Blip-Zip Executive Summary
Are you tired of a siloed healthcare system? Systems thinking offers a revolutionary approach to transforming healthcare from disjointed to dynamic. This article unveils three characteristics and eight behaviors of complex adaptive health systems and how leaders can leverage them to create a more integrated, efficient, and patient-centered system. Get ready for a healthier future!
Blip-Zip Takeaways
- Ditch the Assembly Line: Stop treating healthcare like a machine. Understand the system’s interconnectedness for better outcomes.
- Embrace Complexity: Don’t fear change! Complex systems can adapt and improve. Learn to leverage their characteristics for stability and innovation.
- Think Beyond Cost: Cutting corners can backfire. Invest in social determinants of health for a healthier and more resilient healthcare system.
Key Words and Themes (#Hashtags)
#HealthcareLeadership, #SystemsThinking, #PopulationHealth, #HealthcareTransformation, #StrategicLeadership, #IntegratedCare, #ComplexSystems, #SocialDeterminantsofHealth
Table of Contents
Complex Adaptive Health Systems Characteristics and Behaviors
The U.S. health system is a complex adaptive system influenced by various factors, including the 1900s industrial era, World War II, Medicare and Medicaid, and American capitalism. The Patient Protection and Affordability Care Act (PPACA) 2008 aimed to improve the health system’s Performance. However, transformational leadership, complexity management, and systems thinking are urgently needed to transition the system into the most reliable and healthy population globally.1.
Leaders at all levels must become systems thinkers to address the complex dynamics of the system and its components. Health system problems should be understood as adaptive health systems rather than broken down into parts.
Characteristics of Complex Health Systems
Health systems leaders must develop agile, adaptive, and systems thinking competencies to create a new reality. They should focus on identifying and anticipating trends, identifying opportunities for redesign, and integrating the health system across organizational and community levels. This approach considers three inters: interactions of components within a process, interrelationships of processes within a system, and interdependencies between systems and across time.
Figure 1 presents a three-tiered model of thinking and problem-solving: “Events,” “Patterns and Behaviors Over Time,” and “Systems, Structure, and Dynamics.” This model emphasizes the importance of transitioning from linear to systemic thinking for sustainable solutions. Each level corresponds to different types of thinking and problem-solving approaches. In healthcare, “Events” could represent treating individual symptoms, a form of linear thinking.
“Patterns and Behaviors Over Time” might involve analyzing patient health trends to predict outcomes and demonstrating critical thinking. Lastly, “Systems, Structure, and Dynamics” could signify a holistic approach that considers the entire healthcare ecosystem, embodying innovative thinking.
Figure 1 Characteristics of Health Systems
This model emphasizes the importance of transitioning from linear to systemic thinking for sustainable solutions. As an example of the individual level of care, “Events” could represent treating individual symptoms, a form of episodic and linear thinking. “Patterns and Behaviors Over Time” might involve analyzing patient health trends to predict outcomes and demonstrating critical thinking. Lastly, “Systems, Structure, and Dynamics” could signify a holistic approach that considers the entire health ecosystem, embodying root cause analysis of social determinants.
Further, proactive health systems thinkers use archetypes or mental models to identify functional and dysfunctional characteristics of systems, such as self-stabilizing, goal-seeking, self-programming, program-following, anticipatory, environment modifying, self-replicating, or self-maintaining. This approach is crucial in addressing stakeholders’ diverse interests at all system levels.
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Behaviors
The current health system needs to be fixed due to its management as an assembly line rather than a living and thinking system. This has led to the wrong diagnosis of characteristics and behaviors, which in turn leads to incorrect treatment. The complexity of health system transformation is the new normal today, and leaders and policymakers often think they can manage cost by constraining one system input: money. At the same time, the root causes of poor outcomes remain unaffected or exacerbated.
Systems thinkers mentally imagine a system as a series or set of feedback loops, visualizing outcomes and scenarios such as fixes that fail. knowing the characteristics and behaviors of complex systems is crucial for creating the most reliable health system with the healthiest population. Leaders and health policymakers must be able to identify these systems’ shared characteristics and behaviors.
Complex systems can maintain stability despite changing environmental conditions and incentives. However, the U.S. health system is fixated on cost, quality, and access to care, treating each goal separately. Knowledge and best practices are rarely applied to improve care processes, and information generated by care experiences is seldom shared. 2 The Quadruple Aim aims to integrate population health, the experience of care, and reduced cost per capita.
However, it focuses on delivering health services rather than health determinants or quality of life. The “wicked” nature of the U.S. health system requires better strategic leadership and a systems approach to create more stability and better health outcomes.2-4 Complex health systems contain thousands of feedback loops to maintain stability in the face of the many changes.5
Another characteristic of complex systems is policy or program-following. They follow a sequence of steps or programs to achieve goals regardless of environmental changes or new ideas for improvement at various levels. They have an innate ability to follow steps, one after another, and realize their completion using checked or unchecked feedback in any form. For example, patients trained to go to the doctor’s office because they are not feeling well may follow a different path of investigation until they find the cause of the illness.
Self-reprogramming is another characteristic of complex systems. The more complicated the system, the better its ability to follow complex programs and modify them to avoid repeating errors. High-Reliability Organizations (HRO) operate in complex, high-hazard domains without serious accidents or catastrophic failures. Reprogramming to avoid repeating mistakes is one of the most fundamental concepts in learning. If taken to the next level, a self-reprogramming system will eventually invent new, better ways to achieve the desired goal.5
A complex system is characterized by its ability to anticipate environmental changes, which can be a natural reaction or a result of learning from incidents. High-reliability organization principles, such as persistent mindfulness and prioritizing safety over production-minded performance pressures, can help reduce preventable errors in health professionals. For example, the military aircraft carrier has a culture of safety, where personnel consistently prioritize safety and make real-time operational adjustments to maintain safe operations. Anticipation might result from insight into how the new situation will occur. In this case, the system can anticipate the response accordingly.5
Environment or policy modification is another option for complex systems, which can be unintentional or harmful.5. The U.S. health system is beginning to focus on a culture of health, including incorporating social determinants of health to create healthier communities. This focus is crucial as the impact on the U.S. economy for seven preventable chronic diseases is estimated to be $1.3 trillion annually.6, with lost worker productivity due to health costing employers $225 billion annually.7,8 If the U.S. continues on the current trajectory, spending more than any other nation in the world and enjoying unsafe, unreliable, and mediocre health outcomes, the system could implode.9-11
Self-replicating is another characteristic of many complex systems, with biological reproduction or DNA being the most common and complex to analyze. Social systems also can maintain and repair themselves, as seen in communities rebuilding after a pandemic or tornado. Self-reorganizing is another characteristic of complex systems, as many living systems can reorganize themselves to meet new conditions or achieve new goals.5
Some complex systems also can reorganize themselves to meet new conditions or achieve new goals. Many living systems can also reorganize themselves, but to a more subtle extent. However, actions taken at one time and in one subsystem can have ripple effects in other systems and downstream over time. For example, cutting funds for asthma prevention programs can cause more acute asthma and more hospital admissions, increasing expenses in the medical system. School absences would reduce school performance in the education system and require parents to take off work, negatively impacting productivity in the national system and increasing pressure on the law enforcement and unemployment system.12
Lastly, self-programming or design thinking involves the development of new goals and programs for achieving those goals. Complex systems can invent new goals and create new programs for achieving those goals, often with an empty slate of insights and ingenuity. Examples include the Apollo moon landing and the Eliminate Cancer Moonshot initiative, which were successful due to insightful and ingenious goals.5
Strategic Health Leadership for Integrated Systems
The health and human services sectors are undergoing a period of unprecedented change driven by rapid growth, technological advancements, and evolving workforce dynamics. Health leaders are at the forefront of managing these challenges, necessitating strategic approaches to navigate growth, modernization, and workforce development. Strategic health leadership is essential for transforming dysfunctional health systems into integrated ones. Traditional leadership often views health as a machine with controllable parts, neglecting the interconnectedness of doctors, patients, insurers, and social services. Strategic leaders adopt a holistic approach that considers social determinants of health, such as poverty and education. They use “archetypes” mental models to understand system behavior and address diverse stakeholder needs, resulting in sustainable solutions.
Understanding the characteristics of complex systems is crucial for maintaining stability despite constant change. A sole focus on cost control can worsen outcomes, as the system can rigidly follow protocols. Strategic leadership fosters adaptability, as seen in High-Reliability Organizations (HROs) that prioritize safety and learn from mistakes.
Complex systems can adapt and modify their environment, and the healthcare system is starting to address social determinants to create healthier communities. Strategic leaders understand that cutting asthma prevention programs can lead to negative consequences across various systems.
Summary and Conclusion
The current healthcare trajectory is unsustainable. We need strategic leaders who understand these complexities to design a multi-dimensional strategy for a healthier future. This challenge is a national priority demanding a new generation of leaders equipped with systems thinking to transform.
The U.S. health system must deliver reliable Performance and better health to Americans. However, the current Performance is hindered by a lack of understanding of the complex health system’s characteristics and behaviors. Patient safety outcomes have worsened, with the Institute of Medicine reporting that 98,000 preventable deaths per year are still occurring. 13,14
The U.S. health services industry lags behind other sectors in meeting patients’ specific needs, delivering better care and health, and reducing per capita costs.2 Healthcare and public health organizations must reframe the conversation to create a culture of health and wellness, using systems thinking to create a seamless, transparent, and integrated health system.
Health leaders must catalyze communities of solutions and agencies nationwide, designing and implementing a multi-dimensional strategy to transform the health system into a health wellness and resilience model. Health system planners and decision-makers need to recognize the nature of the system’s interacting parts, define the desired results, and apply concepts and characteristics using an analytic framework. This transformational effort can only be accomplished within a generation of leaders if it becomes a national strategic imperative of the highest order.15
Now it’s your turn! Reflect on the concepts explored here. How can you leverage systems thinking in your leadership practice to improve healthcare? Share your ideas
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Deep Dive Discussion Questions
To further explore the concepts of this article, consider these questions:
- How can you identify the mental models (archetypes) influencing decision-making within your healthcare organization?
- How can you use systems thinking to analyze the potential ripple effects of a new policy or program within your healthcare system?
- Imagine you are designing a healthcare system from the ground up. How would you incorporate the characteristics of complex adaptive systems to build stability, adaptability, and continuous improvement?
- How can you champion a culture of learning and adaptation within your organization to leverage the self-programming characteristic of complex systems?
- Healthcare systems are full of feedback loops. Describe a positive feedback loop you can amplify to improve a health outcome.
- How can you identify the mental models (archetypes) influencing decision-making within your healthcare system?
- Imagine yourself leading a cross-sector collaboration to address social determinants of health. What strategies would you employ to foster cooperation and achieve shared goals?
Professional Development and Learning Activities
Looking to take your learning a step further? Here are some suggestions:
- Self-assess your systems thinking skills. Several online resources offer self-assessments to help you gauge your current understanding and identify areas for growth.
- Join a systems thinking community. Online forums and professional organizations offer opportunities to connect with others passionate about applying systems thinking to healthcare.
- Read books and articles on systems thinking and healthcare leadership. Explore the reference section below for a starting point.
- Research and analyze a successful case study where systems thinking was implemented to improve healthcare outcomes.
- Participate in a leadership development program focused on systems thinking and its application in healthcare.
- Conduct a root cause analysis. Choose a healthcare problem and apply the “Five Whys” tool to uncover its underlying causes.
- Explore case studies—research successful applications of systems thinking in healthcare. Analyze the strategies used and consider their potential adaptation within your context.
References and Links
- The Institute for Healthcare Improvement (Triple Aim): https://www.ihi.org/improvement-areas/triple-aim-population-health
- National Academy of Medicine (Quality Chasm: A Report on the Future of Health Care): https://pubmed.ncbi.nlm.nih.gov/25057539/
- Agency for Healthcare Research and Quality (AHRQ) – The Learning Health System: https://www.ahrq.gov/learning-health-systems/about.html
- Donella Meadows (Thinking in Systems: A Primer): https://www.chelseagreen.com/product/thinking-in-systems/
- American Public Health Association, The Nation’s Health series: Social determinants of health: https://www.thenationshealth.org/content/nations-health-series-social-determinants-health
- Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion: https://www.cdc.gov/chronicdisease/index.htm
- The Commonwealth Fund (Mirror, Mirror 2021: Reflecting on U.S. Health System Performance): https://www.commonwealthfund.org/publications/fund-reports/2021/aug/mirror-mirror-2021-reflecting-poorly
- The Alliance for Health Policy (Looking at the U.S. Healthcare System Through a Systems Lens): https://www.allhealthpolicy.org/
- CMS Office of the Actuary. (2020). National Health Expenditure Projections, 2020-2029. Retrieved from https://www.cms.gov/data-research/statistics-trends-and-reports/national-health-expenditure-data/projected
- The World Bank. (2023). Health Expenditure per capita (current US$). Retrieved from https://data.worldbank.org/indicator/SH.XPD.CHEX.PC.CD?locations=1W
Citations
1. Johnson J, Rossow, C. Health Organizations: Theory, Behavior, and Development Burlington, MA: Jones and Bartlett Publishers; 2018.
2. Cosgrove D, Fisher M., Gabow P., Gottlieb G., Halverson G. A CEO checklist for high-value healthcare. Washington DC: Institute of Medicine of the National Academies;2012.
3. Nickerson J, Sanders, Ronald. Tackling Wicked Government Problems: A Practical Guide for Developing Enterprise Leaders. Washington DC: Brookings Institute Press; 2013.
4. Sanders TI. Strategic thinking and the new science: Planning in the midst of chaos, complexity, and change. New York, NY: The Free Press; 1998.
5. Kauffman Dl, Jr.,. Systems One: an Introduction to Systems Thinking. Minneapolis, Minnesota: Future Systems Inc., S. A. Carlton; 1980.
6. Chatterjee A KS, King J, DeVol R. . Checkup Time: Chronic Disease and Wellness in America. Milken Institute;2014.
7. Stewart WF, Ricci, Judith A., Chee, Elsbeth, Morganstein, David. Lost Productive Work Time Costs From Health Conditions in the United States: Results From the American Productivity Audit. Journal of Occupational and Environmental Medicine (JOEM). 2003;45(12):1234-1236.
8. Shreve J, Van Den Bos, Jill, Gray, Travis, Halford, Michael. Rustagi, Karan, Ziemkiewicz, Eva The Economic Measurement of Medical Errors. Milliman, Inc.;2010.
9. Musgrove P, “The World Health Report 2000, Health Systems: Improving Performance,” World Health Organization, http://www.who.int/whr/2000/en/whr00_en.pdf The World Health Report 2000, Health Systems: Improving Performance. World Health Organization (WHO);2000.
10. NRC. U.S. Health in International Perspective: Shorter Lives, Poorer Health. Washington, DC: The National Academies Press; 2013.
11. Fuchs V. Challenges in Health Care Costs In. New York, New York: New York Times; 2012.
12. Waldman D. We can fix healthcare: Thinking Systems Need Systems Thinking. 2007. http://www.wecanfixhealthcare.info/thinking-systems-need-systems-thinking.html.
13. IOM. Crossing the quality chat zone: a new health system for the 21st century. Washington DC: National Academy Press;2001.
14. Kohn. L.T. C, J.M., . To Err Is Human: Building a Safer Health System. Washington, DC: Institute of Medicine (IOM);1999,.
15. Masterson B, Sanders, Ron. DOD GLOBAL HEALTH ENGAGEMENT ALTERNATIVE FUTURES [NIGERIA-EBOLA] SCENARIO WORKSHOP SUMMARY OUTBRIEF. National Defense University (NDU);2014.
