Changing Healthcare

By Gerrit Van Wyk.

Changing health care as a complex social system.

Karl Weick said ignorance and knowledge go together. Wise people know they don’t fully understand what is happening in a constantly changing world, because what happens is unique to a brief moment in time. They avoid extreme confidence, or extremely caution, because they know either can destroy what organizations need most during change; curiosity, openness, and the ability to make sense of complex problems. Overconfident people are not curious because they think they know everything, and overcautious people are not curious because they are afraid knowing will increase their uncertainty. In both instances their minds are closed, resulting in bad decisions. Wisdom means believing and doubting at the same time. Doing so makes adapting to a complex constantly changing environment easier.

Imagine entering a room and finding a box of bicycle parts. Each group in the room is asked to pick one part and turn that into a functioning bicycle. There are several ways for doing that; one can make your own missing parts, go out and buy them, or find substitute parts, but the easiest way is entering into dialogue with other groups, and agreeing to share parts. There are many groups in health care, and their defining feature is they work in silo’s and only communicate what’s necessary to other groups. Consequently, health care is a collection of bicycle parts, owned by groups who’d rather compete than cooperate meaningfully, which is one of the foundational problems that’s wrong with the industry. We are a collection of bicycle parts not fitted together into a functioning whole.

According to Peter Drucker, health care is the most difficult, chaotic, and complex industry to manage today. Health care is a system, like a bicycle, and health the outcome emerging from the interactions and interconnections of its parts. If the different groups involved in the industry can’t agree to meaningfully cooperate, the health care bicycle won’t move an inch.

Cooperation is impossible without conversation and dialogue, which means ensuring all groups are represented and have an effective voice, which requires a whole lot of open-minded listening. By talking to each other, we get a shared understanding of the problem facing us and how different people would tackle it, which gives us the opportunity to choose the most promising one, and trialing it to see what happens.

When we cooperate and talk to each other, we can agree on small steps we can take in practice and observe the outcomes of the experiment. By sharing with everyone what we experienced from acting, we learn not only how our actions affect others, but also what to avoid and do better, which starts another round of conversation. In other words, we learn our way out of the mess without having to try massive interventions risking massive consequences if they fail, and build shared knowledge of the system. As our collective understanding and learning increase, we cooperate better and with better cooperation comes better patient care that is more efficient and cost-effective.

This approach is bottom up, acknowledges the complexity Drucker talks about, is founded on the principles of that complexity, and democratic, which puts it diametrically opposite to how we do things currently. It is not expensive to implement this approach and it takes time, but one can typically quite quickly see the ship starting to veer into a different direction. The point of systems change is not to save money, become more efficient, or improve quality, it is to improve the way the system works in which case the rest is likely to follow.

Politicians take heat from voters who, as patients, experience the brokenness and mess and demand something must be done. People with the ear of politicians come up with solutions to which politicians ask this question: “will it help me get re-elected, and will it work before the next election?” The sales pitch is: if you mandate the people who work in the system to take their bitter pills, it will bring about a guaranteed cure. We have all the answers! Throw caution to the wind! Ignore this obscure nonsense about systems, bicycles, and complexity! We’ll quickly save you money, improve quality, and make things efficient! Except it never works, other than short-term.

I don’t know of any efforts for changing health care that were not top down, ignored complexity and its principles, or authoritarian. Solutions come from outside in via people who think economics, scientific management, quality control, etc., from other industries can easily be transferred to health care, ignoring Drucker’s admonition. The solutions are on the inside and need to involve the people with the experience and knowledge of what happens on the ground. They know what we need to do, all we need is to ask them.

I learned there are strong barriers to changing things this way. Complex change takes time and politicians don’t have the stamina to wait things out, creative change threatens bureaucracies and careers, doctors protect their status and the status quo and historically are always in the trenches fighting change rather than in the vanguard leading it, other professions see change as an opportunity focusing on improving their status, and so on. It doesn’t mean the barriers can’t be overcome.

They say if you slowly heat the water in a pot with a frog in it, the frog won’t try to jump out until it’s too late. The water in the health care pot is starting to steam and the frog cannot decide what to do. If it won’t jump, no-one can predict what happens next. Doing things the same old way as before means staying in the pot until health care turns into a stew.