Issues… How should we think about clinical
quality improvement for patients whose conditions would graph into
the mid-zone of the Stacey matrix -- somewhat far from certainty and
agreement? Examples: patients with multiple conditions that interact,
psychiatric patients, patients with clear diagnosis but unclear "best"
treatment... Research shows that explicit peer review fails to provide
reliable data on complex conditions, though it does well on simple
ones. So, there is an intuitive understanding that we may need new/different
approaches.
For patients and conditions where certainty and
agreement is high (lower left of Stacy)… we have existing QI tools
such as evidence-based medicine (EBM); clinical paths; patient and
provider education; process analysis; variation reduction... There
is some debate about how large the area of certainty and agreement
is. Further, EBM has "grades" of evidence, ranging from randomized
trials to opinions of experts. Intuitively, it seems that EBM recognizes
a sort of diagonal line moving up the Stacey diagram into the zone
of complexity.
There is general agreement that this is a potentially
fertile area for application of complexity thinking.
Many clinicians see current guidelines development efforts as divisive;
particularly those that are driven primarily by cost considerations
and that fail to recognize the difficulties inherent in trying to
deal with complex patients in a one-size-fits-all way.
This leads us to suggest that the Stacey Matrix could
be used to clarify approaches to guidelines at various levels. Some
aspects of care might be within the high certainty-agreement zone,
while other aspects might be in the zone of complexity. For example,
with psych patients, we might have certainty-agreement about the use
of drugs, but less certainty-agreement on exactly which drugs to use.
Certainty-agreement on the need to involve the family-social unit,
but less certainty-agreement on exactly how to. We could summarize
this as min specs, with some specs getting specific processes and
recommendations, while others are specifically open to multiple experiments.
Bottom line: The Stacey Matrix could bring more rationality and less
divisiveness to guidelines development work.
Post from Mark Levine…
In thinking about this concept, I've redefined the high agreement/high
certainty zone as one where we have good final outcome evidence
(mortality, morbidity, patient satisfaction) and the complexity
zone as the arena where we have only intermediate outcome (blood
levels, surrogate markers, etc).
Given the above assumption, how do we optimize practice
in the two different zones? Briefly, I would say, that we need to
use diffusion of innovation concepts in the final outcome zone and
other CAS adaptability concepts in the intermediate outcome zone.
Those adaptability concepts would include provider to provider support
(relationships building); in effect community building that would
result in a good enough structure (boundaries) to hold the anxiety
of the providers and patients. All the while maintaining an open
mind such that when valid final outcome data became available we
were willing and able to move to the other arena. Of course, there
would be many patients and situations that would never be able to
move to the final outcome arena. Perhaps the complex patient, by
definition, lives in this intermediate outcome zone.
Tales from Past Work and Literature… The article
in the Physician Executive by Lindberg, Herzog, Merry, and Goldstein
contains Al Herzog's case study of the woman with multiple personality
disorder. I am not aware of any other Tales or published papers that
relate to this topic.
From Al Herzog: Re
the Complex Patient: I am not aware of much on this in the literature.
Most of it applies (clinically) to diagnosis, not so much to treatment.
As per my example, if you recall, I employed in my approach the
principles of the critical 15% to change the attractor pattern,
explored and used the power of paradox, etc. What is not in my part
of the paper is the fact that the first patient I wanted to describe
refused to give me permission, calling C/C approach "you are nuts."
I, of course, could not write about her but continued to use this
approach with her. The therapy, which often takes 2-3 years, I was
able to complete in about one year. At one point she asked me why
I thought things seemed to be going faster. I simply said it was
because of my approach. At that point she simply smiled. I would
love to see some of my internal medicine friends (etc) try this
approach with the co-morbid patients etc. and see whether it would
be equally as successful.
How might we measure progress in dealing with these
complex patients? Example: psychiatric patients.
Idea: Per Bak's self-organizing criticality and power laws. In earthquakes,
for example, the distribution of small to major quakes follows a power
law; lots of small quakes and few big quakes. We can't say when the
big one will happen, but the presence of small ones suggests that
a big one will come someday. Perhaps we could measure the frequency
of occurrence of small "breakthroughs" in treatment and infer that
a large "breakthrough" will occur at some point. The absence of small
breakthrough responses to treatment would suggest that the treatment
for this complex patient is not having a desired effect.
Open questions include...
- Could quantitative methods help us sort patients
onto the Stacey diagram?
- What improvement approaches are better for these
patients?
- How do we measure progress in treating patients
in the zone of complexity?
Thoughts About Demonstration Projects… A natural
place to demonstrate new thinking based on the complexity sciences
would be in the midst of current efforts around EBM, clinical paths,
guidelines, etc. that people are naturally finding frustrating. This
current frustration would make for a natural resonance with new thinking
from complexity.
For example, let's say you have a committee in your
organization whose charter it is to oversee the development of clinical
paths (or guidelines, or what ever you call them in your place). But
they are frustrated because their work is not often fully implemented,
clinicians complain that it's too cookbook, it is difficult to come
to consensus and the final product ends up being too vague to be useful...
you know the usual list of problems and complaints.
Now let's teach that committee (and others) about
the Stacey matrix, the concept of min specs, and so on. Let's further
talk about group processes such as Delphi technique which could be
used to openly explore people's mental models about how much agreement
and certainty exists. We could openly display this by mapping opinions
on a giant Stacey Matrix posted on a bulletin board somewhere. With
some new thinking and new Aides to approach the issues (for example,
min specs thinking), we could then challenge the development committees
to either go back and re-think a past effort or apply these concepts
to their next development effort. The aim of the demonstration project
could be to set up conditions for allowing new concepts in the development
of paths and guidelines to emerge. This could generate some true innovations
in approaches to path and guideline development in healthcare.
Ultimate Goal of This Line of Thinking...
the development of methods for placing patients onto the Stacey diagram
and the development of methods for improving care for patients in
the zone of complexity.
