complexity theory and decision making in health system

Complexity Theory and Decision Making in Health

System

• “ I never make predictions, especially about the future.”

• Sam Goldwyn Mayer

How Hazardous is Health Care

# Encounters / Death

Tota

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Health Care

Bungee Jumping

1K10 100 10K 100K1 1M 10M

100K

1K

10

100

10K

1

Mtn Climbing

Driving

ChemicalManufacturing

CharteredFlights

NuclearPower

EuropeanRailroads

ScheduledAirlines

Dangerous Safe

Health Care as a Complex System

• Health care organizations can be viewed as complex systems (Institute of Medicine 2001; Plsek and Greenhalgh 2001; Sweeney and Griffiths 2002).

A

C

BX

Sufficient Cause Cluster Effect

Simple

• Baking a cake is a simple problem. • Simple problems lend themselves to a

recipe approach. • The process and results are generalizable;

and while special skill at cooking is a plus, it is not essential for success.

A

C

BX

K

~D

M

O

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N

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PL

C

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Complicated• Sending a rocket to the moon is an example of a

complicated problem. • Complicated problems are best dealt with using

formulaic and expert-knowledge approaches. • The overall problem can be mechanistically

broken down into component parts (booster rocket, cabin environment, navigational equipment, etc.) and assigned to teams of experts who utilize the proven methodologies of their disciplines.

Complicated• Rockets are similar in important ways,

meaning that success with one rocket provides reasonable assurance of success with future rockets.

• When surprising events do occur, we can study these, build improvements into the system, and thus raise the probability of future success.

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Complex

• In contrast to simple and complicated issues, an example of a complex issue is that of raising a child.

• Success in raising one child is no guarantee of success in raising another.

• Past experience, coupled with advice from experts, can serve as a starting point; but we know that simply applying the formula that worked before may not lead to success, and may even lead directly to failure because of the second child’s resentment at being treated this way.

• Across all disciplines, at all levels, and throughout the world, health care is becoming more complex.

Complex Adaptive Systems: Definition

• A complex adaptive system is a collection of individual agents with freedom to act in ways that are not always totally predictable, and whose actions are interconnected so that one agent's actions changes the context for other agents.

Stacey Diagram

Close toAgreement

Far fromAgreement

Close to certainty Far from certainty

Level of AgreementDecisions will havevarying levels at which the entire system agree that a particular effect is desired.

The Degree of Certainty

Decisions are more certainwhen the cause and effectlinkages are well known.

Stacey Diagram

Close toAgreement

Far fromAgreement


Where there is not enough hard evidence

Where even enough hard evidence is not enough

Stacey Diagram

Close toAgreement

Far fromAgreement


Simple

Simple:

Straightforward

decision-making.

Rational

planning & control

Stacey Diagram

Close toAgreement

Far fromAgreement


Simple

Chaos:

Disintegration

patterns.

No discernible

& anarchy

Chaos

Stacey Diagram

Close toAgreement

Far fromAgreement


Simple

Chaos

Complicated

Stacey Diagram

Close toAgreement

Far fromAgreement


Simple

Chaos

Complicated

Complicated

Stacey Diagram

Close toAgreement

Far fromAgreement


Zone

of

Complexity

Stacey Diagram

Close toAgreement

Far fromAgreement


Good enough planning–minimum specification, simple rulesMultiple actionsExperiment and tune system plan-do-check-act

Listen to the shadow systemUse intuition, muddle throughMetaphorsUse complex thoughts for complex systems

Plan and controlRegulate

Scan forpatterns

Political decision makingNegotiation and consensus buildingCompromise

Judgmental decision makingMission and vision based decision making

What is the fate of a complex system of decisions ?

Close toAgreement

Far fromAgreement


**

Finding more cause components from already known cause clustersand discovering unknown cause clusters


Close toAgreement

Far fromAgreement


*

*Consensus building around shared Values and beliefs


Close toAgreement

Far fromAgreement


**

Falling into chaos : Organizational Collapse, Revolutions, Death

Stacey Diagram• Many organizations are existing in all

areas of the matrix at different times.• Traditional management methods are

effective in the Simple area.• Management methods needs to be

altered in the Complicated areas -–negotiation / compromise–mission & values based

Stacey Diagram• If you try to use traditional management

methods (plan & control) in the Zone of Complexity, you usually get unintended and unpredictable consequences.

• Complex Adaptive Systems can exist and thrive in the Zone of Complexity.

• PDCA cycle is an example of management in the complex zone allowing tuning, experimenting, and good-enough planning.

System Design• The distinction between these systems

is obvious, but frequently not taken into account when system is designed.

• When the human components respond in an unpredictable manner, they are labeled as being unreasonable or “resistant to change.”

• The designer then specifies behavior in greater detail via rules, guidelines, etc.

Thank You!

Any Questions!

complexity theory and decision making in health system

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