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Health System Redesign: Applying Complex Adaptive Systems Approaches

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Abstract

Health system redesign, as argued in this book, is based on three fundamental assumptions:

  • The philosophy of medicine—the value of health services arises from its impact on the health of the people we treat

  • The person/patient is at the centre of a functional complex adaptive health system

  • A seamlessly integrated health system has to understand its purpose, goals, and values to devise its unique “simple (operating) rules”. These together determine the core driver for the “system as a whole” as exemplified by the Mayo Clinic’s motto: “The needs of the patient come first”.

    This overarching principle does not prevent a health system’s subsystems to adopt their own drivers. However, they need to contribute to the seamless integration of meeting the health system’s overall objectives

This chapter illustrates how people/person-centred complex adaptive systems thinking and interventions can guide the redesign of novel approaches at every organisational level.

At the service delivery (micro) level:

  • Clinical care in the consultation. Drawing causal loop diagrams can provide important insights into the dynamics of a person’s illness. The deeper understanding about the linkages between the biological, social, emotional, and cognitive state of the person’s current illness experience allows a clinician to more effectively integrate the management of the personal, environmental, and medical domains.

  • Preventing avoidable hospitalisation of the frail elderly. Monitoring the daily changes in frail elderly patients’ health experiences can identify those at risk of avoidable hospitalisation. The main reason resulting in avoidable hospitalisation, surprisingly, is the perception of lack of social support rather than actual deterioration in organ specific function.

  • Guidelines can be unworkable. When identified, a process known as “positive deviance” allows those affected to quickly develop novel approaches that achieve the desired outcomes. Positive deviance entails (1) to acknowledge that there is a problem, (2) that every individual is part of the problem, (3) that there are barriers to change, and (4) that collective conversations amongst all involved will result in better solutions.

At the community (meso) level:

  • Health system redesign at the community level, particularly in disadvantaged ones, requires community consultation. Since health is a personal experience understanding what impacts on the people’s and community’s health is essential. For example, the most disadvantaged community in Sydney identified community development and renewal, employment skills and opportunities as well as community safety as the top priorities for the improvement of their health.

  • Community health invariably requires a multi-pronged approach. The “Shape up Somerville” initiative exemplifies this approach. The nutrition department worked with schools to improve pupils’ nutrition knowledge and adapted the canteen’s food offerings. The next step engaged the City Council to improve walk and cycle ways as well as play and sports grounds. Optimisation of the school bus routes allowed more kids to safely walk to the next bus stop rather than needing to be driven to school, and working with food outlets identified those willing to offer healthy food choices.

At the policy (macro) level:

  • Health systems need to clearly define their purpose, goals, and values. Purpose, goals, and value statements are the foundations that guide the behaviours and actions of a health system’s agents and thus affect the function of the “health system as a whole”.

  • As the system emerges over time its purpose and values remained unchanged. What changed are its specific goals in light of newly identified needs.

All these examples have one thing in common, they all focus on the person/patient. This focus provides the necessary space required to allow for the essential complex adaptive work amongst all to realise best possible health experiences. This approach invariably results in:

  • More effective and efficient care delivery

  • Greater satisfaction of all involved in health care

  • Achieves equity

  • Makes the system more sustainable

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Notes

  1. 1.

    At the NEJM Catalyst event New Risk, New Business Models held in Boston, October 6, 2016, Dr Rushika Fernandopulle made these observations and drew the following observations: Attempts made by incumbent health plans and systems to address problems such as high costs and poor outcomes have not been wholly successful. Even new processes, rewards, technology, and culture changes meant to improve health care are still largely built for the old system. Despite lots of rhetoric, the real effort is almost always small and incremental. About 12 years ago, I realised that these small, incremental changes were not going to work. The problem is that our current health care system focuses on transactions. Last I checked, those don’t heal anyone. What heals people—the reason we all went into medicine—is relationships. To form those relationships, we must remove transactions, and to do that, we have to change everything. Change the payment model, change the delivery model, change the technology platform, maybe more importantly change the culture. (http://catalyst.nejm.org/videos/relationship-based-care-change-everything/?utm_campaign=Connect+Weekly&utm_source=hs_email&utm_medium=email&utm_content=39615521&_hsenc=p2ANqtz--5tkREDH1pZUnaiETiCgF1p3zHuFRfJ2T3xjcaoReqBDKolXNZ-_4wiS4_d2uXAZQtnxo2yFwBsBiV--RC84XahREgxA&_hsmi=39615521)

  2. 2.

    For a step-by-step approach to developing this causal loop diagram see Sturmberg JP. Systems and complexity thinking in general practice. Part I—clinical application [31].

  3. 3.

    http://www.liverpool.nsw.gov.au/community/our-community/living-in-2168

  4. 4.

    http://www.somervillema.gov/departments/health/sus http://www.nutrition.tufts.edu/index.php?q=research/shapeup-somerville Shape Up Somerville: Building and Sustaining a Healthy Community with Collective Impact https://www.youtube.com/watch?v=aBHz-GzDX8c Shape Up Somerville: NECN— Call to Revolution https://www.youtube.com/watch?v=71V12zS7nQU Mayor Joe Curtatone Speaks at White House for First Lady Obama’s Let’s Move Program 2.9.10 https://www.youtube.com/watch?v=viIJLjVrUcg

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Sturmberg, J.P. (2018). Health System Redesign: Applying Complex Adaptive Systems Approaches. In: Health System Redesign. Springer, Cham. https://doi.org/10.1007/978-3-319-64605-3_10

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  • DOI: https://doi.org/10.1007/978-3-319-64605-3_10

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