Healthcare – Complicated or Complex? Brenda Zimmerman, PhD Director of Health Industry Management Program Associate Professor of Strategy
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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
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