Here at e3 intelligence, we’re always interested in ideas that challenge our way of thinking and ask us to look at the world in a different way. But we also like to see practical and helpful advice that can help us convert theory into actions that make a difference. So, this week we are going to look at one of the biggest emerging ideas in healthcare management – complexity – and ask what we can do to make sense of it.
But first, a question – is your world complex?
Do you work in a healthcare service that is characterised by any of the following:
- extensive external pressure – from regulators, media, government or the public?
- structures and processes which are frequently changing?
- competing priorities, targets and values?
- over-work, lack of resources, unclear objectives?
- political, cultural or professional barriers?
Probably, like most who work in healthcare, you will recognise one or more of these features in your own environment. So, yes, your world is almost certainly complex. But what do we mean by complexity?
Complexity science emerged in the late 20th century as a mathematical approach to understanding seemingly random natural phenomena, such as earthquakes, weather patterns and the propagation of rainforests. At its core is the notion of a complex adaptive system (if you’re new to systems thinking, take a quick look here at our sample learning module on an introduction to systems thinking in healthcare). Building on simple systems theory, a complex adaptive system is a system which:
- is comprised of many interconnected and interdependent variables
- made up of many smaller sub-systems
- which are ‘open’ to interaction with their environment
- that is regulated through feedback and information flow
- to produce a self-organising equilibrium
The last point is important, because complex adaptive systems, as the name implies, will eventually adapt (albeit only momentarily in many cases) to their environment and reach a point of equilibrium or stability. For example, the rainforest will reach a point of development where many different and competing flora and fauna can co-exist by sharing limited resources such as light, water, food and space.
In theory, such systems can be modelled mathematically in order to derive accurate predictions about how they will develop. But in practice, owing to the vast array of variables, random fluctuations and interdependencies, they are very rarely modelled completely. And this is why we describe them as complex – because we cannot ever know enough about all the possible interactions that might occur to fully determine how they will combine.
So what do rainforests have to do with healthcare?
In recent years, management theorists have appropriated some of the ideas of complexity science and adapted them to an organisational setting. In turn, there has been a lot of interest in applying this approach to healthcare. So hospitals, mental health services, primary care facilities, community health centres can all be viewed as being part of one big ecosystem not unlike a rainforest. There are multiple agents (executives, managers, physicians, support staff etc in place of the plant and animal species found in the rainforest) all vying for limited resources (funding, know-how, influence, etc rather than light, food and space) against a backdrop of environmental forces (national and regional policies, regulation and public perception as opposed to weather, disease and outside predators). No wonder it’s complex – it’s a jungle out there!
Are healthcare systems really like rainforests?
Of course not. But, as a mathematical model there are similarities. However, there is one key distinction between a truly complex system and a human organisational system. And that is human agency. For a system to fully conform to the principles of complexity science, it is assumed that there is no over-arching design or purpose which informs the decisions of the various agents. Ants, birds, palms and vines all go about their business with no regard to the production of a stable, balanced ecosystem. Rather it just happens naturally through the aggregation of the millions of tiny variations in behaviour and the millions of tiny feedback responses that happen all the time.
In a human system, however, the agents of decision (the people, boards, teams and committees who make things happen) are frequently aware not only of an over-arching sense of purpose but also of the actions and motivations of those in their neighbouring sub-systems. So complexity theory has some limitations(1). But it is still useful to think of healthcare systems as complex organisations.
So, why is complexity theory relevant?
Because it helps us to shift “our understanding of organisations from that of a mindless Fordian mechanical system to that of a multi-minded sociocultural system”(2). It is no longer sufficient to think of human organisations as staid bureaucracies where central command and control, analytical planning and scientific management will yield optimal performance and satisfaction.
Instead, we are encouraged to look for (and often embrace) complex inter-relationships, personal motivating factors, dynamic innovation and capacity to deal with ambiguity. In other words, how might we best respond to our competing priorities, a raft of targets, changing roles, lack of resources and an email or patient backlog as long as your arm?
But what can we do in the face of all this complexity?
On one level, complexity theory doesn’t offer us any solutions. It does however offer us a fresh way of looking at the world around us. In a very influential series of articles on complexity science and healthcare prepared for the British Medical Journal in 2001(3-6), there is one exhibit which we think has stood the test of time. For those of you haven’t read the articles in question, we’d urge you to seek them out for an excellent introduction to the subject.
The figure in question is this:
In this figure, three zones are identified. The first is the simple zone, where there is a high degree of agreement about what should be done coupled with a high degree of certainty about what might happen. This zone characterises the worldview adopted by the early scientific management thinkers (Taylor, Fayol, etc) and describes an orderly realm, with little disagreement about how to organise a system to best effect. Most activities are amenable to control through careful planning, control and regulation. Whilst no longer viewed as universally applicable, there are still many areas of healthcare business that probably do still fit comfortably into this zone – creditor payments or scheduling appointments perhaps?
At the other extreme, we have the chaotic zone. This is a world in which nothing is certain and about which a consensus view cannot be reached. It is turbulent, unpredictable and messy. By definition, we are frequently taken by surprise when new developments emerge from this zone such as advances in genomics or the exposure of hitherto unknown safety failures. The best we can hope for in this zone is to scan the horizon and watch for emerging patterns that may (or may not) develop into something more concrete.
But in the middle, we have the complex zone. Conveniently, this just describes everything that sits between the ordered regularity of the simple zone and the opaque randomness of the chaotic zone. We can probably never hope to describe, influence or control completely the contents of the complex zone, but we can learn to adapt to them. Helpfully, the authors point to a number of strategies that can adopted to steer us through the complex world in which we find ourselves, and we’ll finish with a few brief notes on each of these.
Learning to live in the jungle
Good-enough planning – have you ever sat in on or contributed to a group designing a new policy, strategy or plan? Have you ever wondered if all that planning is really necessary? Well, you’re not alone. Even the most thoroughly researched, meticulously planned strategy document is often out of date before the ink has dried on the final version. Why? Because, the world is complex and healthcare systems are part of that world. Things change all the time in the environment (new targets are imposed or a timely response is required to an emerging challenge), in the system (interest groups may not be aligned to the direction of the strategy) or in the interdependencies within the system. So it’s a fair question to ask: do you really need such a complicated and lengthy document to describe your strategy or will something simpler do? Something which offers simple rules and a general direction of travel around which the system can self-organise? You may even free up some time to go and do the work of actually implementing your plan!
Multiple actions – because the world is complex, defining and executing only a single course of action is an almost foolproof way of setting yourself up for failure. Instead, would it make more sense to set a number of actions in train? Some may yield benefit and be appropriate to the emerging context and some may not. But, having the flexibility and courage to permit failure (and to learn from it) must surely be a good a principle to follow.
Plan-do-study-act – a tried and tested process improvement technique which encourages lots of small experiments, learning quickly and scaling up when successful. Making smaller incremental changes can often be more effective than executing a grand plan that falls at the first hurdle.
Listen to the shadow system – this is an interesting one. We take this to mean paying attention to what is being said when you’re not around, ie what’s the chatter, the gossip or the word on the street saying about your plans. You will often get different, more honest and constructive views expressed in an informal context and the good manager or professional will be well advised to seek out these views and encourage their expression.
Use intuition and muddle through – sounds like a recipe for disaster, doesn’t it? But there is lots of management research and opinion (see here for example) that points to the tacit and implicit use of intuition as an acceptable and frequently superior decision aid, often formed from years of experience and exposure to multiple similar problems. Just ask any seasoned doctor making a clinical diagnosis. It also allows a degree of flexibility to make decisions quickly in the face of changing circumstances.
Chunking – don’t tackle the whole problem in one go, break it down into smaller and more manageable chunks. Do the most important things first and spread your effort to greater effect.
Metaphors – these are essentially a communication device. Getting your message across can be a hard slog when it’s laden with technical jargon and reams of intricate numerical analyses. Can you cut through the hyperbole and focus on the key message? When a healthcare reform programme is described as “so big, you can see it from space” you get the picture don’t you? No amount of micro-detail about structures, legislation, responsibilities will have the same effect.
Wicked questions – go on, be a devil’s advocate and ask all those ‘why’ (or ‘why not’) questions you’ve always wanted to ask. Of course, this needs to be done in a professional and supportive way, but exposing ideas to a degree of healthy challenge is often the recipe for better decision-making.
And the winner is …
Well, you’ve made it this far. You’ve navigated all the challenges and you’ve learnt to respect the power of the jungle by following a few simple bits of advice. We hope you’ve enjoyed this blog post, but to finish, let us ask you a few final questions:
- Do you really see your professional world as complex, like the proverbial rainforest?
- How useful are the guidelines we’ve described above? Will they work for you in your situation?
- What other tips can you offer for navigating the complex world of healthcare and mastering the environment in which you work?
- Paley J. The appropriation of complexity theory in health care. J Health Serv Res Policy 2010;15:59-61
- Cramp DG, Carson ER. Systems thinking, complexity and managerial decision-making: an analytical review. Health Serv Manage Res 2009; 22:71-80
- Plsek PE, Greenhalgh T. Complexity science: The challenge of complexity in health care. BMJ 2001;323:625-628
- Wilson T, Holt T, Greenhalgh T. Complexity science: Complexity and clinical care. BMJ 2001;323:685-688
- Plsek PE, Greenhalgh T. ‘Complexity science: Complexity, leadership, and management in healthcare organisations. BMJ 2001;323:746-749
- Fraser S, Greenhalgh T. ‘Complexity science: Coping with complexity: educating for capability. BMJ 2001;323:799-803
[photograph courtesy of Roberto Valdés]