Systems Thinking
As healthcare becomes more complex, it is important for leaders to understand the critical concepts that are fundamental to human systems and behavior, where the interactions between parts can be more important than individual actions. Simply stated, a system is a collection of interrelated and independent parts, processes and subsystems, linked inextricably by the interaction of behavior. The following video illustrates some basics of systems thinking.
What you might consider a system is somewhat arbitrary: the health-system enterprise is a system made up of many interrelated component subsystems, but so is the pharmacy enterprise a system with many component subsystems, as is the investigational drug service. Where you draw the line determines the boundaries of the system you choose to examine. Where you set the boundaries defines a "closed system", and in the past, these closed systems operated as silos or "stovepipes", behaving as if each operational entity was independent of all others. One of the advantages of systems thinking is the recognition that any organizational system operates within, or proximate to and with impact on, all other parts.
Systems thinking operates on the basic premise of finding patterns inside and outside of the system -- however it is defined -- then seeking to understand those internal patterns, to identify ways to avoid problems and optimize the overall system. How you define the system depends on what you are trying to accomplish. You might for example place a system boundary around the medication-use process to clearly understand how it functions and where the subsystem issues are, then remove those boundaries to assess how the system is impacted by (and impacts) other systems, and fits into the larger system.
Complex Adaptive Systems
Complex adaptive systems (CASs) are collections of individual agents with freedom to act in ways not always totally predictable, but with interconnectedness so that the action of one changes the context for others -- for our purposes, the people who function within the medication use process, the healthcare delivery system and the health policy framework. The human immune system, the world financial market, a colony of ants, a flock of birds or a pharmacy and therapeutics committee all represent complex adaptive systems, which are characterized by fuzzy boundaries, with changing membership, crossover among different systems, all of which can lead to unexpected individual responses to change. Internalized rules -- often not shared or explicit -- govern individual and group behavior -- which may not always seem logical -- and these rules are constantly changing. Because the individual agents can change, the system can and will adapt over time; development of antibiotic resistance, viral mutation and the influence of a bully on adolescent group -- or work group -- behavior are all examples of this adaptation.
Because systems exist within systems, the evolution of one influences the other related systems. Since the systems are nested, overlapping and interrelated, no one system's behavior can be understood without the context of the whole; the interaction among systems leads to continually emerging behaviors that are fundamentally non-linear and not predictable at a detailed level. Despite the lack of predictability at a detailed level, overall patterns are typically identifiable and often governed by "simple rules", an internal sense of order, innovation and progress that emerges naturally from the system, simple shared rules of behavior that emerge as common patterns: driving in traffic, rules of interaction in meetings, pedestrian patterns of staying to the right, deference to medical staff . . .
Thinking about organizations as complex adaptive systems opens the way for new and more productive leadership and management approaches to emerge. Goals and resources are established with a view toward the whole system and its results, rather than artificially allocating them to parts of the system, and focuses attention to service delivery across the full care continuum. The resulting integrated thinking can result in more creative and holistic thinking instead of the segmented solutions, within tight departmental or functional boundaries, that healthcare organizations have traditionally pursued. How the system addresses patient medication management, discharge medications and associated patient education and how it defines roles and accountability as an example, can have an enormous effect on adherence, compliance and persistence for patients with complex medication regimens for treatment of chronic illnesses. This shift in perspective facilitates a broader focus on an overall aim of better patient care.
Complex adaptive systems provide some significant barriers to leadership effectiveness:
- First, they have fuzzy boundaries rather than the well defined mechanical boundaries like those in tightly defined mechanical systems. System membership changes, people move in and out and change priorities and commitments. Individual agents can be members of multiple systems (and therefore subject to the influences of other systems), complicating problem solving and resulting in unexpected actions and reactions in response to change.
- Internalized rules drive actions and may not be clearly identifiable. Instincts, biases, loose cognitive constructs, and impressions may not be shared, explicit or even logical. And these rules are not necessarily fixed, changing continually with a fluid set of evolving influences.
- Adaptive agents, systems and subsystems embedded in other systems can change, effecting the other parts of the system to drive further change. The evolution of one system influences and is influenced by other systems. Efforts at planned and strategic change conflict with the formal systems and more informal shadow systems. The nesting of systems within systems, all evolving together provides assurance that we can't understand the operation of a single system without reference to the others.
- Novel behavior and unpredictability result from changeable elements, non-linear relationships, behavior that is emergent and sensitive to small changes.
- Finally, self organization, innovation and progress can emerge naturally from interactions within complex systems and do not have to be imposed centrally. Highly collaborative clinical care and surgical teams, the "rules of the road" for driving, merging, entering rotaries, etc, and rules of behavior and interaction in formal meetings are examples of this self-organization capacity that we experience every day.
Simply put, human systems differ from mechanical and process systems. They are far more complex and adaptive. As leaders, we need to be aware of the differences and shape our behaviors, attitudes and approaches to take full advantage of opportunities that arise.
