Thread by @petrosoniak

If you’re a leader and responsible for decision making in your organization, understanding the Cynefin framework is an absolute must.

Leadership requires modification based on the situation.

Here’s a brief 🧵 contextualized within #resuscitation & #healthcare
1/

Created by @snowded this 4 domain framework (5 with disorder) provides decision makers & leaders with a high-level yet practical approach to decision making by appraising the current state & developing an appropriate strategy

Great overview here.
2/
hbr.org/2007/11/a-lead…

Importantly decision making/leadership approaches are dynamic and are adjusted for the current context

Leaders "will need to know when to share power and when to wield it alone, when to look to the wisdom of the group and when to take their own counsel." - Snowden & Boone

3/

Let's look at these 4 domains

Simple:
It’s clear among all involved that there’s a cause and effect. Aka the “known knowns”. These are less common in healthcare as it really is quite a complex industry. But they do occur and there’s a shared mental model by all.

4/

Simple contexts exist like the algorithm used to manage a v.fib arrest. CPR/defib…repeat.

The pitfall here is complacency. Regular checkpoints are needed to ensure that subtle difficulties don’t mount and shift the situation from simple to complicated/ complex.

5/

Checkpoints might be time based or outcome based. But key is to review processes and encourage feedback from team members to promote improvement.

6/

Complicated:
This requires greater expertise to understand the cause/effect relationship. Aka “known unknowns”, where we recognize our own ignorance to a situation. This is often why we do experiments.

7/

We have a question, a hypothesis and we seek an answer among a list of expected outcomes. Usually there are several reasonable options but the challenge is picking the “best” one. It is ok to pick a “good” one and leaders should acknowledge this.

8/

For example, an RSI (aka emergency intubation). There are usually multiple “correct” options but analysis & expertise are key. Plan A, then B then C.

Leaders can also employ 2nd order thinking.
medium.com/@noahmp/second…

9/

Leaders can also look to cross training for their teams so that they may see problems differently. Or gamify the situation…in creating a game, we remove emotion tied to specific components that we might be tied to and more likely think objectively.

10/

Complex:

This consists of the unknown unknowns. Its very difficult to establish right answers. There is unpredictability and flux. Most resuscitations are considered complex. Only in hindsight do we understand why things happen. Here, small trials of action are best.

11/

We use simulation to help hone skills here. It’s critical that leaders explicitly tolerate failure given the high degree of uncertainty (with backstops in place). E.g. hypotensive patient without a clear cause. We’ll trial fluids but if it fails then pressors

12/

Acknowledge trials of action may not work and what next steps are.

Overbearing in these instances is problematic because it stifles creativity, innovation & good ideas from team members.

Here its important to ask “what else am I missing”.

Flatten the hierarchy.

13/

Chaos:

This is multiple unknown unknowns. In medicine, an example is a mass casualty event.

Here leaders shift towards a top-down style.

Immediate action is needed. We encourage taking a quick first step. Script out the next 3 steps, next 5 minutes. Then regroup.

14/

Re-appraise the situation and once shifted into complex or complicated context, then pivot the leadership style.

15/

As a leader, consider the context in which your operating and titrate your approach accordingly. Understanding which domain you're in is critical, as is understanding when that domain changes & how you must adjust accordingly.

For more, follow @petrosoniak & @AdvPerformHD

End