The Heart of Complexity

Advancing Clinical Quality

Kevin Dooley, Ph.D., Mark Levine, M.D., and Paul Plsek

• Participants had many reasons for attending. Some were:
  • To explore the paradox of variance reduction vs. variety
  • To apply the principles to improving team function of formerly fragmented caregivers.
  • To understand why it is so difficult to sustain TQM. Why doesn't it stick? Where does it fit in with complexity?
  • What is the clinical pathway? How can we set up a system that promotes healing and health? (The old stuff doesn't work. But people think complexity stuff is too complicated.)
    

• "TQM has been very time and labor intensive... and we're not getting out of it what we wanted. I don't see it taking care of patients. TQM doesn't seem doable... especially with so many cuts."
  
  
• "We're only doing it to meet standards."
  
  
• "In TQM, there is too much focus on process -- and not enough on outcome."
  
  
• "TQM is driven economically -- to reduce costs. But physicians should be patient advocates."
  
  
• "There aren't enough success stories or 'heroes.'"
  
  
• "Teams have not been durable. Members are too stretched."
  
  
• "We've made the error of commanding teams, and making them happen. They should be able to do that without having to be commissioned. We over-structured it."
  
  
• In the evolution of a complex system, you sometimes need scaffolding -- a temporary structure to help you build the system, and later can be taken down. Teams may be a form of scaffolding.
  
  
• It's easy to command and control as leaders. Pat Rush said "I made the first agenda item of every meeting to say is there anything anybody would like to discuss? I totally open up the agenda. Also, I have abolished all standing committees. It's basically like the marketplace idea. Groups disband as soon as the work is done."

• Measuring innovation is much harder than measuring traditional cause and effect. Stories and case studies are what works. Quality improvement efforts can happen much more effectively by stories, which offer ambiguity and multiple perspectives. Language is a much more powerful and effective way to communicate complexity than mathematics.

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