High-Value Health Care: Implications from Complexity Theory
special feature
High-Value Health Care: Implications from Complexity Theory
By Leslie A. Hoffman, RN, PhD, Department of Acute/Tertiary Care, School of Nursing, University of Pittsburgh, is Associate Editor for Critical Care Alert.
Much of the recent attention to the high cost of health care has focused on opposing political viewpoints. Less attention has been given to an equally important issue: How do health care delivery organizations reliably deliver high-value health care and, by doing this, ensure optimal patient outcomes? One strategy involves keeping current with scientific advances. Through scientific journals, seminars, and continuing education, we update knowledge and initiate or "tweak" clinical practice guidelines to incorporate change. This approach, alone, is insufficient. To ensure optimal patient outcomes, it is necessary to create an infrastructure that ensures what is known about how to deliver optimal care gets enacted at the bedside and motivates those delivering care to seek ways to further improve practice as part of their daily routine. This article will discuss ways to ensure this outcome occurs from the perspective of complexity theory.
COMPLEXITY THEORY
To achieve desired outcomes, experts have advocated that we need to conceptualize health care delivery as a complex system and apply principles of complexity science to achieve desired goals.1-3 In a mechanical system, component parts interact linearly to produce a predictable output. Complex systems interact nonlinearly and, therefore, often produce unexpected results. The following observations are central to complexity theory:2,3
- Small-scale changes in initial conditions can produce massive and unpredictable changes in outcome.
- Very similar conditions can produce very dissimilar outcomes.
- Effects are not straightforward continuous functions of causes.
- If something works once, there is no guarantee that it will work the same way the second time.
- Local rules and behaviors generate diversity and heterogeneity that undermine the ability to generalize "what works."
Complexity theory, which emerged from the natural sciences in the late 20th century, provides a framework for understanding unexpected phenomena. Cause does not always lead to effect, small shifts may lead to massive changes, and totally unpredictable events can occur. Some degree of unpredictability is expected and is the sign of a healthy complex system.1-3
THE ICU — A COMPLEX ENVIRONMENT
The critical care environment is a classic example of a complex system. Like all complex systems — work environments, family relations — the delivery of critical care combines predictable and unpredictable elements into an evolving and emergent whole. Viewed from an orderly mechanistic perspective, education would provide knowledge that will produce change that is universally adopted and, in turn, leads to optimal patient outcomes. This perspective is the way many envision change — a series of steps that result in predictable outcomes. However, in reality, the landscape (the ICU) is dynamic and consists of a number of peaks and valleys. Moving from point A to point B is complex because there are hidden valleys (obstacles) that influence success.3
PRACTICE EXAMPLES
The following examples are attempts to illustrate the thinking that embodies complexity theory through studies conducted in the critical care setting. Each illustrates the need to search for hidden explanations when results do not follow the expected course.
Sedation Administration
Using data from a randomized, controlled trial designed to evaluate a paired sedation and ventilator weaning protocol, Seymour and colleagues4 tested the anecdotal belief that nurses administer greater doses of sedatives at night in the mistaken belief that this action promotes more restful sleep. Their hypothesis proved correct. Compared to daytime doses, sedative doses were larger at night in nearly half of the patients receiving benzodiazepines (33-45%) and propofol (30-59%), an outcome associated with failed spontaneous breathing trials (SBT), coma, and delirium. Notably, these increases occurred despite patients being managed using sedation protocols that were part of this clinical trial. These protocols, however, did not direct sedation at night. Thus, patient outcomes (failed SBT) may have resulted from less obvious factors, rather than patient condition.
Rapid Response Teams (RRTs)
RRTs have been advocated as a means to reduce mortality in patients outside the ICU. Although early publications reported significant improvements in clinical outcomes, the only randomized, clinical trial that examined RRT outcomes did not demonstrate benefits.5 As well, multiple reviews have reported no consistent evidence of benefit.6 Based on this evidence, RRTs appear to have no value. However, many practitioners dispute this conclusion. Two studies that examined RRT outcomes using other indicators identified both new benefits and new challenges. From interviews with administrators, attending physicians, hospitalists, staff nurses, and respiratory technicians, Benin and colleagues7 reported positive findings associated with RRTs that included increased morale and empowerment among nurses, reduced neglect of non-acutely ill patients during emergencies (reported by bedside nurses and housestaff), improved retention of nursing staff, and a positive learning experience for all involved. A second study identified staff perceptions (e.g., we should be able to manage this) as a reason for not activating the RRT when patients met call criteria.8 Thus, RRTs appear to have unrecognized benefits and unforeseen challenges that relate to behaviors of care providers in diverse health care systems.
Infection Control
Hand hygiene is a cornerstone of infection prevention. From a mechanistic perspective, the key to improving hand hygiene practices entails education about the need to comply with this practice, benefits in terms of personal protection, and easy access to hand hygiene products. However, despite decades of attempting to influence behavior, compliance remains low. Searching for a less obvious reason, two studies identified a solution. The first study identified improved compliance when the first person entering and exiting the room performed hand hygiene, which further improved if this individual was the attending physician.9 The authors attributed this improvement to the structure of medical education, i.e., learning from experts and role modeling. The second study identified improved compliance when posted signs were changed from "hand hygiene prevents you from catching disease" [personal consequence] to "hand hygiene prevents patients from catching diseases" [patient consequence]. The authors attributed the significant increase in compliance to greater concern regarding patient-focused threats vs personal threats.10 In their explanation, clinicians are frequently exposed to disease and, therefore, discount messages about personal threat or respond negatively to such messages because they do not want to acknowledge risk. Both studies reflect a search for the less than obvious when attempting to change behavior and success of this quest.
SEARCHING FOR HIDDEN EXPLANATIONS and SOLUTIONS
Hidden explanations only become obvious after they are identified. Thus, it becomes important to identify a means to discover less obvious explanations and solutions. Two approaches offer a possible means — focus groups and quality improvement (QI) initiatives. When using focus groups, stakeholders are asked to respond to open-ended questions with the goal of eliciting hidden reasons that motivate behavior. Done in a group format, they can take the form of staff meetings or be more formally scheduled. QI initiatives can be used to engage medical and nursing staff in projects to test possible ways to change behavior. They can also be used as a means to engage staff in the QI process if they are structured to include all stakeholders, including attending physicians, housestaff, residents, interns, and nursing staff.
CONCLUSION
As is well known, small-scale changes in initial conditions can produce massive and unpredictable changes in outcome and very similar conditions can produce very dissimilar outcomes. Complexity theory offers an explanation for this consequence by focusing on less obvious factors and behaviors that cause deviation from the expected goal. When what should work does not, it suggests that other explanations should be sought. As these often are behavioral in nature, engaging all members of the unit in a quest to seek ways to further improve practice as part of their daily routine is also helpful. n
REFERENCES
- Gleick J. Chaos: Making a New Science. (1987). London: Abacus.
- Morrison KRB. Research Methods in Education. Chapter One. What is complexity theory? http://cw.routledge.com/textbooks/9780415368780/A/ch1doc.asp. Accessed on September 14, 2012.
- Cooper HC, Geyer R. What can complexity do for diabetes management: Linking theory to practice. J Eval Clin Pract 2009; 15;761-765.
- Seymour CW, et al. Diurnal sedative changes during intensive care: Impact on liberation for mechanical ventilation. Crit Care Med 2012; 40. [Epub ahead of print.]
- MERIT study investigators. Introduction of the medical emergency team (MET) system a cluster-randomised controlled trial. Lancet 2005;365:2091-2097.
- Chan PS, et al. Rapid response teams: A systematic review and meta-analysis. Arch Intern Med 2010;170:18-26.
- Benin AL, et al. Defining impact of a rapid response team: Qualitative study with nurses, physicians, and hospital administrators. BMJ Qual Saf 2012;21:391-398.
- Shearer B, et al. What stops hospital clinical staff from following protocols? An analysis of the incidence and factors behind the failure of bedside clinical staff to activate the rapid response team in a multi-campus Australian metropolitan healthcare service. BMJ Qual Saf 2012;21:569-575.
- Haessler S, et al. Getting doctors to clean their hands: Lead the followers. BMJ Qual Saf 2012;21:499-502.
- Grant AM, Hofmann DA. It's not all about me: Motivating hand hygiene among health care professionals by focusing on patients. Psychol Sci 2011;22:1494-1499.
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