by Michael Rohwer
In this fourth installment, Michael Rohwer gives a high-level view of management concepts better suited to the nature of the Complex Adaptive System we call healthcare—a necessary perspective if we are to avoid collapse.
Earlier I explained how the nature of Complexity causes our best initiatives to go sideways when managed from the top down. My most recent article included examples of innovation in other industries (personal computer, internet, digital camera) that used the process of nature we call “Complexity” to grow tremendous improvements in the value delivered and the ability for everyone to experience higher productivity at significantly lower cost. Now I’d like to discuss the shift in thinking and management needed to accomplish this same exponential outcome for healthcare. To begin, we must identify the places where management and change are most effective.
All systems have places or mechanisms where an intervention will have the most traction and effectiveness. Donella Meadows, in her book “Thinking in Systems: A Primer,” calls these “points of leverage.” The first two are complementary and our starting place. The first is the management paradigm or philosophy and the second, the purpose of the system.
The most powerful lever to optimize a Complex Adaptive System is the management philosophy. As noted in prior articles, the current method is traditional management that finds accurate expression in the machine metaphor. Our current paradigm constrains the value delivered to a standardized commodity and creates efficiency by minimizing inputs. If healthcare were a machine and not a Complex Adaptive System (and more fitted to a living metaphor), this would work perfectly.
The successful examples given in the prior article all operated with a management philosophy that maximized the value delivered. This may sound like heresy to those deeply embedded in the current system. Therefore I need to point out this is a different type of management. We will still constrain unnecessary and inappropriate care and we will still require that scientifically derived evidence remain the gold standard. We will continue to use many of the existing processes. How they are used and managed will be different and much more effective. We will be more likely to achieve our goals, such as the IHI Triple Aim. To achieve these goals, we must move to the second-most powerful place of action, the purpose of the system.
A clear and unambiguous understanding of the system’s purpose is foundationally necessary. Measures of output and productivity are validated against it. In this way, every activity in the system is judged based the output it creates or enables. For healthcare, this turns the system on its head—or, perhaps more accurately, stands it on its feet. It stops being a centrally planned and controlled system driven from the top by bureaucrats immersed in their expertise far from the actual delivery of care. Instead, it is intimately connected to actual accomplishment and driven from the roots by value delivered.
Without a primary connection to the purpose and its accomplishment, people naturally attach to intermediate and process goals related to their work or function. As a result, we see dedication to process that over time has its own often self-serving goals. The same holds for infrastructure. The EHR is a great example. When HITECH was designed and implemented, why were interoperability standards￼￼￼ delayed? The value created by all systems, not just Complex Adaptive Systems, is through connections. This decision redirected value away from system performance in favor of more parochial interests. Without measured outcomes, clever argument and extrapolations substitute for results. All of this spins out additional time and energy expended in maintaining a system that simultaneously fails to produce what we need most. And our current self-serving system compromises the highest duty of the provider to serve the member.
At this point, you may be asking how a system designed to maximize the value to the member is controlled. The knowledge gap between the member and the medical community is large. What prevents the delivery of bogus science or inappropriate procedures? These important questions go to the heart of how a Complex Adaptive System is managed.
First, it needs to be stated at the outset that a Complex Adaptive System cannot be designed. That is, we cannot predict exactly what its structure will be at any given point in the future. This is because it has a strong tendency to learn, adapt, and self-organize. It keeps redesigning itself. In fact, today’s problems have come from yesterday’s solutions and each iteration of change will create both new opportunities and new problems. This is why the simplistic linear thinking of traditional management doesn’t work and why continuous measurement of output is so important. To manage a Complex Adaptive System, each change in the system must be identified. If necessary to improve or preserve the output wanted, small adjustments made. This monitoring and adaptation requires the ability to observe and act quickly. Since our ability to understand and manage falls as systems grow, the most logical place to manage and achieve our goal is in the community where the purpose of the system is realized.
Three mechanisms are used to prune and redirect a growing Complex Adaptive System:
- Rules (incentives, punishments, parameters, and constraints)
- Information flows that are the mechanism through which the system grows
- Feedback loops that balance or reinforce behaviors
WB Rouse, in “Healthcare as a Complex Adaptive System,” lists the following organizational behaviors and what is necessary to manage healthcare as a Complex Adaptive System.
Comparison of Organizational Behaviors
So where does all of this leave us? First, we need to change our management philosophy from traditional management’s focus on limits to one based on maximizing true value to the member. The purpose of the system needs to be clean and unambiguous. I prefer “to enhance and preserve human health.” This definition guides the development of measures so we never lose sight of the goal and have an early indicator of trouble.
We understand that Complex Adaptive Systems continuously evolve and that we will need to continuously track that change, and shape the system to our goals using Rules, Information Flows and Feedback Loops.
What I have covered in this article is conceptual; my goal is to describe something much more specific and operational. That’s where we go next.