Healthcare – Complicated or Complex?

Brenda Zimmerman, PhDDirector of Health Industry

Management Program Associate Professor of Strategy

Heart Rate Dynamics ( from Dr Ary Goldberger,Harvard)

Heart Rate Dynamics

Heartsongs

• Listen to the “songs” of healthy hearts• Not random and yet not a rigid

pattern

• Between orderly and disorderly

Lessons From Physiology• “As humans we are complex

and chaotic when healthy and rigidly orderly when ill.”

Stuart Davidson

• Healthy heart has difference, irregularity, and is sensitive to changes in context ---- it is adaptable!

“You don't see something until you have the right metaphor to let you perceive it”. Thomas Kuhn

Believing is seeing. ” Karl Weick

Mental models

• Assumptions • Metaphors

• Challenge of implicit vs. explicit mental models

Common ImplicitMental Models

• Scarcity• Gap analysis–

what isn’t working

• Parts• Complicated• Machine – like

Common ImplicitMental Models

Alternatives/Opposites

• Scarcity• Gap analysis–

what isn’t working

• Parts• Complicated• Machine – like

• Abundance• Appreciative

inquiry – what is working

• Relationships• Complex• Life – like

In Health Care (almost) Nothing is Simple

• Distinguish between “complicated” and “complex” problems

• Dealing with complex problems as if they are complicated is like looking for your car keys in the lamplight

• Seemingly intractable complicated problems can often be viewed more optimistically and unraveled when they are seen as complex

Following a Recipe Rocket to the Moon Raising a Child

• Formulae are critical and necessary

• Sending one rocket increases assurance that next will be ok

• High level of expertise in many specialized fields + coordination

• Separate into parts and then coordinate

• Rockets similar in critical ways

• High degree of certainty of outcome

• Knowable

• Formulae have only a limited application

• Raising one child gives no assurance of success with the next

• Expertise can help but is not sufficient; relationships are key

• Can’t separate parts from the whole

• Every child is unique

• Uncertainty of outcome remains

• Unknowable

Complicated Complex

The recipe is essential

Recipes are tested to assure replicability of later efforts

No particular expertise; knowing how to cook increases success

Recipe notes the quantity and nature of “parts” needed

Recipes produce standard products

Certainty of same results every time

Known

Simple

Following a Recipe Rocket to the Moon Raising a Child

• Formulae are critical and necessary

• Sending one rocket increases assurance that next will be ok

• High level of expertise in many specialized fields + coordination

• Separate into parts and then coordinate

• Rockets similar in critical ways

• High degree of certainty of outcome

• Knowable

• Formulae have only a limited application

• Raising one child gives no assurance of success with the next

• Expertise can help but is not sufficient; relationships are key

• Can’t separate parts from the whole

• Every child is unique

• Uncertainty of outcome remains

• Unknowable

Complicated Complex

The recipe is essential

Recipes are tested to assure replicability of later efforts

No particular expertise; knowing how to cook increases success

Recipe notes the quantity and nature of “parts” needed

Recipes produce standard products

Certainty of same results every time

Known

Simple

Following a Recipe Rocket to the Moon Raising a Child

• Formulae are critical and necessary

• Sending one rocket increases assurance that next will be ok

• High level of expertise in many specialized fields + coordination

• Separate into parts and then coordinate

• Rockets similar in critical ways

• High degree of certainty of outcome

• Knowable

• Formulae have only a limited application

• Raising one child gives no assurance of success with the next

• Expertise can help but is not sufficient; relationships are key

• Can’t separate parts from the whole

• Every child is unique

• Uncertainty of outcome remains

• Unknowable

Complicated Complex

The recipe is essential

Recipes are tested to assure replicability of later efforts

No particular expertise; knowing how to cook increases success

Recipe notes the quantity and nature of “parts” needed

Recipes produce standard products

Certainty of same results every time

Known

Simple

Following a Recipe Rocket to the Moon Raising a Child

• Formulae are critical and necessary

• Sending one rocket increases assurance that next will be ok

• High level of expertise in many specialized fields + coordination

• Separate into parts and then coordinate

• Rockets similar in critical ways

• High degree of certainty of outcome

• Knowable

• Formulae have only a limited application

• Raising one child gives no assurance of success with the next

• Expertise can help but is not sufficient; relationships are key

• Can’t separate parts from the whole

• Every child is unique

• Uncertainty of outcome remains

• Unknowable

Complicated Complex

The recipe is essential

Recipes are tested to assure replicability of later efforts

No particular expertise; knowing how to cook increases success

Recipe notes the quantity and nature of “parts” needed

Recipes produce standard products

Certainty of same results every time

Known

Simple

Following a Recipe Rocket to the Moon Raising a Child

• Formulae are critical and necessary

• Sending one rocket increases assurance that next will be ok

• High level of expertise in many specialized fields + coordination

• Separate into parts and then coordinate

• Rockets similar in critical ways

• High degree of certainty of outcome

• Knowable

• Formulae have only a limited application

• Raising one child gives no assurance of success with the next

• Expertise can help but is not sufficient; relationships are key

• Can’t separate parts from the whole

• Every child is unique

• Uncertainty of outcome remains

• Unknowable

Complicated Complex

The recipe is essential

Recipes are tested to assure replicability of later efforts

No particular expertise; knowing how to cook increases success

Recipe notes the quantity and nature of “parts” needed

Recipes produce standard products

Certainty of same results every time

Known

Simple

Know When Your Challenges Are In the Zone of Complexity

CertaintyClose to Far from

Clo

se to

Know When Your Challenges Are In the Zone of Complexity

CertaintyClose to Far from

Clo

se to Simple

Plan, control

Know When Your Challenges Are In the Zone of Complexity

CertaintyClose to Far from

Clo

se to Simple

Plan, control

Chaos

CertaintyClose to Far from

Clo

se to

Simple &complicated

Plan, control

ChaoticSeek Patterns

CertaintyClose to Far from

Clo

se to

?

Nature of complex systems• Interdependence –

cause and effect less clear

• Unpredictability• Emergence• Embedded systems• Nonlinearity• Distributed control• RELATIONSHIPS

ARE KEY

IOM “Crossing the Quality Chasm”

• Inspiration from complexity science• Principles of complex adaptive systems

resonated• Simple rules that repeat

– Current system– Ideal system

Simple Rules – allow for swarming

• They give enough of a sense of direction without over-specifying

• Local solutions can be discovered (at the “edge” rather than center)

• Following same rules – can result in different solutions – Creates coherence rather than

consistency

Lessons from complexity• Learning takes place at the edge of the

system - not the center

• Sustainable change is initiated at the edge of the system – not the centre

• Adaptation to changing external conditions occurs at the system’s edge– not the center

• Command and control makes it worse• Dr. Eric Knox, at AHA Patient Safety

Fellowship 2003

Patient Safety• Goal is to reduce harm, injury

• Error producing conditions:– Unfamiliarity with task– Shortage of time– Poor communication– Information overload– Poor instructions– Etc..

• Swiss Cheese Model – “gaps” – system Reason, 2001

The Patient Safety Problem -Simple• People are making mistakes

• Hire the best

• Create rules to correct behaviors

• Tell people to follow rules

• If non-compliance, shine light

• Get rid of or correct “bad apples”

Patient Safety - complicated

• To err is human (slips, trips and lapses)• Refocus on system problems• Decrease reliance on memory and

other faulty human aspects• Standardize, routinize, reduce

variability • Human factors engineering• Safety culture

Patient Safety - Complex

• Relationships are key• Focus on Humans – not just as “error

producers” or faulty machine parts• Communication focus • Include full system into processes – patients,

families, clerical staff, etc. • Look at patterns - simple rules that hold

system• Role of surprise and emergence – what is

working/why

Complexity ConsistentMental Models

• Relationship-Centred Care

• Patient and Family Centred

• Holistic• Embedded

Systems

• Abundance• Appreciative

inquiry – what is working

• Relationships• Complex• Life – like

“Managers would rather live with a problem they can’t solve

than with a solution they can’t fully understand or control.”

• Eric Bonobeau, researcher in swarm intelligence and CEO of Icosystems