ORIGINAL ARTICLE
Healthcare Management Forum
Decision-making in healthcare as a complex
adaptive system
Craig Kuziemsky1
Abstract
Healthcare transformation requires a change in how the business of healthcare is done. Traditional decision-making approaches
based on stable and predictable systems are inappropriate in healthcare because of the complex nature of healthcare delivery. This
article reviews challenges to using traditional decision-making approaches in healthcare and how insight from Complex Adaptive
Systems (CAS) could support healthcare management. The article also provides a system model to guide decision-making in
healthcare as a CAS.
Introduction
Healthcare delivery is undergoing a transformation from care
in single settings and providers to care across multiple
providers and settings. These new approaches to care delivery
bring new complexities around how healthcare delivery needs
to be structured and managed. For example, managing patients
with chronic illness in a collaborative manner requires the
integration of processes of care delivery such as information
exchange and decision-making over time and space and across
providers of different skillsets and expertise. However, a
substantial gap exists between how care delivery should be
provided and how it is actually provided. Key elements of
healthcare delivery such as support for collaborative care delivery
and patient participatory medicine remain as challenges.1,2
A large part of the problem is that the healthcare delivery
system is not designed to support the above-mentioned
endeavours. Despite our best attempts at meaningful health-
care transformation, we continue to struggle with unintended
consequences from reform efforts.3,4 Examples of these
unintended consequences include a continued prevalence of
medical errors, despite dedicated efforts and initiatives to
prevent them.5 In fact, at times, the very solutions we
implement to solve specific issues become the basis for further
unanticipated problems. For example, the 1999 Institute of
Medicine Study To Err is Human brought attention to the
prevalence of medical errors.6 A follow-up Institute of Medi-
cine (IOM) study in 2001 advocated increased use of infor-
mation technology as a driver to healthcare reform, including
the reduction in medical errors.7 As a result, we saw more
Health Information Technology (HIT) strategies put in place to
reduce medical errors.8 However, studies began to emerge
suggesting HIT could in fact be causing further medical errors.
In an ironic turn, the very technologies we designed and
implemented to reduce classic errors led to a whole new
category: technology-induced errors.9
A fundamental question to ask is why do strategies and
interventions in healthcare so often fall short of desired
objectives and bring about unintended consequences? A pri-
mary reason is healthcare problem solving often focuses on
2016, Vol. 29(1) 4-7
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DOI: 10.1177/0840470415614842
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what is visible such as the task at hand while failing to
acknowledge the larger system within which healthcare
delivery exists. Yet it is often systems issues that must be
rectified when problem solving. Many healthcare problems are
an effect of the interactive and multi-dimensional nature of the
system and rarely can be reduced to one root cause or a single
factor.10
Changing the business of healthcare
A September 2013 report from the Health Council of Canada
stated that while clinical tasks are done well, the business of
healthcare reform needs to be done differently.11 A starting
point is to look at what we mean by the business of healthcare
reform. Healthcare delivery draws upon traditional management
disciplines such as accounting, management science, finance,
and organizational behaviour. However, the way in which
these disciplines inform decision-making in healthcare
requires rethinking because healthcare is a complex adaptive
system, meaning that we cannot study issues and problems in
terms of isolated entities. New approaches for the design and
delivery of healthcare services are needed. While healthcare
delivery can be improved through the better use of existing
resources and a fundamental change in how healthcare
services are organized and managed, it has been suggested
that a reason for a lack of change is both resistance within
the system and an inability to effectively understand how
change needs to occur.4 Healthcare decision-making and
planning can be broadly classified into two categories. One is
at the clinical level where decisions are made on treatment
options and therapies. The other is the healthcare management
level where resources and the delivery of services are planned.
In the latter category, healthcare has long drawn on classic
approaches from decision and management sciences to support
planning and decision-making. Yet these approaches have not
1
University of Ottawa, Ottawa, Ontario, Canada.
Corresponding author:
Craig Kuziemsky, University of Ottawa, Ottawa, Ontario, Canada.
E-mail: kuziemsky@telfer.uottawa.ca
Kuziemsky
led to meaningful change in healthcare delivery due to the
complex and interrelated nature of the healthcare system.12,13
Healthcare as a complex adaptive system
A Complex Adaptive System (CAS) is a system that displays
properties such as emergent behaviours, non-linear processes,
co-evolution, requisite variety, and simple rules.14,15 As a
system becomes more complex, the number of components and
interactions between each component increases both within the
system and between the system and its environment.16
Healthcare can be classified as a CAS because the various
elements such as care delivery, education, and policy consist of
a series of interacting parts that work in non-linear and
evolving ways. Collaborative care delivery is a specific
healthcare process that represents a CAS due to the fact there
are multiple participants separated by time and space, and the
rules of engagement for how they should work together may be
emerging and evolve over the course of time.
The CAS tenets described earlier such as emerging
behaviours or non-linearity are what necessitates new problem-
solving approaches in healthcare. Classic problem-solving
approaches to address the obvious or politically relevant
problem (eg, more beds to address Emergency Department
[ED] wait times) will not effectively solve complex problems,
as it addresses the visible issue while ignoring the underlying
complexity inherent within the issue. As HL Mencken quoted
in Sturmberg 2014 stated, ‘‘For every complex problem, there
is an answer that is clear, simple and wrong’’.17 The complexity
of healthcare delivery is what differentiates decision-making in
healthcare from other domains. While approaches such as
LEAN have provided process efficiency in the automotive and
manufacturing industries, its success lies in the ability to
decompose processes, identify issues, and then reassemble the
processes. Such functional decomposition cannot be used in a
CAS such as healthcare because of the degree of interrelated-
ness.18 Yet much of the decision-making and problem solving
in healthcare has been based on functional decomposition and
thus has produced the wrong answer to problems.
Applying CAS principles to support
healthcare management
Despite the complex nature of healthcare delivery and agreement
that healthcare is indeed a complex domain, some have argued
that use of CAS as a lens for healthcare management is simply
the new fad.16 A critique of much of the existing research on
CAS in healthcare is that it is descriptive in nature, does not
provide an explanation for how, or when, CAS should be used
to support management in healthcare, and may be nothing
more than a convenient metaphor that lacks methodological
rigor.19
Studies on CAS in healthcare have ranged from empirical to
rhetorical and that there is a lack of methodological guidance
for using CAS to inform decision-making. Applying CAS to
healthcare requires a balance between understanding complexity
and designing formal approaches to represent it. But this is
5
not an easy task, given that healthcare delivery is defined
by multiple interacting and interdependent parts, limited
stability, and an inability to use basic control levers such as
‘‘cause and effect’’ or ‘‘command and control.’’16
There are good examples of how CAS has provided valuable
insight on why traditional decision science approaches do not
work in healthcare. While it is common, and perhaps even
rational, to accept the lowest cost alternative for problem
solving, using that strategy in healthcare can be problematic for
a number of reasons. Early examples of CAS and healthcare
finance showed how treatments such as laparoscopic surgery,
while more costly than traditional surgery, offers several
benefits such as shorter recovery time and reduced risk of post-
operative complications.20 Thus, increased costs upfront
should be offset by savings downstream. Common funding
models such as fee for service do not provide incentive for
coordinated or collaborative care delivery, as it focuses on
individual episodes of care. Bundled payment models can
enable more efficient care delivery by providing incentive for
better productivity with the same amount of resources.13
Insight from CAS has also provided insight on how healthcare
services are planned and delivered. Typical responses to issues
such as wait times in the ED or lack of acute care beds in a
hospital unit is to deal with the visible variable, such as adding
more clinical staff to the ED or more beds in the unit. While a
solution to the visible problem (eg, adding more beds and
imposing wait time limits) may fix the problem in the moment,
the problem, and possibly other unintended consequences, will
arise again in the near future. Further, due to the evolving
complexity of healthcare systems, the remerging problem may
even be worse than before.21,22
Towards a framework for CAS-supported
decision-making in healthcare
A challenge with the current decision-making paradigm in
healthcare is that decisions, be they financial, human resource,
or service delivery, are typically made separate from the
context of how healthcare delivery should be provided. While
the common goals of healthcare delivery is collaborative and
continuous care delivery based on providing value for the
patient, we continue to make management decisions based on
isolated concepts or goals, such as access to services or wait
times for a procedure. The results of such decisions are
unintended consequences.
In developing decision science approaches for understand-
ing healthcare as a CAS, there are three key factors. First is that
healthcare systems have limited stability and developing
models with simplistic ‘‘cause and effect’’ analyses or using
traditional scientific management or reductionist decision-
making methods will not work.12,23 Second, traditional levers
that guide linear systems such as supply and demand or quality/
cost cannot be used for systems control. Third, metrics used to
evaluate the system need to be at the system level and not
developed to fit a particular problem context (eg, at the level of
6 Healthcare Management Forum
Figure 1. System model to support decision-making in healthcare as a complex adaptive system
a single process or decision) while ignoring the various
interacting components of a CAS.
Despite these challenges, we can integrate decision science
approaches and CAS. Domains outside healthcare have used
Agent-Based Modelling (ABM) and simulation in combination
with CAS to represent complex scenarios within manufacturing
and logistics settings, including representation of emerging
behaviours.24 However, a key assumption in their model is that
the emerging behaviours can be identified and incorporated
into the model.24 To achieve that, a bottom-up approach needs
to be used so that objectives, interconnections, and emergent
behaviour caused by self-organization can be identified. Once
we have followed the above-mentioned steps, we are then able
to design an ABM that models a CAS as it pursues a global
outcome.
Figure 1 shows a system model that is an adaption of the
above-mentioned approach in the context of healthcare
decision-making and delivery. The system model has two parts:
system understanding and system modelling. System under-
standing is where we analyze and unpack a CAS to identify its
parts and relationships. The first step is the establishment of a
global outcome that will guide the system. For example, Porter
has argued that high value for patients needs to be the over-
arching goal of the healthcare system.25 From the establishment
of a global outcome comes the identification of the processes
that must be in place to achieve the outcome and most important,
the identification of the concepts and relationships within
the processes. The concepts and relations represent the
behavioural rules of engagement of the system, including
identification of emerging properties and non-linear system
elements. If we use collaborative care delivery as an
example process, the concepts would include care providers,
locations, and information flows, while the relationships
would identify the ‘‘rules of engagement’’ for how concepts
interact both within a concept ‘‘bundle’’ as well as between
bundles (eg, across different care settings).
The behavioural rules that are identified form the basis for
system modelling as they provide the insight for modelling
concepts and identifying manipulation of them within the
model. They also provide insight on the extent of complexity as
the more concept-relation ‘‘bundles’’ we assemble in a model,
the greater the number of interrelations within the model, and
the greater the degree of complexity. Finally, a CAS model
needs to be looked at from an upstream–downstream continuum.
The behavioural rules of a system will not be static but rather
will evolve over time and a model will need to be adjusted
accordingly.
Discussion
While it is widely acknowledged that healthcare is a complex
domain and thus CAS should inform how healthcare delivery is
devised and managed, to date we still largely rely on classic
decision-making approaches, which have led to poor outcomes
and unintended consequences from systems reform efforts.
An acknowledged shortcoming in much of the existing
research is that it is descriptive in nature without guidance on
how to study healthcare delivery as a CAS. This article took
steps to addressing that shortcoming by providing a background
on healthcare as a CAS and developing a system model to
guide formal decision modelling approaches in complex
healthcare settings. The key contribution from the system
model is that we must have system understanding of how the
Kuziemsky
system works with respect to concepts and the relationships
between them before we can model or use formal decision
science approaches. Healthcare processes have varying
degrees of complexity. System understanding should be done
as a precursor to all decision-making to understand the inter-
and intra-complexities of the processes, no matter how large
or small, to mitigate unintended consequences.
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