Sholom Glouberman
IMHL
McGill University
[email protected]
Health
and
Everything
Complicated and Complex Systems
European Health Leadership Programme
INSEAD
December 6, 2006
This presentation is on the web site www.healthandeverything.org
Health and Everything
Important Notice
• This presentation is based on work done for
the Romanow Commission with Brenda
Zimmerman of the Shulich School of Business
• No need to take notes
• This Presentation is available on our web site
– www.healthandeverything.org
• For more information you can write to me at
– [email protected]
Health and Everything
Simple
Following a Recipe
• The recipe is
essential
Complicated
Complex
A Rocket to the Moon
Raising a Child
• Formulae are critical • Formulae have only a
limited application
and necessary
• Recipes are tested to • Sending one rocket
assure replicability
increases assurance
of later efforts
that next will be ok
• Raising one child
gives no assurance of
success with the next
• No particular
expertise; knowing
how to cook
increases success
• High level of
expertise in many
specialized fields +
coordination
• Expertise can help
but is not sufficient
• Recipes produce
standard products
• Rockets similar in
critical ways
• Every child is unique
• Certainty of same
results every time
• High degree of
• Uncertainty of
certainty of outcome
outcome remains
• Optimism re results
• Optimism re results
• Optimism re results
Health and Everything
In Health Care Nothing is Simple
• In health care we might distinguish between
“complicated” and “complex” problems
• Although many aspects of health care
systems are complicated others are best
viewed as complex
• Dealing with complex problems as if they are
merely complicated is like looking for your
car keys in the lamplight
• The advantage of the distinction is that
problems that are thought to be intractably
complicated can be viewed more
optimistically and often unraveled when
they are seen as complex
Complicated
Complex
Health and Everything
Acute Diseases
Chronic Diseases
• Abrupt onset
• Often all causes can be
identified and measured
• Diagnosis and prognosis are
often accurate
• Specific therapy or treatment is
often available
• Technological intervention is
usually effective: cure is likely
with return to normal health
• Gradual onset over time
• Multivariate cause, changing
over time
• Diagnosis is uncertain and
prognosis obscure
• Indecisive technologies &
therapies with adversities
• No cure, pervasive
uncertainty: management,
coaching & self care over time
is needed to improve health
• Profession & laity must be
reciprocally knowledgeable to
improve health
• Profession is knowledgeable
while laity is inexperienced
Adapted from: Halstead Holman, MD (Stanford)
Health and Everything
Some Characteristics of Complex Systems
• 3 groups of characteristics and
examples of them can help us
understand these different
perspectives
– Structure Cluster
– Evidence Cluster
– Causality Cluster
Health and Everything
Structure Cluster
Complicated Systems Complex Adaptive Systems
• Highly structured
• Interactive open
closed systems
systems
• Objective: Smooth
• Discontinuous
running with clear
change at tipping
accountability
points
• Sustainability:
• Sustainability:
Equilibrium as an
Inevitable Change in
end state
a stable context
• Reversibility in time
• Irreversibility
(time’s arrow)
Example: Aging
Health and Everything
Two Views on Aging
• The body is a closed
system
• Smooth running
maintains status
• Efforts to return to
non-aging equilibrium
when ill
• Aging is a curable
illness
• Aging is accelerated or
retarded by numerous
factors
• Illness and health
interact
• Graceful Aging
• Aging is inexorable
Health and Everything
Evidence Cluster
Complicated Systems
• Reductionism/Analysis
• Averages dominate
–
ignore outliers
• Classical economics
ignores historical evidence
• Measures of efficiency fit
and best practice
• Search for structural
constancy
Complex Adaptive Systems
• Holism/synthesis
• Outliers can be key
determinants
• History contains
meaning of change
• Feedback loops that
affect relationships
• Experience coevolves
with the field
Example: Why Emergency Rooms are Overloaded
Health and Everything
A Vicious Cycle in ERs
Increased
pressure
on urgent access
Less funding
for non-urgent
social support
More resources
needed for
urgent services
Money must
come from
other services
Health and Everything
A Virtuous Cycle in ERs
Increase funding
for less urgent
primary support
Free money
for primary
services
Decrease pressure
on urgent access
Stabilize
resources
for urgent services
Health and Everything
Causality Cluster
Complicated Systems
• Simple causality
• Designed and intended
outcomes
• Deterministic
• Seeking Certainty
• Assumed predictability
• Focus on boxes
• Structures determine
relationships
Complex Adaptive Systems
• Mutual causality
• Adaptive and emergent
• Probabilistic
• Accepting Uncertainty
• Anticipation in changing
context
• Focus on Arrows
• Structures and
relationships are interactive
Example: Determinants of health
Health and Everything
Thinking in the Box(es)
Environment
Lifestyle
Human
Biology
Growing Health Care Costs
Other
Factors
Disease
Health
Care
Cure, Care
Clinical Epidemiology,
Health Care Evaluation,
Health Services Research, etc.
Health and Everything
More Thinking in the Boxes
Social
Environment
Individual
Response
-Behaviour
-Biology
Health &
Function
Physical
Environment
Disease
Well-Being
Genetic
Endowment
Health
Care
Prosperity
Health and Everything
Thinking Outside the Box
Social Environments
Individual
Built Environments
Complex Interactions
Among Them
Other Factors
Natural Environments
Health and Everything
Graphic Representation of Health
Externalities
Externalities
Health and Everything
Conclusion
• We have been trapped into a narrow way of
defining and responding to current issues as
if they were merely complicated
• We actually do not in fact manage in this
narrow way.
• Most managerial expertise and ingenuity in
fact respond to complex environments taking
into account local conditions
Health and Everything
Pointers for Intervening in Complex Systems
• Seek minimal interventions to maintain stability
• Gather positive & negative Information:
– (Appreciative inquiry)
• Respect history
• Consider interactions
• Encourage self-organized networks
• Large variation of interventions
• Select and Seed
• Fine-Tune Processes & Interventions
Health and Everything
For More Learning
• The International Master for Health
Leadership at McGill University is a
programme designed to help health
professionals and others manage in the
complex health environment using Henry
Mintzberg’s five mindsets approach.
• For more information go to
www.IMHL.ca