“Curmudge, for the past five years we have been, figuratively, shouting from the rooftop, ‘Adopt a Lean culture in health care. It will reduce waste and increase efficiency and patient safety.’ You want to do something different?”
“Not really, Julie. Now that we are in an office building downtown, shouting from the rooftop would be a bit impractical. We’d be a blip on the Appleton skyline and would attract the attention of the building management and local law enforcement. We’ll stick with writing, and our topics will include broader health care issues as well as Lean. Our next subject will be complex systems, a system composed of interconnected parts that as a whole exhibit one or more properties not obvious from the properties of the individual parts.”
“Please elaborate, Curmudge. Some examples would be helpful.”
“Complex adaptive systems are special cases of complex systems. They are complex in that they are diverse and made up of multiple interconnected elements and adaptive in that they have the capacity to change and learn from experience. Examples of complex adaptive systems include ant colonies, manufacturing businesses, and health care.”
“Finally! I am now with you.”
“These are a few characteristics of complex adaptive systems:
System behaviors may appear to be random or chaotic.
They are composed of independent agents whose behavior is based on physical, psychological, or social rules rather than the demands of system dynamics.
Because agents’ needs or desires are not homogeneous, their goals and behaviors are likely to conflict. In response to these conflicts or competitions, agents tend to adapt to each other’s behaviors.
There is no single point(s) of control. System behaviors are often unpredictable and uncontrollable, and no one is ‘in charge.’ “
“Here’s more that speaks directly of health care, written by engineers:
‘A complex adaptive system such as health care is not amenable to the controls and feedback forces we (engineers) generally ascribe to a system.’
‘A complex adaptive system such as health care is not amenable to the controls and feedback forces we (engineers) generally ascribe to a system.’
‘Health care delivery today is in turmoil. Despite rapid advances in medical procedures and the understanding of diseases and their treatment, the efficiency, safety, and cost-effectiveness of the delivery of health care have not kept pace. Improvements in the delivery of services in other industries have simply not been transferred to health care.
The question is why not. Here are a few of the most obvious reasons.
For one thing, the third-party reimbursement system is not conducive to a competitive environment in which customers (i.e., patients) can seek out the most cost-effective treatment or provider.
Second, health care delivery is still a cottage industry in which many components of the overall system operate as independent agencies. (As described by Levy, physicians practice the “craft of medicine” in which each functions as an independent expert.)
Third, the quality of care delivery and benefits are difficult to quantify. Finally, the annual cost of health care is increasing by double digits.’ “
“Those observations, Julie, appear to be reasonable, at least to you and me. And I suspect that most people would agree with the quote above that, ‘Health care delivery today is in turmoil.’ Further, we have learned in the past 5 minutes that a reason for the turmoil is that health care delivery is a complex adaptive system and that in such a system no one is (or can be) ‘in charge.’ ‘These systems are so complicated that no one person can fully grasp everything that is going on.’ “
“Sometimes, Curmudge, I can’t even fully grasp everything that is going on with my family.”
“Then you can appreciate how difficult—perhaps impossible—it is to manage a complex system like health care delivery across a large nation like the United States. Here are some more reasons:
‘There is no reliable model of the health care sector. Price doesn’t play the same role in health care as it does elsewhere in the economy.
Complex systems have unintended consequences. In trying to solve one problem we create other problems.
Complex systems cannot be managed from the top down. People in Russia now admit that the Soviet Union didn’t understand enough about their entire economy to manage it all from Moscow. ‘ “
‘There is no reliable model of the health care sector. Price doesn’t play the same role in health care as it does elsewhere in the economy.
Complex systems have unintended consequences. In trying to solve one problem we create other problems.
Complex systems cannot be managed from the top down. People in Russia now admit that the Soviet Union didn’t understand enough about their entire economy to manage it all from Moscow. ‘ “
“I’ve got it Curmudge—sort of. But if centralized management of health care delivery in the U.S. is fraught with difficulties, how do other countries with centralized health care do it?”
“We’ll tackle that next, Julie, but we may have to wait an extra week for our discussion. I’ll need to take some time off to move from the big house that I shared with the late Mrs. Curmudgeon into an apartment.”
Kaizen Curmudgeon
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