Insights November 2016
Open Letter

Harnessing Simple Rules for System Thinking in Healthcare Transformation

Allan Best

This letter is part of series of Open Letters from Canadian leaders in Healthcare. To see the complete series please click here.

It’s become a mantra for health system improvement to stress the importance of building innovation on an evidence foundation. But there are three problems:

  1. As we move from looking for evidence of what works, from the individual to organizational to system and policy levels, there is less and less clear evidence. So, if we want to make significant improvements, do we sit on our hands and wait for the evidence, or instead get creative - blending research and practice wisdom with innovation and continuous improvement?
  2. Significant improvements rely on coming to grips with the complexity of health systems. Complex systems are fundamentally different, not meshing comfortably with our usual leadership and management practices.
  3. There is a huge talk-do gap. Leaders increasingly understand at least aspects of the complexity, but the truly essential thing is to put understanding into action.

I see efforts made to weave together four threads in managing complexity and achieving system transformation:

1. A stronger bridge between research and policy. The time has come to go beyond lines that divide research, evaluation, and quality improvement to provide “a new kind of evidence base that supports adaptation and learning.”[1] Creating strong partnerships between academia and the health sector is challenging – cultures, timelines, priorities, and funding mechanisms don’t connect easily. Stepping up to this challenge is crucial.

2.  New strategies and contextual understandings for large system transformation in complex adaptive systems. Complex systems are fundamentally different - the hallmarks include dynamic emergence, local adaptation, nonlinearity, and the pivotal understanding that relationships trump transactional leadership.

  • Changing complex adaptive systems requires: Designated AND distributed leadership - Alignment of vision and goals, functional responsibility for key roles, active management of change process
  • Feedback loops - Active participation of all stakeholder groups, real-time tracking of what’s working and why, tight linkage between accountability and quality improvement, opportunity to improve
  • Local history and context - What works in one jurisdiction may well not work in another. System change needs to rest on how success happens in this community, the typical facilitators and barriers to making change, and core values both in the community and in health system settings
  • Professional power - The deal breaker often traces back to alignment of professional and regulatory drivers, strength of incentives, turf issues and facilitation of change process. Without tackling these fundamentals, meaningful system change doesn’t happen.
  • Patients and families - These days, patient and family-oriented services is recognized as a key principle; well-accepted BUT neither good research on how best to understand what this means nor how to implement new ways of providing services.

3. Four key principles for setting the table for successful implementation.

  • Clarity of purpose - Get out of siloes we’ve built, co-create a compelling, values-based vision for a functionally integrated system, and who needs to play what role to achieve it.
  • Alignment of effort - Create structures with clear roles for every person and group within an organization/network. The result is an effective and functionally efficient organization or system with clear lines of accountability and authority.
  • Credibility of leadership - Focus on relationships and culture, sharing control, walking the talk, investing in change.
  • Integrity in the organization - Personal and organizational values are particularly important in contexts that are continually changing. Leaders must ensure that they are publicly living out core values.

Only after these first four requirements are in place can policy makers meaningfully construct the system needed to ensure system improvement - addressing the fifth key principle of accountability. The problem is that leaders want to spell out accountability measures at the front end of a complex change process, and that flies in the face of what we know about complex systems and change.

The fundamental challenge is that traditional management strategies and skills don’t work well in complex systems. High tech innovation relies on high touch ways of working with multidisciplinary teams and networks, across traditional health system boundaries and levels.

4. System Thinking Tools. The good news is that there is a wide range of tools that health organizations and collaboratives can use to strengthen their systems thinking capacity and increase transformation. For example:

  • Concept mapping allows hundreds or even thousands of stakeholders to participate on line in co-creating a common language and logic for system change. The rapid realist review methodology we’ve developed provides timely research synthesis tailored to local context.
  • Network analysis and dynamic mapping drill down to assess current network functioning and pinpoint leverage points for interventions.
  • Research collaborators can work with leaders to build bottom up feedback and quality improvement evaluation that meshes with accountability needs. As recently summarized by Greenhalgh et al, 2016: “impact metrics must reflect the dynamic nature and complex interdependencies of health research systems and address processes as well as outcomes”[2]

In sum, complex healthcare systems raise the bar for effective leadership and system change strategy, but there are simple rules and helpful tools if we can bridge collaboration from research to policy and practice.

[1] Finegood, D., & MacLeod, H. (January, 2015). Blurring the lines between research, evaluation, and quality improvement. Longwoods Healthcare Ghost Busting Essays.

[2] Greenhalgh, T., Jackson, C., Shaw, S., & Janamian, T. (2016) Achieving research impact through co-creation in community-based health services: Literature review and case study. Milbank Quarterly, 94(2), 392-429. 

About the Author(s)

Allan Best, Ph.D., Managing Director, InSource Research Group, Associate Scientist, Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Clinical Professor, School of Population and Public Health, University of British Columbia


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