Making Sense: From Complex Systems Theories, Models, and Analytics to Adapting Actions and Practices in Health and Health Care (original) (raw)
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Health Systems as Complex Systems
American Journal of Operations Research, 2013
Health systems are paradigmatic examples of human organizations that blend a multitude of different professional and disciplinary features within a critically performance environment. Communication failure and defective processes in health systems have a tremendous impact in society, both in the financial and human aspects. Traditionally, health systems have been regarded as linear hierarchic structures. However, recent developments in the sciences of complexity point out to health systems as complex entities governed by non-linear interaction laws, self-organization and emergent phenomena. In this work we review some aspects of complexity behind health systems and how they can be applied to improve the performance of healthcare organizations.
Understanding health system reform - a complex adaptive systems perspective
Journal of evaluation in clinical practice, 2012
Background Everyone wants a sustainable well-functioning health system. However, this notion has different meaning to policy makers and funders compared to clinicians and patients. The former perceive public policy and economic constraints, the latter clinical or patient-centred strategies as the means to achieving a desired outcome. Design Theoretical development and critical analysis of a complex health system model.
Perturbing Ongoing Conversations About Systems and Complexity In Health Services and Systems
Journal of Evaluation in Clinical …, 2009
Perturbing ongoing conversations about systems and complexity in health services and systems 1. Carmel M. Martin MBBS MSc PhD FRACGP1,*, 2. Joachim P. Sturmberg MBBS DORACOG MFM PhD FRACGP2 Article first published online: 26 MAY 2009 DOI: 10.1111/j.1365-2753.2009.01164.x The term ‘unintended consequences’[1] has become ubiquitous [2] in health policy and delivery circles. We argue that this is a sign of the growing unease arising from the realization of the limitations of the still dominant reductionist research approaches, ‘evidence’ and linear thinking in relation to health system1 and health services2 policy redesigning. Complexity theorists argue that many of the problems of health services and systems will not be solved through the application of more reductionism [3]. The most revered tool in reductionist research is the randomized controlled trial (RCT). However, as Cartwright has pointed out RCTs have very significant limitations for real world problems. ‘The claims of . . . RCTs to be the gold standard rest on the fact that the ideal RCT is a deductive method: if the assumptions of the test are met, a positive result implies the appropriate causal conclusion. . . . the benefit that the RCT conclusions follow deductively in the ideal case comes with a great cost: narrowness of scope. . . . (in order) to draw causal inferences about a target population, which method is best depends case-by-case on what background knowledge we have or can come to obtain’[4]. Health services researchers, decision makers and practitioners are now faced with at least two challenges: how to respond to the limitations of current research and decision-making models that have taken us ‘just so far’; and how to integrate other sources of evidence into policy and practice in the real world [5]. What matters is making sense of what is relevant, i.e. how a particular intervention works in the dynamics of particular settings and contexts. It is not very useful to change a system based on deductive, in Cartwright's words – average explanations. As Stengers [3] pointed out – the most useful questions addressing complex problems must imply an open situation: ‘What will the intervention be able to produce?’ and ‘What kind of behaviour will emerge? What are our frames of reference? What are our ideas and values in relation to success?’ In relation to policy development Glouberman, an applied philosopher adds: ‘Frameworks for understanding policy development do not merely describe the process. They invariably indicate what a “well-functioning” process is like. And so they place a value on certain structures and behaviour. As our theories change, so do our views of what is good’[6]. Responses to the challenges to our contemporary frameworks are many and varied. They include the rise of translational research [7], narrative evidence-based medicine [8], the quest for utility in patient-reported outcome measures, together with new statements about trials and multifaceted interventions [9–12]. Acknowledging these challenges is not only a sign of understanding the crisis of scientific knowledge [13], but also evidence that new conversations have started [7,14,15]. Common to complex systems are two fundamental themes – the universal interconnectedness and interdependence of all phenomena, and the intrinsically dynamic nature of reality [16]. ‘At each level of complexity we encounter systems that are integrated, self-organizing wholes consisting of smaller parts and, at the same time, acting as parts of larger wholes’[17]. Notable international examples of an emerging and evolving discourse about complex systems in health services research and quality improvement include the Institute of Medicine's report ‘Crossing the Quality Chasm’[18] with a resultant series of US quality initiatives, and Glouberman and Zimmerman's report to the Romanow Commission in Canada [19]. Approaches to understanding complex systems developed by Kurtz and Snowden [20] for IBM international e-business management have been successfully applied, with frontline health care providers taking a lead to improve outcomes in the successful redesign of New York State Veteran's Affairs [21]. Other examples include the successes of taking a systems approach to tobacco control on overall smoking rates within the Veterans Affairs health services clients [22] and in the broader health systems against major resistance by the licit and illicit tobacco industry [23,24]. Ongoing challenges to smoking cessation and tobacco control strategies remain. Deprived communities are not only at greater risk from the adverse effects of smoking related morbidity, they are also at greater risk from social factors that predispose to smoking. In addition, social and environmental factors such as unemployment interact with endogenous or biological risk factors such as a predisposition to anxiety or other mental illness. As Galea et al.[25] argued in a overview of the social epidemiology of smoking, there are complex multiple interacting factors at individual and societal levels (biopsychosocial levels). In the future, it is important to make sense of the complexity ‘of not only how social factors may influence substance use in isolation but also how social factors may modify relations between biological characteristics and substance use behaviour’[25]. Atun [26], Evans [27] and Shiell [28] have recognized that economic evaluations of a complex adaptive health system need to encompass multiple perspectives and dynamic influences in an environment. For example, opportunity costs result from a decision to take a certain approach that entails not pursuing or even considering some options [29]. These opportunity costs are important in health service decision making, as a basis for efficient use of resources. Reductionist analysis of opportunity costs is content with restricted possibilities, i.e. it accepts the categorical exclusion of certain individuals or community considerations in its economic evaluations, that later show up as unintended consequences on the wider health system. For example, studies exploring the economic impact of doctor behaviours suggest that ‘assigning a monetary value (aiming to reduce opportunity costs) to every aspect of a doctor's time and effort may actually reduce productivity, impair the overall quality of performance, and thereby even increase costs' [30]. The focus on the monetary value of narrowly defined tasks incurs an opportunity cost as it undermines doctors' social contract for altruism with patients, society and other professionals [30], outweighing the ‘calculated benefits accrued’[31]. This example and others demonstrate that narrowly focused and static evaluations cannot assess the true efficiencies in complex health systems [29]. Slowness in the uptake of complexity 1. Top of page 2. Slowness in the uptake of complexity 3. The way forward 4. References Somewhat surprisingly, despite the flurry of interest in recent decades, diffusion of knowledge and innovation about complexity and adaptation in systems for health care has been slow [15,28]. Reductionism remains the dominant paradigm and is increasingly influencing policy like the introduction of simple disease management protocols or pay-for-performance targets [30]. Clinician work is increasingly being reduced to a series of discrete activities based on a business model driven by the agenda of cost containment [30] rather than improved patient health. Moreover, there has been almost no discourse to distinguish what is amenable to reductionist approaches and what is not, and how to apply holism and holistic frameworks and approaches. Why might this be the case? Singer, the Director of the Max Planck Institute for Brain Research in Frankfurt, Germany provides important insights towards answering this question [32]. The rise of human culture and civilization, great works of philosophy, literature and art or the modern communication systems via the Internet and the blackberry are not explained by our decentrally organized brains, and the dynamic states and plasticity of the many billions of linked and interacting neurons in the brain. Both our brains and our social organizations have evolved to be complex, dynamic and adaptable with emergent properties not explained by the structures that they contain. Singer reflects, apparently, ‘our cognitive abilities have evolved in a world in which there was no advantage to be gained by understanding nonlinear complex multidimensional processes’[32]. Whether or not the current dominance of reductionism [13] is a social or an evolutionary brain phenomenon, in history, there has always been the counter position of holism. As stated by the eminent Greek philosopher Aristotle [33], ‘the whole is greater than the sum of the parts’. Thus, despite a tendency to reductionism, ‘this does not mean that we cannot or will not develop analytical methods to identify these (complex) system states and to track them chronologically; however, the descriptions will be abstract and vague, and will bear no similarity to our familiar perceptions and concepts’[32]. So we must conterintuitively work to develop appropriate abstract frameworks and categories, and reflect on our ways of knowing, if we are to gain a deeper understanding of the processes that operate in complex systems, and how to intervene more successfully [29,32]. Our main imperative to go beyond the more intuitive and reductive is the lack of success of many well-intended health services interventions [34,35] and the unintended consequences of interventions in the real world of health systems [36–38]. However, many may still see the current limitations in knowledge and practice, as a stimulus to more rules, and greater compartmentalization, categorization, description and reductive measurement of the complex processes of the health systems in which we operate rather than take up the challenges of Singer, Senge...
Theoretical Medicine and Bioethics
In an era of a dynamic, uncertain, complex, and ambiguous health challenges [sic] at all levels and in every setting, this Primer on systems thinking, as it pertains to health, is urgently needed" (p. vii). Thus begins Johnson and colleagues' Primer and it certainly appears at a propitious time as we continue to investigate the COVID-19 pandemic. Why propitious? Specifically, the pandemic has revealed how dysfunctional the global healthcare system is and how badly it needs repair. One such means is through systems theory and thinking. Rather than the reductive approach which exemplifies traditional biomedical thinking and results in fragmented healthcare, systems thinking provides a holistic approach to meet the dynamics and complexities requisite to deliver quality and safe healthcare. After a brief preface, which frames the authors' motivation for the Primer, they discuss systems thinking and its application to the healthcare system throughout five chapters. The first chapter is an introduction to systems theory and thinking. The authors initially discuss systems theory and its foundations, most notably Ludwig von Bertalanffy's general systems theory. Rather than uniting the sciences via their reduction to physics, Bertalanffy strove to unify the sciences by integrating them as a dynamic and complex system. The authors then turn to complex adaptive systems (CASs) as the paradigm for understanding the functioning of healthcare systems. They discuss the various components and attributes of CASs, including agents, interconnections, self-organization, emergence, and co-evolution, among others. Next, the authors cite the World Health Organization (WHO) regarding the requirements of systems thinking: "a deeper understanding of the linkages, relationships, interactions, and behaviors among the elements to characterize the entire system" (p. 9). The authors then explore systems thinking by reframing a problem from a perspective of the "whole"
Health Care Organizations as Complex Adaptive Systems
From its roots in physics, mathematics, and biology, the study of complexity science, or complex adaptive systems, has expanded into the domain of organizations and systems of organizations. Complexity science is useful for studying the evolution of complex organizations --entities with multiple, diverse, interconnected elements. Evolution of complex organizations often is accompanied by feedback effects, nonlinearity, and other conditions that add to the complexity of existing organizations and the unpredictability of the emergence of new entities.
2018
This commentary addresses two points raised by Kitson and colleagues' article. First, increasing interest in applying the Complexity Theory lens in healthcare needs further systematic work to create some commonality between concepts used. Second, our need to adopt a better understanding of how these systems organise so we can change the systems overall behaviour, creates a paradox. We seek to manipulate systems that self-organise and follow their own internal rules. Although, our actions may impact and indeed meet some of our objectives, system behaviour will always emerge with unpredictable consequences. Likewise, outcomes at the aggregated level of the system never reaches an optimal point as defined by the 'external controller. ' Kitson and colleagues' theoretical model may struggle to resolve the paradox of gaining control over the multiple knowledge translation (KT) systems covered by the model, because theoretically these systems retain control under the principle of self-organisation. That is not to suggest that individual agents cannot influence system dynamics just that the desired outcome cannot be guaranteed. Indeed, for systems to change they will need strong incentives. Citation: Chandler J. The paradox of intervening in complex adaptive systems: Comment on " Using complexity and network concepts to inform healthcare knowledge translation.
The dynamics of health care reform--learning from a complex adaptive systems theoretical perspective
Nonlinear dynamics, psychology, and life sciences, 2010
Health services demonstrate key features of complex adaptive systems (CAS), they are dynamic and unfold in unpredictable ways, and unfolding events are often unique. To better understand the complex adaptive nature of health systems around a core attractor we propose the metaphor of the health care vortex. We also suggest that in an ideal health care system the core attractor would be personal health attainment. Health care reforms around the world offer an opportunity to analyse health system change from a complex adaptive perspective. At large health care reforms have been pursued disregarding the complex adaptive nature of the health system. The paper details some recent reforms and outlines how to understand their strategies and outcomes, and what could be learnt for future efforts, utilising CAS principles. Current health systems show the inherent properties of a CAS driven by a core attractor of disease and cost containment. We content that more meaningful health systems refor...
Understanding Complex Systems Innovative Healthcare Systems for the 21st Century
Chapter 5 The Infector Stigma: Centralizing Health Policies in an Age of Global Migration Flows Liborio Stuppia, Emilia Ferone, Lamberto Manzoli, Andrea Pitasi, and Massimiliano Ruzzeddu Abstract The key focus of this paper is on the link between the development of global health policies and the management of social stigma about the infector. The specific battlefield to deal with this topic is the policy modeling and policymaking of the migration flows and the labeling of the foreigner and stranger as a potential infector. In this labeling process, common sense stigma mixes pop scientific beliefs and ideological biases. This mixture can generate social risk at a higher level than health risk. That is why it is strategic to design viable strategies to prevent that health policies can be turned into no science-based politics. Health policymakers, in the current global scenarios, are tackling transnational and supranational problems, which go beyond the area of competence of national— even less local—traditional health authorities. Furthermore, those phenomena show two general features that make difficult any activity of comprehension and decision-making: on one hand, any reliable information is missing; on the other hand, those data belong to very diverse domains, so that their interpretation requires many different cultural backgrounds. Typical example is the health policies linked to global migration flows, especially those that, in the very last years, have been taking place in the Mediterranean context both from East and from South. There is general agreement on the fact the main problem related to the management of this refugee and migrant flows is the lack of a central authority, who is in charge of any crisis no matter where it takes place. In fact, national authorities manage those emergencies according to protocols.
Health Care Management: The Contribution of Systems Thinking
2006
Dynamics in the analysis of health care systems. It demonstrates that the disappointing results observed in health care management are due to a lack of adoption of systemic methods to study these systems. The paper portrays the consequences and causes of policy resistance in health care systems and how they can be overcome by using the System Dynamics (SD) methodology. After a description of the previous areas of application of SD in health care management, an initial qualitative study of health care system reforms in the Republic of Georgia is described to demonstrate the extent of complexity involved in such systems.