by Michael Rohwer
An understanding of Complex Systems and their importance is a recent phenomenon. Appendix B in the 2001 IOM “Crossing the Quality Chasm” presented Healthcare as a Complex Adaptive System (CAS) but offered little practical advice. Even as some industries took advantage of CAS, knowledge remained buried in Systems and Computational Science. Today there are good examples from other industries and better understanding of Complex Systems and Networks. If we in Healthcare were starting over with that knowledge, Healthcare would look and operate very differently and more effectively.
UNDERSTAND HEALTHCARE AS A COMPLEX ADAPTIVE SYSTEM (CAS)
A CAS is alive and never in equilibrium. It continually self-organizes to create new behaviors and circumstances that are unpredictable but not random. The science of a CAS is probabilistic.
Healthcare’s current “traditional management”—a mechanical, industrial model—presumes an Ordered System. Ordered Systems produce reliable outputs. This model works well for human-designed systems. However, a CAS is a natural process producing outcomes not outputs, an important distinction.
THE MEMBER IS PART OF THE SYSTEM, NOT A TARGET POPULATION
Unlike Ordered Systems that produce outputs for use outside itself, a CAS produces outcomes for itself. Because Healthcare is a CAS, the member is and needs to be part of and participating in the system. This seemingly subtle point changes perspective, and that changes how we think and what we do. Because the CAS will always shift to serving itself, it ultimately won’t serve any outside entity regardless of corporate alignment around the slogan of the month. This may explain why Healthcare currently limits value delivered to individual members while creating more value for large institutional providers.
THE PURPOSE OF THE SYSTEM IS TO CREATE A HEALTH OUTCOME IN EACH MEMBER
A health outcome is measurable. It is the primary actionable metric around which the system is managed. Intermediate measures not tied to actionable metrics become vanity metrics that divert resources away from the purpose.
THE MANAGEMENT PHILOSOPHY MAXIMIZES VALUE TO THE MEMBER
Modern business operates on this principle; it drives innovation, lowers cost, and raises quality. Examples include the personal computer, digital camera, ATM machines, and the internet. And while each of these is a machine produced using traditional industrial-model management, the market is a CAS. These have dramatically altered our world because the CAS was used to drive innovation and change.
INNOVATION AND GROWTH OCCUR AT THE EDGES
Natural systems, like plants from seeds, grow from small components. Emergence and innovation are not centrally designed and controlled, but are natural adaptations. For Healthcare, the engine of innovation is the community where local providers provide care to members. The current Healthcare management system must be retooled to drive innovation at this level.
MANAGEMENT AND CONTROL USING POINTS OF INFLUENCE
In order for Healthcare to achieve its goals of delivering scientifically supported care within available resources, its management must be suited to its nature. A CAS is managed by using influence at key points of leverage1 to control and redirect emergent circumstances toward the goal.
- The system exists for a purpose. Directing work toward the purpose is a powerful alignment tool.
- The operating paradigm to achieve the purpose sets the agenda for planning. This is the shared social agreement around the nature of what needs to be done.
- Self-organization exists in every workplace and throughout nature. It is a powerful engine of growth and innovation. The system is substantially inhibited or enhanced by policies that suppress or enable it.
- Rules (incentives, punishments, parameters, and constraints) redirect growth.
- Information flows drive growth.
- Feedback loops balance or reinforce behavior.
PROVIDER PERFORMANCE IS TRANSPARENT AND SHARED
The ability of each practitioner and supporting provider organization to deliver the system’s purpose--optimal health outcomes in each member—should be transparent and shared. This information will create competition by empowering members and referring practitioners. It is essential that members have the ability to judge providers and practitioners in ways that practitioners also find valid.
VALUE METRICS ARE BASED IN A COMMUNITY PROBLEM CONTEXT
Each community must be able to create metrics that are aligned with local initiatives and goals. National standards inform local activities and the results of local initiatives feedback to national organizations through common metadata standards and processes.
SYSTEM INTEGRATION IS LIGHT, ENABLING SCALE-FREE (RE)ORGANIZATION
For Healthcare, a CAS, to be able to meet its goals, practitioners and members need to be able to reorganize easily. This adaptability is possible due to advances in information systems and the science of Complex Networks. For example, payment based on a virtual network of practitioners around the member having a specific problem creates a team-based perspective. Practitioners will also be more efficient with a lightweight connecting infrastructure that is not owned by a competitor or packaged with constraints on their ability to serve the member. Being able to operate in an adaptable environment will allow each practitioner to choose his or her optimal practice.
INFORMATION INFRASTRUCTURE SUPPORTS REDUNDANT SERVICES TO PRODUCE RESILIENCE
Modern information infrastructure allows for multiple competing vendors to be connected. An infrastructure that selects for interoperability enables more competitive choices for communities. Configuration of small components having standard interfaces enables the network and the community to be resilient and adaptive.
1“Thinking in Systems,” Donella Meadows,