Republished CEGE Connection Blog article from April 2020.

“This research, though still ongoing, has shed some light on the need for conversation in the context of systems thinking. Health care providers, administrators, support services, patients and many other stakeholders are all factors who play an important role in our system. Fostering an understanding is the first step for us to appreciate the interconnections and roles that exist when identifying problems and coming up with solutions, especially as we work to navigate COVID-19 and map out sustainable health care systems for the future.”

Keira Lum, MBA

I would have never expected that the current reality of a global pandemic would so closely reflect the nuances of a research project for school. COVID-19 and the world’s response to the virus, highlights the complexities of the healthcare system and exemplifies complexity science in systems theory, which became my research topic of choice for a school credit.

While in the final year of my Master in Business Administration degree at Dalhousie University, I choose to complete a directed reading to fulfill one of my required course credits because it was a chance to learn something that I was highly interested in and because the winter course offerings did not align with my future focus. A directed reading is a course that a student is able to customize and structure under the guidance of a professor in a topic of their choosing. My professor of choice happened to be an eccentric finance prof who spent most of my first year preaching about this strange topic called complexity while trying to ensure students understood the time value of money and the importance of reading the news. I was intrigued, and after finishing his book, thought complexity would be an interesting topic to explore further. However, in wanting to explore this topic, I also sought to understand and leverage my recent 8-month co-op experience completed at a Toronto Health Network on the Operational Excellence team as part of my degree. As such, I chose to research and try to understand the role of complexity science in healthcare.

The health care system and its challenges have been a well discussed topic over recent years, such as ending hallway medicine; how to build a continuum of care between acute care centers and communities; how to navigate funding restraints at a federal and provincial level; what to do with the influx of patients entering long term care as people live longer with various qualities of life; etc. The list is long, and sobering when you try to comprehend where to and how to begin addressing such issues. When this conversation begins, it shines a light on the complexity of the system but requires an understanding of systems thinking in order to propel an appreciation for such interconnections and unpredictable results that exist. The understanding of these systems becomes necessary before we begin thinking of solutions to such problems.

In systems thinking, there are several types of systems, however for the purpose of my research and directed reading, the focus compares complicated versus complex systems. The terms complicated and complex are often used interchangeably and without knowledge of systems theory, many incorrectly apply or categorize problems in the wrong system.

A complicated system is governed by rules and laws (ie. the rules of physics) which leads to predictable outcomes. An example of this is observed in administering the flu shot to a patient. Conversely, complexity occurs when there are interconnections (relationships) between several agents or factors within a system, such as a patient’s relationship with their healthcare professional, or the general public and government healthcare agents. Unlike complicated systems, agents within complex systems may adapt their behaviour based upon the nature of their connections. This leads to resulting behaviours or outcomes which are completely unpredictable such as a population’s response to the spreading of a virus. This also results in properties such as emergence, feedback loops, the butterfly effect and/or paradigm shifts.

Understanding the differences between complicated versus complex systems is important because it underscores how we operate within and address these systems. When addressing complicated problems, we often end up with reductionist thinking, where one focuses on static properties of elementary parts. In looking at complex problems, we need to use holistic thinking which assess a situation as a whole compared to a collection of parts. This is important because, it requires that we understand the environment and context in order to understand the system or problem as a whole.

My directed reading and research aimed to highlight the importance of acknowledging and understanding healthcare complexity when identifying problems and developing solutions through the research questions: Are we aware of and do we appreciate complexity in healthcare? As well as, what may prevent us from understanding complexity in healthcare? As healthcare has elements of complexity, my goal was to understand whether various stakeholders in the system understood complexity in healthcare and what factors exist which prevent us from understanding complexity in healthcare.

My research methods included interviewing several stakeholders from within the system consisting of health care professionals such as nurses, physicians, surgeons, allied health professionals (physiotherapists, occupational therapists, pharmacists, social workers, speech pathologists, kinesiologists, etc.), health care professionals in training, health care administrators and most importantly, patients. These stakeholders helped shine a light on whether we are aware of and appreciate complexity in healthcare and what factors prevent us from understanding it.

When I began my interviews in February of 2020, COVID-19 was spreading throughout China into other neighbouring countries. The realities of what the next month would bring were not as apparent at the time my first few interviewees gave their responses. However, as my interview process continued, access to the stakeholders I sought to engage with, became more challenging as the Canadian healthcare system transitioned into risk management and crisis mode. Interviewee responses, though still highlighting pre-existing challenges, factors and definitions related to complexity, were grossly intertwined with the very real state of the COVID pandemic.

When interviewing stakeholders in the health care system, responses regarding what complexity in health care meant given their role varied. What became apparent as the individual definitions were analyzed was that all definitions were based on the person’s experience and grossly framed by their position within the system, their bias, training, specialization and experience. Many health care providers (HCP) primarily thought of complexity in the context of patient complexity and patient care, which incorrectly led some to believe that they may have fostered a strong and complete understanding of complexity at a systems level. Some (40%) interviewees identified specific domains that exist surrounding patient care, such as their individual medical knowledge, social complexities and interactions with other health care providers and patients, and lastly the system’s complexity. Health care administrators, and individuals with significant experience in the system (working as an HCP or through exposure as a patient and approximately 30% of the respondent pool) had a greater understanding and appreciation of the interconnections that exist within the health care system from acute level systems to community healthcare systems.

What these initial research findings revealed was that many, if not all, stakeholders who were interviewed have some understanding of complexity science within healthcare given their role. This research also highlighted that many interviewees were quick to identify complexities that directly related to their role and immediate challenges that they faced on a daily basis. This meant that it was more likely for an administrator or director who is frequently exposed to the budget within an organization, to identify budgetary constraints and its relatedness to their operations as a challenge and layer requiring navigation in a system. In contrast, a health care provider such as a social worker, would be more likely to highlight challenges surrounding the structure of the system. For example, the accessibility to resources within the systems they work within (ie. an acute care center), or in a neighbouring system that they may need to access (ie. community outreach programs or long-term care). This does not mean that each individual stakeholder is unaware of these other layers, factors and connections, but rather that they may not be a priority.

When trying to recognize factors that prevent stakeholders from understanding complexity, respondents identified a wide range of factors from experience within the system and exposure, to individual bias, upbringing, specialization and training. Factors that stood out include: an identification of lack of interest due to time and capacity. Many felt that though complexity exists in the work they do, appreciating it and truly aiming to understand it within their position requires time. Time that respondents don’t have as they are already operating at capacity with a full patient case load, efficiency and budgetary initiatives or are strained by a global pandemic. As such, observing complexity, appreciating it and using it to build solutions is often de-prioritized, which sometimes leads to a poor understanding of how to identify, classify and solve problems.

Additionally, many people fail to think of healthcare unless they need it, or currently, unless it is broadcasted at large by the media due to a pandemic. The reality however, is that many people who engage with the healthcare system do so through their position as health care workers or administrators, support services, or because they have to as patients or patient families. Limitations in knowledge of the healthcare system and how it operates at a macro and micro level is something that prevents us from understanding and appreciating healthcare complexity. This includes anything from political incentives, funding models, operational decisions, risk management, patient care, transition of patient care between acute care centers and the community, accessing care at home, aligning services, accessing health related information, etc.

This lack of knowledge and information was identified as a gap among most boards of directors who govern health care centers. It was observed by some of the senior health care administrators that directors who often came from out of industry to govern a health care centre, struggled to understand the interconnections and processes that exist within healthcare. This is often the same for first time patients who are exposed to the system when ill or injured, or even to seasoned patients who are entering a new part of the healthcare system because their care needs have changed. Knowledge and access to information, especially accurate information is an important factor identified that may prevent one from understanding healthcare complexity.

As an extension to our knowledge, too much knowledge as a result of specialization was also deemed a factor that prevents one from understanding complexity. When one is specialized in a specific area of patient care or administrative operations, it is not uncommon to wear blinders and fail to see other aspects of the system. This is because our roles are sometimes structured so that understanding other variables or factors in the system are not necessary. This is incredibly common with sub-specializations where one is incredibly knowledgeable in a very specific area but may not always engage at a holistic level.

In contrast, some respondents indicated that too much information resulted in paralysis by analysis and an inability to understand the complexity that exists. An example of this was commonly identified with new electronic medical records, where health care providers are inundated with patient information in one digital location. Despite the benefit of having access to most if not all of the patient charts, for many providers, this adds a layer of complexity. It becomes more challenging and time consuming for providers to navigate more information which is an overwhelming process and has been identified as a disruptor in how they would like to provide patient care.

Overall, many factors exist beyond the ones identified in this research and in this article, which prevent one from understanding complexity. However, despite these factors we still have a responsibility to be open-minded and understand these interactions. This means acknowledging how our roles and decisions interact with other areas of the healthcare system while deciding on what is best for patient care or operational efficiencies.

This research, though still ongoing, has shed some light on the need for conversation in the context of systems thinking. Health care providers, administrators, support services, patients and many other stakeholders are all factors who play an important role in our system. Fostering an understanding is the first step for us to appreciate the interconnections and roles that exist when identifying problems and coming up with solutions, especially as we work to navigate COVID-19 and map out sustainable health care systems for the future.

COVID-19 became a perfect example of a complex system and the nuances of interconnections within and beyond the healthcare system. These interconnections are influenced by thousands of factors which vary drastically as the virus continues to spread.  Two examples that stand out are the social and economic responses as a result of COVID-19. In trying to tackle COVID-19 we need to keep a few things in mind. Identifying the problem or problems as either complicated or complex are crucial. Different systems require different approaches when building out solutions, and to get to this point we need to begin with an understanding and appreciation for systems theory, factors involved and their interconnections. In approaching complex problems, we need to use holistic thinking and be cognisant of the fact that our decisions will have unforeseeable impacts down the road.

Keira Lum, MBA
April 2020

Editor’s Note:  Special thanks to Dr. Rick Nason for introducing Keira Lum to CEGE Connection.  We are thrilled to publish Keira’s research and insights. We wish her the very best as she pursues her research on complex systems within our healthcare system.