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Thinking of Healthcare in Loops

Billy Cassano

Technological advancements and the shift from volume to value-based care in the healthcare industry provides an uplifting outlook for its patients. This also increases the importance of  collaboration among the many participants in the healthcare ecosystem and leaves some questioning their own financial viability during this state of uncertainty which will not be going away anytime soon.

To understand how to deal with uncertain situations we could to turn to the philosophies of John Boyd, a U.S. fighter pilot and military strategist who dealt with uncertainty in a very different arena, in air-to-air combat. He would advance his theories throughout his life and, as John Boyd scholar Frans P.B. Osinga explains, Boyd’s view was that “uncertainty is a fundamental and irresolvable characteristic of our lives, no matter how good our observations and theories for explanation are.”

Boyd only published one essay but he also gave hundreds of briefings within the military and the pentagon with a slide deck that he evolved throughout the years. This presentation, according to Boyd, is “a compendium of ideas and actions for winning and losing in a highly competitive world” and contains what Osinga calls a “condensed essence of Boyd’s thought: the OODA loop”. The OODA loop stands for Observe, Orient, Decide, and Act. This is what it looks like in its more simplified form:

Thinking in Loops

The OODA loop is a constant recurring cycle. We go through these loops even throughout the most mundane aspect of our lives, consciously or otherwise. When we drive a car we are making observations: speed limit signs, brake lights, someone texting and swerving into your lane. We then orient ourselves, taking into consideration our past experiences and new observations to create the best understanding of the situation that we can. We then make a decision (e.g. slow down and give some space in case of a full stop by the cars ahead), and act out that decision.

Once we have acted out our decision we then make another observation which will give us feedback about whether our assessment was accurate. We run through these loops all day long at varying levels of tempo and at varying levels of gravity.

Considering Boyd’s background as fighter pilot, we can see how the OODA loop would be helpful to conceptualize what your opponent is running through in their mind at the same time. If you can run through your loops faster than your opponent and remain unpredictable, you would disrupt their ability to cycle through the loop and force them to focus on new, unanticipated observations.

The speed of these loops and the risks involved are tremendous and so thinking of the OODA loop in the middle of an air-to-air battle would not help you to stay a step ahead, but having a deep rooted understanding of this process would help your maneuverability and chances of survival as the situation unfolds.

Speed and tempo are important (especially on a tactical level), but to assume that going fast is the only point of the OODA loop is to miss out on a key aspect to the framework. In fact, on the higher, strategic levels Boyd put more of an emphasis on updating our current mental models and developing new ones which would improve our ability to orient. The OODA loop is a learning tool. In fact, in 1972 Boyd wrote his wife while stationed in Thailand saying “I may be on the trail of a theory of learning quite different and–it appears now–more powerful than methods or theories currently in use”.

Osinga notes the varying tactical and strategic levels and says that “although conceptually the activities at the different levels are similar, Boyd recognized that in practice adaptation at each level required a specific type of action and involved a specific time horizon.”

Again, we can relate to this idea in our daily lives. When we go to a restaurant or to get a haircut, we might want expedited service. But when we are ill, we do not want our physicians to operate with the mindset that speed outweighs the importance of a developed understanding.  We want our physicians to make proper observations, to orient to the observations thoughtfully which will allow them to make the best diagnosis (decide) in their power, and allow for adequate access to the recommended treatment (act).

Once this treatment has been given, a new observation will be available and we want our physician to be agile enough to change course if needed. Again, this is a recurring cycle and speed of these cycles factors into the overall access to care for the population, but a balance of value and speed needs to be found.

Grand Strategy

Similarly, we want to approach our data governance model with a big picture, grand strategist point-of-view and we can use the OODA loop as a guide–turning uncertainty into opportunity.

Each of these four components of the OODA should be assessed at the individual, team, and organizational levels and it should be understood that this process is dynamic and can be viewed from a much more sophisticated model (as you can see below):

Observe

We will never have perfect or complete information, but we can improve the quality, timeliness, and variety of the data that we are observing. The sheer amount of information is too large to fully consume and interpret. How do you sift through the all the noise to find the signal? What data might you be ignoring that may very well be salient? How diverse are the skill sets and backgrounds of your team members?

These are the kinds of questions that will help you identify if you are skewed too far in one direction, favoring precision over diversification or vice versa. This is something we have seen in healthcare with Payors looking to Providers for more detailed patient data so they are not reliant solely on claims data, which they have in broad abundance. This new set of detailed data would enhance their observations.

Orient

Boyd called orientation the ‘scwerpunkt’ which is german for “main focus, focal point, or center of gravity.” The reason for this is our orientation is made up of our past experiences, our beliefs, our culture, and our mental models. It is the process in which we interpret our environment and this process must be refined and adapted as the world around us changes.

This is also true for our teams. In order for us to adapt as a team, we must collaborate which is why we see such a push for interprofessionalism in the healthcare industry. Boyd recommended to “expose individuals, with different skills and abilities, against a variety of situations - whereby each individual can observe and orient himself simultaneously to the others and to the variety of changing situations”. He goes on to say that “In such an environment, a harmony, or focus and direction, in operations is created by the bonds of implicit communications and trust...”

Data and information is simply not enough. We need to have good judgement and this is  something that we can, and should, constantly be improving. As Osinga points out, “Without judgment, data means nothing. It is not necessarily the one with more information who will come out victorious, it is the one with better judgment, the one who is better at discerning patterns.”

As teams work together closely they will form a sense of trust which is vitally important. What good is it to have a diverse set of skillsets and backgrounds if they don’t trust that they can share their opinions?

Decide

In Boyd’s later presentations he had the word “hypothesis” next to “decide”. When we decide, we are forming a hypothesis about what we think to be the best mental model given our observations and orientation. In order for us to improve our decision-making and hypothesizing we must practice and in order to practice we must have a principle-based vision to be used as a guide. In the words of John Boyd, “what is needed is a vision rooted in human nature so noble, so attractive that it not only attracts the uncommitted and magnifies the spirit and strength of its adherent, but also undermines the dedication and determination of any competitors or adversaries.”

This grand strategy vision helps to motivate toward a worthy ideal, while it also reduces friction by ruling out any decision that is not aligned with this vision. If the vision doesn’t exist or is unknown, it will become much easier for teams to get distracted by tasks that seem productive but do not align with the grand strategy. This will be exacerbated when teams are faced with inevitable adversity.

Act

And lastly, we act. Not surprisingly, Boyd also looked at this ‘Action’ component as a way to test our hypotheses. This is fairly straightforward, but we should not overlook that we must have capacity to act out these decisions we make. This will take having the right people in the right places and being prepared to act out the decisions we make.

Take St. John’s Mercy Hospital in Joplin, MO for example. On May 22, 2011, the hospital was torn apart by a tornado which left them without no power, no water, and with every single window in the facility blown out. Fortunately they had long-standing emergency management plan and effectively carried patients out of the eight-level hospital and transported them to other hospitals in and near Joplin. They had also converted to a digital medical records system earlier in the month which helped the sister hospitals to access patient information and care for them as they were transferred. This level of preparedness helped to save numerous lives.

On and On

Developing this adaptive mindset will allow you and your team to be prepared to react more effectively to the amorphous healthcare industry. Again, uncertainty is a constant. The more we accept it, the better we can find opportunity within the chaos. When this mindset is adopted we develop a more experimental culture–a learning organization.

Please reach out to us if you would like us to help you turn develop learning organization that is best prepared for an uncertain terrain.