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No state has fallen further than Kansas in America’s Health Rankings. We used to be 8th in 1991.
Why did we slip so far down in the rankings? The answer might surprise you; it’s based on a leadership challenge.
At the Kansas Health Foundation, our bold vision is to make Kansas the healthiest state in the nation and to do so, this movement must be powered by Kansans in positions of authority and influence to shift Health outcomes.
Starting with the launch of the 2025 publication, Leading Health, written by President and CEO of the Kansas Health Foundation, Ed O’Malley, this podcast aims to break down key concepts of this leadership challenge and actionable ways that we can work together to make a real impact on Health in Kansas.
In each episode, Ed O’Malley, and Senior Advisor at Kansas Health Foundation, Susan Kang, will highlight a chapter in the book and discuss with Kansans who are actively engaged in expanding our definition of Health.
Leading Health is an invitation to move the needle on Health in Kansas, and we invite you to join us in leading the way.
Ep13
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[00:00:00]
Ed O'Malley: Well, welcome back to another episode of Leading Health, the podcast where my colleague Susan and I dive into this book, leading Health, how You and 30,000 Kansans [00:01:00] Help Communities Thrive. Today, we're gonna talk about chapter. 13, which is work systemically. But Susan, really quick, let me, let me just back up for people.
Recap and Mindsets
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Ed O'Malley: So what we've done along this journey is we started by talking about the chapters in part one where we land the idea of capital H Health versus lower H Health, we. Clarified, who do we mean by the 30,000? And we talked about America's health rankings as a north star, a rallying point. And of course, we landed the fact that we have slid so far in the health rankings and we want to turn that around.
Part two of the book is really the surprise. It's the surprise. You think it's a health challenge. It's not a health challenge. It's a leadership challenge, and part two describes what we mean by that and specifically about how it's a leadership challenge for the 30,000.
And by now the listeners know what we mean by the 30,000. Part three, of course, is [00:02:00] about, well, what are the mindsets that we need the 30,000 to hold? Now, last episode, we explored the first of those mindsets, which is the idea that we need people to work upstream. We need people to think further ahead.
That charity is fine, but charity doesn't change things. It doesn't transform things. It treats current conditions, and we need people to, yes, keep doing charity, but get beyond that and get further. Quote unquote, upstream. Today we're gonna talk about working systemically, and these two things really go well together.
Now, of course, the big picture here is this podcast. This book is trying to fan the flames of a different kind of conversation in Kansas about capital H Health. So Susan, it's good to be back with you today. It's
Susan Kang: Ed, I'm super happy to be here with you to talk about chapter 13, which is mindset number two. Right. You, you just talked about that a little bit. And I, you know, so. I love this idea about thinking bigger and achieving [00:03:00] wider impact. And it's not about just helping out one person, but about helping out thousands.
And we're excited to have Kari Bruffett back to, to help us bring these, bring the concepts to life. And so, Ed, there are a number of different concepts that are, that are brought up in this chapter. Would you mind starting with this concept of the two by two? That to, to explain to us the importance of that.
Ed O'Malley: Yes. I'm gonna dive into that two by two. I, I, I wanna land an idea first, because two by twos can be confusing. So first lemme just say that.
Systemic Thinking Basics
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Ed O'Malley: You know, the, the idea of systemic thinking, which is a pretty wonky term, and, you know, there are books on it and I've heard a lot of really, really smart people talk about systems theory and all this stuff, and, and I get it all.
And I, I, I wanna try to simplify it for people first. Like, what we're really saying is that we need to [00:04:00] work on a bigger scale. So rather than thinking about helping a person, we have to think about helping a population of people. You know, rather than thinking about helping a person or a family, we need to help a community.
We need to help a county. We need to help the state. So we have to think bigger. That's one thing I love about America's health rankings. It really forces us to think better. We're not gonna solve. Climbing the health rankings by helping Aans and get healthier. We're only gonna do it if we really change the whole conditions of how things are playing out here in the state that lead to lots of people getting healthier.
So, so that's kinda what we mean by working systemically. And this mindset, it's so critical for the 30,000 because again, the 30,000 can direct attention. They can focus our energy and if they help us think about a systemic mindset. Instead of an individual [00:05:00] mindset, we're gonna make more progress. So lemme just give you some quick examples and then I'm gonna get to that.
Two by two.
Susan Kang: Okay,
Ed O'Malley: great. And you know how much I love two by twos.
Susan Kang: Yeah, no, I, I agree. And I think once the listeners understand what the two by two is, I think it's gonna be magic.
Ed O'Malley: I love two by twos so much that one time I actually created a two by two, about two by twos.
Susan Kang: Okay. That's super nerdy.
Ed O'Malley: It is. And we will not try to explain that to people.
But let me dive back into this individual mindset versus systemic mindset.
Individual vs System Examples
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Ed O'Malley: So, so like, here's an example, you know, from the book. So. An individual mindset when it comes to secondhand smoke. We all know the dangers of secondhand smoke, which it's kind of interesting to think about.
There was a time when people didn't think that was dangerous. Right? Right. So it's a good advancement of health. Right. But an individual mindset, if we're trying to work on reducing secondhand smoke might be, you know, convincing a parent. To stop smoking so their children don't suffer the consequences of secondhand smoke.
[00:06:00] Well, that's good. That's good. But a systemic mindset would be passing legislation, like the clean indoor air laws from the early 2010s. Right, right. Like that's better. Yeah. Okay. Another example like. Businesses when it comes to hiring like a large, an individual mindset would be a large business creating an exception in their hiring policy.
So they can hire this particular convicted felon, this particular person, convicted of a felony. That's good, you know? But that same business, deciding to stop asking about past criminal convictions and job applications. Is better. Like that's a more systemic way of thinking about how do we create opportunity for people.
So what we're trying to do with this chapter is help the reader in this podcast episode help the listener think about the difference between an individual mindset and a systemic mindset. You know, here's one last example, like food accessibility. [00:07:00] If we have an individual mindset. About how do we solve the problem of people accessing healthy food?
We might deliver fresh fruits and vegetables to one family in a food desert, or sponsor, one family having access to some kind of food delivery service. That's great, right? We should do that. But a more systemic mindset would be changing economic development policies to make a grocery store economically viable in that food desert.
You know, like changing tax policies, adjusting the tax increment financing laws or whatever it might be to make that more sustainable. That's a more systemic mindset.
Two by Two Framework
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Ed O'Malley: Okay, let's get to the two by two. Now, some people might not know what we mean by that, so think of like a quadrant. And there is a horizontal axis, and that horizontal axis is on one end, on the far left end is a.
Having an individual mindset. [00:08:00] And on the far right end is having a systemic mindset. So that little continuum there is from on the far left, having an individual mindset to a systemic mindset. On the far right now, we just kinda talked about the differences there. Now, the last chapter, we talked about upstream.
So what I wanna do is ask people, and I know this is a little tricky for those listening, but to ask people to imagine now a vertical axis. That is about upstream and at the top of that vertical axis, axis is thinking upstream.
Susan Kang: Mm-hmm.
Ed O'Malley: Working upstream and at the bottom of that vertical axis is thinking and working downstream.
Now all of this is on page 128 in the book, so people can find it there. It's also on our website. And you can find that@kansashealth.org. But this two by two, that is [00:09:00] juxtaposing, that's a big word for me. Juxtaposing the individual to systemic mindset on the horizontal with the upstream to downstream thinking on the vertical.
Alright, it's a little wonky. Susan, are you still with me?
Susan Kang: I'm with you.
Ed O'Malley: I'm with you.
Susan Kang: Okay.
Ed O'Malley: Alright. And what we're trying to say. With describing this little two by two. And you know, you can't write a book without putting a two by two in it, right? So that's kind of a prerequisite, right? But what we're trying to say is all four of these quadrants, so we end up with four quadrants, right?
Quadrants One and Two
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Ed O'Malley: You end up with like, if you're looking at the diagram, the bottom left quadrant, we're in the individual space and the downstream space. So that's things like a food pantry. That's really important. Like food pantries are really, really important. Or, you know, a, a soup kitchen, like a place where people can go to get a meal that's so important.
Or another example of [00:10:00] something in that downstream individual quadrant would be things like coat drives. Like let's make sure every kid has a winter coat. I mean, that's great, right? That's really important to have a coat drive. So, so that's what we mean by like individual and downstream. Now we wanna be really clear, like we love all that stuff.
Right,
Susan Kang: right, right.
Ed O'Malley: We don't want anybody to stop doing that stuff. Right. Okay. Or let, let's play a, a little more, let's go to the upper left quadrant. So now this is upstream stuff. Yeah, it's not downstream. It's not like waiting till somebody's hungry and then feeding them a meal or waiting till they're cold and giving 'em a coat.
Now we're upstream, but it's still focused on the individual mindset, right? Mm-hmm. So it's things like, you know, mentoring an individual so they can advance in their career and get beyond like, fast food jobs to a higher paying job. Mm-hmm. Or, or funding a scholarship for a needy individual. That's awesome.
But you know, that's gonna change the life of that individual. Like we're working far enough upstream, it's probably literally gonna change their life, but it's [00:11:00] still just at an individual level. So we still like all that. Right,
Susan Kang: right, right.
Ed O'Malley: Yeah.
Susan Kang: Yeah. 100%. Can't
Ed O'Malley: get rid
Susan Kang: of it. This is good. Yeah.
Ed O'Malley: Can't get rid
Susan Kang: of it.
Yeah. Yeah.
Ed O'Malley: Okay. But now
Susan Kang: that's important.
Ed O'Malley: Now.
Quadrants Three and Four
---
Ed O'Malley: Now let's play with the bottom right part of this graphic. Okay. So the bottom right quadrant. So now we're, we're into the systemic side of this little graph. And I'm really hoping people are either drawing this along with me on a napkin or on the their hand, perhaps.
Or, or, or, or looking at this on our website, or they have the book open to page 128. But in that bottom right quadrant, we're talking about systemic now. But we're, we're back downstream, so this is still good stuff. This looks like, you know, like making sure there's an emergency room within geographic reach of every kansan like that, that is so critical.
We, we need that. And that's probably not gonna help us climb the health rankings, but we, we need that. Or back during the pandemic, you know, sending [00:12:00] everybody, like that mass mailing of COVID-19 tests. Remember that I do. They all showed up in the mail. Yes. From the federal government. Like that was an example of it was working downstream.
But it's pretty systemic. It's not just focused on an individual. Right. We love all that stuff. Right,
Susan Kang: right.
Ed O'Malley: Okay. And there's a lot of things happening in those three quadrants I just described. Okay. It's the fourth quadrant,
Susan Kang: which is on the upper right.
Ed O'Malley: Yeah, it's the upper right quadrant. That's the quadrant.
Susan Kang: Mm-hmm.
Ed O'Malley: That we need so much more activity in. And this is the quadrant that is. It's, it's in the upstream area. So it's leveraging everything from that last chapter. And it's also leveraging the thinking from this chapter. It's upstream and systemic. Look, this is what we need to get more traction on climbing the health rankings.
So thi this is things like we, we need to reimagine how we do literacy education in Kansas [00:13:00] because our numbers have been falling dramatically. And if we don't dramatically change the way kids in Kansas learn to read, it's gonna be really hard to improve health period. Right? This is things like.
Making sure that economic incentives are fairly distributed in ways across the state so that all the different types of populations are benefiting from the economic incentives that exist. Right. So a community like Northeast Wichita, which is facing some of the biggest health disparities, has every chance possible to have economic activity.
Right? Right. This is things like. Funding for public health so we can keep the population healthy to begin with rather than the wait till people get sick. Okay. So that is a lot to explain. Susan. I hope we still have listeners with us after explaining it two by two o over over a podcast, but hopefully it made some sense to people.
Susan Kang: Yeah, I mean, I think there's, you know, I think it is [00:14:00] helpful for us to look at the graphic either in the book or in the show notes below. But yeah, no, I think this is a really, really important foundation to be laid as we talk about upstream and systemic work.
Ed O'Malley: Yeah.
Parkinsons Example
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Ed O'Malley: I wanna just give one more quick example that I mentioned in the book.
My, my father battled Parkinson's for 18 years.
Susan Kang: Yeah.
Ed O'Malley: And, you know those, there are a lot of people listening, I'm sure, who have a loved one or somebody in their life who, who also is battling that disease, which is the fastest growing brain disease in the world.
Susan Kang: Yeah.
Ed O'Malley: Okay. Parkinson's and I volunteer with a group called Club Parkinson's here in Wichita.
And it is fabulous. It is amazing. It is helping. Individuals with Parkinson's, with exercise and helping them battle the disease and my monthly contribution is helping make membership fees more affordable. I love it. It's great. But it's still an individual intervention. It's, frankly, it's on the left side of [00:15:00] this two by two and it's pretty downstream.
Susan Kang: Mm-hmm.
Ed O'Malley: It's helping people who already have Parkinson's have a little bit better life. An upstream and systemic. Like way of trying to help Parkinson's might be something like, like funding research to learn why is it the fastest growing brain disease? What is in our environment that is leading to so many more people having Parkinson's disease?
That would be that upper right quadrant of upstream. And systemic. Okay. We've covered a lot of ground.
Kari Joins the Talk
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Ed O'Malley: Let's get Kari Bruffett back with us now. She joined us at an earlier episode back when we were talking about Kansas at 29th. Of course, she's the CEO of the Kansas Health Institute. Has a great background and civic life in Kansas.
As a cabinet secretary worked with the University of Kansas Hospital System. Let's get Kari back into this conversation with us today.
Susan Kang: Welcome Kari.
Kari Bruffett: Yeah, thanks for having me again.
Susan Kang: Oh, we're so excited to have you back to [00:16:00] talk about our, this chapter, chapter 13 which is working systemically. So as you know today, we're digging into this simple, but sort of a little bit, sometimes an uncomfortable idea of helping people's good. We know this, right? But changing systems is even better.
Right. Yeah. Because we get to, that's the, the individual versus the, the many, you know and we wanna help one, but we wanna, it's even better if we can help a, a lot more people. So if we wanna close the health gap and actually move the needle individual acts of charity is just not gonna be enough, right?
And so we wanna think bigger and we wanna think more systemically so. Tell us about a time when you did a good deed. Right. Most of us, we like to think that we've done some good deeds, I hope. Right? And when you, you know, that helped maybe one or two people out but realize that a systemic approach would actually be necessary to truly move the needle.
Kari Bruffett: Yeah.
Karis Good Deed Story
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Kari Bruffett: So I was a college student. I went to Fort Hayes State University out in Hayes, Kansas. And I was a journalism major and. [00:17:00] Went away to a journalism conference in a big city, an unfamiliar big city. It was probably the first time I'd kind of navigated a big city on my own. A group of us went out to lunch during a break and there was a gentleman who was outside the restaurant who was looking for money and he wanted a meal to eat, and we're like, oh, okay.
This was kind of unfamiliar at the time for somebody from Hayes. So we're like, Hey, come inside and we'll buy you lunch. Brought him inside to get lunch, and almost immediately the staff said, Hey, hey, no, no, it's, he needs to be removed. He's, he comes in here often mm-hmm. And he's always bothering people to buy him lunch and so on.
So we went ahead and bought lunch and I was like, well, you're, you know, restaurant, your food's not so good that you should be so proud of it. But, but we bought him lunch and took it outside and, I think the implication from the staff was somehow like we'd been duped, right? So in the moment, I think that was the lesson they were trying to give to us.
Like he's just, you know, playing here for a meal. I don't think that was the case. I don't know that gentleman's story. I didn't know it then. I certainly don't know it now. Now [00:18:00] with hindsight, I think a lot more about what was probably. Behind his need for a meal. Mm-hmm. Again, the food wasn't there, wasn't so great that it was like, oh, he just has to have a meal there every day.
He needed more than just a meal. And I think in that moment I realized it was important. Like you said, it was important to give 'em that food. And that's an important thing for us to, to do as individuals, to think about our, our neighbors and our our fellow Kansans and other folks that we wanna really help support.
But what we did in that moment, not only wasn't.
Beyond Food Access
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Kari Bruffett: Wasn't at the bigger than an individual level. It also wasn't really thinking upstream. We didn't have that knowledge. But in, in retrospect, you think about what he probably needed was not just access to food, but access to income, maybe housing stability, maybe access to healthcare services.
Maybe a way to get around and get a better way to get around and transportation. Mm-hmm. That sort of thing as well. So you talked about the two by two. In the in, in the early part of this [00:19:00] conversation. And for him, the solution definitely in that moment that we saw was both individual and very downstream.
It was the urgent need of that moment, important to meet. But it wasn't systemic where probably a lot of his needs were as individual, and it certainly was or it wasn't. Upstream where probably a lot of his needs were, and it certainly wasn't systemic.
Charity Versus Systems
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Kari Bruffett: And I just thought about, you know, the challenges we face as, as Americans who I do think have a strong sense of personal charity and, and caring for each each other.
Yeah. And. That we sometimes rely on that or think that we can rely on that or rely on our neighbors to also do that. To, to take care of some of our biggest challenges. And even with the best of intent not only were we only thinking downstream 'cause that's all we could do in that moment. But we also weren't thinking systemically.
You know, I was from another state. I wasn't gonna change the, the policies of that state or city at that time. But I, I often think back on that as one of my first and early examples of something that opened my eyes [00:20:00] to. More than just the need of the moment. Yeah.
Susan Kang: Thank you. Thank you for sharing that.
Leaders Who Shift Norms
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Ed O'Malley: You know, Kari, one thing that makes me think about is going back to, the role of the 30,000, Kansans with authority, elected officials, pastors, rabbis, school superintendents and principals, community minded businesswomen and businessmen. They can help propel charity.
Mm-hmm. They can help create norms around charitable activity and charitable giving. Right. And they should, and that's great. And though they also have the power to propel different thinking.
Kari Bruffett: Yeah.
Ed O'Malley: We don't want people to stop caring about making an individual act of kindness. Right.
An individual act of goodness, an individual intervention. And only the 30,000 though. I mean the 30,000 kind of, I mean, they, they, [00:21:00] they are pushing and pulling the levers of society, you know? Mm-hmm. And so they have the ability to get us to think differently about how those levers push and pull and combine to get us the results we're getting or get us different results.
Yeah. It's such a special privilege.
Kari Bruffett: Yeah, absolutely.
Postpartum Medicaid Win
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Kari Bruffett: And as an example, I think about a policy change that's happened in the last few years in Kansas. That it's more than a technical change. It was a, a significant change or more than a small change. But it made a big difference. And it went from maybe solving an individual problem to really thinking systemically.
And that was when Kansas extended what's called postpartum Medicaid eligibility. So, um. for a long time. Historically, the women who were eligible for Medicaid and who were pregnant after the pregnancy, they would have an, an additional 60 days of Medicaid coverage if they didn't otherwise qualify for Medicaid some other way.
And often that sort of was extended to about 90 days because of [00:22:00] timing. But we know. That many of the drivers of maternal morbidity and mortality, so death and serious illness are, are related to maternity. Doesn't end after 60 days or even 90 days, whether it's hypertension or depression or diabetes.
Those things, those complications last far beyond and, and an individual act to help someone who lost their Medicaid eligibility after. 60 days might've been navigation to say, okay, you're no longer eligible for this, but let's get you enrolled in a program that, that you are eligible for, or help, help get subsidized health insurance from somewhere else.
That's what we would do. A systemic answer response is to say, well, is it 60 to 90 days? And often when those illnesses take effect, not only does that have an effect on the health and wellness of those women, but it has an effect on the Medicaid program too because women might become more likely to be eligible again [00:23:00] because they now are don't. Have the income that would've made them ineligible for Medicaid and their back on, but now they have greater illness.
So there's, there's all sorts of program reasons also to continue the eligibility. So the extension of eligibility for up to a year which is something that was made of an option in federal policy a few years ago and states have incrementally implemented that. And now almost all states have implemented it because they recognize that that is a systemic action that.
Impacts individuals, but also helps the entire program. And it's something you can do rather than trying to deal with the individual healthcare challenge and continue to have coverage and access. And when you have coverage in the Medicaid program, it's not just about access to healthcare, some of in Medicaid, there are also access where there are connectors that connect you to access to other services.
For Big H, capital, H Health that also support health and wellness of not just the mom, but the baby as well.
Ed O'Malley: I, I think most our listeners know [00:24:00] this, but in case they don't, Medicaid is the government health insurance program, right? That is a federal state partnership to provide health insurance for those in poverty.
And different states have different rules about who's covered under that. But I, I think folks all understand that, but sometimes people do get confused with Medicaid, Medicare, right? All these different terms and things like that. It's a, that's a great example, and I love you mentioning that. Like almost all the states now have done that, so it's not really a partisan issue, right.
It seems like it is a systemic response to a presenting challenge that is an efficient way to improve health that just works. So I love that example. Yeah.
Susan Kang: Yeah.
Community Upstream Success
---
Susan Kang: Kari, I'm gonna switch gears a little bit. Okay. Around communities, you're, so, you're a researcher, you worked with a lot of different communities, and I'm curious to know about like, maybe a success story.
So, have you ever like, worked with a community who maybe, you know, they were doing great downstream work, right. Helping mm-hmm. On more of an individual or, you know, narrower [00:25:00] scope. Of people and they, they made a change and, you know a systemic change Yeah. To have greater impact.
Kari Bruffett: Yeah. And we have a, probably a few examples from some of my colleagues who work on Pathways to Healthy Kansas, which is sponsored by Blue Cross Blue Shield of Kansas.
And they work with community coalitions that identify. Issues in their community where they really want to invest and improve health. And some of those issues are downstream kind of issues. Mm-hmm. Mm-hmm. And, and those communities who have worked for a long time in pathways have started to move further upstream as well.
So, and one of the key ways that they do that I think is really interesting Calls back a little bit to our conversation many chapters ago in chapter four about collaboration, was they also listened to the community. Mm. So they engaged others, not just looking at that, that downstream data point that they're trying to move, but they started to ask other people why.
You know, sort of the five whys, right? Mm-hmm. What are the reasons we have these [00:26:00] and have started to invest more in that, in that upstream work, systemic work as well. So some of the examples you've given about, you know, you can do a food bank or you can also try to think about how you can. Work with a, bring in a, a, a, a permanent grocery store and, and in other communities trying to link up other ways that food is provided to, through other programs like Meals on Wheels to sort of expand that to other populations, for example. So, yeah. Again, you know, some of that might seem downstream, but it's by, by leveraging other systems that maybe are multiple downstream, that becomes kind of the systemic work as well. It's maybe downstream, but it is systemic because it's not just saying, here's the one program that we're going to invest in.
It's how can we leverage what we have in our community to provide something better? Systemically for our community.
Susan Kang: Yeah.
Housing Plan Example
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Susan Kang: I wanna just quickly share a story in Lawrence that's happening around the unhoused. Population. I mean, we have a lot of, you know, because we are [00:27:00] accepting of a lot of unhoused people, we have different people from different counties that end up in Douglas County.
Mm-hmm. And you know, there's a, there's a new initiative. It's a policy initiative, it's systemic in nature where we're trying to find housing for. Our unhoused population, and it's called, you know, a Place for Everyone. It's a it was adopted in 2024. It's a five year plan, and it's, the idea is to try to, you know, provi provide housing, right.
You know, small sort of pallet homes. Mm-hmm. And I just think it's, I mean, this is, I feel like that's another sort of a success story of thinking systemically instead of just helping, you know. Mm-hmm. One person at a time.
Ed O'Malley: Yeah.
Why Systems Trigger Pushback
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Ed O'Malley: So what I wanna explore is, like, I think some people either their eyes glaze over when they hear people.
Talk about systemic thinking or, or they actually really critique the whole notion of it.
Kari Bruffett: Mm-hmm.
Ed O'Malley: You know, and I just think it could be interesting for us to explore a little bit like what, like, like what's going on there, [00:28:00] you know? Because you know, like the postpartum example is a great one. Mm-hmm. The housing example is a great one.
These are ways of trying to solve a problem that our. That, that, that, like the intervention is big enough to actually create a, a result that affects the population we're focusing on rather than just a person or a family in that population. But I do think there are people who, like, this isn't the way they think.
This isn't the way they talk. And I, I'd love to, this, I'd love to ex explore what, what, what do we think is going on there and like Kari, I mean, you're interfacing with all kinds of people in the capital and beyond at the, as the work at the Kansas Health Institute. And any thoughts on this idea of like, what trips people up on this idea?
Kari Bruffett: Well, I think sometimes, and you've talked about it previously, and I'm sure in other chapters have talked about it with other guests too. The, the importance and significance of individual responsibility as a philosophical approach for a lot of folks. And it that can even not be [00:29:00] strictly on the, a political partisan sort of distinction either where we're thinking about the individual.
So when you are thinking about systems, it might seem to some that you're saying, oh, you're like removing personal responsibility or you're not accounting for that. I don't think that's so, Believe very strongly in individual responsibility. I do think that systems that allow people to have choices and, and maybe make the healthier capital h healthier choice a little easier.
Yeah. More affordable more likely that still rewards, or I don't say rewards, but it accounts for individual choice and not just individual responsibility, but individual agency people want that. And people don't want to be thought of as just part of a system, right? The individuals do want to be treated with respect but systems.
Can be designed to treat them with respect and create those opportunities for those choices. So I, I think those things don't have to [00:30:00] contradict. And I do think that can sometimes be a barrier to thinking or talking about systems. We talk about it in other parts of policy though, and it's systemically, and I think we get, we are able to overcome that idea that there's a dichotomy between individual choice and responsibility and systemic change in policy. So I think we can do it in health.
Ed O'Malley: Yeah. You know, it's, I really appreciate the way you're, you're describing that and, and we've said it a lot. We say it in the book, and we've said it a lot on this podcast, if the playing field is level and people aren't taking care of themselves, or they aren't making good choices, well then.
The heck with the heck with them, right? I mean, I'll never say exactly the heck with them, but you know, like that's different. But if the playing field's not level. And because of, current or historic laws or regulations or, or, or policies or just practices, then we need to level that playing field.
I think what we're talking about when we talk about working [00:31:00] systemically is saying, let's level the playing field for everybody rather than help this one person. Figure out how to get through the unlevel playing field. Like we, we can do that. And so I, but it's better if we can just level it.
And I love the way you're describing this. I, I do think like this when people have a, a negative, like if somebody's listening to this and they have a bit of a negative reaction to this, this call we're making for the 30,000 to work more systemically. It could be rooted in kind of a sense of a belief in the individual and a and, and a, and a sense of responsibility for the individual.
And so, you know, really smart people can hold multiple things at the same time. So we can hold on one hand the belief that we need to respect and honor the individual and allow for accountability for individuals. Mm-hmm. We can, we can hold that. And at the same time hold this idea of like, well, maybe we need to also figure out how to intervene.
That's a weird word. But, you [00:32:00] know, create change more systemically. And I, and I, sometimes it's useful to give an example of something that was put in place a long time ago that we probably don't even think about anymore as a systemic intervention. But once upon a time, the federal government wanted to spur more home ownership.
Kari Bruffett: Mm-hmm.
Ed O'Malley: So they created the mortgage tax deduction. Which is a massive systemic mm-hmm, mm-hmm. Approach to to encouraging home ownership, especially among the middle class. And it worked like it worked. And to this day, those of us who own homes are very familiar with the fact that you get to deduct your interest payments.
And that is an example of rather than helping one person get into a home, how can we help a population of a nation increase the rates of home ownership? That was a systemic mindset. Whoever had that idea mm-hmm. However, many decades ago.
Systems Not Just Government
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Kari Bruffett: You know, I think the other thing that can be challenging is we think of systems or some folks will [00:33:00] hear systems and they think that means government and that, so then we're only saying that it's a government solution and it may, it may require mm-hmm.
Like a government policy change like the one you just described. But systems are beyond that. We ex, there's systems around us, whether we identify them as systems or not. Whether you
Susan Kang: our family is
Kari Bruffett: a system. Yeah. Our families are systems, right. I mean, our social. Networks or systems we have. Those are, and, and systemic change can happen at that level too.
So I think maybe trying to separate the idea that system, it means only government. It certainly includes government, but it doesn't mean only government might help folks too to, to really think about. Systemic change?
Susan Kang: Well, you know what, I think what makes systemic change a little bit harder is that it takes collaboration and collective work with other people.
Mm-hmm. It's not just me, you know taking a coat to a shelter, right. That's just me and the shelter.
Kari Bruffett: Yeah.
Susan Kang: That's it.
Kari Bruffett: Right.
Susan Kang: But when we're talking systemic change, you know, even in a family, you know, it requires a family meeting. It requires for people [00:34:00] to get on the same page about what the goal. Of a particular, you know, endeavor is Right, right.
A particular rule. Like, you know, everyone has to abide by it anyway. Okay.
Two Questions To Go Upstream
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Susan Kang: So be, we're like, I, I wanna make sure that we have enough time. So just really quickly, what's one question you think, especially the members of the 30,000 Yeah. Can ask in real time to help groups consider whether like they're thinking systemically enough.
Kari Bruffett: Yeah, I'm gonna give you two questions, if that's okay. Actually go, it'll end up being more like six because one of them is the five why's, but, okay. The first one is and this is something from a Pathways example too. So an exercise that my colleagues work on with those community coalitions in those pathways communities across Kansas is if this problem shows up again next year.
What system level factor do we wish we had addressed today? So sort of saying if it, what we're doing this time for intervention, if it comes next year, what would we have not dealt with? And then that sort of [00:35:00] forces the, the conversation to, well, let's consider dealing with that or having a, a systemic change or upstream change that we can have.
So that's one. The other is like the tried and true five why's. So. Let's talk
about, you keep
asking the whys, right? Yeah, yeah. Okay.
Five Whys In Action
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Kari Bruffett: So you community says, we've got a lot of uncontrolled hypertension. And we say, well, why is that oil people aren't getting to the pharmacy to pick up their medication, or they're not medication compliant.
Well, why is that? They don't have a cars or, and there's no bus route, doesn't go to the healthcare facilities. So, and why is that? Well, we don't really plan our transportation routes with healthcare. Why is that? Because they don't meet together. So the, maybe the solution isn't, let's figure out how to get like a lift home delivery for everybody for their medications.
That might be something we can have that. But maybe instead it's transportation and health planners meet together and think together even before they realize not just to solve that problem, but just to plan together for [00:36:00] their collective needs. So, and that forces thinking systemically because you've just down that pattern of questions there.
We got to something that was well outside of lowercase H Health and capital H Health because it had the transportation folks in the room as well.
Susan Kang: Yeah, yeah.
Ed O'Malley: That's an awesome example. Yeah. I mean, that is super powerful and actually it's, it's a great example for lots of reasons, one of which is because the.
The solution. Like you follow that, that series of why questions and it gets to well, well the health, the healthcare people and the transportation people are never planning together.
Kari Bruffett: Right.
Ed O'Malley: That's a pretty easy solution.
Kari Bruffett: Yeah.
Ed O'Malley: And by the way, if you're somebody in the 30,000 that has the type of authority where you could call those people together, like that's a pretty simple intervention versus.
Concocting an incredible and maybe amazing but complicated system of home delivery and, and [00:37:00] technology and Right. And drones dropping off prescriptions and like that all could be cool too. Yeah. Or maybe we just need to like have an annual meeting with the right people where we're asking the right questions.
Right. And helping people figure out how to just leverage each other. Yep. Yeah.
Systemic Can Be Easier
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Ed O'Malley: Such a good, yeah, such a good, so what it got me thinking about is. The system level thinking doesn't have to be harder thinking.
Kari Bruffett: Right.
Ed O'Malley: It doesn't mean harder solutions necessary. Yeah. It just means different thinking.
Kari Bruffett: Yeah. Ah, yep.
Susan Kang: I think that's gonna be, I mean, so I, you know, my big takeaway from this conversation actually is really to get to the kernel of the problem or mm-hmm. Topic or the issue that we're working on. I like the idea of, you know, asking the five why's, you know, to really get at the, what is the, what is the kernel that is causing this issue.
Right. Yeah. And it helps us to identify sometimes an easy, systemic, you know, solution. Sometimes maybe a little bit harder, but I, I mean, I really, I really like that. Yeah. So I [00:38:00] encourage our listeners to, you know, to ask the five why's and see where you get on any one of those issues that you're working on.
It could be, you know, a big, broad issue around work. It could be a, maybe a smaller issue around your family.
Kari Bruffett: Yeah, I, I would take away from, from our conversation too, that not only does the systemic response have to not necessarily have to be harder, and maybe it's in some ways gonna benefit something far outside of even what, even capital H Health, if we work systemically.
But it doesn't have to contradict or compete with the idea of individuals as well. Mm-hmm. So there's still an individual who's picking up his or her prescription as part of that that system as well. They're also part of the system.
Susan Kang: Mm-hmm. Thank you.
Ed O'Malley: Yeah.
Leadership In Upper Right
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Ed O'Malley: I think what, what's going through my mind is a lot of different takeaways.
One, I, I'm a little blown away by that, that last one of like, the system approach might actually be easier. I think often I would've, I would've thought it, it would be harder but necessary. [00:39:00] But your little example of the five whys got us to something that might be easy, less expensive, easier to implement.
So that's one takeaway on my mind. But the, the more kind of philosophical and holistic takeaway on my mind is that, that we need the 30,000. I need to remember just personally in my own leadership, that, that it takes leadership to make all the things in all four of those quadrants happen. Okay. But it takes a special kind of leadership to create more of the things in that upper right quadrant that upstream and the systemic, and it takes leadership.
Leadership can come from anybody, okay? But it takes leadership from the 30,000 Kansans with authority. It takes leadership from them to get communities and to get the state focusing more. On that upper right, upstream and systemic. It, it's been a, a, a great conversation. Kari, [00:40:00] thanks for joining us and I know you'll be with us for our next episode as well.
We get you back to back, which we're excited about, so we'll continue that conversation very soon.
Kari Bruffett: You bet. See you soon.