“Wicked problems result from the mismatch between how real-world systems work and how we think they work.” -- Derek Cabrera: Systems Theorist and Cognitive Scientist
Nowhere is a wicked problem clearer than in healthcare. We have borrowed “best practice” management paradigms from manufacturing and skillfully applied them to most of healthcare’s parts, yet overall, it continues to be the largest category of inflation. The mismatch? Healthcare’s real-world is a biologically and socially complex adaptive system and how it works is vastly different than the factory floor. The result? Demoralized front-line practitioners facing constraints and mountainous layers of complicatedness that create cost not affordable care.
We have a wicked problem.
While some parts of healthcare may be complicated, Healthcare overall is a Complex Adaptive System. Managing the parts rather than the whole will never produce better, more affordable care. The first step is to understand the difference between Complicated and Complex.
Complicated is not Complex
Complicated systems inherently have order and are created by designing each part and putting them together through specific interactions. Parts and subsystems are encapsulated and designed to work predictably. To manage complicated environments, tight controls and prescriptive actions create the system’s environment, how it works, and insulates it from the outside. The number of elements, interactions and functions may grow and grow, making the system increasingly complicated; but it doesn’t become complex. The reason it doesn’t is that elements and interactions in an ordered system are static. They cannot change.
Complex adaptive systems (CAS) on the other hand never stand still. Elements in a CAS have agency, which means they are free to make choices and act. Agents can change behavior and those they interact with can respond with their own choices (as any physician, patient and social service provider can attest!). These agents and interactions lead to the emergence of unplanned new organization in response to local priorities within the system. Because the full scope of influences and the condition of all agents is unknowable, precise change is inherently unpredictable. Social systems, ecosystems, the stock market, politics, education, are examples of CAS. Even the human brain is a CAS of neurons and supporting cell types.
Healthcare is a CAS.
Which leads us back to our wicked problem: Our current approach for the entire system comes from a management paradigm meant for ordered systems. So, how do we manage?
Better healthcare management begins with a better diagnosis. We have misunderstood the underlying forces of healthcare delivery. As a result, we have used too much of the wrong medicine. What works for systems that are Complicated won’t work for those that are Complex and Adaptive. We can only succeed if we resolve the mismatch between our management assumptions and the reality of the problems we seek to solve.
Our opportunities are to work in new ways that transform our current approach to one that is agile and resilient – like the complex adaptive system we serve. Such an approach will simplify practitioner’s work by enabling them to self-organize to meet the needs of each patient at every point of care.
To see how this is possible, healthcare can learn much from examples from other industries.
Which is where we will go next.