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24 October, 2017 10:38:07 AM / LAST MODIFIED: 24 October, 2017 11:32:21 AM


Healthcare transformation

Despite our best attempts at meaningful healthcare transformation, we continue to struggle with unintended consequences from reform efforts
Dr. Mohammed Abul Kalam
Healthcare transformation

Healthcare transformation requires a change in how the business of healthcare is done. Traditional decision-making approaches based on stable and predictable systems are inappropriate in healthcare because of the complex nature of healthcare delivery.
Healthcare delivery is undergoing a transformation from care in single settings and providers to care across multiple providers and settings.

These new approaches to care delivery bring new complexities around how healthcare delivery needs to be structured and managed. For example, managing patients with chronic illness in a collaborative manner requires the integration of processes of care delivery such as information exchange and decision-making over time and space and across providers of different skillsets and expertise. However, a substantial gap exists between how care delivery should be provided and how it is actually provided. Key elements of healthcare delivery such as support for collaborative care delivery and patient participatory medicine remain as challenges.
A large part of the problem is that the healthcare delivery system is not designed to support the above-mentioned endeavours. Despite our best attempts at meaningful healthcare transformation, we continue to struggle with unintended consequences from reform efforts. Examples of these unintended consequences include a continued prevalence of medical errors, despite dedicated efforts and initiatives to prevent them. In fact, at times, the very solutions we implement to solve specific issues become the basis for further unanticipated problems. For example, the 1999 Institute of Medicine Study To Err is Human brought attention to the prevalence of medical errors. A follow-up Institute of Medicine (IOM) study in 2001 advocated increased use of information technology as a driver to healthcare reform including the reduction in medical errors. As a result, we saw more Health Information Technology (HIT) strategies put in place to reduce medical errors.

However, studies began to emerge suggesting HIT could in fact be causing further medical errors. In an ironic turn, the very technologies we designed and implemented to reduce classic errors led to a whole new category: technology-induced errors. A fundamental question to ask is why do strategies and interventions in healthcare so often fall short of desired objectives and bring about unintended consequences? A primary reason is healthcare problem solving often focuses on what is visible such as the task at hand while failing to acknowledge the larger system within which healthcare delivery exists. Yet it is often systems issues that must be rectified when problem solving. Many healthcare problems are an effect of the interactive and multi-dimensional nature of the system and rarely can be reduced to one root cause or a single factor.
Healthcare delivery draws upon traditional management disciplines such as accounting, management science, finance, and organizational behaviour. However, the way in which these disciplines inform decision-making in healthcare requires rethinking because healthcare is a complex adaptive system, meaning that we cannot study issues and problems in terms of isolated entities. New approaches for the design and delivery of healthcare services are needed. While healthcare delivery can be improved through the better use of existing resources and a fundamental change in how healthcare services are organized and managed, it has been suggested that a reason for a lack of change is both resistance within the system and an inability to effectively understand how change needs to occur. Healthcare decision-making and planning can be broadly classified into two categories. One is at the clinical level where decisions are made on treatment options and therapies. The other is the healthcare management level where resources and the delivery of services are planned. In the latter category, healthcare has long drawn on classic approaches from decision and management sciences to support planning and decision-making. Yet these approaches have not led to meaningful change in healthcare delivery due to the complex and interrelated nature of the healthcare system.  
A Complex Adaptive System (CAS) is a system that displays properties such as emergent behaviours, non-linear processes, co-evolution, requisite variety, and simple rules. As a system becomes more complex, the number of components and interactions between each component increases both within the system and between the system and its environment. Healthcare can be classified as a CAS because the various elements such as care delivery, education, and policy consist of a series of interacting parts that work in non-linear and evolving ways. Collaborative care delivery is a specific healthcare process that represents a  Complex Adaptive System due to the fact there are multiple participants separated by time and space, and the rules of engagement for how they should work together may be emerging and evolve over the course of time.
Despite the complex nature of healthcare delivery and agreement that healthcare is indeed a complex domain, some have argued that use of Complex Adaptive System as a lens for healthcare management is simply the new fad. A critique of much of the existing research on Complex Adaptive System in healthcare is that it is descriptive in nature, does not provide an explanation for how, or when, CAS should be used to support management in healthcare, and may be nothing more than a convenient metaphor that lacks methodological rigor. Studies on Complex Adaptive System in healthcare have ranged from empirical to rhetorical and that there is a lack of methodological guidance for using Complex Adaptive System to inform decision-making. Applying CAS to healthcare requires a balance between understanding complexity and designing formal approaches to represent it. But this is not an easy task, given that healthcare delivery is defined by multiple interacting and interdependent parts, limited stability, and an inability to use basic control levers such as “cause and effect” or “command and control.”
A challenge with the current decision-making paradigm in healthcare is that decisions, be they financial, human resource, or service delivery, are typically made separate from the context of how healthcare delivery should be provided. While the common goals of healthcare delivery is collaborative and continuous care delivery based on providing value for the patient, we continue to make management decisions based on isolated concepts or goals, such as access to services or wait times for a procedure. The results of such decisions are unintended consequences.
In developing decision science approaches for understanding healthcare as a Complex Adaptive System, there are three key factors. First is that healthcare systems have limited stability and developing models with simplistic “cause and effect” analyses or using traditional scientific management or reductionist decision-making methods will not work. Second, traditional levers that guide linear systems such as supply and demand or quality/cost cannot be used for systems control. Third, metrics used to evaluate the system need to be at the system level and not developed to fit a particular problem context while ignoring the various interacting components of a Complex Adaptive System.
While it is widely acknowledged that healthcare is a complex domain and thus Complex Adaptive System should inform how healthcare delivery is devised and managed, to date we still largely rely on classic decision-making approaches, which have led to poor outcomes and unintended consequences from systems reform efforts.

The writer is Former Head, Department of Medical Sociology, Institute of Epidemiology, Disease Control & Research (IEDCR),  Dhaka, Bangladesh



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Editor : M. Shamsur Rahman
Published by the Editor on behalf of Independent Publications Limited at Media Printers, 446/H, Tejgaon I/A, Dhaka-1215.
Editorial, News & Commercial Offices : Beximco Media Complex, 149-150 Tejgaon I/A, Dhaka-1208, Bangladesh. GPO Box No. 934, Dhaka-1000.

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