AUSTRALIAN INSTITUTE

OF HEALTH INNOVATION
Faculty of Medicine, Health
and Human Sciences

Rational decisions versus “muddling through”

Module 3, Lecture 1
September 8, 2020
Critical Crisis Thinking: Module 3: As the crisis develops – Predictions and Confidence

Jeffrey Braithwaite, PhD,

FIML, FCHSM, FFPHRCP, FAcSS, Hon FRACMA, FAHMS
Professor and Director
Australian Institute of Health Innovation
Director
Centre for Healthcare Resilience and
Implementation Science
President Elect
International Society for Quality in Health
Care (ISQua)
AUSTRALIAN INSTITUTE
OF HEALTH INNOVATION
Faculty of Medicine, Health
and Human Sciences

AUSTRALIAN INSTITUTE OF HEALTH INNOVATION

Our goal is to co-create high-impact health
services and systems research that drives positive
change in policy, practice and behaviour for the
benefit of all.

aihi.mq.edu.au
 AUSTRALIAN INSTITUTE
OF HEALTH INNOVATION
Faculty of Medicine, Health
and Human Sciences
Heal | Learn | Discover
 Australian Institute of Health Innovation (AIHI)

NHMRC Professor Jeffrey Braithwaite Professor Enrico Coiera Professor Johanna Westbrook
Partnership Centre
for Health System Founding Director, AIHI
Sustainability Director Director
Director Centre for Health Informatics Centre for Health Systems
NHMRC MRFF Centre for Healthcare and Safety Research
Keeping People Resilience and
Out of Hospital Implementation Science

NHMRC Project NHMRC Centre of Research

NHMRC Centre of Research NHMRC Partnership Project in
Grant CareTrack Excellence in Implementation
Excellence in Digital Health Digital Support for Aged Care
Aged Science in Oncology
Crises
Crises develop in unexpected directions and thereby challenge
the readiness and resources of organisations. It is essential to
know what the situation “actually is”, but it may be difficult to find
the relevant evidence.

• What predictions can be made and how are they made?

• By whom, and when (usually, after the event!)
• What will the responses or reactions to interventions be from
people, society, and professions?
• What could the unexpected reactions be?
Pandemic - Policy
 AUSTRALIAN INSTITUTE
OF HEALTH INNOVATION
Faculty of Medicine, Health
and Human Sciences

Part 1:
Introduction
 “Muddling Through”
Lindblom, C.E. 1959. The Science Of “Muddling Through”. (Public
Administration Review, 19(2):79–88)
Lindblom, C.E. 1979. Still Muddling, Not Yet Through. (Public
Administration Review, 39(6): 517-526)
Muddling
• Used to describe coping with current constraints and opportunities
• Describes practice decisions made on the spot to fit the situation in the
moment
• Associated names: incrementalism, satisficing, gradualism, adaptive
actions, taking "baby-steps", degrees of manoeuvrability, and
evolutionary rather than revolutionary approaches
 “Muddling Through”
Typical working conditions in health care:
• an open system where what happens in the surroundings
can never be neglected or taken for granted
• a complex system where outcomes often emerge from non-
linear dependencies that defy linear cause-effect reasoning
• unanticipated problems and challenges, responses can
never be completely prepared in advance
• resilient performance relies on the continual adjustment to
incrementally satisfy functional goals.
[Hollnagel, E. The necessity of muddling through In: Braithwaite J, Hollnagel E and Hunte G. (eds) Resilient Health Care Volume
6: Muddling Through With Purpose, Boca Raton, FL: CRC Press: Taylor & Francis Group; (Accepted/In press).]
 “Muddling Through”

“Muddling” can help us understand how

productive behaviours are enacted in the
complex, ambiguous, deceptive, sometimes
chaotic, and always uncertain settings of health
care.

[Hollnagel, E. The necessity of muddling through In: Braithwaite J, Hollnagel E and Hunte G. (eds) Resilient Health Care Volume 6:
Muddling Through With Purpose, Boca Raton, FL: CRC Press: Taylor & Francis Group; (Accepted/In press).]
 Resilience
Normal meanings of resilience:
• Prevent something bad from happening
• Or the ability to prevent something bad from becoming
worse
• Or the ability to recover from something bad once it has
happened

[Westrum, RW. A Typology for Resilience Situations” (in E. Hollnagel, D.D. Woods and N. Leveson, Resilience
Engineering. Concepts and Precepts, 2006).]
 Resilience defined
Hollnagel:
“A system is resilient if it can adjust its functioning
prior to, during, or following events (changes,
disturbances, and opportunities), and thereby sustain
required operations under both expected and
unexpected conditions”

[Hollnagel, E. Many sources].

Resilient performance
• Quick to respond
• Adaptive rather than “tough”
• Monitoring of the situation
• Built into the DNA of the organisation
• Workarounds, heuristics
• Improvisation, flexibility, capacity to manoeuvre
 AUSTRALIAN INSTITUTE

Part 2: OF HEALTH INNOVATION

Faculty of Medicine, Health
and Human Sciences

Cognition and
sensemaking
as predictive
models
 Cognition:
System 1 and System 2 thinking
Two kinds of thinking – Amos Tversky and Daniel Kaheman

System 1
• Fast thinking
• Instinctive, automatic, emotional, rapid
• Skilful behaviour – experienced physicians who can accurately
diagnose a disease at a glance
• Examples – detect hostility in a voice and effortlessly complete
the phrase “bread and …”

[Kahneman, D. Thinking fast and slow, Toronto, Canada: Doubleday Canada, 2011.]
 System 1 and System 2 thinking
System 2
• Slow thinking
• Deliberative, reasoned and logical, effortful and more
demanding of attention
• Examples – when we park a car in a narrow parking space or
fill out a tax form or decide to change careers

[David Plunkert
Holt. Two brains
running. The New
[Kahneman, D. Thinking fast and slow, Toronto, Canada: Doubleday Canada, 2011.] York Times; 2011.]
System 1 and System 2 thinking

When System 1 encounters something not easily

understood and is unexpected it enlists System 2 to
make sense of the irregularity.
Seven properties of sensemaking
Weick, K. 1995. Sensemaking in Organisation.

Sensemaking is:
1. Grounded in identity construction
2. Retrospective
3. Enactive of sensible environments
4. Focused on and by extracted cues
5. Social
6. Ongoing
7. Driven by plausibility rather than accuracy
We are always
sensemaking and being
resilient in complex
health care organisations.
Complexity Science in Health Care:
A WHITE PAPER
 AUSTRALIAN INSTITUTE
OF HEALTH INNOVATION
Faculty of Medicine, Health
and Human Sciences

Part 3:
Thunderstorm
asthma
Resilience Assessment Grid

Ability to respond

Ability to monitor
Actual

Factual Potential Critical

Ability to learn Ability to anticipate

[Hollnagel E. Epilogue: RAG - the Resilience Analysis Grid In: Hollnagel E, Paries J, Woods D, Wreathall J,
(eds). Resilience Engineering in Practice: A Guidebook. Surrey, UK: Ashgate Publishing Limited; 2011.]
Melbourne, thunderstorm asthma,
November 2016

Over two days in

November 2016,
nearly 10,000 people
presented at hospital
EDs with breathing
difficulties, and nine
people died.

[Pearce T. Review of response to the thunderstorm asthma event of 21-22 November 2016: Final Report.
Melbourne, Australia: Victorian Government; 2017. ]
 Thunderstorm asthma
Conditions
• Second wettest September on record, resulting in high pollen levels (>
100 pollen grains/m3 of air), particularly of ryegrass (Lolium perenne).
• Lolium perenne produces huge volumes of pollen and elicits a strong
allergic response. However, pollen grains are too large to enter a
person’s lower airways.
• November 21, unusually hot day for the time of year. By 4pm, it was
still 34.4oC and a strong wind was blowing.
• Pollen grains, sucked up into the warm updraft of the storm cells,
absorbed moisture, ruptured, resulting in fine pollen grains now able to
enter the lower airways, being returned to earth in the storm’s
downdraft.
Mechanism of
pollen transport
and rupture during
a thunderstorm
asthma event

[Department of Health and Human Services. The November 2016 Victorian epidemic thunderstorm
asthma event: an assessment of the health impacts. Melbourne, Australia: Victorian Government; 2017].
 Daily ICU admissions in Australia in 2016

November 26
[Thien et al. (2018) The Melbourne epidemic thunderstorm asthma event 2016: an investigation of environmental triggers, effect on
health services, and patient risk factors. Lancet Planetary Health 2:e255-e263.]
 Total number of Ambulance Victoria cases by hour for 21-22 November 2016

[Thien et al. (2018) The Melbourne epidemic thunderstorm asthma event 2016: an investigation of environmental triggers, effect on
health services, and patient risk factors. Lancet Planetary Health 2:e255-e263.]
Hourly presentations to Melbourne and Geelong hospital emergency departments

Presentations

[Thien et al. (2018) The Melbourne epidemic thunderstorm asthma event 2016: an investigation of environmental triggers, effect
on health services, and patient risk factors. Lancet Planetary Health 2:e255-e263.]
Age and sex distribution of asthma-related hospital admissions to Melbourne
and Geelong public hospitals

Age group (years)

[Thien et al. (2018) The Melbourne epidemic thunderstorm asthma event 2016: an investigation of environmental triggers, effect
on health services, and patient risk factors. Lancet Planetary Health 2:e255-e263.]
Hourly respiratory presentations to Victoria public hospital emergency departments

Time of day (hours)

[Thien et al. (2018) The Melbourne epidemic thunderstorm asthma event 2016: an investigation of environmental triggers, effect on
health services, and patient risk factors. Lancet Planetary Health 2:e255-e263.]
 Anticipate
• Despite thunderstorm
forecast, no anticipation
of impending emergency
• Clinicians recognised as
‘thunderstorm-induced
asthma’ but no way to
communicate widely
• State communication
systems not suited to
rapid-onset problems

[Pearce T. Review of response to the thunderstorm asthma event of 21-22 November 2016: Final Report.
Melbourne, Australia: Victorian Government; 2017. ]
 Monitor

During the thunderstorm

asthma event, there were
leading indicators, such as a
surge in demand for
telecommunications,
ambulance and hospital
services.

[Pearce T. Review of response to the thunderstorm asthma event of 21-22 November 2016: Final Report.
Melbourne, Australia: Victorian Government; 2017. ]
 Respond

Despite rapid onset of

events, the Emergency
Services
Telecommunications
Authority (ESTA),
Ambulance Victoria (AV)
and Victorian hospitals
responded quickly and
increased the scale of their
respective operations.

[Pearce T. Review of response to the thunderstorm asthma event of 21-22 November 2016: Final Report.
Melbourne, Australia: Victorian Government; 2017. ]
 Learn
State government review
created 16 recommendations
(10 related to improving data
integration and/or information
systems).
Interagency working group
established to share knowledge
and improve procedures for
detecting and anticipating the
severity of future events.

[Pearce T. Review of response to the thunderstorm asthma event of 21-22 November 2016: Final Report.
Melbourne, Australia: Victorian Government; 2017. ]
 AUSTRALIAN INSTITUTE
OF HEALTH INNOVATION
Faculty of Medicine, Health
and Human Sciences

Part 4:
Bushfires
 AUSTRALIAN INSTITUTE
OF HEALTH INNOVATION
Faculty of Medicine, Health
and Human Sciences

2019-2020 Australian Bushfires

Bushfires
• ‘the worst bushfires in our history’, ‘exceptional in size
and impact’, ‘unprecedented’, and ‘by far Australia’s
costliest natural disaster’
• Began September 2019
• Burnt 19.4 million hectares since 1 July 2019
– Larger than the Amazon and California fires combined
• Firefighters were fighting a fire about 6,000km long at one
point (Europe from north to south is 5,297 kms)
Impact
• 33 Deaths
• Over 3000 homes destroyed leaving people displaced
• 19,000 farmers, foresters and fishers were impacted
• Estimated that over one billion animals have died
― 170 species: 19 mammal species, 13 frog, 10 reptiles,
9 bird, 29 aquatic species and 38 plant species
• Tourism industry loss $2 billion
― Projected to lose a further $4.5 billion
Climate Change
• NSW had its warmest January to August period on record
– 1.85°C above average
• 15% decline in rainfall late autumn and early winter and a
25% decline in average rainfall in April and May
– Rainfall for January to August 2019 was the lowest on
record
• Drought results in low soil moisture
• Climate changes are lengthening fire seasons
– Reducing opportunities for fuel reduction burning
Challenges

• Funding cuts
− $26.7 million Office of the NSW rural Fire Service
− $12.9 million Fire and Rescue NSW
• Lengthening fire seasons causes overlapping in
states/territories and countries
− Affects resource sharing
Recovery Funding
• Victorian Government has invested $250 million towards
affected communities
• $75 million towards the disposal and demolition of damaged
buildings (donated by the Commonwealth and Victorian
governments)
• $17.5 million rescue package for wildlife and tourism
• 27th January: Victorian Government announced $64 million
package to help fire-affected communities
Recovery Funding
• $86 million Bushfire community recovery package
(Commonwealth-state disaster funding)
− Emergency mental health services, community recovery
hubs, recovery and resilience grants
• Estimated $500 million in donations from private individuals
and charities
Response
• Establishment of a new agency – Bushfire Recovery
Victoria (BRV)
• 55 disaster management inquiries
− 1,336 recommendations handed down
Danger Index

[Climate Council. (2019). This is

not normal: climate change and
escalating bushfire risk. Climate
Council Briefing Paper, 12.]
 AUSTRALIAN INSTITUTE
OF HEALTH INNOVATION
Faculty of Medicine, Health
and Human Sciences

Part 5:
COVID-19
 AUSTRALIAN INSTITUTE
OF HEALTH INNOVATION
Faculty of Medicine, Health
and Human Sciences

As the Covid 19
crisis develops:
CASE STUDY OF FOUR
COUNTRIES
Case Studies
AS THE CRISIS DEVELOPS

Sweden
Thailand
Sweden • Population 69,799,978
• Population 10,102,834 • Developing economy New Zealand
• Developed economy • Universal health• care system 4,824,471
Population
• Government funded Thailand Australia
providing • Developed
essential health economy
universal health care • toPopulation
services all Thai 25,516,773
• Heavily
citizenssubsidised
system, primarily funded • Developed economy
health care system
through taxes levied by • Advanced health care
providing low-costs to
Australia system providing both citizens
county councils and New Zealand
municipalities New Zealandpublic and private health
care to Australian citizens
 Australia
AS THE CRISIS DEVELOPS
• Steps taken
― National Cabinet announced on 15 March 2020. Federal and State leaders
plus chief medical officers
― JobKeeper wage subsidies instituted and increase to JobSeeker payments
to assist in keeping economy moving
― Initial $AUD2.4 billion funding including telehealth, increased testing and
contact tracing, fast-tracking increases in capacity of health workforce,
beds, equipment and diagnostics
― Redirection of services i.e., elective surgeries on hold, private hospital
wards closed and held in reserve
― Clear communication and guidance to population i.e., when to get tested,
physical distancing, hand hygiene, work and school from home, advice to
aged care sector to protect the most vulnerable
― Mandatory quarantine introduced for returning travellers
 Thailand
AS THE CRISIS DEVELOPS
• Steps taken
― Early awareness of the pandemic as first case detected in January 2020
― Sophisticated airport screening despite daily flight arrivals from Hubei
province in China
― In March 2020 a state of emergency was declared
― Army of health force volunteers, predominantly female, were trained and
sent to rural areas to educate locals on hand hygiene and physical
distancing
― Volunteers helped triage cases, prioritised testing and dispelled rumours
and misinformation
― Cultural practice of mask wearing for colds and flus assisted to control and
slow the spread of the virus
― Thailand employed systems developed and refined with SARS and MERS
infections
― Recovered quickly from some early missteps around communication and
consistency
 Sweden
AS THE CRISIS DEVELOPS

• Steps taken
― Much softer approach than other European and Nordic countries i.e., no
hard lockdowns, wearing of masks and physical distancing, whilst
encouraged were voluntary
― Public Health Agency argued that lockdowns only work temporarily, and
too ineffective to justify the impact on people
― Relied heavily on the sensibility of Swedish citizens to do the right thing
― High schools and universities were closed down, however under 16yr olds
encouraged to attend school
― Work from home encouraged
― Outdoor gatherings of more than 50 people were banned, however cafes,
restaurants, bars and nightclubs remained open for seated patrons
― People over 70yrs of age encouraged to stay home
 New Zealand
AS THE CRISIS DEVELOPED

• Steps taken
― Aggressive response to the pandemic early, clearly stating they had
chosen elimination over suppression
― NZ Government’s Covid-19 Advisory panel, led by Professor Michael
Baker, urged a “go hard, go early” mentality
― On 25 March 2020, despite no deaths and only 205 active cases, NZ
imposed one of the strictest lockdowns (Level 4) in the world and closed
it’s borders to non-nationals
― Mandatory quarantines for all returning nationals
― Mobile testing units
― Only essential stores: pharmacies, grocery and petrol allowed to open
― Work from home order, non essential travel banned, limited outdoor
activity for essential exercise and shopping only
― Social interaction was limited to within households
Current status
AS AT 7 SEPTEMBER

Deaths: 762 Deaths: 58 Deaths:

Deaths:5,835
5,639 Deaths: 24 Deaths: 887,549

Confirmed cases: Confirmed cases: Confirmed

Confirmedcases:
cases: Confirmed cases: Confirmed cases:
26,319 3,444 84,985
78,048 1,776 27,288,595

Recovered: Recovered: Recovered:

Recovered: Recovered: Recovered:
22,467 3,281 N/A
N/A 1,634 19,371,650

Active cases: Active cases: Active

Activecases:
cases: Active cases: Active cases:
3,090 105 N/A
64,112 118 7,029,396

Population: Population: Population:

Population: Population: Population:
25,516,773 69,799,978 10,102,834
10,102,834 4,824,471 7,800,000,000

[https://www.worldometers.info/coronavirus/#countries]
Research not yet published
AS AT NOW

• 1,131 survey responses from 97 countries

• Most (70% plus) said they had an effective plan

• Most (almost 80%) said they established a task force
• Most (almost 60%) said they reported testing
• Most (over 80%) now had PPE
• All responses differ across WHO regions

[Tartaglia et al, unpublished data, under review]

Finally
A QUESTION FOR YOU

• What do you now think about being able to

• Think through before an unknown crisis hits

• Predict with confidence when, how and where the crisis
will emerge?
 AUSTRALIAN INSTITUTE
OF HEALTH INNOVATION
Faculty of Medicine, Health
and Human Sciences

Discussion:
comments,
questions,
observations?
Australian Institute of Health Innovation
 Acknowledgements
Complexity Science/ NHMRC Partnership CareTrack Aged/ Patient Research support
Genomics Centre for Health System Safety Dr Kate Gibbons
Dr Kate Churruca Sustainability A/Prof Peter Hibbert Kelly Nguyen
Dr Louise Ellis Prof Yvonne Zurynski Dr Louise Wiles Dr Wendy James
Dr Janet Long Dr K-lynn Smith Ms Charlie Molloy
Dr Stephanie Best Alex Vedovi
Dr Mitchell Sarkies Gilbert Knaggs NHMRC CRE Implementation Research Candidates
Dr Zeyad Mahmoud Isabelle Meulenbroeks Science in Oncology Chiara Pomare
Dr Emilie Auton Dr Gaston Arnolda Hossai Gul
Implementation Science Dr Yvonne Tran Kristiana Ludlow
Human Factors and
Prof Frances Rapport Dr Bróna Nic Giolla Easpaig Sheila Pham
Resilience
Mia Bierbaum Dr Klay Lamprell Luke Testa
Dr Robyn Clay-Williams
Dr Andrea Smith Renuka Chittajallu
Dr Elizabeth Austin
Dr Jim Smith Admin and project support
Teresa Winata
Dr Karen Hutchinson Sue Christian-Hayes
Diana Fajardo Pulido
Tayhla Ryder Jackie Mullins
Health Outcomes Chrissy Clay
A/Prof Rebecca Mitchell Caroline Proctor
Dr Reidar Lystad
Dr Virginia Mumford
Vu Do
Acknowledgements

Provision of thunderstorm asthma slides by Dr Robyn

Clay-Williams.

Background research and preparation of other slides:

Jackie Mullins
Kelly Nguyen
Kate Gibbons
 Recently published books

2018 - Healthcare 2017 - Health Systems 2017 - Reconciling Work-

2019 – Working Across 2018 –Delivering Improvement Across the Globe:
Systems: Future as-imagined and Work-
Boundaries Resilient Health Care Success Stories from 60 Countries
Predictions for Global Care as-done

2016 – The Sociology of 2015 - Healthcare Reform, Quality
and Safety: Perspectives,
Healthcare Safety and
Participants, Partnerships and
Quality
Prospects in 30 Countries
2010 - Culture and Climate
2015 - The Resilience of
2013 - Resilient Health Care in Health Care
Everyday Clinical Work
Organizations
Forthcoming books

Gaps: the Surprising Truth

Surviving the Anthropocene
Hiding in the In-between

Transforming Healthcare with Counterintuitivity: How your Muddling Through With

Qualitative Research brain defies logic Purpose
 Contact Details
JEFFREY BRAITHWAITE PhD
Founding Director
Australian Institute of Health Innovation
Name
Director
Company
Centre for Healthcare Resilience and Implementation Science
Title
Professor
Faculty of Medicine, Health and Human Sciences, Macquarie
Phone
University
Email
Sydney, Australia
President Elect
International Society for Quality in Health Care (ISQua)
Email: jeffrey.braithwaite@mq.edu.au

AIHI website: http://aihi.mq.edu.au

Web: http://www.jeffreybraithwaite.com/

Wikipedia: http://en.wikipedia.org/wiki/Jeffrey_Braithwaite

AUSTRALIAN INSTITUTE
OF HEALTH INNOVATION
Faculty of Medicine,
Health and Human Sciences