Systems are everywhere. There are small systems, like atoms or cells, and large systems, like the US economy or global trade networks. When people discuss politics, education, or healthcare, they’ll often mention the political system, the education system, or the healthcare system. But what is a system and why should we care? And what does it have to do with hospital operations?
A system is generally defined as an entity composed of interrelated and interdependent parts that are organized in some way. Unsurprisingly, a hospital satisfies this definition. It has many different working parts and people – operating rooms, inpatient units, laboratories, nurses, physicians, administrators – and all of its subcomponents display some level of organization. All the people and processes interact to generate certain outcomes and behaviors, not all of which we may expect.
W. Edward Demings, whose work focused on the improvement of quality and productivity, once said “a bad system will beat a good person every time.” No matter how determined the individual or how heroic their effort may be, a bad system will eventually wear them down. This sentiment could easily be applied to many different areas of hospital operations, from staffing to surgical scheduling to patient flow.
But if a bad system will always beat a good person, what hope is there? The answer lies in understanding the system. The most effective politicians aren’t necessarily the ones with the loudest voices; they’re the ones who know how to message their platform, which stakeholders to pull in, where to compromise and why. They understand the leverage points of the system in which they work. Again, the parallels with modern hospitals are obvious.
In her essay titled “Leverage Points”, systems theorist Donella Meadows enumerates a hierarchy of leverage points for intervening in or changing a system. Leverage points at the lower end of the hierarchy have little influence over a system’s behavior; leverage points higher up, however, can often induce significant change:
- Constants, parameters, numbers
Parameters are small fry in the grand scheme of systems thinking. You can tweak them all you want and the system will stay pretty much the same. Deciding whether to give a surgical service a 5-hour block or a 6-hour block is an example of a parameter. Neither decision will have an outsized influence on broader operations.
- Information flows – who does and doesn’t have access to information
In the absence of reliable, timely information, many decisions within a system become difficult to make with reasonable confidence. Staffing information, for example, is sometimes kept on pieces of paper or in color-coded binders spread across various units. The effort to collect that information ends up consuming the ability to act on it quickly. Hospital IQ’s Workforce Solution alleviates this pain point by enabling real-time, collaborative adjustments to workforce plans.
- Rules of the system – incentives, punishments, constraints
If you want to understand and predict how people will behave in a system, you need to understand the incentives and constraints. For example, surgeon report cards on coronary artery bypass graft (CABG) mortality rates in Pennsylvania and New York were published in an attempt to improve outcomes. However, the report cards actually created an incentive for surgeons to avoid risky cases that might reduce their public scores. Without understanding incentive structures, someone intervening in a system can induce counterintuitive and even counterproductive behaviors.
- Power of a system to evolve, change, and self-organize
The power to evolve and adapt to changing circumstances is one of the most remarkable features of any system. Indeed, without the ability to change and self-organize, many systems would wither and die.Examples of self-organization can be found in any hospital. Nurses develop numerous methods of communicating — whether about patients, physicians, or schedules — that may not be formalized in a training manual but are nevertheless critical for day-to-day hospital operations. Clinical staff might develop new and innovative ways of preventing pressure ulcers or central line infections. These adaptations and changes help hospitals, and the healthcare system more generally, improve patient outcomes.
- Mindset or paradigm out of which the system arises
A system’s paradigm is the set of beliefs, stated and unstated, shared by the people working within a system. At a hospital, this could be “The patient comes first.” It could also be “Look out for number one.” In either case, the mindset will almost always trump any changes to a system’s parameters, incentives, or goals.Work done by Peter Pronovost, the current Chief Clinical Transformation Officer at University Hospitals – Cleveland and a former critical care specialist at John Hopkins, to reduce central line infections demonstrates how paradigm shifts can influence care. A simple approach involving checklists significantly reduced the number of central line infections at hospitals in Michigan, saving hundreds of lives. But it wasn’t the checklist per se that catalyzed change; after all, similar approaches have failed at hospitals when not implemented in good faith. The catalyst was a change in the organizational paradigm. Administrators authorized nurses to intervene when doctors failed to follow the checklist; physicians and executives pushed suppliers to create an all-in-one central line product. The shift in values drove the shift in behavior and outcomes.
As payment models in the US move towards value-based care, hospitals will increasingly need to find operational efficiencies to remain successful. By understanding not just how to intervene in a system but where to intervene, hospital leaders can expand their operational toolbox and ensure they achieve meaningful and lasting results.