Understanding Medical Systems

Understanding the Structure and Dynamics of Systems

A system is defined as a collection of interdependent elements that interact to achieve a common purpose. Examples of systems include the process of treating patients with diabetes; a hospital; the development and testing of new medical procedures; and a medical practice, including locations of care, billing, and collection of fees. The diversity of these examples illustrates the arbitrariness of the description of a system. A description of a system of care for patients with diabetes, for example, is a logical construct that represents a particular point of view. What is included in and excluded from the description is strictly a manifestation of that point of view.

Many people in health care organizations identify strongly with their individual professions or departments. Management structures, professional organizations, methods of billing for services, and research studies reinforce these divisions [2-4]. This fragmented environment allows the structure of medical systems to evolve piecemeal. Individual constituents of systems add elements in their spheres of influence to compensate for the perceived weaknesses of other constituents, thereby increasing the complexity of the system and substituting one problem for another. For example, a payer adds an approval step that must be completed before a patient can be referred to a specialist. In reaction, informal processes are created to circumvent the approval step or to resolve conflicts about the appropriateness of a referral.

Improvement to a system results from new structures that are purposefully designed. To create functional systems, users must look beyond their professional or organizational identities [5]. Effective changes to the referral system in scenario 1 require that primary care physicians and specialists see the elements of their practices as part of the same system rather than as separate systems at odds with one another. The physicians and office staff in scenario 2 must recognize the common system in which they work to make progress on the problem of the missing laboratory results. Even a rudimentary understanding of the structures and dynamics of systems combined with clinical knowledge can equip a physician to diagnose the faults of a system and design remedies.

Scenario 1: The System of Specialty Referrals

The system of specialty referrals described contains an intermediate approval step deliberately placed between the specialist and the referring physician to prevent the inappropriate use of specialists. Adding this step is a weak intervention in the system that adds extra steps, causes delays, and devalues the clinical judgment of physicians. Physicians may agree with this assessment of the results and respond that the inspection step was added without their concurrence. They may suggest that administration simply remove the approval step. However, this is a facile answer from one part of the system to the difficult issue of providing good care at an affordable cost from the system as a whole. Although the approval step was probably added to reduce costly, inappropriate referrals, whether real or perceived, such steps are usually reliable markers of weaknesses in the system. However, removing the step would result in a simple return to the old system with its weaknesses intact.

A more positive approach would be to redesign the system on the basis of clinical expertise and cooperation among the physicians involved. Consider a system without an approval step but in which 1) primary care and specialty physicians agree on a set of criteria for referrals, 2) specialists provide feedback to the primary care physicians on patients who were inappropriately referred to them according to the criteria, 3) specialists develop diagnostic and administrative aids for primary care physicians aimed at optimizing their referrals, and 4) administrators and physicians monitor the performance of the system by tracking the number and appropriateness of referrals.

The structure of the redesigned system differs significantly from the original one. It does not have an approval step; it has a feedback loop from the specialists to the referring physicians to optimize the use of clinical knowledge throughout the system. Action to improve the appropriateness of the referrals is focused on the system as a whole and is done by examining patterns of referrals after the fact rather than by impeding an individual referral.

Some organizations are using this improved structure as the basis for “service agreements” between primary care physicians and the specialists to whom they refer patients. The primary care physicians agree to acquire, with the help of the specialists, a set of core competencies to care for a specific patient population. The specialists agree to provide same-day access for any patient with a condition that the primary care physicians cannot diagnose or manage.

Scenario 2: The System for Obtaining and Communicating Laboratory Results

The second scenario involves the administrative tasks associated with getting a laboratory result into a patient's chart. It does not include the important clinical decisions of what laboratory tests are appropriate or how the results should be interpreted in the diagnostic process. Because the tasks involved are administrative, it is understandable that physicians may delegate the solution of the problem to administrative personnel. However, this view ignores the interdependence of all of the persons, including physicians, working in this system.

Physicians tend to view administrative systems as simple and linear-order the test, send the sample to the laboratory, perform the test, communicate the results, file the results in the chart. Closer scrutiny of this system reveals great complexity caused by needless variation in the system. Physician preferences, styles, or lack of interest are some sources of this variation. Use of multiple laboratories for the same tests is another source. Standardization of the processes by which laboratory results are placed in the chart can reduce this variation.

Further examination of the system also reveals that viewing it as linear is an oversimplification. Although the core of a system may be linear, many interacting tasks impinge on that core. For example, laboratory results may arrive while the chart is being used for another purpose. Organizations that have made progress on the issue of missing laboratory results seem to include some or all of the following components in the structure of their system: 1) a standard way for laboratories to report results; 2) synchronization of tasks, such as retrieval of charts from files, to the day before the patient's appointment; 3) a way to minimize the time that charts are out of the central filing area; and 4) a process for recognizing which charts are incomplete.

The above scenarios illustrate several important principles for the improvement of systems. Physicians who are interested in expanding their knowledge of medical systems and how to improve them can experiment in their own systems by using the applications that accompany each principle.

Principle 1

Principle

A system needs a purpose to aid people in managing their interdependencies. The structure of the system follows from the purpose. The purpose of a system and the aims to improve it are, in turn, based on value judgments. If clinical judgment is valued, the structure of a specialty referral system will differ from that of a system in which clinical judgment is not valued. New knowledge, new therapies, and changing economic forces dictate that existing systems must undergo continual improvement if those systems are to fulfill the unswerving purpose of obtaining the best outcomes for patients.

Application

State the purpose of your practice. Consider what role service and cost containment have in that purpose. Set one or more aims for improvement relative to the purpose of your practice: for example, optimization of the use of referrals to specialists or reduction of the incidence of missing laboratory results. Invest time and other resources to accomplish the aims. Examples of improvement aims can be found in a recent paper by Berwick [6].

Principle 2

Principle

The structure of a system significantly determines the performance of the system. In the two scenarios discussed above, the systems had flawed structures. Improvements in these systems were related to changing to more effective structures. Persons who do not understand how the structure of a system affects its performance will often propose a solution that is more of the same: more money, more people, more checking, more equipment, or more rules. If improvements occur as a result of these changes, they are usually costly or short lived.

Not all aspects of a structure need to be changed to obtain significant improvement. Well-focused, intelligent changes can sometimes produce substantial, enduring results. Systems theorists [7, 8] refer to these sensitive elements of the structure of a system as leverage points or triggers. No comprehensive method for developing high-leverage changes exists, but there are ways to make finding them more likely [9, 10]. Learning to move beyond events to see the structure in the system that underlies the problems is a start. Structural changes that are made on the basis of commonly accepted attributes of effective systems predictably result in systemic improvement: for example, providing a feedback loop to aid cooperation (specialists give feedback to primary care physicians about the appropriateness of referrals), establishing standard processes to reduce undesirable variation in the system (standard processes are used to order, report, and document laboratory tests), and shortening cycle times (the time that medical charts are out of the central filing area is decreased).

Application

For each aim that you establish for the practice, elicit from the persons who work with you the aspects of the system that must be changed to accomplish the aim and the ideas that are worth testing. Push for substantive change rather than more of the same. Be wary of adding approval steps or increasing complexity. For example, ask a member of your staff to describe how a laboratory result gets or does not get documented in the chart, starting from the time when you write the order.

Principle 3

Principle

Changes in the structure of a system have the potential for generating unintended consequences. Unintended consequences are said to be a system's revenge for changes made to it [11]. Unintended consequences should be distinguished from known side effects or tradeoffs, such as hair loss from chemotherapy, that are tolerated because the net outcome is viewed as positive. Consider the physicians in a single practice who, in response to patients' complaints about long waits to get appointments, agree to see each other's patients, if necessary, to improve access. At first, patients are able to get an appointment with one of the other physicians more quickly. However, as many as 20% of patients seen by someone other than their own physician make another appointment to see their own physician about the same problem. This reaction to the new policy increases the number of appointments and increases the delay in getting an appointment-exactly the opposite of what was intended.

A systems perspective recognizes that unintended consequences are a predictable result of changing systems. Persons who are interested in the improvement of medical care take this fact as a caution for intelligent change, whereas persons who are interested in maintaining the status quo use it as an excuse to resist change. Intelligent change is guided by sound theory, research, or other empirical evidence and is tested first on a small scale by using a balanced set of outcome measures ([12]; Nelson EC, Splaine ME, Batalden PB, Plume SK. Building measurement and data collection into medical practice. In preparation).

Application

Look for opportunities to test a change on a small scale. As part of the test, list some potential negative consequences and ways to collect data to study their occurrence. To learn more about unintended consequences, choose a change that was recently mandated out of frustration by you or someone else. Ask staff about the implications of the change.

Principle 4

Principle

The structure of a system dictates the benefits that accrue to various people working in the system. From a systems perspective, improvement requires many parties to change. The current system allots compensation, work schedules, work loads, prestige, and authority to individual persons in varying degrees. The redesigned system may be an improvement overall, but it will probably change the nature of the benefits for some persons. Successful change must be negotiated and requires that each person's motivations and incentives be considered [13]. One benefit may be forgone and another gained.

Several approaches can be used to negotiate change effectively. To help persons see beyond their own self-interest, focus on the needs of patients. Help persons recognize when a personal loss is offset by a personal gain. Increase the length of time in which persons evaluate costs and benefits; what seems unacceptable at first may become more attractive over time. Recognize that burdens associated with the transition to a new system may be a major source of resistance; provide resources to smooth the transition. Identify and exploit diverse needs (for example, evening or weekend hours may be a loss to some persons and a gain to others). It is crucial for those leading the changes to be fair and to look for ways to compensate those who take a loss; few persons will be so altruistic as to assume most of the burden for a change.

Application

As part of an improvement effort, list the changes in costs and benefits associated with the redesigned system, such as the financial gains and losses associated with a shortened length of stay in the hospital for a particular illness. Experiment with one or more of the approaches suggested above to resolve the conflicts associated with the new financial implications.

Principle 5

Principle

The size and scope of a system influence the potential for improvement. The size and scope of a system are determined by the elements that are included in the description of the system. For example, a primary care practice is a system. However, one could describe a larger system that includes the primary care practice and also the specialty practices to which it refers patients. The increased interdependencies and potential ways of structuring them that flow from considering the larger system enhance the opportunity for improvement. Of course, enlargement of the system requires increased skills to manage and work in the larger system. Physicians should anticipate trading some loss of control for the opportunity to influence a larger system. Taking the larger system perspective may interest some physicians in gaining new knowledge of business or of the economics of the health care market. For most physicians, it will mean increased cooperation with colleagues from other specialties or professions.

Application

Engage persons outside of your practice with whom you interact to develop changes to an expanded system. For example, describe the rehabilitation system for a patient recovering from an acute episode of a chronic discase. Include patients, family members, other medical practices, health plans, hospital personnel, and home care agencies in your description.

Principle 6

Principle

The need for cooperation is a logical extension of interdependencies in systems. Once people acknowledge their interdependencies and affirm the existence of a common aim, they recognize the need to cooperate (Clemmer CP, Spuhler VJ. Cooperation: the foundation of quality improvement. In preparation). The two scenarios illustrate the need for cooperation between physicians and others to define a new structure. Optimization of a system often requires persons in the system to move beyond parochial interests and take a local loss for a larger gain. For example, physicians in a specialty practice may lose some patients in the short term by cooperating with and educating primary care physicians who will take on some specialty tasks. In the longer term, the specialists will be in demand by those interested in providing high-quality care at an affordable price. Standardization of the process of ordering laboratory tests in the medical office will initially cause inconvenience for some physicians who must abandon familiar work habits.

Physicians are in a particularly powerful position to engender cooperation in the system and therefore to influence significantly its current and future performance. Failure to cooperate will not remove the interdependencies in the system, it will only make them toxic.

Application

After enlarging the description of the system to include entities outside of your practice, look for opportunities to cooperate. Take the first step by suggesting a change to improve the larger system that you would test. Expect reciprocation and suggest to others how they could help you. For example, after rounds in a hospital or long-term care facility, ask the nurses what changes you or your staff could test to help them admit, care for, or discharge your patients.

Principle 7

Principle

Systems must be managed. Simply declaring a group of elements a system does not mean that it will function as a system. The interdependencies must be managed, especially after a change to a system. The standard process for ordering laboratory tests and getting the results in the patients' charts in a timely manner will deteriorate without vigilant management. New physicians and office staff must be trained in the procedures. The criteria for specialty referrals must be amended periodically. The frequency and appropriateness of the referrals must be monitored. Someone, often a physician, must be responsible for initiating and managing these tasks.

Application

After testing and implementing a change that results in improvement, establish procedures to hold the gains. Periodic audits or simple measurements can be an effective means for doing this. For example, develop a checklist of problems associated with documentation in the medical record. Choose a day every 2 weeks to use the checklist to record problems. Plot the number of problems per day over time to monitor the performance of the system.

Principle 8

Principle

Improvements in systems must be led. Improvement of a system requires changes to its structure. A leader is needed to overcome the inertia in the present system and provide the will for change [14]. Primary care physicians and specialists will not get together spontaneously to design a new referral system. Unless a physician provides leadership, administrative staff will not make changes to the system of ordering and documenting laboratory results, especially changes that oblige physicians to alter their usual practices.

The structure of a system will remain fixed without this leadership. This does not mean that the performance of the system will remain unchanged. Changes in the outside environment coupled with an unchanging structure in a system will almost always cause deterioration in the performance of the system in relation to its purpose.

Application

An effective leader develops skills through trial and learning. You may find it difficult at first to be an effective leader, but be persistent. Continue to look for opportunities to improve your ability to lead. For example, lead the reduction of inappropriate use of hospital emergency departments by patients in your practice. It will probably be both more difficult and more rewarding than you thought it would be.

Conclusions

Their prominence in highly interdependent medical systems confers tremendous power on physicians, individually and as a profession. With this power comes an ethical responsibility to be deeply concerned about the medical system as a whole. For example, a physician who approaches the problem of missing laboratory results as failure on the part of a clerk to accomplish a simple filing task will contribute little to the solution. If physicians focus only on patient outcomes while leaving others to worry about cost, they will continue to lose control of how medicine is practiced.

The physician who is willing to learn about the nature of systems, how to control them, and how to improve them can significantly influence medical systems. Being a good citizen in a democratic system requires one to be informed on the issues and to cast a vote. Being a good citizen in a medical system requires the appreciation of its systemic nature and the will to use that knowledge to change it, the better to accomplish its purpose.

Dr. Berwick (Series Editor): Institute for Healthcare Improvement, 135 Francis Street, Boston, MA 02215.