Jump on Board and Join the Health and Human Services Revolution: Learn 8 System Archetypes to End Health System Dysfunction

Blip-Zip Summary

Master 8 System Archetypes: The Key to Fixing Our Broken Healthcare System! This article delves into how these hidden patterns impact the healthcare system, creating dysfunction. It provides actionable solutions for leaders to build a more sustainable and equitable healthcare system.

Blip-Zip Takeaways

• Unmask Hidden Traps: Learn eight system archetypes that cause unintended consequences in health and human services transformation and integration.
• Break the Cycle: Discover how these mental models or patterns lead to dysfunction and declining health outcomes.
• Lead the Revolution: Become an upstream leader with actionable strategies to build a better health and human services system.

Key Words and Themes (#Hashtags)

#HealthcareLeadership #SystemsThinking #SocialDeterminantsofHealth #PopulationHealth #HealthEquity

Introduction to System Archetypes

Systems archetypes are common organizational behavior patterns first studied in the 1960s and 1970s. These patterns or mental models can appear in any setting and often recur. Some patterns are good, while others are not, and they can coexist and lead to problems.

The US healthcare system is experiencing increasing instability and dysfunction. Some health systems are trying to set up insurance systems, hire doctors, and guarantee patient satisfaction. However, other companies, such as pharmaceutical and device manufacturers, must be more interested in these new strategies.

Several problematic policy, organizational, and leadership patterns harm the healthcare system. Understanding these patterns is essential to identifying and addressing the root causes of issues. For example, poor diet and lack of exercise lead to many American adults and children becoming insulin-resistant, which increases chronic disease rates.^1,2 National policies need to focus more on preventive care and healthy lifestyles.

Complex adaptive health systems behave differently than simple non-living systems, and understanding the common characteristics they possess and the problems they present is helpful. Around 30 cents of every dollar spent on medical care in America is wasted, amounting to $750 billion annually. This waste is due to poor prescribing practices, patient behavior, and perverse practices in the pharmaceutical industry.^3,2. Addressing this waste is crucial for the sustainability of our healthcare system.

Complex health and human systems can be challenging to navigate and present opportunities for errors and harm. A highly adaptive complex system can typically process more information, anticipate changes more accurately, learn quickly, act more flexibly, and respond more appropriately to various circumstances.⁴. Preventable mistakes harm one in four patients, or about 250,000 patients die from medication errors yearly.^5,2

Leaders are key to identifying problematic patterns and organizational behaviors when working with complex systems. Understanding these patterns can empower leaders to identify and address unwanted conditions or problems.

Recognizing System Archetypes As Circles, Delays, and Loops

Systems archetypes are mental models or concepts that help identify everyday habits and patterns of behavior that lead to unwanted effects. This theory uses diagrams to show how different system parts interact and how they cause positive, negative, or neutral effects. By identifying these patterns, we can find ways to improve the system and create better outcomes.

Circles of causality are a common feature of systems archetypes. They show how actions cause reactions and how those reactions can be positive, negative, or neutral. Feedback is given as reinforcing and balancing feedback, which can be visualized as a typical circle of causality. Sometimes, feedback or reactions take time and may cause delays. Any system can be drawn as a structure or diagram using circles of causality with actions, feedback, and delays.

By understanding these circles of causality, we can find the best ways to improve a system. We can change the things that cause adverse effects and strengthen those that cause positive effects. This way of thinking helps us create sustainable solutions and better outcomes for everyone. The figure below provides a typical visual.

Figure 1: Typical Archetype And Reinforcing Or Balancing Loops

When we talk about reinforcing feedback loops, we mean a process that amplifies a trend. Positive feedback accelerates growth, while negative feedback speeds up decline. However, sometimes actions can magnify future issues such as lack of trust, delegation, and empowerment. This can lead to defects, corrections, adjustments, and inaccurate or incomplete information that cause problems associated with lack of feedback and delays in diagnoses.⁶

Even something as simple as a misapplied, illegible, or improperly labeled blood tube can cause errors or delays in processing. According to national data and literature, missed and delayed diagnoses are the most common claims in the ambulatory care setting.

Here’s an example: when a supervisor’s behavior is supportive, it increases employee performance, which results in better quality care and personal attention to patients and reinforces the supervisor’s supportive behavior. However, when the supervisor’s supportive behavior diminishes, employee performance declines, resulting in worse supervisor support, further decreasing performance. This cycle of human activity is typical of a balancing loop despite the change in the quality of care.

Balancing feedback loops will be present or emerge from somewhere, depending on the problem. Balancing or stabilizing feedback works if a goal exists, such as reducing the gap between the current and desired states, such as access to care. Negative feedback adjusts the current status (i.e., delayed or extended wait times for care) to a desirable target (i.e., standards for access to care).

A Veterans Affairs (VA) study showed veterans who visited a VA. Medical centers with facility-level wait times of 31 days or more had significantly higher odds of mortality, illustrating the forces of limiting growth and an inability to achieve equilibrium. Actions should focus on the causes of long waits for health care and the development of effective resource allocation policies –balancing loop feedback to decrease long waits for health care services.⁷

Delays in systems and policy implementation can lead to incorrect perceptions of responses, such as long lead times in primary care preventative medicine. These delays can cause under or overestimating needed action, leading to instability or breakdown. Leaders and legislators often believe good intentions and logic are sufficient to achieve outcomes without producing evidence of effects.⁸  

The national patient-centered medical home (PCMH) model is innovative, integrating primary care services into specialty care, reimbursement reform, new information technology, and the chronic care model. However, quantitative assessments have yet to be conducted, creating oscillations. The expectation of short-term cost savings may be unrealistic. Investment in an information infrastructure and training practice is required. Interpretation and expectations must be tempered, as it takes four to five years to yield noticeable results. Many organizations are pressured to report results in less than two years, some shorter.

8 Archetypes to Identify Systems Pathologies and Prevent Dysfunction

Systems archetypes help problem-solvers apply principles and achieve sustainable solutions while preventing long-term or delayed unintended consequences. They provide guidelines to determine which archetype is at play and how to use interventions for better outcomes, such as improved health for a population or increased quality of life and productivity for a community.

A summary of the most common systems archetypes is summarized below in Table 1. They explained in more detail along with unique forms:

Table 1: Archetypes in Health and Human Services

Archetype Description	Health and Human Services Example
Shifting the Burden: A symptom is solved with short-term and primary solutions. The solution produces side effects that affect the primary solution. The attention then shifts to the short-term solution or the side effects.	Emergency Beds for Homeless: A homeless shelter focuses on providing emergency beds and meals to address immediate needs. This short-term solution doesn’t address the root causes of homelessness, such as lack of affordable housing or mental health issues. The shelter may become overwhelmed with repeat clients, neglecting efforts to connect them with long-term support services. Reduce ER Wait Times: To reduce wait times in the emergency room (ER), a clinic implements a policy of seeing patients with minor illnesses without an appointment. This quick solution initially reduces ER wait times. However, the influx of non-emergency cases overwhelms the clinic, leading to longer wait times for everyone and potentially delaying care for patients with more serious conditions.
Fixes that Fail or Backfire: The solution is rapidly implemented to address the symptoms of an urgent problem. This quick fix sets in motion unintended consequences or a third-order effect that is not evident early on but adds to the symptoms.	Too Strict of a Discharge Policy: To reduce hospital readmission rates, a hospital implements a strict discharge policy. While this may initially decrease readmissions, it can lead to patients being discharged prematurely, unprepared to manage their conditions at home. Ironically, this can increase the risk of complications and future readmissions.   Mandatory Overtime for Nurses: A hospital mandates overtime shifts for nurses to address a nursing shortage. While this fills staffing gaps in the short term, nurse fatigue and burnout increase, leading to higher error rates and nurse turnover, ultimately exacerbating the shortage.
Limits to Growth or Success: An effort initially generates positive results. However, over time, the effort reaches a constraint that slows overall performance no matter how much energy is applied.	Community Health Center Expansion: A community health center expands its services to meet growing demand. However, appointment wait times lengthen with additional staff or resources, and the quality of care needs to improve. This can lead to patient dissatisfaction and decreased service utilization.   Focus on Hospital Readmission Rates: A hospital implements a program to reduce patient readmissions within 30 days. While the program is successful initially, focusing solely on readmission rates disincentivizes preventative care and may lead to premature discharges, potentially increasing health complications and long-term costs
Drifting or Eroding Goals: As a gap between goal and need or performance is realized, the conscious decision is to lower the target. The effect is a gradual decline in system performance.	Childhood Obesity Rates: Public health initiatives struggle to reduce childhood obesity rates. Discouraged by slow progress, funding, and program intensity are gradually scaled back. This resource decline further hinders progress, leading to a gradual increase in childhood obesity rates.   Lowering Graduation Criteria and Rates: A school district facing persistently low graduation rates lowers its graduation requirements. This reduces the achievement gap in the short term, but overall educational attainment and future opportunities for students decline.
Growth and Underinvestment: Growth approaches a limit avoidable with investments in a capability or a service capacity. However, a decision not to invest in performance drives degradation further, resulting in a demand not to invest.	Foster Care Placement Takes Back Seat: A child welfare agency prioritizes foster care placements over investing in preventative services to keep families together. While foster care provides a temporary solution, it can be disruptive for children and strain the agency’s resources in the long term.   Telehealth Services: A community health center implements telehealth services to expand access to care in rural areas. However, underinvestment in staff training and technology infrastructure limits the effectiveness of telehealth services, ultimately discouraging further investment.
Success to the Successful: Two or more efforts compete for the same resources. The successful attempt gets a disproportionately more significant share of the resources at the expense of others.	Funding for Specialty Care vs. Preventive Care: A hospital expands its oncology department due to high patient volume and profitability (successful effort). This diverts resources away from preventive care programs (less profitable), potentially leading to a rise in preventable cancers in the long run, plus increased disparities between communities and populations.
Escalation: Parties take mutually threatening actions that escalate their retaliation, attempting to “one-up” each other.	Nursing Home Care Plan Disagreements: A nursing home and a family disagree on a resident’s care plan. Each side digs in its heels and takes action to pressure the other, creating a hostile environment that negatively impacts the resident’s well-being. Medicaid Eligibility Disputes: A state and federal agency disagree on eligibility criteria for Medicaid, leading to finger-pointing and delays in processing applications. This back-and-forth escalates, causing a backlog of applications and leaving low-income residents without access to healthcare.
Tragedy of the Commons: Multiple entities enjoy the benefits of a shared resource but ignore its effects. Eventually, the resource dwindles, and the activities of all entities in the system perish.	Housing Infrastructure Shortfall: Multiple families move into a new housing development without proper infrastructure. Overuse of shared resources, like water wells or septic systems, leads to depletion or malfunction, negatively impacting the health and well-being of all residents. Antibiotic Overuse: Individual doctors readily prescribe antibiotics for minor illnesses to appease patients’ expectations. The widespread overuse of antibiotics contributes to antibiotic resistance, a public health threat that undermines the effectiveness of antibiotics for everyone.

These examples, while generic, offer applicability to all health settings. Understanding system archetypes empowers health and human service leaders to identify patterns that can lead to unintended consequences. By recognizing these patterns, leaders can anticipate challenges, design proactive solutions, and build a more sustainable and equitable healthcare system.

Understanding and Uncovering Archetypes in the Context of Health

Systems archetypes are a way to understand how a person’s environment affects health. They can be used to analyze health and human services in individual and community health in the short and long term.⁹  Systems archetypes have a specific structure, which includes variables and feedback loops. Feedback loops describe how things can go wrong, like when people with lower socioeconomic status have worse health. The most common structure is the “fixes that fail” archetype. This structure has variables like a symptom, a quick fix, and an unintended consequence.

The flow between the quick fix and unintended consequence includes a delay or reason for the archetype. This structure has two feedback loops: one for a quick fix and one for the unintended consequence. For example, controlling costs and utilization may seem like a success, but if more attempts are made to control costs without considering the quality of care or patient behaviors and attitudes toward personal health, the success can become detrimental.

In another example, studies on provider practice and variation have identified practices inconsistent with state-of-the-art evidence-based medicine, resulting in the provision of ineffective care.¹⁰

Variables are part of the feedback loops and can be changed by other variables. Examples include limits to success, growth, underinvestment, and tragedy of the commons. The “systems that fail” archetype has the “squeaky wheel” as its storyline. This means a quick fix is applied to something causing a problem to reduce the symptoms and associated noise. However, the storyline gets complicated when the quick fix’s unintended effects or variables become consequential and worsen the situation.

Table 2 outlines how ignoring Social Determinants Of Health (SDOH) can cause healthcare system dysfunctions and suggests preventive measures for upstream leadership.

Table 2: Impact of Neglected SDOH and Upstream Leadership Actions

Archetype	Impact of Neglected SDOH	Upstream Leadership Actions
Shifting the Burden	Treating chronic illnesses exacerbated by poor housing or food insecurity creates a revolving door for patients. Band-aid solutions like readmission reduction programs address symptoms but neglect root causes.	Invest in community health workers who address SDOH alongside clinical care. Advocate for policies that improve housing and food security.
Fixes that Backfire	Focusing solely on hospital readmission rates without addressing social needs might lead to patient discharge to unsafe environments, increasing readmission risk.	Conduct root cause analysis to identify SDOH contributing to readmissions. Develop discharge plans that consider social needs and available support systems.
Limits to Growth	Increasing hospital capacity might only solve issues if a growing population has access to preventive care due to poverty or lack of transportation.	Invest in community clinics and mobile health units to expand access to preventive care—partner with social service organizations to address transportation barriers.
Drifting or Eroding Goals	Witnessing high rates of preventable disease due to SDOH might lead to lowered expectations for population health outcomes.	Publicly commit to addressing SDOH alongside clinical care. Partner with community leaders to develop metrics that track progress in addressing SDOH
Growth and Underinvestment	Hospitals might prioritize expensive technological advancements over investing in social support programs with long-term benefits.	Conduct cost-benefit analyses to demonstrate the economic advantages of addressing SDOH. Advocate for funding models that incentivize holistic healthcare that considers SDOH.
Success to the Successful	Increased focus on profitable specialties like cardiology might lead to neglecting less profitable departments like preventive care, which are crucial for addressing SDOH.	Develop balanced funding models that support all aspects of healthcare, including preventive care. Encourage collaboration between specialties to integrate SDOH considerations into all care models.
Escalation	Hospitals and social service agencies might get into turf wars over responsibility for addressing SDOH, leading to fragmented and ineffective care.	Foster open communication and collaboration between healthcare and social service providers. Establish clear referral pathways and shared metrics for addressing SDOH.
Tragedy of the Commons	Individual hospitals might focus on short-term cost reduction by quickly discharging patients, neglecting the broader societal impact on public health.	Develop regional healthcare collaboratives that share best practices and address SDOH issues collectively. Advocate for policies that promote population health and invest in preventive care infrastructure.

Neglecting SDOH creates a complex web of challenges within the healthcare system. By understanding these challenges through the lens of system archetypes, leadership can identify leverage points for intervention. Taking preventive actions addressing the root causes of health disparities through collaboration and investment in social support systems is critical to building a more sustainable and equitable healthcare system.

Summary and Conclusion

Systems archetypes are fundamental concepts and patterns that signify various behaviors and issues that might arise within a system. These archetypes can be incredibly helpful in strategic planning as they allow for identifying potential problems before they escalate, making them much easier to manage. They provide a language and mental framework that can be used to document, communicate, and analyze a system’s behavior.

Doing so offers a helpful framework for dealing with change and eliminating negative patterns, ensuring the system functions smoothly. Once we understand system archetypes, we can leverage this knowledge to build robust systems that generate sustainable solutions immune from pathologies.

Are you ready to explore these concepts further and learn how to leverage them to become a transformative leader in health and human services?

Deep Dive Questions: Unmasking Dysfunction

Understanding systems archetypes is only the first step. The following questions will challenge you to critically analyze your leadership approach and the healthcare systems you navigate:

• Have you witnessed any system archetypes discussed in your leadership experience? If so, how did they manifest, and what were the consequences?
• Can you identify opportunities to utilize systems archetypes for proactive problem-solving within your organization?
• How can you use these concepts to champion upstream solutions that address the Social Determinants of Health (SDOH)?
• Imagine you are leading an initiative to improve population health outcomes. How could an archetype like “Limits to Growth” influence your approach?
• ·  Think about a recent policy change in healthcare. How might a systems archetype explain its potential positive and negative impact?

Professional Development and Learning Activities:

Sharpen your strategic problem-solving skills with these practical activities:

• Map It Out: Select a current challenge within your health system. Diagram the relevant system archetype and identify critical variables and feedback loops.
• Case Study Challenge: Research a real-world example of a health system dysfunction. Analyze the situation through the lens of systems archetypes and propose alternative solutions.
• Collaborative Learning: Facilitate a discussion with colleagues or peers about the role of systems archetypes in health leadership. Explore real-world applications and brainstorm innovative approaches.
• Action Plan Development: Choose a specific archetype and brainstorm potential interventions to disrupt its adverse effects. Consider its impact on leadership strategies.
• Case Study Analysis: Research a successful healthcare transformation initiative. Analyze how it addressed a system archetype and the leadership strategies employed.

References and Resources

This article offers a springboard for further exploration. The following resources provide in-depth information and practical guidance on systems archetypes and healthcare leadership:

• Strengthening health systems by health sector reforms, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4651248/
• Universal health coverage in the framework of the 2030 global agenda for sustainable development: agreements and challenges, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7100864/
• Reforming Health Care: The Single System Solution, https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0456
• The New Health Agenda: A Framework for Health Care Reform ([invalid URL removed]) by Donald M. Hohenberg and Patrick Suri (2009) examines healthcare reform through a complex systems lens.
• CDC: Healthy People 2030 (https://health.gov/healthypeople) from the Office of Disease Prevention and Health Promotion (ODPHP) outlines national health objectives emphasizing upstream solutions and population health.
• IHI: The Foundation for Health Leadership (https://foundationhli.org/) provides leadership development programs specifically designed for health and human services professionals.
• The Center for Social Determinants of Health (https://www.cdc.gov/publichealthgateway/sdoh/index.html) from the Centers for Disease Control and Prevention (CDC) provides a wealth of information on SDOH and their impact on health outcomes.
• Guidelines for Drawing Causal Loop Diagrams, https://thesystemsthinker.com/guidelines-for-drawing-causal-loop-diagrams-2/
• The Robert Wood Johnson Foundation. (2023, April 10). County Health Rankings & Roadmaps. https://www.rwjf.org/en/grants/grantee-stories/programs/county-health-ranking-roadmap.html (Provides data and rankings on health outcomes across counties in the US)

Citations

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