On Healthcare as a Complex System: Ensuring Context and The Capacity to Adapt

There is a minor brouhaha in the world of healthcare quality and process improvement.  It started with a perspective piece written by Pamela Hartzband and Jerome Groopman published in a January issue of the New England Journal.  In the essay, (and I'm paraphrasing) Groopman and Hartzband argue that process improvement tools like LEAN are "medical Taylorism" that lead to to rapt attention to process measures while resulting in unhappy patients and clinicians. They write:

The author's main argument is that tools like LEAN encourage measurement of the wrong things and that

clinical care is largely too complex for these types of tools to be effective

.

Cue the ensuing bedlam:  Advocates for LEAN launchedmultipleattacks on the article, primarily arguing that LEAN has done great things and that the authors confused LEAN (Toyota production) with Taylor's simple industrial strategies, or with "process improvement" efforts that aren't actually LEAN.  John Shook, CEO of the Lean Enterprise Institute wrote a blog criticizing the article:

Clinicians have always looked with some skepticism at LEAN.  I'm a believer, having witnessed massive operation improvements at places like Virginia Mason that took LEAN seriously. As I wrote

last month

, I'm convinced that operations science is the key to improving healthcare.

For some time, like Groopman and Hartzband, I've also been suspicious that

some systems don't lend themselves to improvement via engineering tools

.  They aren't linear and  they are too complex to be figured out using linear process analysis.

My thinking got a boost this week

 when I was introduced to the Cynefin framework and its original proponent, Prof. David Snowden.  The concept received a lot of attention in HBR a few years ago.

The main take-away is that all systems can be categorized on a spectrum that runs from "simple" to "chaotic".  To improving systems you need to recognize which type of system you are dealing with, and 

tailor your tools and strategies accordingly.   

Tools designed to improve simple systems can not be used to fix or interpret complex systems. 

If you have an hour, watch this lecture that Snowden gave at OSU a few years ago.  The guy is a genius and a superb speaker. https://www.youtube.com/watch?v=pHjeFFGug1Y Snowden writes:

Snowden argues that there are four primary system domains: simple systems, complicated systems, complex systems and chaos.  Simple systems are the domain of "best practice" and lend themselves to conventional process analysis tools.  Complex systems, in contrast are far more nuanced.  He writes:

A complex system, unlike a simple one, contains multiple "agents" who continually modify the system through interaction.  Specifically, in the face of decision-making in the face of "unknown unknowns" people in complex systems develop the ability to borrow solutions from adjacent innovation- a process called exaptation. It is this "discovery" and repurposing of adjacent innovation that is how complicated decisions are best made. In his OSU speech, Snowden argues that process improvement

tools like six sigma work best for simple systems

. They don't work in complex systems.  Worse, by using simple tools to eliminate all excess capacity

you lose adaptive capacity

- the ability to run experiments and find solutions.  Snowden mentions that this was one reason why the innovative company 3M migrated from six-sigma a few years ago.

Snowden makes the point that the dominance of the engineering metaphor is the real problem in management science today.

In fairness, I've never heard a LEAN expert argue that everything in healthcare should be standardized.  A LEAN black belt that I worked with a few years ago was clear that you should

"standardize only what should be standardized, and no more."

 Her take, I suspect, was an implicit acknowledgment that

stopwatches in the exam room is not at all what

Taiichi Ohno had in mind.