

Right checks and balances. That’s why systems thinking.

0:16:18 – Doctor Mary McHugh

Exactly that’s why systems thinking is so important. It increases the probability that the changes that you make and the decisions you make will produce desirable outcomes rather than undesirable outcomes.

0:16:33 – Kimberly King

So, with that being said, then, what are the five core principles of systems thinking?

0:16:41 – Doctor Mary McHugh

Yeah, well, they are interconnectedness, feedback loops, holism, as I mentioned, the whole is bigger than the sum of its parts. Another key one is emergent properties, which are results of the system produced by interactions among components, but they’re not observed necessarily in the individual component itself. For example, in medicine, if I removed your pituitary gland, you would suddenly become sterile, because all of the functioning of your reproductive system is based on hormones that the pituitary puts out, that interacts with your reproductive organs, and then the reproductive organs send hormones back to the pituitary to tell it how it worked. And it’s that feedback system. So emergence means that within a system, there’s going to be results that cause other results that cause other results, and that’s kind of how a system works, interconnectedly to produce the final outcome that you’re looking for.

0:18:01 – Kimberly King

So that was kind of my next question is how does that concept of emergence fit with systems thinking? Is that kind of what you were just explaining?

0:18:11 – Doctor Mary McHugh

Yeah, it is, and emergence basically means that within a system, there’s going to be results from subsystems, and the problem is when you don’t know what all the components of the system are, you’re very likely to make changes that affect results that are essential to the system but that you didn’t know about. And so in emergence you get the result from processes you didn’t know that bring about results that are in that, you know- That’s what emerges, is small results inside that work to bring about the main result at the end of the system processing, or the main result that you’re really interested in. You know, to the system. They’re all equally important.

0:19:14 – Kimberly King

Yeah of course.

0:19:16 – Doctor Mary McHugh

But if you make a change in one part of the system, you have essentially changed a system which interacts and has feedback loops, and there’s really no telling what might happen if you don’t understand the system itself.

0:19:36 – Kimberly King

So what principle of systems thinking represent the concept that cause and effect may not directly be related?

0:19:46 – Doctor Mary McHugh

I would say that’s probably dynamic complexity and in a system, cause and effect- the fact that cause and effect are not always directly related is called dynamic complexity and essentially a single action can have unforeseen consequences. For example, introducing a new technology might solve one problem but create other problems. You know, for example, the coal-fired factories solve one problem, which is people need energy, but they create another problem called pollution, that people breathe in the products of coal fire burning and that damages their lungs and people live a lot shorter period of time because they get diseases like emphysema and lung cancer and things like that. So dynamic complexity means that things are very complex because they interact and they affect many things other than the one effect that we as humans might be interested in.

0:20:58 – Kimberly King

Can you talk about what is a system analysis and why is it important in systems thinking?

0:21:12 – Doctor Mary McHugh

It’s important in systems thinking because if you recognize these characteristics of a system, then you can- first you do your systems analysis, so you find out what are the components of the system- and ideally you graph those in a flow chart or some other picture, because the human brain can only process about seven bits of information at a time, which, interestingly, is partly why the original telephone numbers were only seven digits long. Because people could remember that long enough to dial the number and not have to go back to the phone book. We don’t use phone books today and we punch numbers in and we reply to numbers, so that’s not as critical a factor with phone numbers anymore. But Bell Laboratories did that original research testing people how many digits can the average person remember to dial a phone number.

And when you stop to think about it, that’s not a whole lot of bits of information to keep present in your short-term memory. And so what we as humans do tend to do is what we would call reductionistic. You try to reduce it to the simplest parts. But systems aren’t simple, and so when you do that you can leave out some really critical components that may affect how successful your decisions are. But if you do keep it in mind, you’re more likely to take account of more data. Even if you can only think about this here and this here. You know, and I know, that as we get more pieces of information that we put into our decision, the less likely we are to overlook something and make a decision that completely destroys something else that’s really critical.

How many times has it happened that you have, in your life, made a decision and later found out that it wasn’t successful because you didn’t know about some other piece of the real world that had an impact on the outcomes of your decision? Well, systems thinking recognizes that’s a major problem with decision making in pretty much any arena of life and tells us well, here’s a way to not do it. Here’s some strategies, some thinking strategies that you can use to reduce the probability of a really bad decision.

And one of those is to analyze things so that you do get the relevant information, and that way you’re much better in knowing that the decision that you make is based on good information and not lack of information.

0:24:14 – Kimberly King

So my next question and I think you’re also answering this is those strategy systems. That thinking is most likely to help a person and understand the workings of that system. You kind of were just and again it’s sort of checks and balances, isn’t it really?

0:24:30 – Doctor Mary McHugh

1. It really is, and I don’t necessarily use the term checks and balances, although it is, but that kind of describes what a feedback system is, and so I tend to use the word feedback systems much more often, because most people can imagine feedback a little easier when they’re not talking about government. Government it’s, maybe it is checks and balances, but it may not be as good a feedback as we might hope.

0:25:05 – Kimberly King

Got it. No, that makes it’s even a more fair way of saying that I think. So what are the differences between common thinking and systems thinking?

0:25:16 – Doctor Mary McHugh

Well, some of the big differences between common thinking- the first and most important is that we grew up with linear thinking. A causes B. If I jump off a ledge that’s 10 feet high onto concrete, I’m very likely to break a bone, so it’s probably better not to just take a wild jump from 10 feet high onto concrete. Okay, if I cook the meat, it’s going to be easier to chew and digest than if I eat it raw, which is why human beings cook most of their food and it’s more digestible and I’m less likely to get foodborne illnesses, because heat of 160 kills most pathogens. And so there’s a lot of reasons that people learned to cook their food and that’s pretty linear. If I cook the food, I’m less likely to get some pretty nasty diseases.

When you’re dealing with a whole system, it isn’t usually that straight and that linear. With systems you usually have interconnectedness. So you know, A to B to C to X to G to Y brings you to a shape like a spade in the cards. Okay, so it’s, it’s not just letters, it’s not just numbers. In a system there’s lots of different kinds of components generally. Another one is that we tend to address problems in isolation, and with systems thinking what you, what you realize is that many problems that we human beings deal with are really systems problems.

Deming, who was a very famous and one of the first people who founded the whole quality improvement movement. What he said is really a huge proportion of problems that happen in industry are not people problems meaning somebody did something wrong, but they are system problems, that the system was designed such that people could not do anything other than the wrong thing. And I look at that and a lot of us in healthcare try to look at that when there are clinical errors made. So we will do a careful analysis, called a root cause analysis, to find out okay, if Angela gave the wrong drug, why, what happened that she gave the wrong drug?

Now, yeah, indeed, in some cases Angela just got careless. But why did she get careless? What kind of a workload did she have? Did she not have enough time? In one case, years and years ago, there were several errors where nurses who, in a labor and delivery unit, were supposed to be giving a drug called Pitocin that causes the uterus to contract better so that the baby can actually be born. But there’s another drug called Pitresin. So Pitocin, Pitresin, they sound a lot alike.

And therefore, if you’re organizing your drugs on the shelf alphabetically, guess what are right next to each other- Pitresin and Pitocin. Even worse, what Pitresin does is it knocks your blood pressure way down, which, if you’re trying to birth a baby, that can kill the baby. Because you don’t have enough blood pressure to send blood to the baby through the umbilical cord while you’re trying to birth. And even worse, both drugs were put in identical shaped and sized vials with almost identical looking labels. So there were a bunch of errors where nurses were in a hurry to go get Pitocin and they grabbed the wrong drug and either mothers or babies died as a result.

So one of the two drug makers had to make radical changes to their vials so that it looked a lot different. So it might still be put on the shelf, but you very seldom would use Pitresin in a labor and delivery. Where you would primarily use it is for a mother with a certain kind of problem called preeclampsia, whose blood pressure shot through the roof. So they did need it, but they also learned to put the two drugs in different places.

0:30:13 – Kimberly King

Wow. Yeah, that’s a wake-up call.

0:30:15 – Doctor Mary McHugh

Yeah, badly designed systems can cause human beings to fail. First and foremost, we know human beings did not evolve like a computer to do a huge number of very complex tasks perfectly and repeatedly, and yet that’s what we have in healthcare. So we need a lot of supports for the mind and a lot of systems to support people doing the right thing, and what I like to say is we need to re-engineer healthcare so that we make it much harder to do the wrong thing than to do the right thing, and that’s not always the case right now.

0:30:58 – Kimberly King

Hmm.

0:30:59 – Doctor Mary McHugh

Sometimes it’s much easier to do the wrong thing. And kind of going back to the differences is. Our typical thinking focuses on immediate solutions, and when I was doing systems analysis with people, I would first meet with a client and ask them so what’s the problem? And they’d tell me we need a computer. Okay, needing a computer isn’t a problem. What do you need the computer for? That’s the problem, and as human beings, we tend to confuse our solution with the problem and jump to a solution when we haven’t done a systems analysis.

And the solution may just make things worse, particularly since it ignores feedback loops. If I’ve got one problem here and I jump to the solution, I haven’t asked myself well gee, if I make this change, are there other parts of the system, depending on what I changed, that are now going to get messed up? So those are basically the differences between systems thinking and linear thinking, which is the more natural kind of thinking for human beings, and that’s really all- linear thinking is all we really needed when we were still a nomadic hunter-gatherer species. But today is different.

0:32:29 – Kimberly King

Yes, it is. Certainly it is. Well, Dr. McHugh, this has been so interesting and we appreciate you joining us. If you want more information, you can visit National University’s website at nu.edu. And again, doctor, thank you so much for your time today.

0:32:46 – Doctor Mary McHugh

Thank you so much. I hope it was helpful to people. Super interesting.

0:32:51 – Kimberly King

Thank you, thank you, thank you. You’ve been listening to the National University Podcast. For updates on future or past guests, visit us at nu.edu. You can also follow us on social media. Thanks for listening.