Lessons for health care leadership and management from … farming
As we navigate into a new world of health care, shifting providers rewards from volume to health care outcomes, service experience and cost, something has to be different about how we organize and lead ourselves.
In the “hard” sciences, system theory has greatly shifted in the last few decades. Scientists used to think they could keep digging into the subsystems of weather, or immune response, or subatomic particles (what they call deconstruction), and by understanding and controlling the subsystems we could control or at least predict the outcomes of the large system. We were looking for linear “cause and effect” systems.
But, as physicists and immune biologists have discovered, the really small subsystems are behaving according to rules that are very, very different from cause and effect. From all these lines of research has emerged the concept of complex adaptive systems.
Complex adaptive systems is a theory based on relationships, emergence, patterns, and iterations. It acknowledges that “mechanical” systems thinking (cause and effect) does work for some processes for which there is a high degree of certainty (outcomes from actions) and agreement among people taking the actions.
An example is a surgical team doing a routine surgery in an uncomplicated patient. However, this paradigm of thinking does not work when applied to a number of human systems. This paradox is displayed in the accompanying diagram by Zimmerman. The OR team lives in the lower left. Complete chaos lives in the upper right (something like a street riot…). In the zone of complexity lives things like the right design for primary care.
Complex adaptive systems have properties that can be studied to find new ways to think and manage in this zone. A few are: co-evolution, nonlinearity, adaptation, and emergent behavior. People who have spent lots of energy experimenting with how this applies to health care suggest the following complex adaptive system thinking to guide us:
• Use biologic metaphors to guide our thinking
o “This urgent decision is like treating an ED patient whose pressure is dropping- no time for lots of imaging and labs- make an intervention and adapt to what happens next….”
• Create conditions in which the system can evolve naturally over time.
• Provide simple rules and minimum specifications. Examples might be:
o Always focus on improving health
o No new investments in old ways
o Operate within these resource limits; otherwise, do what you want
• Set forth a good enough vision and create a wide space for natural creativity to emerge from local actions within the system
Several writers have made the point that leadership and management of emerging successful health care systems think like farmers, not like engineers. Command and control never works in complex adaptive systems. Farmers use knowledge and evidence from past experience. However, the farmer creates conditions under which a good crop is likely. The outcome is an “emergent” property of the system and conditions, and cannot be fully predicted. Moreover, as the crop emerges, the farmer can adapt to what is happening and alter conditions to optimize the outcome.
This framework helps me think about how we healthcare leaders put complex, adaptable, smart people in circumstances where they can “grow a good crop” of healthier people for our communities.
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