Research Project Your project must be submited as a Word! document (docx, doe). Your proc wile indidually graded by your insteuctor at take upto five to seven days grate, Besure that each of our ies contains the following information: + Yourstuden: ID ournber + Theesam number + Your emailaddeess Tosubmityour graded projec, follow these steps + Login co your student poral '+ Click on Take Exam next othe lesson you'te working on + Find he exam number for your project atthe top ofthe Projeet Upload page + Fall the Instructions proved to complete your exam, Be sureto keep a backup copy of any ile you submit tothe school Background eathcate organizations ae constantly improving the quality ofthe cate pases have cometo expect. They at to-achieequity goa by ng the cos of healheare. Limproving the individual experience of are and the health of the popalation, while aloe Procedures For iis project complet only one ofthe fllowing projects, Be sue to complete both Parts aid forthe project you've chosen, and then submit ‘eto your instructor for grading ‘Project Choice 1: Dynamic Complexity “Part a Resse the tstuetons forthe exercise of Chapter in your tex Describe how dynamic complexity applies to he xanple ofthe exercise, | Hfyou need help refer to your textbook and alsa tothe We resourees sed in your texto, “ | Part Review Exercise 3 fom the practice lab section at the back your text, Read he ease study presented and then answer questions 2 an Project Choice 2: Errors art A. Review the exercise of Chapter 13 in your text Review the ease scenario presented andthe Ist of erors. Create a table withthe headings 1egory/Typeof Failure” and “Ero ike the table shown, The, from the list of posible errors, Ist each error by the eype. Ifyou need help refer toyourtexthook and use the Web resources stein your textbook, ‘Part B. Review txercse 11 fom the practice lab section atthe back ol your text, Head the Instructions presented and hen anser FMEA, Worksheet, Part land?Printed by: ladiel2S@gmail.com. Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publisher's prior permission. Violators will be prosecuted. SS CHARACTERISTICS OF COMPLEX SYSTEMS 3 Learning Objectives After completing this chapter, you should he able © cus ane ay problems, + recognize different types of systems and the role of systeyp ns penpective can explain recurrent onganigational + describe system characteristics that contribute to dynamic complexity, and © eaplain the influence of dynamic complexity om managerial devision making, begin to ee recurring problems>-sometins in an inva organic and sometimes across theenfire fick, Problems thought to be 0 ‘one manager may come back at a later time for a different manager. The ‘ce president of nursing a lang hospital may centralize and cfs-rain nurse cxlucator positions to meet necessary budget cts for the years year later, the new vice president of nursing atthe sane hospital ake unit-based nurse educator postions adres the unmet sinical ore hires. Consider the following situation (Gicurgopoulos and Mann 1962, 549-31) f Thethosptal faces a number of problems concerning the nursing staff... one ‘major problems... attracting and retaining a sufficient professional nursing taf, especially nn-supervisory nursing staf... The problem lies inthe fat thatthe numberof professional nurses being trained in nursing schools is much too low to meet an ever increasing demand for professional nurses by hospitals and other sources... Belng understaffed, hospitals often assign tothe professional nurse a ather heavy workload that is not seen as norma or reasonable by many nurses -+-Another important problem ...iyolves the composition ofthe total cursing staf the question of optimum balance inthe proportions of taf members who ate registered nurses, practical nurses, and ades A people accumulate years of expefience in the healtheare field, th od on nceds ofits new Printed by: ladiel25@gmail.com. Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publisher's prior permission. Violators will be prosecuted.Applying Qi Although this situation may appear to address a manager's current challenges with nursing shortages, the exceept was taken from the book The Community General Hospital, which was published in 1962! During. the more than 50 years since that book was written, health services organizations seem to have rade little headway in issues related to workforce planning and management Nursing shortages, for example, appeared and disappeared in waves the 1960s, 1970s, 1980s, early 1990s, and again in the early slecades of the twenty-first 66 percent a shortage of nurses, 50 percent shortages of min practitioners an physician assistants, and 43 percent a shortage of alied healtheate professionals (AMIN Healtheare 2013). ‘The projected supply of healthcare warkers will not meet the demand associated with future population growth sind aging ( Compounding this problem, the Alfordable Care Act of the already-strained healthcare delivery system with newly insured patients Individuals are facing longer wait tines to sce physicians difficulties accessing specialty care, reduced appointment duration, inadequate services, and overall frustration as a result of workforce shortages. Being short-stalfed requires careful management of antyanization’s healthcare resources. For example, the lack of expericneedl registered murses is easing acute care fxilities, such as the Rapid City Regional Hospital in South Dakota, 10 adjust the numbe of available beds evéry day on the basis of the numbeF of nurses available cach shift (Grant 2016). Regardless of how healthcare systems/mmight change in the future, constant remains. Organizations stil ide! people on the front lines of heaheare delivery—physiians, nurse, advance pratitonens, an lied _boalth profesional, As heslheare delivery ystems becomte more complet, rganizations without a suflcient umber of siled and dedicated workers will fd it difficult to achieve quality goals. < Why do budget problems and workforce shortages remain nagying cs fr health services managers? The reasons lic inthe complex nature af hnealtheare, healthcare‘organizations, and the healthcare field. In healthcare, asin other sectors, "systems thinking is needed more than ever because we are being averwhelmed with complexity” (Senge 1990, 69), Today, one may rephrase Senge’s 1990 comment to read, “Systems thinking is imperative in complex Incalth services organizations because they are much more complex than they having large were in 1990. ‘number ofvari- ‘bles that imeract In healthcare systems, the term complex refers Wwitheachotherin large number of variables that innumerabie.and unpredictable ways. Considering the multiple determi Shen rperi ; henson mbt ceupenentscpanis beat serves o teract with each other Printed by: ladiel2S@gmail.com. Printing is for personal, private use only, No part of this book may be reproduced or transmitted without publisher's prior permission. Violators will be prosecutedCharacteris Systems the posible iterations ae mind bing. Heath an heh service tmyanzaos ar chactezed by tars wich “ean an fet arse aml wher he ets eerie of inerventons et tn (Senge 2006, 71), This charaterbac represent anther pe comple two asdyeamic complexity. Inthe reseee of dynamic complerin the dane ‘same action has dramatically different effects in the short run and the long complexity fun. an action hs one se comseucnces land avery erent cet SBE Prorat rll marth pein aieay, cly produce nonobvious consequences” (Senge 2006. 71), and where the ‘When fice with dani cmplesi manager i cet steentioms seem ine that ter the findamental ichavior ofthe system ha causing dhe rable, SEEM, thetic, the sola only temporary. Ao seen ithe uiing shortage Genesee a) cxample, although interventions may ofler temporary relief, the problems resurface again and again, ‘The stating point for altering fundamental system Beiavior is always a mystery. Every system improvement we now know as bing successful started ‘out as 3 puzzle in which the variables that mattered ere unknown and the cause -and- como Tw Health Enforcement ‘Corrections tant cists Gece Emsoes of the larger system, Macrosystems are the organizations providing health seevices, such as hospitals, nursing homes, community health clinics, and emergency amedical services, ‘These macrusystems are “connected via individuals and reams, regulations and rules, al technology" (Johnson, Miller, and Horowitz 2008, 3), The many health organization mergers, partncrabps, and afilations following passage of the 2010 Affordable Care Act have ereated a number ‘of regional healthcare delivery systems comprising, multiple macrosestems (PricewaterhouseCoopers 2016 In each macrosystem are innumerable microsystems, Microsystems, are made up of the "people, machines, and data at the level of direct patient care (the treatment team within the hospital or the physician office practice for example)” (Sehyve 2005, 2). Just like the parts of a macrosystem, the \@gmail.com, Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publisher's prior permission, Violators will be prosecuted.Chapter 3: Characteristics of Com Systems parts of a microxys ineract with each ener vo fom an interdepende ‘whole, During research into the rontine clinical teams in various healthcare settings, Goditey, Nebon, at Bataklen (2004, 5) coined the phrase clinical smicrosystem to describe "a small group of people who work together on a Iar basis wo pronide care to disercte subpopulations of patents.” These ca mierosssts are “the place where patent, familie, and are 1 rect... They are living unite that change aver ime and always havea patient «person with a alth ced) at their center” (Micronstem Academy 2016), An example of a microsstem (or clinical microsstem, a» sine would call itis the team of people working inthe cardiac catheterization la during. patients” (Godby, 2 coronary angiography procedure. This tcam ofien consists ofa cardiologist, Nelson, and ore nurses monitoring the patient's vital signs, a crab mupse and a ®atalden 2004, 5) ‘circulating nurse, an X-ray technician, and one or more nurses of cardiovascular invasive specialists assisting with recording and other duties) These people have diferent eaponsiblites, yt the augiography procedité cannot yet dane ‘sthout cach of them working interactively with other fram members Asystem reflects the whole, and “systems thinking is 4 view of systems thinking reality that emphasizes the relationships and interactions of cach part of the 72 view of reality the other parts” (McLawblin and Olson 2012, 39), Rather EEEMBRESeS than considering each part ofthe system t@ be unigue and separate, systems, “andinraions thinking acknowledges he infinite ame Fungi par an ehc way in Lea which the parts interact, 5 wellas the nature of the interactions. Recognizing {h® system tall tw ech part functions within the stem ss whole and hon an — actions affect all ther aspeesb.of the apstem i ital to unk ‘Olson 201,39) of systems thinking. ~., i “The importance of developing a lear unskertanding Bf the parts of system and how they interact i illustrated by the ancient parable fom India about the blind men and the elephant, "There are many versions of this storys hosweser,the common denominator that each mart els a derent part uf he animal, andonly that part, to learn what an elephant is. When the men compare their andértandings ofan elephant, they ate in complete disagreement parablé demonstrates what can happen when people have distinctly different perceptions about the same sytem, In these situations, demain relationships benveen the elements and understanding how they are connected is more challenging. careto discrete Dynamic Complexity Several system characteristics comity complexity (Sterman 2000). Five characteristics, predominant in healtheare and health 1 the presence of dy Printed by: ladiel25@gmail.com. Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publisher's prior permission. Violators will be prosecuted.y Mana A Systems Ap) services organizations, are described in this section: chany dependency, sight coupling, and nonlinearity (see exhibit 3 oll, history Change Systems are dyn: rates and scales withi occurs at dierent care. Consider ati constantly changing. Chay and among systems, especially in heal three levels of this characteristic of dynamic complexity in health services First, the human body changes continuously. ‘This fact meas that key inputs (patients with a clinical problem) to and outputs (patients”stanus after clinical intervertion) of healtheare systems are moving targets. Second, the ‘organizational comtexts in which health services are carried out are dynamic in nature, Employees moe i research provides an ongoing stream of new evidence, and technological advances offer new clinical and management approaches. Third, the communities and political environments in which we live and in which healthcare organizations operate change—that is, the environment changes with economic cycles, political ideologies, and cleetion eyeles. Unlike orher complex systems, such as av the level of change and the degrce of uncertainty that characterizes man, the problems faced by practitioners make healthcare a particuladly hazard complex system (Runciman! Merry, and Walton 2007). {Implications for Healthcare Managers, From the day a petion is born to the day she dies, sc isin a constant state of change, gréwing and developing physiologically and emotionally. Ne ww SS exuiern3.2 System = Charactersties 2” Eee Contributing ae are to Dynamic are moving target Complexity Nonlinearity Trade-offs. tte s unrelated compromises tothe euse, rst be made to achieve goals Tighe coupling l ‘System parts have prompt History dependency ‘aed aor impact on The past influences ‘one another the present Printed by: ladiel2S@gmail.com. Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publisher's prior permission. Violators will be prosecutedplex Systems fhuman systems are alike or precisely predictable in thir esponses toa medical intervention, As a result, functions that may seem straightforward in other industries, such a proxtuct standardization, become more ecu for healthcare ‘managers. For example, the practice of using a standardized list of drug. names and brands (i..3 hospital formulary) to reduce medication expenses is accepted practice. However, when the dynamic nature of patient physiology is introduce the manager recognizes that in addition to the question, “What are the set oF «drug names and brands that will be most custeflective?” he also needs 0 ask, “How should the approved drugs be selected, and what ae the consequences to patients?” To aid in grasping the subtle bur important nuances involved in lividualizing treatment plans, consider the process of rying’an,a pair of blue jeans. People have their own favorite brand of blue jeans tit ft well even though another brand may be advertised as having a similar size ancl style. The hospital formulary essentially dictates to doctof®'that the patient may buy only slim-eut size 10 jeans and mor relaxed-ft size 10 jeans (Kelly and Pestotnik 1998), Studies on variations in genetic makeup and the nature of genc-environment interactions promise to shed light in yet unimaginable ways on why certain treatments of medications may work better ki person than another, The emerging ficld of pharmacogenomics may permit. drug seleetion in the future to be based on an individual's unique genetic “a blotecino taakep.alsing the prdigan ej bea sence npn mage aan pharmacotherapeuties (Medline Plis and Merriam-Webster 2016). Preémptive techniques of med: medicine—"removing the initial molecular evemt—precluding the possibilty ne, pharmaco: of thar thing even happening” (Culliton 2006, W96)—willfkely alter the 98% and genomics 2 and isconcerned Fundamental role of healtfcare delivery organizations in the fa castes : rug therapies, Trade-offs tocompensate ‘The ned undersand the nature of wale tay sem uanecenary or tara managers ght to weigh pros versus cons OF opportunities vrais risks as Sep aaa they cander organizational decision options. Trade-offs may be scen as an responses toa “ accept atribute of management situafions, However, an understanding of single therapeutic dynamic complexity fosters an appreciation for the system consequences af imen” Medtine local management trade-off decisions. “Time delays in feedback channels mean Webster 2016) the long-run respon intervention i often diferent its short-run response. High leverage polices olten cause worse-before-better Ibchavior, while low leverage policies often ge befire the problem grows worse” (Stern. pharmaco- therapeutics rate transitory improvement “the sady ofthe therapeutic uses and effects of drugs” (Medtine {Implications for Healthcare Managers. Plus and Metiam- Classic examples of low-leverage policies are found in the studies of attempts Webster 2016), to reduce health syste ng the length of hospital stays, One ‘costs by real Printed by: ladiel25@gmail.com. Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publisher's prior permission. Violators will be prosecutedying Quality study reported tha healthy newboons diacharged fromthe henpital 48 hour, for sooner after delivery, saving the costs of longer say, had a significantly higher Fisk or readmission, nvrbiiy, and niconatal mortality (Farha an Raja 2011). Another analysis found that hospitals with shorter lengths of stay were more likely to discharge Medicare patients to nursing fltes and inpatient schabiltation facies, suggesting tha some hospitals may be using post acute care a substitute tor inpatient care (Sacks tal, 2016 1s manager in thes cases viewed the healthcare sytem a microystem (ex. the hospital department where patients received care) ar the hospital _xminitrator viewed t 3 macrexptem (this hoxptal), the interventions chosen to reduce system cont might have been viewed as succes, However, i one views the healthcare syst a8 4 micganytem that aeute phase of care (eg. the department where patient care occurred, the hospital but ako the downstream providers (eet hana, emergency services, clinic services, nursing and rehabilitation facilities) and takes account onthe relationships among all providers influence patent outcomes, the longer-term behavir of the syste can be abnerved, From a systems perspective, the acute care manager is csponsible for the acute care unit or hospital and also forthe effect thine lasaldisions have onthe rest of the system gfwhich the managers component f apart. ‘This perspective dacs not meatt that the manager of a hospital department or the hospital administrator should nor strive vo reduce hospital ents. tk docs mean that managers fifaincial officers, CEOs, and poligyiakers shoul e aware ‘oF how deciéans made and implemented in tele domains of respo affect other parts ofthe healthcare sytem pusitvely and negatively: When 2 negative impact on anonher part of the sytem i aniipated, the manager shauld be proactive in the short term-fo ‘Kelp minimize the negative effects and preserve positive patient outconats, With the emergence of accountable ‘re organizations, managers myst learn how to optimize the macrosystems ef telsheare delivery while improving the microystems ther common trade of challenges fr healthcare managers surround the differences between expense an investment decishons within organizations and departments. The long-term effeer ofa managers short-term deci ‘ay not be felt by another component in the macronystem, but perhaps i will surfice in the fitre in the manager's nvn department or organization. For example, docs the manager sacrifice capital improvements to fund contract sworn in expentinures ng staff development activities may meet short-term financial priorities, these efforts ill inthe category of law-leverage policies hecanse the problems ‘of facie aging staff shortages, and the need fora competent workforce will surly be fice by the manager inthe future, Without an appreciation of syste Jules not only the 1¢ shore term? Des managers reduce state: to lower current expenses? Although chovning contract workers and red Printed by: ladiel25@gmail.com. Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publisher's prior permission. Violators will be prosecuted.13: Charae 5 of Complex Systems consequences, one manager may be rewarded for short-term “success” with a promotion, while his successor inherits the longer-term problem. In the torr sample, the organization may be willing to trade the rare adverse medication event for dollar savings realized from product standardization. However, this decision could compromise patient outcomes and unintentionally contribute to polarizauon and conilct between clinicians and managers. History Dependency Syates are history dependent, In other words, what has happened inthe past influences what fs happening right now, "We have always done i this seay" methods of healthcare livery ae offen perpetiatd despite pesca supported Knowicdge that points tw more elec practice, Some ofthese dated practices include (Mclnyk 2016), + recording vital signs every four hours at night on sfable patients, despite thei uced for undiseupte slep for recovery, = + removing urinary catheters only on 4 physician's orders, though the removal of catheters according to 4 nurse driven protocel is efficient and may prevent urinary tractfiections; and + continuing the practice of 12-hae nursing shifs, when research indicate adverse outcopics for nurses and paticnts Some actions taken in he past are reversible, while some canon be esi overturned, For example, a strategic cision by’ hospital tu convert some inpatient beds to skilled nursing beds could be difficult te reverse when more inpaticn bos are needed Implications for Healthcare Managers ¢ patient nd the onganization, Because ior dgfendency mayen of advasifements in the care of chronic illnesses, rather than succumb to complications of une illness, elderly adults are often under treatment for several chronic illnesses concurrently, Persons with cystic fbosis or barn with congenital heart defects now enjoy aie expectancy into adulthouxk; previously these conditions usualy were tal in childhood. Unhealthy b cxcesive alcobol, drugs, oF cigaretes, even when discontinued, may have long Laing health consequences. Undertauing 3 patents history i important not ‘only for clinical providers but also for health services manager. For exampl 4 patient's health history influences resources requiee for his care paticnt being treated for asthma, hypertension, and diabetes requ labor intensive care when having his gallbladder removed than an otherwise Printed by; ladiel25@gmail.com. Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publisher's prior permission. Violators will be prosecuted.A Systems Approach healthy athlete undergoing the same surgery. [n recognition ofthese dierences, managers must be willing to make nurse staffing adjustments for patient acuity (Huston 2013). “The manager must realize not only how past events have shaped current events but also how past decision-making strategies and directions may influ her ability to successfully achieve current and future goals. Using the nursing issue example, ithe organization has historically rewarded managers for n budgetary expectations, a significant increase in nurse salary costs ‘caring for sicker patients without corresponding increases in, patient care revenue might be difficult to sell given the organization's history cof rewards and decision making. Tight Coupling tightly coupled A system is characterized as tightly coupled when its “parts exhibit relatively time-dependent, invariant and inflexible eonnections with litle stack” (Scott 2003, 358). An example iyan elegantly gaftet configuration of dominoes that the parts “exibit feisvelyime. can be set in mosion by 4 push eoaeris pice. Iva tightly coupled sytem, dependent, it can be difficult for people to recognize and correct mistakes to prevent an Imari. undesirable etsome, Tight eiuping i alo present when “the actors in the Connections with s¥stem interact strongly with one another” (Sterman 2000, 22). Wil sack (Set 2003, 358) Implications for Healthcare Managers Organizations in fidustries outside of health services that are most commonly iuentfed a tightly coupled include nucleae power plans and ara carters (Dlogace and Spath 2011), Healtheare organizations ofien demonstrate loosely couple s6cil structures such as department, divisions, andl professional groups, yetthe tasks carried by the microsystemin the organizations are often tightly _svipld, For example, cardiologist ures, and Xray technicians belong 4 “Separate, distinct, loosely coupled provessional groups and departments within the structure of the organization. Yet, when these people come together asa tnirosystem in the cardia eathcterzation lab, the tasks they perform while ing a angiegram procedure ate tightly couple. In this ightly coupled ct futient entity mistake or the administration of wrong ‘medication can quickly lead to disastrous consequences hecause the link between actions and outcomes is more direct. ‘Numerous interactions among and between peuple, processes, and departments individual organizations and interactions among services along jinaum of eae require managers to be attentive to the concept of 1. lesigning, and instiutionalizing tools that promote a, ourdination, and strengthened {relationships among players ar required competencies for contemporary health services managers. Checklists that detail proper patient management practice, cond Printed by: ladiel25@gmail.com. Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publisher's prior permission. Violators will be prosecuted.Chapter 3: Ch s of Complex Systems bbar-cadeu patient identification mechanisms, and standardized bandos between caregivers ar just three of the many tools used to improve the quality of patient care in tightly coupled systenms (Dlugacz and Spath 2011). Nonlinearity The term nonlinear, as it refers to a system characteristic, means that the sontnear “effect is rarely proportional to the cause” (Sterman 2000, 22). Because the ‘elating toa system in which parts in nonlinear systems may interact in numerous ways, these interactions een often follow “unexpected sequences that are not visible or not immediately, prepartional othe comprehensible” (Seott 2003, 358). fn a nonlincar system, small devatiny cause” (Sterman may have huge, unpredictable, and irregular few 2000,22) Implications for Healthcare Managers Here san example ofthe nonlinear nature of healthcare spats. A respitatory therapist just starting che alicmoon shifts the object of an outburst of anger from a patient's family. The therapist relates the encounter to a colleague at the nurse's station: “AULT dil was say, Hello"! Thi situation may’ bin snind the old idiom “the straw that broke the camels back.~ In ic, this isan securate desertion of the encounter. “The patient and her family had accumifned a sequence of unsatsfcto experiences during the hospital stay; sy allt ook was one more encounter trigger theiranger. though this timewas the fist thatthe afiernoomn therapist hha met the Family his was the fast in a series of interactions herween the patient and the healthcare system that caused this funy geet IP patient complains to the manager bout this therapist, what should the mat Without an appreciation fr the nonlinear nature of ystems, the mara bbe tempted to discipline the employee. However, if the mianager docs have such an appresiagjn, she may tey wo investigate the dequence of events that culminated ite family's dissatisfaction. Although each event was relatively harmless wien considered individually when linked together with the family’s overall experiences, they contributed to an gnacceptable encounter. From this invesiation, the manager may densify greas that ean be improved to enhance the patients overall experince with the care delivery process. Another example of the nonlinear narare of systems may’ be seen in strategies used to reduce personnel expense in healthcare organizations. Because personel expenses make up such a large percentage of operating budgets, changing the staff mis—that i, reducing the number of profesional stall (e.g. registred nurses, medial technologists, pharmacigs) and increasing the proportion of asstive personnel (e.g. nue aides, laboratory assistants, pharmacy technicians)—is 3 Whew this invervention is studied fram a systems perspective, however, the re scaqcnes of activities al thc interclationships re more reais seen, The Printed by: ladiel25@gmail.com. Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publisher's prior permission. Violators will be prosecuted,a a Quality Management in Healthcare: A Systems Approach planned consequences of this cost-cutting strategy in one organization included an increase in the overall employee turnover rate because of the frequeney with which entry-level, assistive personnel left thei jobs, Becau cost-cutting strategy was used by managers across different types of professions and departments, the stress and cost of continuously recruiting, hiring, and training new employees more than offset the savings hoped! for from lowering the average hourly wage. When viewed from one department's point of view, the cost-reduction strategy may appear to be reasonable; however, when the compounding effect of this cost-cutting strategy is viewed across the entire organization, the strategy designed ty reduce custs actuallt undermines the ‘organization's ability to do so (Kelly 1999) ‘Summary Like “quality” “stern” can carry a ypriery of connotations, In this text, a system Feirs t a set of connected par that fi together to achieve a purpose “The connected parts may be a health system that contains many organizations (3 megasystenn), an organization (a maeroxystem), or 3 stall unt or clinical team in an onganization (a mirosystem ystems thinking, a management discipline, acknowledges the large umber of parts in system, che infinite number of ways in which the parts interact, and the dture of the interactions. The healthcare system, whether the term refers r0.a single patient care unit a faility OF all providers ina state of throughout the nation, is dynamically complex, The five syatem characteristics contributing to the presence of dynamic edinplesity are change, history dependency, tight coupling, and nonlinearity “Exercise 3.1 7 Objective: To practice identifi dynamic complet Instructions: Deseribe how the following example illustrates one or more of the system cha teristics that conteibute to dynamic compleaity Example: Mediesl Associates is for-profit medieal group of 40 physicians that ‘operates two facilities and offers services in several medical specialties, including cardiology; car, nose, and throat; fimily medicine; gastroenterology: general surgery; pediatrics; and obstetrics and gynecology. Medical Associates is open from 8:00 am until 6:00 pm, Plans are being. developed te exten its hours to 9-00 pin two days a week. For several years, ‘Medical Associates discounted its listed fees by 3 percent to 5 pereent for its Printed by: ladiel25@gmail.com. Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publisher's prior permission. Violators will be prosecuted.Chapter 3: Characteristics of Complex Systems ‘managed care contracts, but a few years ago, it had 1 aceept larger dis to remain in the networks of health plans. Lower reimbursements led Medical Associates to changes stag fam eying Solely on eitered nurses (94s) tohiingmekaassstans (A) as wel Cute. physicians assignedto prinary care service ar assigned on Rr MALO asi with patience. Physics assigned to surgery ae asigned one RN forever two physicians. As RNS reir or reassign they have been replace with MAS, On ive recent occasions when an assigned ta senor physician resigned, he senior physkian demandes tha he AN signed toa uno physiion be reassigned to him and that anew MAbe hed {ofthe vacancy wih he junior physician Tis aha system of swing has ‘ased internal ume between the senior and junior physcan and ha fade subsequent resignation of vo RNs who didnot wart tobe ressiged...Cnfsian x around staff reporting lalionships and who hasthe autor Wo changefob assignments. (Seidel and Lewis 2024, 215). Companion Readings Anderwn, A, 2014, “The Impact of he Atfodable Cate Act othe Health Care Warkioce The Heritage Font. ued March 18 or ena 0 research/repots/2014/08/nginpt- ahealordble-carese-00h health-care-workforce.- = - Caton D.1 2008, “Sena Mlb: A Convention wth Celera Schlag Karl E, Weick" Herat Buines Revie (41 84-90. Lipt A 2012. Uindertaning Hea Carey Compe Sythe Foundation foe Unintended Consesunes* Journal ofthe Amerie Metical Azciaton CN) Malin, SE. Mucthing, G, Moore, 1H. Was {$Ofinical Microsystems, Part: The Builing Blocks of Health Sestemns" Te Joint Commission Journal ou Qualitygnd Patient Safety. Published lu. hep: // renpternong/pceteit/aplals/2014 /05 /4_ ality safety 01 tine pM [Now England Complex System Invtitute. 2016, “About Complex Systems." Accessed November 8. wwwnnecsiedu/guide. Peters, D.H. 2014. “The Applisation of Systems Thinking in Heablh; Whe Use Stems “Thinking?” Health Research Policy and Stems, Publishes August, Htps:// health: policy sstemsbinmedkentel cen /articles/W0.1186/147R AS05123] Senge, PM. 1990, “The Leader's New Work: Burkling Learning Onganizations.” Sloaw Management Review (Fall): 149-68. Printed by: ladiel25@gmail.com. Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publisher's prior permission. Violators will be prosecuted,Applying Quality Management in Healthcare: A Systems Approach Web Resources Applied Systems Thinking: hap:/ /applicdystemsthinking com Dartmouth Institute Microxystem Academy: hutps:/ /clinicah system.org Society of Organizational Leaning: www.solnline System Dynamics Society: www systemdynamics.rg re References AMN Healthcare, 2013, Clinical Workfore Survey. Retrieved June 30, 2016. www amnalthcarecom/uploadeaFley/MainSite//Comtent/Healtheate_ Industry Insights Industry Research /etecutivesurvey 3 pl Andenon, A. 2014. 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Nelon, and Batablen, 2004, Clacal Mieromtem Action Guide: Improving Healthcare by Improving Your Microsatcm, Dartmvuth ber 2. hy finial sng/ap siten/ uploads /2014/07 /CMAGO40104 pa. rant, R2016, “The US. fs Runing Out of Nunes.” The Adanti, Pushed Febeuary 3. www.theatlantc.cum/health /arcive/2016/02/aussing shortage 459741 Huston, €. 1 2013. Profesional bones in Nursing: Challenyesand Opportunities. New York: Lippincott Willanas & Wilkins, Printed by: ladiel25@gmail.com. Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publisher's prior permission. Violators will be prosecuted.Chapt teristics of Complex Systems Insitute of Medicine 196, Healthy Communatcs New Parner or the Futur af Public Health Wssington, DC: National Asdemies Pres Foti, F KS. HL Abi and, D, Hermit. 2008, System Rane Pra Improving the Safety and Quality of Patient Care ty Recognizing and opeoving the Systens ia Whivh We Work." 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"Plague: Spm Thinking ard Saft: From Research te Implementation, ol; Camarpts and Method sted by K, Henhcn, J, Rats, 8, Mark, and D1 Lewin, Ageney for Healthcare Resch and Quali. Publis February. wns 08 oho NBK2OS23 Kelly, Safety” In Advance Patvent Printed by: ladiel25@gmail.com. Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publisher's prior permission. Violators will be prosecuted.Appl 18 Quality Management in Scout, RA, 2003, Oppanizatione: Rettonal, Natural ad Open Stems, Sth ed. Upper Salle River, NI: Prentice Hall ann |B. Lewin, 2014. The Middleburs (Operations, Chica: Health A Senge, P. M. 2006. The Fifth Discipline: The Art and Practice af the Learning Organization, Jd ed. New York: Doubleday Cutten 1990. The Fifth Discipline The Art and Practice of the Learn ‘New York: Doubleday Curren: Sterman, 1D. 2000. Busines Dyuamics: Stems Tinting World. Boston: Iria MeGraw Hill, Seidel ok Healthcare Siatey aid inistation Pres Ompamtcation nd Modeling fora Complex Printed by: ladiel25@gmail.com. Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publisher's prior permission. Violators will be prosecuted.Printed by: ladiel25@gmail.com. Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publisher's prior permission. Violators will be prosecuted. PRACTICE EXERCISE 3: DYNAMIC COMPLEXITY Objective To practice identf\ing dynamic complexity in a patient care experience Instructions 1, Read the case stndy 2. Review the system characteristics that contribute to dynamic ‘complexity ~ Change Trade off History dependency ~ Tight coupling For further explanation Of these system characteristics, please refer to LD. Sterman, 2006, “Learning from Evidence in a Compley World,” American Journal of Public Health 96 (3): 505-14 3. Explain how these system characteristics are expressed in the case study Case Study This case is adapted from D. L. Kelly and S. L, Pestomik’s 1998 unpublished manuscript “Using Causal Loop Diagrams to Failtate Double Loop Learning in the Healthcare De Mrs, Bh was a 66-year-old widow living on af ry Setting.” ed income, She had been diagnosed with high Hood presure and osteoporosis. Her peivate doctor knew 1¢ medication with which to treat her hig hher well. When he selected pressure, he took into account her age, the fact that she hal osteoporosis, dather isues, He chose a drug that had proven beneficial for patients st 289 Printed by: ladiel25@gmail.com. Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publisher's prior permission. Violators will be prosecuted,Applying Quality Management in Healthcare: A Systems Approach ‘Mo. B and had minimum side effects, Mes. B did well on the medication for ten years. Her insurance covered the cost of her medication, except for a smal ‘out of pocket eopayaent ‘The las time Mrs. B went wo her local pharmacy to rfl her preseption, the pharmacist informe hee tha her insurance company had contracted with pharmacy benefits management (PRM) company. (The ole ofa PBM company isto perform a variety of cost-cutting services for health insurance plats, One of these services isto decide whieh drugs an insurance vompasy Will p the PBM company’s preferred proxluct isis known a frmaary.) HMts ‘wanted to continue 10 take the same meddication, i woul €bst he five kiotes her usual eopayment. She was quite disturbed becuse she could ot afford this price inerease and did ot filly unnrstanal e ssance cnnpany’s ew policy. The pharmacist offered to call Mrs. Bs dactor, explain the stuation, and ask him whether he would change her prescription to the PBA preferred brand. When the physician was contacted he was not aware of the PBM ‘company’s action and was not completely familiae with the preferred product. “The pharmacist cscussed Me. Bs nt withthe physician and desribed the financial consequences of continuing to receive her original prescription Metis esi wth he pharmacist, the physician conan oy ‘option was to approve the sWiteh, which he did. ‘Mrs. begat taking the new brand of high blood pressure medicine (One week after seating on the new deug, she develope a persistent cough that aggravated héF osteoporosis and caused her rib pain, When the cough and pain eOnginued for anorler week, Mrs, beyan to take over the counter medicines for the pain, She unknowingly opened here wa reaction beoween her boext pressure mediation andthe pain lication: ethosttis hypotension Pine when rising from_a Wing to an upright position). One her ey te algae ad, and bokeh ap. ‘was admitted to the hospital for surgery, where she developed a unnary ) Siete 8 Moodaram hed ty Seeay de dent