Complexity, leadership, and management in healthcare organisations
BMJ 2001; 323 doi: https://doi.org/10.1136/bmj.323.7315.746 (Published 29 September 2001) Cite this as: BMJ 2001;323:746All rapid responses
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Complexity Science
Editor.__ We want to applaud BMJ for their ongoing leadership with respect
to matters regarding health care innovation. Your recent series of
articles [1,2,3,4] on complexity science emphasizes the observations
expressed in the most recent report of the Institute of Medicine [5].
Complex adaptive systems, of which healthcare certainly pertains, rely on
simple rules that assist them in keeping their focus on their goals and
outcomes at both the local process level and general organizational level.
Healthcare must apply these same, basic principles to realise its own
potential and mission.
Generally, medicine has always been very good at
designing and developing new and improved complex, technical aspects of
care, but there are numerous opportunities to improve in both the
application and delivery of healthcare hardware. Excellence in the service
industry is accomplished when there is interaction among the horizontal,
vertical, and front-to-back organisational sections that generate
productive relationships [3]. The simple rules that define the interactive
roles of even a small technical team, assist in generating output based on
thoughtful recognition of all involved parties and their outcomes.
Similarly, healthcare must find a way to ensure the free flow of
information that our complex armamentarium delivers, in a way that
enhances the performance of those involved in patient care and the overall
quality of health outcomes.
Elements of organisational culture and
professional identity are factors that can conflict with the interaction
of the individual in dealing with both the technical and non-technical
aspects of health care delivery. Unclear or outdated protocols, confusing
directives, or undefined role hierarchy can undermine even the most
popular organisational innovations. In our recent study[6], process
ownership and accountability were critical elements needed to prevent role
conflict. The complex and highly technical potential was not realized due
to faulty interactions between local process assumptions and generalized
systemic oversights. To interface with the economically driven market
forces, healthcare needs to do more than simply react to the perceptions
of threats and opportunities. It must first define the roles that are
required as owners of the entire interrelated system, not just as local
chiefs of individual process fiefdoms within an organisation. Second, time
must be allotted for continual reorganisation and revitalization of the
individual processes within the organisational system, and how they
perform on their own and within respect to the complex milieu. Batalden
calls this process 'cognitive spacing' [7] whereby members of the process
team set aside regular time for reflection on how their process is
performing with respect to the goals of the process and the complex, ever-
changing goals of the overall system. As physicians, we are not in
healthcare as a business, although we are in the business of healthcare.
As such, we can learn to apply basic organisational principles that have
long proved successful in shaping value-based interactions between the
local process, the systemic organisation, and the complex marketplace.
Complexity management in health care can reduce waste, improve quality,
and increase satisfaction of providers and patients. This will add value
to healthcare, keep us grounded in our forefathers' vision of progress via
continual improvement, and help to keep our system manageable no matter
how complex our processes become.
Mark A. Best, MD, MPH, MBA, quality health consultant
Eastview, Kentucky, USA
Lee Slavin, MD, MPH, MHA, quality health consultant
Cleveland, Ohio, USA
1. Plsek PE, Greenhalgh T. The challenge of complexity in health
care. BMJ 2001; 323:625-8.
2. Wilson T, Holt T, Greenhalgh T. Complexity and clinical care. BMJ
2001; 323:685-8.
3. Plsek PE, Wilson T. Complexity, leadership, and management in
healthcare organisations. BMJ 2001;323:746-9.
4. Fraser SW, Greenhalgh T. Coping with complexity: educating for
capability. BMJ 2001;323:799-803.
5. Institute of Medicine. Crossing the Quality Chasm: A New Health
System for the 21st Century. Washington DC, National Academy Press 2001.
6. Slavin L, Best MA, Aron DC. Gone but not forgotten: The search for
the lost surgical specimens: Application of Quality improvement
techniques in reducing medical error. QMHC 2001;10(1):45-53.
7. Batalden PB. private communication.
Competing interests: No competing interests
Complexity theory is fascinating. Two or three simple rules interact
to produce those rich patterns and textures that are familiar in everyday
life as waves, coastlines, trees. For excellent and relevant examples look
at work on boids or floys in other parts of the complexity universe.
(Overview and links at www.sciam.com/2000/1100issue/1100amsci.html). Bear
in mind the herding of cats when looking at these models!!
But if I am about to expire for lack of a 60min clot-buster I really
would prefer the NHS response to be machine-like in its ability to hit me
quickly with the needle. Complexity theory explaining why this does not
always happen may help the coroner; not of much comfort to me perhaps?
I would interested in learning more about the conditions under which
people in general or leaders can deploy complexity theory to real
advantage beyond the conceptual stage, and especially the steps needed to
protect such thinking from the incursion of "old-think" management.
Experience elsewhere suggests that most people are very unhappy to work
with rampant complexity and seek to remove it from their lives by sticking
to rules and rituals that ultimately can be a barrier to good performance.
As any good drug rep knows, the trick is to un-freeze, modify and re-
freeze these patterns painlessly.
Competing interests: No competing interests
A different novel approach to management is always refreshing and
interesting.
However, the example given of delay in administering thrombolysis because
of patients’ delay in calling for medical help is not very illustrative or
helpful. A better example should have been given. I agree that the only
solution for reducing delays because of patients’ lack of knowledge is
through symptom awareness campaigns, but I fail to see what this has to do
with the new concepts being proposed.
When channel four TV was being talked about, I wrote to the Minister of
Health to suggest that in any new TV contract, one minute should be
reserved for public health education at peak hour, say 8.00-8.01 p.m. on
Friday or Saturday night, every week.
I agree with their statement that patients should be the source of
control. The poor quality of secondary care and long waiting lists will
continue as long as UK patients have to accept what is dished out to them,
such as long waits and cancellations at the last minute. New concepts must
be piloted, such as giving patients vouchers for specialist consultations,
operations or for more expensive investigations.
How long can we carry on with a purely tax-funded secondary care sector?
That was good for the fifties, but surely not good enough for the 21st
century, when people expect better standards.
As for primary care, perhaps it should remain tax funded and free at the
point of use, as it is such a cost-effective system. However, we can do
far more in primary care if we are given adequate resources and
incentives. For diabetes, a group of practices could share a dietitian and
a chiropodist. For heart disease, PCTs could contract out echocardiograms
to reduce the long waiting list. I know of highly trained and poorly paid
demoralised hospital cardiac technicians who would love to be self-
employed, if PCT give them a contact. They would own their own echo
machine, cut waiting list and cost per echo. For inability to recruit and
retain district nurses for inner city areas, we should try employing
district nurses who will work one or two days a week in practices, their
moral improved by contact with practice nurses, doctors and other staff.
Working on ones own in isolation all week cannot be moral boosting for a
district nurse. The fast expanding role of nurse practitioners is normal
practice in many developing countries with shortage of doctors. Practice
staff budgets, health visitors, and other resources must be fairer. Most
PCGs have continued to maintain the gross inequalities in allocation of
resources to practices.
We need changes, both in primary and secondary care. New approaches are
always welcome. I look forward to the authors’ next articles.
Guy Ah-Moye
GP
gahmoye@btinternet.com
Competing interests: No competing interests
I read with interest the paper by Paul E. Plsek and Tim Wilson (1).
Although this is an important contribution, the following observation are
made.
The inability of contemporary science to describe natural systems
consisting of non-identical elements that have different and non-local
interactions has tended to limit progress in disciplines ranging from
basic molecular biology to human healthcare. Many biological systems
remain incomprehensible because their multifactorial nature has been
combined with a reductionist approach based on the linear conception of
cause and effect.
The fascination for the small and infinitely small aroused by the
introduction of the microscope as a basic instrument for magnifying the
appearance of small objects in the anatomical sciences led to the
definition of anatomic details invisible to even the most acute
observation of the human eye (2).
The reductionist approach, which consist of breaking up the whole
system into its component parts, to understand the system through the
properties of its parts, began with the scientist and philosopher René
Descartes and was triumphantly taken to completion by Isaac Newton.
Although widely used in the physics and mathematics since the
beginning of the twentieth century, the concepts of irregularity,
complexity, non-linearity, fractal and self-similarity have not yet been
fully applied to the medical sciences (2, 3, 4).
Specifically, natural systems cannot be defined as linear systems and
their behaviours cannot be mathematically explained by using linear
equations. Natural system are mainly characterized by two properties: a.
hierarchical structure (many levels of organization and of different
complexity can be detected into the structure of the system) and b. non-
linear behaviour. These fundamentals properties justify the attribute
given to every natural system, as complex non-linear system.
The concepts of emergence and of organized complexity define a human
being as a complex system consisting of different anatomical structures
interconnected each other at many levels of organization, have various
degrees of complexity, and are governed by specific laws that only operate
at a particular level. At each level, the observed phenomena have
properties that do not exist at lower levels of organisation (i.e. the
concept of temperature is central to physical thermodynamic but has no
particular importance at the level of individual atoms, which are governed
by the laws of the quantum theory).
Non-linear systems theory has also been referred to as complexity
theory, complex system theory, dynamical system theory or, more recently
chaos theory. Chaos theory is the study of how simple system can be
generate complex behaviour. Chaos is a relatively new, term which has
acquired new meaning with the advancement of physics and non-linear
dynamics (4). Chaos is referred to the behaviour of a dynamical system
characterised by at least three properties: a) sensitivity to initial
conditions when very small differences in starting values result in very
different behaviour; b) initial condition values can only be specified
with finite accuracy; c) chaos is distinct from regular periodicity
(periodic behaviour, is highly predictable because it always repeats
itself over some finite time interval) and randomness (behaviour never
repeat itself and is inherently unpredictable and disorganised) but has
characteristics of both. Although chaotic behaviour looks disorganised
(like random behaviour) it is really deterministic (like periodic
behaviour).
Based on these general assumptions, the medical sciences have a
relatively new approach which can be of help to understand the complex
nature of the human beings and the management in their non-linear
healthcare system.
1. Plsek PE, Wilson T. Complexity, leadership, and management in
health care organizations. BMJ 2001; 323: 746-749.
2. Grizzi F, Dioguardi N. Anatomy, chaos and complexity. Tripartite
Meeting of the Anatomical Society of Great Britain & Ireland,
Anatomische Gesellschaft and Nederlandese Anatomen Vereniging, Cambridge,
UK, 24 July 2000.
3. Barabasi AL, Albert R. Emergence of scaling in random networks.
Science. 1999; 286; 509-512.
4. Coffey SD. Self organization, complexity and chaos: The new biology for
medicine. Nature Med. 1998; 4; 882-885.
Competing interests: No competing interests
Intuitive awareness of people development and how that interweaves
with real life results in thinking which can be mapped onto Chaos Theory.
It is a profoundly satisfying way of thinking which helps us to
understand why the traditional scientific method does not always produce
results which reflect the real life which multiple intuitive observers see
at the coal face, leading to confusion.
Given the moral and ethical imperative to ensure health, social and
education sector workers are given sound guidance leading to efficiacious
interventions for the population they serve, the emergence of chaos theory
within these systems marks an important and long overdue scientific shift.
In my own work and writing such thinking has been applied throughout
my career, in the last decade specifically in work with individuals with
autism and other developmental disorders (1) I use the metaphor of
`tapestry` to help myself and others visualise the interweaving processes
at various interwoven levels of explanation.
1. Reweaving the Autistic Tapestry. Blakemore-Brown. L.C. 2001
Competing interests: No competing interests
Sirs,
Paul E. Plsek and Tim Wilson in their intriguing article (BMJ 2001;
323: 746-749) write properly that complexity thinking suggests that
current organisational leaders in both policy and operations should begin
looking more across the parts and at the system as a whole. The National
Health Service might be better thought of as the National Health
System. The science of complex adaptive systems brings new concepts that
can provide fresh understandings of troubling issues in the organisation
and management of delivery of health care. In addition, on the base of 44
-years long and well established experence at the bed-side, I state
accordingly that such complexity of management in healthcare organisation
copies perfectly what is really happens in all biological systems.
In fact, healthy physiologic function is characterized by a complex
interaction of multiple control mechanisms that enable an individual to
adapt to the exigencies and unpredictable changes of everyday life (2, 3).
As implied by its name, non-linear dynamics studies systems, such as those
in physiology, in wich out-put is not proportional to in-put. Physiologic
processes show highly variable fluctuations resembling “chaos”. The term
“chaos” describes an apparently unpredictable behaviour that may arise
from the internal feed-back loops of certain non-linear systems.
This healthy variability is not just random, uncontrolled
fluctuations, however. Allthough the precise mathematical definition of
“chaos” is somewhat complicated, its presence in the body can be
characterized by two things: first, it is there by design, for instance it
is not caused by the random firing of neurons; second, the behaviour of a
chaotic system is complicated and unpredictable.
As a matter of fact, vasomotility and vasomotion of every tissue-
microvascular-unit physiolocically show an highly complex type of
variability, “constrained randomnes”, reminescent of “chaos”, which may be
evaluated at the bed-side with the aid of a new physical semeiotics,
Biophysical Semeiotics, as we demonstated previously (2, 3) for the first
time clinically, by mean of numerous ureteral reflexes
8HTTP.77digilander.iol.it/semeioticabiofisica).
Biophysical Semeiotics, based upon Auscultatory Percussion and the so-
called Auscultatory Percussion-Reflex-Diagnostic, studies these non-linear
dinamics of all biological systems.
In Auscultatory Percussion as well as A.P. Reflex-Diagnostic and
consequently in the new, original semeiotics, auscultatory percussion of
the stomach plaies a primary role. Notoriously, the stomach is ruled by
upper and lower neuronal plexus, that are in direct relation with celiac
plexus, in which bring to an end numerous reflexes, caused by trigger-
points stimulation of allmost every tissue. Therefore, doctor who will
learn Biophysical Semeiotics has to study, first of all, this application,
that allows him to recognize clinically, for instance, promptly and easy,
an acute or chronic appendicitis, indipendently from its location and/or
seriousness. (See Appendicitis on Home-Page)
References
1. Stagnaro-Neri M., Stagnaro S., Appendicite. Min. Med. 87, 183 1996
2. Stagnaro-Neri M., Stagnaro S., Deterministic Chaos, Preconditioning
and Myocardial Oxygenation evaluated clinically with the aid of
Biophysical Semeiotics in the Diagnosis of ischaemic Heart Disease even
silent. Acta Med. Medit. 13, 109 1997
3. Stagnaro-Neri M., Stagnaro S., Deterministic chaotic biological
system: the microcirculatory bed. Theoretical and practical aspects. Gazz.
Med. It. – Arch. Sc. Med. 153, 99 1994
Competing interests: No competing interests
The excellent series of articles on complexity science in health care
(1) highlights a decade long quest to bring chaos and complexity science
to medicine, health and health care delivery (2). Extensive practical
applications of the theoretical concepts outlined in these articles have
been described and published, and support consideration of more widespread
application (2-5).
The more general and inclusive term chaos has been used, to mean all
ideas arising from chaos theory, which include not only complexity but
also pattern formation, deterministic (technical) chaos, adaptation,
evolution and learning. Chaos has been described as Complexity Hidden
Amidst Observed Simplicity and its reverse (2-3).
Chaos has been used as a new basic, organizational, management and
leadership science in various projects including a two year Diversity and
Health project 1994-96, with results as expected from the ideas proposed,
a Women, Diversity and Health project over the same time and a Health
Promotion project since 1990, among others (2-4).
These projects considered the validity of variation in context, as in
seeking different guidelines for risk reduction in the South Asian
population with excess premature CAD (5), and in the use of treatment for
homocysteine or Lp(a) elevation in high risk individuals (recognizing
complex dynamic interactions), especially in the setting of low-cost and
low-risk treatment with the possibility of great benefit for individuals and
sub-populations.
This and other work led to the bold proposal in 1995 for a chaos (and
complexity) based medicine and health care, not only as its art, science
and philosophy, but in its organization and organizations, leadership,
management, and research and education (2-4).
The novel ideas expressed in this series of articles have been tested
and found useful in medicine and health over the past decade and add to
the call for a chaos and complexity based health care system.
1) Plsek P, Wilson T. Complexity, leadership, and management in
health care organizations. BMJ 2001; 323: 746-749.
2) Rambihar VS. Chaos from Cos to Cosmos: a new art, science and
philosophy of medicine...and everything else. 1995 Vashna. Torono.
3) Rambihar VS. A New Chaos Based Medicine beyond 2000: the response
to evidence. 2000. Vashna. Toronto.
4) Rambihar VS, Wilson J, Vali Y, LeBlanc L, Jagdeo DG, Caryer C,
Howes E. Chaos 2000: a new science of nursing for a new millennium. Chaos
and Complexity in Nursing Journal 1999; 4: 35-38.
5) Rambihar VS. South Asian Heart: preventing heart disease.
1996. Vashna. Toronto.
VS Rambihar. MD
Competing interests: No competing interests
Humility=Complexity thinking
but we don't think...this way
Competing interests: No competing interests