Changing how we think about healthcare improvementBMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k2014 (Published 17 May 2018) Cite this as: BMJ 2018;361:k2014
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There is currently a worldwide nursing shortage; developed countries are facing a nursing staff shortage, with nearly all of the countries relying on nurses from abroad to ease this situation. Nurses are one of the largest sectors of the healthcare workforce, and migration has affected both source and destination countries. Many countries have difficulty achieving a stable supply and demand of nurses because of the constantly changing health care employment needs and competition for recruitment of potential workers (Sherwood, & Shaffer, 2014).
Typically, the nurse migration stream moves primarily from unindustrialized countries to developed countries. With the migration of nurses there is an increase in remittance to the source countries. Unfortunately, however, much of the money is not reinvested into the healthcare system. Although overseas nurses send large sums of funds to their home countries, it was unable to offset the loss of skilled nurses.
Nurses migrating from developing to developed countries are often leaving behind an already deprived health care system. Migration of these nurses from poorer nations causes a malicious cycle in the healthcare system. The undesirable work conditions and low compensation spur health professional immigration to more developed countries (Li, Nie, & Li, 2014).
For those nurses remaining in the public sector the workload dramatically increases, working conditions deteriorate and the level of stress nurses experiences is escalated (Kingma, 2018). With the migration of nurses there is a move of skilled nurses to developed countries leaving behind a brain drain in the country and having less skilled nurses to deliver healthcare. If the healthcare system is to be improved the governing body or policy makers need to put policies in place to address these issues to prevent the negative consequences on the healthcare system and in turn the clients being served by these facilities.
Migration has also increased the challenges associated with the recruitment and retention of health professionals. Shortages have been found to increase workload and therefore burnout among those health workers who remain in the country (Murphy et al., 2016). In developing countries there is also a shortage of supplies needed to provide appropriate healthcare to the larger public accessing care at these facilities. To improve the healthcare system there is a need for multi sectoral collaboration.
Competing interests: No competing interests
Jeffrey Braithwaite makes a cogent case for an appreciation of ‘complexity thinking’ in healthcare, drawing on an obvious wealth of personal and published experience.  The challenge for practitioners is to draw on such insights to actually deliver pragmatic approaches to improving existing efforts to deliver care. Such approaches may be informed by experience elsewhere – while Braithwaite asserts that no other industry is as complex as healthcare, many other safety-critical fields have developed a robust approach to managing complex systems which healthcare may benefit from. Several of these such as defence, aerospace, manufacturing, and construction are linked by the academic and practical experience within the Engineering and Design communities. These are in turn closely allied to the fields of Operational Research and Improvement Science – all have well-developed theories around systems and complexity with a range of practical tools to explore, create and evaluate system improvements.
Recent work by the UK’s Royal Academy of Engineering, Academy of Medical Sciences, and Royal College of Physicians to develop a consensus systems approach to improving healthcare has been summarised in the flagship report ‘Engineering Better Care’. This draws on an extensive programme of workshops, discussions and case studies from across the different communities and looks to distil the essence of a systems approach into a series of iterative questions which need to be answered by those seeking to improve care, whether at the local or national level. These questions support Braithwaite’s thesis that both people and systems are at the core of improvement, but goes further to suggest that the areas of design and risk, while less well explored in healthcare, are similarly fundamental. Indeed, risk management and a formal design process are often wholly lacking from medical improvement initiatives.
Many terms used here may need unpacking for the uninitiated. ‘Systems’ involve people, equipment, processes, institutions, and culture and are as applicable to direct clinical care as to large-scale healthcare provision. ‘People’ involve all those – often beyond the obvious – who have a stake in the area of interest. ‘Design’ is not limited to the creation of physical artefacts, but encompasses processes, experiences, or policies. Finally ‘risk’ involves not simply a retrospective attempt to prevent a previous adverse outcome from recurring, but a prospective attempt to both minimise harm and promote excellence. A ‘systems approach’ is then a coordinated effort to address each of these areas, within the resource limitations of a given project, so as to improve care without creating further harm.
One aspect of this work which may be challenging to clinicians is that while clinical insight may be necessary to improvement efforts, it is by no means sufficient. What appear to be obvious solutions, with a clear causal chain, may turn out to be futile or even harmful once scrutinised through a systems lens. Clinical requirements are in fact a subset of the wider suite of stakeholder needs which need to be traded off against each other in order to maximise the chances of effecting positive change while managing risk. This may require facilitation by experts steeped in the necessary methodologies rather than being owned entirely by clinical leaders. This should not be surprising – as noted elsewhere, hospitals would not use clinicians to defend them in lawsuits, or indeed to plan infrastructure developments or manage human resources. In each of these areas a clinical appreciation is essential but needs to be matched by appropriate expertise from elsewhere. As Braithwaite states, improvement efforts are stalling – we should not be afraid to engage with, and learn from, experts in the management of complex systems if we are to tackle this.
Competing interests: PJC was the lead author for the Royal Academy of Engineering report 'Engineering Better Care'. TB, JW, and AK were all contributors to this report.
Changing how we think about healthcare improvement , while alluding to complexity, does not really address the complex issues facing the “healthcare system” as a “socially designed complex adaptive system” .
Prerequisites for real change
(1) Generally speaking, how many people require healthcare, and where is that care provided?
It may be surprising but most of us are healthy or healthy enough not to require health professional services. Kerr White’s 1961 ground-breaking study has since been repeated in many contexts showing that health and the need for healthcare services follow a Pareto (or 80:20) distribution , i.e. 80% of the community is healthy or healthy enough not to require health professional input, of the 20% that seek health care, 80% (or 16% of the community) require primary care services, of the 20% that require additional care, 80% (or 3.2% of the community) require secondary care services, and the remaining 20% (or 0.8% of the community) receives tertiary hospital care .
(2) Does the healthcare system actually provide care for health?
Current health systems, for all intense and purposes, are focused on non-health. Health professionals at large concern themselves with – if possible fixing – but mostly managing the diseases of their patients. In other words, the system more accurately is a “disease management system”, and as far as it goes, it is doing a good job under that label [5, 6].
(3) Why is improvement no longer a viable option?
Improvement and reform assume that the current system is fundamentally sound and that tweaking it at the edges will achieve the desired outcomes. Tweaking entails that the fundamentals of the system, or its current paradigm, are fine! If it is true, as many now believe, that the health system is failing, we need a different mindset, or paradigm, with which to look at the problem. We need a shift from thinking about disease and disease alleviation/management to health and well-being, accepting that the emergence of disease over the lifetime is a biologically inevitable fact – and most notably that most elderly people regard their health as good or better despite their increasing number of morbidities . Focusing on health as a “personal experiential state” [8, 9] is paramount as self-rated health is the strongest predictor of health service use and mortality [10, 11].
Designing a “real health system”
Health systems are organisations, they are socially constructed complex adaptive systems. Organisations function based on 4 key principles – its “a-priori definition” of its purpose, goals and values which provides the foundations for delineating its key operational principles (aka “simple rules”). In a complex adaptive organisation “control and decision making” are dispersed and decentralised, allowing the organisation to rapidly adapt to changing demands and environmental circumstances [12-16].
Understanding that the prevailing health systems can only deliver – and indeed does deliver – what it is designed for based on the 4 principles that drive any organisation also guides the necessary steps forward to solve the prevailing problems. What we need is a rethink and redefinition of the purpose, goals and values for a “health-focused” health system, and what our key operational principles (or ”simple rules”) should be.
These are the key components for health system redesign . If you want to engage in this – very slowly emerging discourse – you may want to join discussion at “Health System Redesign” (https://www.linkedin.com/groups/13553062).
1. Braithwaite J. Changing how we think about healthcare improvement. BMJ. 2018;361.
2. Sturmberg JP. Health System Redesign. How to Make Health Care Person-Centered, Equitable, and Sustainable. Cham, Switzerland: Springer; 2018.
3. White K, Williams F, Greenberg B. The Ecology of Medical Care. N Engl J Med. 1961;265(18):885-92.
4. Sturmberg JP, Martin CM. Complexity in Health: An Introduction. In: Sturmberg JP, Martin CM, editors. Handbook of Systems and Complexity in Health. New York: Springer 2013. p. 1-17.
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6. Sturmberg JP, O'Halloran DM, Martin CM. Health Care Reform - The Need for a Complex Adaptive Systems Approach. In: Sturmberg JP, Martin CM, editors. Handbook of Systems and Complexity in Health. New York: Springer; 2013. p. 827-53.
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12. Kottke TE. Simple Rules That Reduce Hospital Readmission. The Permanente Journal. 2013;17(3):91-3.
13. Begun JW, Zimmerman B, Dooley K. Health Care Organizations as Complex Adaptive Systems. In: Mick SM, Wyttenbach M, editors. Advances in Health Care Organization Theory. San Francisco: Jossey-Bass; 2003. p. 253-88.
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Competing interests: No competing interests
I welcome Braithwaite's analysis on the elusiveness of systems-wide progress in quality in health and believe that it is a wake up call to policy and decision makers, clinicians and researchers working in the field. He has clearly explained the value and contribution complexity science can bring to this issue. And has thrown down the gauntlet that our current conceptualisations are 'broken' and we need to change "our collective mindsets".
Braithwaite helpfully provides us with some recommendations on how to get change (see the "attractors" and "repellents" in Box 1 and twenty "enablers" in his table). But , to me, questions still remain (for example) about when and for whom should these suggestions be used? What outcome(s) result when they are used? How do these suggestions fit into the concepts of "work-as-imagined" and "work-as-done". To illustrate, in Box 1 "Systems can change when: ... Stimulated by medical progress...", but in what circumstances does this happen, for whom and to what extent, how and why? To progress we need to better understand these recommendations - what causal processes underlie then, when do they operate, for whom and what outcomes do they cause.
Fortunately, help is at hand. Using a realist lens to understand these recommendations would be one way to understand causation behind these rules and also to work out the contexts in which to use them, for whom and what outcomes they cause. If primary research is being used to make sense of these recommendations then a realist evaluation approach could be used (1). When evidence synthesis is needed to learn about the recommendations from across health improvement studies then realist review is more suitable (2).
For those wanting to pick up the more modest gauntlet of researching his recommendations using realist reviews and realist evaluations, so as to make them even more useful, quality and reporting standards and training materials and resources exist - www.ramesesproject.org
(1) Pawson R, Tilley N. Realistic evaluation. London: Sage; 1997.
(2) Pawson R. Evidence-based policy: a realist perspective. London: Sage; 2006.
Competing interests: I teach a module on realist review and realist evaluation: https://www.conted.ox.ac.uk/courses/realist-reviews-and-realist-evaluation I have been and am currently paid to provide realist methodological support to a number of funded projects (for list of projects please see: https://www.phc.ox.ac.uk/team/geoffrey-wong)
Jeffrey Braithwaite opened a very valuable discussion about complexity in healthcare and how it should influence our thinking about healthcare improvement.
One important organizational aspect of healthcare lies within information and communication technology (ICT) that also is characterized by high complexity. Therefore, I like to refer to an article entitled:
Cultivating complex ICT in health care: the gardeners perspective (by W. Fierz) with the following abstract:
It is a widely hold view that management of information in health care with the help of information and communication technology (ICT) should follow a certain strategy in order to cope with the complexity of health care. However, when looking for a theoretical background for a strategy that is apt to complexity one has to go beyond the field of ICT and consider new conceptual frameworks that have already started to influence science, society and organizational life. It follows from such novel veins of thinking that complex organizations in a changing environment can not be strictly planned anymore but need a more flexible and caring approach that rather needs the skills of a gardener than those of an engineer. Here, it is advocated that a strategy for ICT in health care should also follow such avenues.
The full article is available at:
Competing interests: No competing interests