Last week, I wrote about the recognition that healthcare systems are not linear or mechanical: they are complex and not predictable using the tools of linearity and cause/effect. Unfortunately, our friends in government and the payment world have reached their tolerance for our behavior. Costs are so out of control that the regulators and the rules are multiplying fast. Here in Massachusetts, we in health care deservedly are now subject to high degrees of control and regulation to keep us from pushing our fragile economy back into recession as business and families struggle to afford our care.
Regulation, however, assumes a degree of cause and effect that does not exist in healthcare systems. The law of unintended consequences seems apt here. Regulating pieces of the system that we believe to have a cause and effect on outcomes is bound for failure. Do we need to control costs? Absolutely. I believe a global budget is a better mechanism than trying to figure out the mechanistic cause- and-effect factors, and regulate them.
In the concepts of complexity theory, health care is practiced in a system that is more than the sum of its parts (the characteristic called “emergence”). What we need is a master plan, not management by details. That goes for state and federal regulation, and management of health systems. Complex systems can engage in “emergent” self-organized behaviors with the guidance of a “master plan” that harmonizes aims, limits, and resources. As Atul Gawande pointed out, this is what happened to American agriculture.
A master plan built on complexity theory concepts might pool budgets, focus only on whole system measures and not as much on the sub-components, and focus on minimum specifications (simple rules) rather than complicated plans. To succeed in a chaotic environment, organizations need to operate closer to the edge of chaos, to be open to emerging ideas and practices, incorporating them along the way. This is very difficult for traditionally trained managers who feel compelled to exert control, stay within budget, and view deviations as needing to be controlled.
This has led to the idea of “positive deviance.” This is the notion that in every community there are deviances from the past that are “positive:” people and behaviors that enable them to find better solutions to problems than their peers, while having access to the same resources and facing similar or worse challenges. How do we harness these deviances? Of course first by recognizing them, then by investing resources in them to see where it goes.
Organizations that figure out how to make their health care systems more like a farm -- recognizing deviance and emergence as opportunities -- will be more successful. We need to notice the plants that are doing better, and give them more attention, water, space, whatever they need. Our friends in government and payment might best look only at total budgets and whole system measures, leaving the regulation of the details alone, so organizations can operate closer to the edge of chaos, adopting disruptive innovations, positive deviances, and other improvements without worrying about operating outside of regulation. I think all of us would get what we need faster if this approach were taken: better health, and from innovations and emerging approaches that we don’t even know about yet.
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