Systems Thinking in Healthcare and Cultural Shift By Dr. Singh

Any attempt to change healthcare and the culture of providers, patients or employees involved in healthcare must involve a systems thinking approach. An appreciation that one is dealing with a complex human social, financial and cultural web of interactions. Any pressure at one point may cause unintended consequences at another. The system may compensate for an individual's efforts to transform it in such a manner that it not only neutralizes the original action or intent but also counteracts and produces an entirely opposite effect.

Cures to any healthcare issues are seldom clear-cut or obvious and any attempt to fix things in a simple manner often turns out to be simplistic. A deep understanding of the interactions is involved especially when one is dealing with population medicine or at a network level.

We have seen instances where seasoned managed care providers were sent to a busy office to help improve utilization and improve quality. When unnecessary referrals were curtailed, the specialists got upset and saw this as a threat. They rallied patients against the primary care provider, filed complaints at the HMO plan level, used abusive language against him and threatened him with lawsuits. While this happened, the patients who were aggrieved at what they saw as denial of care and fall in quality and choice, started calling CMS with complaints and leaving the primary care physician in droves. At the same time, the staff at the primary physician's office rebelled at his high-handedness and review of inappropriate referrals as unreasonable and against the culture of that office. Thus, an excellent provider ended up achieving the exact opposite of what he had intended when he attempted to change the culture of healthcare in that county.

In retrospect, the provider should have spent more time in developing a deeper engagement with the patients, explaining to them the approach to excellent healthcare, allaying their fears and concerns, spending more time with them and building relationships. A systems approach is holistic and not random or arbitrary. It looks at the complex network of relationships, positions and interests of various specialists, vendors and patients. It also creates a shared vision and team learning. Thus, the provider becomes a partner in the patients' care, co-managing with them, open to their suggestions while sharing his expertise and knowledge, and having conversations and discussions that are open- ended. He is no longer seen as a threat to the patients' wellbeing; on the contrary, a bond of trust and engagement is developed between the provider and the patient.

Also, the provider should have had a dialog with the specialists and reviewed his concerns about the quality of care, always keeping the patient's quality of care at the center of the discussion and focusing on a decision process that is evidence-based, objective and mutually shared. As soon as subjectivity is removed, waste of resources is reviewed gently and further expectations and lines of communication created, there is a shift in perspective among the specialists. To be sure, the specialists have an interest in continuing the status quo since they are primarily paid on a fee-for-service basis. This can be allayed by creating win-win situations where the primary develops long-term relationships with the specialist and brings in the leverage of volume or better engagement with patients.

At the same time, the primary should have communicated with his office staff the nature of change he was trying to accomplish, making them understand the reason for the shift and how it would improve quality and outcomes. Once the nature of communication and relationships is changed, any change is not a surprise and is understood, if not always welcome.

We see similar situations if a provider is asked to be a physician adviser (PA) at a hospital. While administration expects the PA to improve length of stay, reduce the number of queries or unsigned Medicare forms or use resources appropriately, it does not wish to push too hard for fear of losing the attending physicians from admitting patients to the facility. If the PA contacts the attending physicians about the need to complete their records, and the attending is upset and complains to the administration, the usual response is for administration to back down leaving the PA confused and upset. Thus, no fundamental shift in culture at the hospital is effected and only superficial changes are accomplished. A systemic change would entail administration and the PA working as a team, creating clear expectations among admitting providers, sharing report cards and performance data transparently with all hospital staff and creating objective means to evaluate the standard of care being practiced in the hospital. Such an approach would involve intense and constant dialogue among physicians and administration along with the PA, and would create a common platform with a goal to improve outcomes and patient care in the facility that is immediately measurable and achievable.

A systems approach takes the blame-game away or the opportunity to be victims, since we are neither for nor against the system. We are an integral part of the system. Once we realize that, the rest becomes easy. The sight turns inward and personal mastery and responsibility becomes critical. With such a sensibility, a true leverage can be found which truly causes a change in the system that may be healthier, more wholesome and healing to all the participants in the web of healthcare.

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