Systems and Design Thinking
Applied to Out-of-Hospital CPR
and AED Performance
Larry M. Starr, Allan Braslow, John Pourdehnad &
Gnana Bharathy
Author Affiliations for this Research
Larry M. Starr, PhD
Director, Graduate Studies, Organizational Dynamics
University of Pennsylvania & Systems Wisdom LLC
Allan Braslow, PhD
Visiting Scholar, Organizational Dynamics
University of Pennsylvania & Systems Wisdom LLC
Author Affiliations for this Research
John Pourdehnad, PhD
Affiliated Faculty, Organizational Dynamics
Associate Director, Ackoff Co-Laboratory for
Advancement of Systems Approaches
University of Pennsylvania & Systems Wisdom LLC
Gnana Bharathy, PhD
Project Manager and Analyst
University of Technology Sydney & Systems Wisdom LLC
Author Affiliations for this Research
Allan Braslow
John Pourdehnad
Gnana Bharathy
Presenter Disclosure Information
Larry M. Starr & Allan Braslow (John Pourdehnad &
Gnana Bharathy)
Systems and Design Thinking Applied to Out-of- Hospital
CPR and AED Performance
FINANCIAL DISCLOSURE:
 One study was funded by a global AED
manufacturer.
UNLABELED/UNAPPROVED USES DISCLOSURE:
 No relevant relationship(s) exist.
Preface: Spoiler Alert
Conclusions of Applying Systems and Design Thinking
1. Working backward from what is desired is easier than
working forward from what currently exists.
2. Designing by stakeholders and users is more effective
and creative than designing with or for stakeholders
and users.
Preface: Spoiler Alert
Conclusions of Applying Systems and Design Thinking
3. Implementation is not easy, but it works best when
the “what and how to do something” are integrated
into the design of a new system.
4. Systems thinking is a mindset or a framework, like
wearing glasses. Systems thinking informs what you
see and understand, how you make decisions and
solve problems, and why you or others act in a
particular way.
Systems and Design Thinking Applied to Out-ofHospital CPR and AED Performance
Agenda
1. Decades-long Challenge of SCA Survival
2. OHCA, CPR and AED Projects Require:
New Thinking, New Language, Different
Approach/Method
3. Study 1: Need (Sell) More AEDs
4. Study 2: Design the Ideal Bystander CPR/AED
Learning Experience
5. Applying Design Methodology
Systems and Design Thinking Applied to Out-ofHospital CPR and AED Performance
Agenda
1. Decades-long Challenge of SCA Survival
2. OHCA, CPR and AED Projects Require:
New Thinking, New Language, Different
Approach/Method
3. Study 1: Need (Sell) More AEDs
4. Study 2: Design the Ideal Bystander CPR/AED
Learning Experience
5. Applying Design Methodology
1. Decades-long Challenge of SCA Survival
1960: Cardiopulmonary resuscitation (CPR) was
developed.
1979: The automated external defibrillator (AED) made
its debut.
1990s: Early Public Access Defibrillation (PAD) programs
are developed.
_________________________________________________
http://www.heart.org/HEARTORG/CPRAndECC/WhatisCPR/CPRFactsandStat
s/History-of-CPR_UCM_307549_Article.jsp
Decades-long Challenge of SCA Survival
1991: “…no national averages are available for the
proportion of people who survive OHCA cardiac
3%
arrest…,
Current estimates: no more
than 1-3% live to be discharged
from the hospital. The true
percentage is probably even
less .”
Cummins RO, Ornato JP, Theis WH,
Pepe PE. Circulation 1991;83:1832-1847
97%
Decades-long Challenge of SCA Survival
8%
1991:
2005:
2008:
2012:
1-3%
5.7%✲
7.2%✲
8.3%✲
92%
✲Cardiac Arrest Registry to Enhance Survival (CARES).
Chan PS, McNally B, Tang F, et al. Circulation 2014;130:1876–82.
Decades-long Challenge of SCA Survival
Q: Why, after so many years and
so many resources devoted to
improvement in CPR and
defibrillation, is the SCA survival
rate so low?
Decades-long Challenge of SCA Survival
A: Perhaps because SCA survival is a
different type of problem than
addressed by the community.
What if we change our way of
thinking/understanding?
What if we change our method of
problem solving?
Special Task Force on Reframing the System of
Survival for SCA: University of Pennsylvania, 2007
Benjamin Abella; Jean Bail; Matt Dane Baker; Lance
Becker; Danny Benau; Nicholas Bircher; Allan Braslow;
Robert T. Brennan; Kathleen G. Burke; Elliot Cole; Ted
Crites; John M. Field; Keith Griffiths; Dave Gaieski;
Ward M. Hamilton; Eugene Janda; Guy Knickerbocker;
Mary E. Mancini; Raina Merchant; E. E. (Chip) Miller;
Vinay M. Nadkarni; Mary Newman; Frank Poliafico;
John Pourdehnad; Arthur Romano; Donna Siegfried;
Jasmeet Soar; Larry M. Starr; Charlee Tufts; Rebecca
Wear Robinson; Lynn White
Systems and Design Thinking Applied to Out-ofHospital CPR and AED Performance
Agenda
1. Decades-long Challenge of SCA Survival
2. OHCA, CPR and AED Projects Require:
New Thinking, New Language, Different
Approach/Method
3. Study 1: Need (Sell) More AEDs
4. Study 2: Design the Ideal Bystander CPR/AED
Learning Experience
5. Applying Design Methodology
2. Projects Require New Language, Thinking,
Methods
How do most people think
about OHCA performance
and survival?
Conventional Way: Analyze
Analytic Thinking
For Complicated Problems
Thinking Approach
 Analyze/reduce the
problem to root causes
 Focus on independent,
linear, additive parts
Solving Method
 Use evidence-based,
best-practice research
 Improve or optimize
each critical part
Conventional Way for Complicated Problems
 Analysis is the conventional way to think
about and understand problems.
 Application of evidence-based research is
the conventional method to solve problems.
 One size of thinking and solving fits all.
Example of Analysis: Survival = Sum of 5 Parts
Linear, Additive Chain of Survival Metaphor
Rae TD, Page RL. Community Approaches to Improve Resuscitation After
Out-of-Hospital Sudden Cardiac Arrest. Circulation 2010;121:1134-1140.
BUT: Complex Problems are Different
“Given these complex relationships and
characteristics of a health system, applying
conventional approaches…will not take us
far enough. These approaches are usually
described as linear input-output-outcome
impact”
Systems thinking for Health Systems Strengthening,
World Health Organization, 2009
Complexity requires a radical shift in mindset
“We need a radical shift in the intervention
and evaluation approaches for (the type of
problems in) health systems, along with an
accompanying shift in mindset among
designers, implementers, stewards and
funders.”
Systems thinking for Health Systems Strengthening,
World Health Organization, 2009
Complex Systems Problems
Health Systems Complexity
 mechanical (technology) systems
 biological systems
 social, political, organizational systems
SCA survival emerges from the
interactions among these sub-systems
Complex Systems Problems
A System is a Whole that
cannot be understood only by analysis
 cannot be solved only by evidencebased research methods
What is Another Way to Think?
Shift Your Mindset: Analytic to Systemic
Systems Thinking
For Complex Problems
Thinking Approach
 Look at the problem as a
system
 Focus on interactions and
interdependencies within
the system
Solving Method
 Use design-based
methods
 Seek changes that will
improve or optimize the
whole system, not the
parts
Systems Thinking for Complex System Problems
Systems thinking is appropriate for
systems and their complex problems.
It requires you to:
 Consider a situation or challenge in its
entirety including “external” elements
 Focus on the relationships of the parts
with each other, rather than considering
the parts individually
Systems Thinking Misunderstood
Changing One Part Affects the Whole
Improving Individual Parts Reduces the Whole
Optimizing individual components
within a system tends to pessimize
the whole system—and hence its
overall purpose.
W. Edwards Deming
Systems Thinking Perspective
CPR instructor Allan is walking along the edge of a
river. He wants to cross, but sees no bridge and no
tunnel. After a while, he sees his friend John, another
CPR instructor across the way.
Allan shouts, “How do you get to the other side?”
After a brief pause John replies: “Allan, you’re ON
the other side.”
Systems thinkers are laughing!
Systems Thinking Applied
Allan says the glass is half-full.
John says the glass is half empty.
Larry says the glass is too big.
Systems thinkers use this as a “pick-up line”
Another Method to Solve Problems
Design Thinking is a Method of Problem Solving
2nd and 3rd generation design thinking is a
user-based problem-solving processes to
gain insight and yield innovative solutions
for complex problems and opportunities.
http://wagner.nyu.edu/courses/padm-gp.2145
Analytic Research Problem Solving Steps
http://bit.ly/1kKBO36
Design Thinking Problem Solving Steps
Systems research is
distinctive
What if…
“abductive”
reasoning
http://goo.gl/uKhjY/
Systems and Design Thinking Applied to Out-ofHospital CPR and AED Performance
Agenda
1. Decades-long Challenge of SCA Survival
2. OHCA, CPR and AED Projects Require:
New Thinking, New Language, Different
Approach/Method
3. Study 1: Need (Sell) More AEDs
4. Study 2: Design the Ideal Bystander CPR/AED
Learning Experience
5. Applying Design Methodology
4. Study 1: Need (Sell) More AEDs to Industry
“SCA survival is low
because there are too few
AEDs.”
4. Study 1: Need (Sell) More AEDs
Analytic Thinking Client Expectations
There would be more AEDs sold if there were:
 Better ways to determine the optimal number
and placement of AEDs
 Better ways to determine and ensure service and
training for AED users
 Better practices and processes for AED
governance across diverse commercial
environments
Our Approach: Systems and Design Thinking
1. Apply a Systems Thinking framework
 Research: Situation awareness to
understand the current reality of AED
buyers/users and to test assumptions
2. Apply Design Thinking methodology

Ideate then generate a prototype/pilot model
through a co-design process
3. Validate the model
Our Approach: Situation Awareness Method
State of the
environment
Level 1
Perception
Performance of
actions
Level 2
Comprehension
Situation Awareness
Decision
making
Level 3
Projection
Understand Current Reality: Situation Awareness
What is out there?
What are the connections?
What is the big picture?
1. Perception:
Collect and see
the dots
2. Comprehension:
Connect the dots
into one or more
patterns
3. Projection: Describe the
meanings and anticipated
outcomes of the patterns
Study 1 Results: Situation Awareness Outcomes
Situation Awareness revealed:
People think about at least
8 interacting elements
when considering an AED
Study 1 Results: What People Think About
Legal environment
 Regulations, laws, insurance, policies
Culture
 Some organizations and communities
promote themselves as heart safe; others
do little; ethical issues are involved
Study 1 Results: What People Think About
Trust
 FDA is challenging reliability, quality,
safety of AED manufacturers; AEDs differ
in several ways
Training readiness
 Those who witness SCA even if trained
may not call for an AED; CPR-trained
people may not act
Study 1 Results: What People Think About
Access
 If someone asks for AED – will it be found?
Decision making
 Do those in the AED decision making
position believe that “buying an AED is
enough” to be prepared?
Study 1 Results: What People Think About
Cost
 To acquire, service, maintain and update
an AED
Governance
 Who is the authority for use and follow-up
of an AED?
Study 1 Results: A Systems Model of Reality
Systems Thinking Applied
Systems Thinking Applied
A common response is to only
call 911 which will get
emergency personnel to the
victim, but very often too late
because CPR and use of an
AED were not initiated before
their arrival.
Bystanders may choose
not to act because of fear
of liability or lack of
confidence in their skills,
even if they have received
CPR/AED training.
Bystanders often do not
recognize the situation as
requiring their attention or
specific actions.
While the victim waits for help,
he/she
is surrounded
inaction
Sudden
Cardiac
Arrest is abycomplex
or ineffective
action.
event
and survival
is dependent on
the response of a bystander who is
However…
often a layperson.
As time passes, the
chances of survival
diminish.
They may eventually notice that
something is wrong, but may not
be able to recognize it as a
Sudden Cardiac Arrest. Often, it is
a trained medical professional
nearby who reacts and provides
emergency care.
Upon recognizing a situation that requires
action, bystanders will often not react for any
number of reasons. They may panic, may not
know what to do, others around them may
influence whether or not they act, and
sometimes a person’s reaction is dependent
on their relationship to the victim.
Domestic and international
researchers, as well as
organizations like AHA,
ARC, FDA, and NIH provide
evidence that early
Future
regulatory
requirements favoring AED
CPR/AED
greatly
improves
deployment
and utilization may pertain directly to
chances
of survival.
workplaces. In the meantime, federal regulations
for workplaces recommend CPR/AED training (but
not AED equipment).
AED legislation requiring AEDs and
associated training in various public and
addition to
private setting isIncontrolled
byinfluencing
the state.
corporations,
legislation
Legislation can be influenced by AHA, Red
immunity
for good
Cross, FDA, AED provides
manufacturers,
voters,
Samaritans with training
and laypersons.
A Sudden
Cardiac
Arrest and the
attempting
to provide
associated
problem
situation could
emergency
care.
Perhaps
on
this
floor.
occur anywhere
Reduced risk of
liability and lawsuits
in the event of injury
or death as a result
of intervention.
People willing to help
Such as an office building…
Improved
Bystander
People trained to help
Corporations or building
management may be required
to invest in an infrastructure to
support ongoing EQUIPMENT
AND TRAINING initiatives to be
in compliance with regulations.
1 AED covers 70.560 sq ft
Environmental and Health (www.readisys.com)
Lead: oversee the AED
program; IT: provide support/syncing for security
system that includes AEDs; Procurement: purchase
AED; Finance: approve spending on purchasing
AED, training, practice & evaluation; Facilities
Management: maintain AED access/functioning
with safety lead
Study 1 Conclusions
1. AEDs are perceived similar to other enabling
technologies, e.g., computer hardware and
software, communication devices.
2. What many lay responders desire is an “AED
(SCA) system integrator” because SCA is
understood as a system and they want a person
or process to connect and manage the many
interacting elements – legal, social, cultural,
trust, etc. - into a cohesive whole.
Study 1 Conclusions
3. A bystander has difficulty when confronted
by a community SCA because he/she must
personally assume responsibility for system
integration.
4. When integration is accomplished within an
organization, AEDs contribute to the
organization’s SCA system of survival.
Study 1 Conclusions
1. “SCA survival is low because there are
too few AEDs.”
2. The problem is NOT properly formulated.
3. The relationship between AEDs and SCA survival
is indirect, complex, interactive, and non-linear.
4. To sell more AEDs requires improved
understanding of how people think about AEDs,
and application of systems thinking.
Systems and Design Thinking Applied to Out-ofHospital CPR and AED Performance
Agenda
1. Decades-long Challenge of SCA Survival
2. OHCA, CPR and AED Projects Require:
New Thinking, New Language, Different
Approach/Method
3. Study 1: Need (Sell) More AEDs
4. Study 2: Design the Ideal Bystander
CPR/AED Learning Experience
5. Applying Design Methodology
4. Study 2: Design the Ideal Bystander
CPR/AED Experience
Pilot /Prototype Study
Special Task Force Members:
 LS and AB
 Physician: Penn State University Heart and Vascular
Institute
 Physician: Children’s Hospital of Philadelphia
 Professor: Biomedical Writing, University of the
Sciences in Philadelphia
 Graduate Students
Design Methodology: Steps
1.
Research: Conduct a “mess
formulation”
2.
Ideate: Collect elements/properties
for an ideal design
3.
Generate an ideal/prototype design
Design Methodology: Steps
1.
Conduct a “mess formulation”
2.
Collect elements/properties for an
ideal design
3.
Generate an ideal/prototype design
Design Methodology: Steps
1. Similar to situation awareness, a “mess
formulation” provides understanding of
an organizational system’s
-conflicts, obstructions, and confusions
-benefits and effective elements which
contribute to the experience of CPR/AED
learning
-likely contributors to performance
Stakeholder/Participants: 10 Communities
 Members of pre-hospital EMS systems;
 AED manufacturers;
 Personnel working in CPR professional
societies;
 Personnel working in government health and
regulatory agencies;
 Personnel in CPR education and curriculum
design;
Stakeholder/Participants: 10 Communities
 Personnel in CPR/AED research groups;
 Wide range of graduate students;
 Wide range of academic faculty, staff and
public safety officials;
 Attendees at community CPR classes;
 Personnel who did not or would not attend
CPR classes
Results: 1. Comparing Models
Mess Formulation
and
Traditional Perspective
of the
CPR/AED Experience
Traditional Perspective
System Perspective
Design Methodology: Steps
1.
Conduct a “mess formulation”
2.
Collect elements/properties for an
ideal design
3.
Generate an ideal/prototype design
Design Methodology: Instructions
2. Stakeholders were told:
 The entire CPR/AED education system
was destroyed.
 Nothing exists although the knowledge
and technology remain available.
 There are no CPR/AED agencies, leaders,
programs, curricula, courses, instructors,
materials, etc.
Design Methodology: Instructions
You are the designer for the NEW system
that you want to be in place right NOW…
Provide the elements of your Ideal CPR/AED
learning experience
 These are the properties that describe what you
want in order to learn CPR/AED that would enable
you personally to be prepared to respond whenever
or wherever it may be needed
Design Methodology: Step 2 Results
Ideal CPR/AED Learning Experience
More than 300 characteristics aligned within
12 categories for an ideal CPR/AED learning
experience were identified.
Design Methodology: Steps
1.
Conduct a “mess formulation”
2.
Collect elements/properties for an
ideal design
3.
Generate an ideal/prototype design
3. Design Methodology: Step 3 Results
Advocacy
Access
Values
Training
COMPETENT AND
READY TO ACT
EDUCATION
POPULAR CULTURE
SPORTS
COLLEGE
PLAY
HIGH SCHOOL
PRE SCHOOL
WORK AND
FORMAL ORGANIZATIONS
MEDIA
TV
RADIO
SOCIAL and
PROFESSIONAL
EVENTS
MOVIES
ELEMENTARY
For Profit
Government
Non-Profit
Finance
Technology
Social Computing
Risk
Responsibility
Advocacy
Access
Values
Training
COMPETENT AND
READY TO ACT
EDUCATION
POPULAR CULTURE
SPORTS
COLLEGE
PLAY
HIGH SCHOOL
PRE SCHOOL
WORK AND
FORMAL ORGANIZATIONS
MEDIA
TV
RADIO
SOCIAL and
PROFESSIONAL
EVENTS
MOVIES
ELEMENTARY
For Profit
Government
Non-Profit
Finance
Technology
Social Computing
Risk
Responsibility
Recommendations Emerged from the Design
1. CPR/AED course completion cards
- should include Good Samaritan Law
protections printed on the card
2. CPR/AED rehearsal training
- should be included with all facility
public safety scenario drills (e.g., fire)
Recommendations
3. CPR/AED program participants
- should demonstrate performance outside
the classroom in the presence of bystanders
4. The educational system support of SCA,
CPR and AEDs
- should begin descriptions of lifesaving in
preschool, and progress in complexity with
grade levels
Recommendations
5. Hands-only CPR
- should begin in middle school. CPR/AED
competency should be required for all high
school, college sports, and for graduation
6. Online and in-person training integration
- should be available for CPR/AED practice and
assessment (virtual reality)
Recommendations
7. CPR/AED training and assessment
- should be available at no cost to the
learner
8. All smart phones
- should have an app that includes early
access instructions and link to EMS help
Recommendations
9. Companies that sell products that contribute
to SCA risk (e.g., tobacco)
- should be required to financially support CPR and
AED training, and support the purchase of
associated equipment
10. US highway food/gas service areas
- should have employees trained in CPR and
equipped with AEDs (like airports)
Systems and Design Thinking Applied to Out-ofHospital CPR and AED Performance
Agenda
1. Decades-long Challenge of SCA Survival
2. OHCA, CPR and AED Projects Require:
New Thinking, New Language, Different
Approach/Method
3. Study 1: Need (Sell) More AEDs
4. Study 2: Design the Ideal Bystander CPR/AED
Learning Experience
5. Applying Design Methodology
5. Apply Design Methodology Here/Now
GREAT NEWS!!!
The Bill and Melinda Gates Foundation has
provided an unlimited financial gift for the
redesign of the ECC Update experience.
With 2 important restrictions
`
Design Methodology: Important Restrictions
1. The ECCU Conference mission remains:
 to transform knowledge into coordinated
action through unique methods of
knowledge dissemination
2. All the elements for an ideal update
remain available, if needed:
 knowledge, technology, materials, etc.
`
Design the Ideal ECC Update Experience
 Provide the elements of your ideal ECC
Update experience:
 These describe what you want in order to be
updated and to reach your highest level of
ECC competency
Design the Ideal ECC Update Experience
 You are designing from “nothing”
 There is nothing to improve because nothing is in place
 Focus on what you want – your ideal interests, needs
and experiences
 Do not focus on what is not needed
 One conversation at a time
 Encourage wild ideas
 Go for quantity
 Be visual
 Do not worry about resources
 Do not worry about implementation
Systems and Design Thinking Applied to Out-ofHospital CPR and AED Performance
Agenda
1. Decades-long Challenge of SCA Survival
2. OHCA, CPR and AED Projects Require:
New Thinking, New Language, Different
Approach/Method
3. Study 1: Need (Sell) More AEDs
4. Study 2: Design the Ideal Bystander CPR/AED
Learning Experience
5. Applying Design Methodology
Questions?
Answers?
Coffee?
Thank you
“This is really an innovative approach, but I’m afraid
we can’t consider it. It’s never been done before.”
https://www.pinterest.com/markveyret/
being-a-great-innovator/
For Further Information:
Larry M. Starr
[email protected]
Allan Braslow
[email protected]
John Pourdehnad
[email protected]