Complexity and Teams with Diversity

Teams may not be the right approach to addressing simple puzzles and problems. When we are faced with complex challenges (where dilemmas, and paradox are abundant), we find ourselves needing many people involved in solving and resolving the challenges.  It is in the realm of complexity that the rising value of teamwork emerges—in some ways like what chaos and complexity scientists call a “strange attractor.”  When our challenges flow into full levels of complexity then the team becomes essential to success navigation. We are no longer solving or even resolving—we are navigating in the realm of complexity. The diversity of perspectives and experiences to be found in a carefully constructed and effectively functioning team are essential in addressing complex health care problems, dilemmas and polarities.

In rapid and dynamic shifts between states, often Mystery emerges, where even effective navigation can become impossible no matter how well functioning the team. Given the matter of life and death that is abundant in health care systems, it is particularly important for any team to acknowledge those elements in the operation of their system that are beyond their control—or even predictive power.  Thus, teams must become facile at recognizing when complexity blurs into mystery and chaos—and recognize the limits even of teams to successfully navigate through mystery.

A key example of a massive mystery in US healthcare is the annual process of identifying nearly $1 trillion in “unnecessary care and waste”, what is also called “low-value care” without any substantial progress in reducing this apparent waste.  How is it we can clearly identify a massive source of low-value spending, while facing mounting poverty, hunger, those living without a house, climate challenges, educational challenges and mounting student debt?  A 20% reduction in waste in healthcare could launch massive new public health, educational and environmental initiatives that could profoundly impact the health and well-being of Americans. Yet, year-after-year we remark on the massive nature of waste and remain mystified on how to begin to move healthcare toward becoming a less wasteful industry.

Why does that happen?  VUCA-Plus, particularly through being likely the most complex human system in the world, with payment & health delivery systems that baffle even the most expert physicians, nurse, administrators, and financial people across the nation. Even massive new legislation, like the Affordable Care Act have generally failed to reduce unnecessary and low-value aspects of healthcare spending.  Many states are in the midst of attempting to begin to constrain total cost of healthcare in their states—led by Massachusetts, which is over 10 years into the effort, yet experiencing rather limited results in cost containment.

California has recently entered the arena of total cost of care containment, taking lessons from many other states in creating a new Office of Healthcare Affordability with an expansive mandate to constrain the rate of inflation in total healthcare spending and re-directing investments toward higher-value care such as primary care, behavioral health, and health equity.    Impactful results will likely require broad inter-professional teams that address healthcare spending through the lens of complexity, rather than hoping single-lever solutions will produce needed results of improved health outcomes with more equitable and responsible spending patterns.

Any effectively operating team will be thoughtful of the difficult and often emotionally difficult discernment to be made regarding those issues that they can (at least in part) control and those which are outside their control. The latter issues require a realistic assessment of what can be done to align with and (if necessary) buffer the impact of an external force and circumstance—such as are found in many VUCA-Plus environments.

Flocking and Feedback

Healthcare teams, like sophisticated flocks of geese, can adapt and flourish through a multitude of dynamic conditions and threats—through local and distant feedback loops, streamlining movements that reduce energy consumption, and collaborative leadership with simple, adaptable rules that save not just the individual goose from the hawk, but the entire flock in an instant. Collective intelligence emerges in high-performance teams—the whole becomes greater than the sum of the parts. The rag-tag collection of novices with a computer and high-levels of teamwork outperforms the most talented, expert on the most complex challenges facing his or her industry.

Yet, the science of Complex Adaptive Systems in healthcare remains scant, though compelling.   It is not surprising, then, that a complex spectrum of approaches to Complex Adaptive Systems in healthcare have emerged. In their own way, the articles we have published (Fish and Bergquist, 2022; Fish and Bergquist, 2023; Bergquist and Fish, 2023) represent emergent phenomena within the broader complex adaptive system. A simple basic rule in healthcare literature is “we will publish our best sense of the current state of things in a peer-review way to evolve our learning.” Thus, publishing on CAS within the context of healthcare is in itself, complex, emergent, and our brief overview of some of the prominent examples in the healthcare literature is an attempt to find patterns and attractors to pull us and healthcare toward a better understanding of and navigation within CAS.

Complex Adaptive Systems likely represent the highest order of evidentiary framework within the realm of VUCA Plus. There are some early signs of attempting to integrate CAS into healthcare organizational dynamics, in particular within Primary Healthcare—a high-value component of healthcare systems that is often neglected, under-resourced, and misunderstood.  Widespread variability in resource allocation and centrality across nations is also all too common.  In Europe, most countries invest heavily in primary healthcare, approaching 15-20% of all healthcare spending, while in the United States, less than 5% of total spending is on primary healthcare.  Primary Healthcare may be suffering from the machine-thinking model of healthcare in the United States, where Fee-for-Service payment models favor procedural actions by clinicians far more than cognitive engagement by clinicians and healthcare teams.

The Meikirch Model

Bircher and Hahn (2016, F1000Research) take us on a wild exploration of Meikirch Model of health in the broader context of complexity and how it may apply to the field of primary healthcare.  The Meikirch Model describes health in this fashion:

1. Health is a dynamic state of wellbeing emergent from conducive interactions between individual’s potentials, life demands, and social and environmental determinants.
2. Health results throughout the life course when an individual’s potentials and social and environmental determinants suffice to respond satisfactorily to the demands of life.
3. Life’s demands can be physiological, psychosocial, and environmental and vary across individuals and contexts, but in every case unsatisfactory responses lead to disease.