We all know it. Patient outcomes are greatly affected by patient experience. Even if technology should evolve to the point that make physicians obsolete, the patient experience will live on—and make or break the day. The undeniable fact of the matter is that patient health care experiences really do reflect quality of care. However, as technology evolves (and as it will undoubtedly continue to do), we must resist the urge to view the evolution of healthcare delivery as inherently dependent upon technology’s maturation. At the end of the day, quality healthcare delivery is a concoction of many ingredients, with patient-provider interaction at the top of the list.
Innumerable projects and pilots have been launched with foundations ranging from retail settings, such as The Gap, to the manufacturing industry, typically Toyota. While many of these initiatives show improvement in a metric, sustainable performance, the patient cycle or continuum of care has been consistently frustrated throughout. Efficiencies in one element lead to backlogs in others. Certainly LEAN principles try to address this and find that it takes more than a dose of Gemba and infusion of Kanban to heal healthcare delivery. Similarly, health system executives have thrown incentive dollars at activities such as encouraging physicians to have discharge orders completed by 11:00 a.m., only to find that the constipation of bed flow and turnover remain unaffected with patients spending the first 12 hours of a four-day hospital stay waiting for a bed. It’s hard to overcome that first impression.
LM Holden, William B. Rouse, and others have described healthcare as a “complex adaptive system.” Accepting this framework explains why increasing capacity to an area or system may actually reduce overall performance (Braess’ Paradox), as the Nash Equilibrium prevails (each staff member, from patient transport to nursing, have no incentive to change their routes, simply seeking individual benefit – my job is done). So then, how do we teach this disjointed every task for itself “elephant to dance?” Kevin Kelly, in his book Out of Control, Michael Creighton with Prey, and The National Geographic guy, each in quite different ways, develop the concept of swarm.
The swarm theory was, and is, a valid approach to management, based on other business models, most notably the manufacturing industry. The goal is to reduce both operational expense and inventory, while simultaneously increasing throughput, thereby achieving better flow. The swarm theory originates from the consensus, among scientists, that a single ant, or bee, isn’t intelligent, but the colony, as whole, demonstrates stunning intelligence as they work together to achieve a singular goal, despite the disagreement and contradictory objectives of individual members of the colony. Conversely, the same can be said of healthcare delivery systems: how can the simple, singular actions of an individual add up to the complex behavior of a group? The answer is as simple as is it revealing—they’re acting toward a common, manageable goal. Certainly, there are statistical fluctuations, so we cannot precisely predict outcomes, but avoiding bottlenecks, or constraints, is a significant factor, and identifying the simple set of elements from which all other substances are composed is a substantial advantage. While this is not a revolutionary concept, it remains a consistent theme, as evidenced by its inclusion in Dan Trietsch’s “System-wide Management by Criticalities: Hierarchical balancing of stochastic resources,” published in Human Systems Management. Trietsch contends, correctly so, that management by constraints can be improved by matching the criticality of each constraint with its economic value. The result, in short form, is that subsystems learn to meet the demand placed on them with a specified service level, defined by the complement of the criticality. In essence, it’s up to us to break constraints, find the remaining ones, and apply the principles. Then, we identify the system’s constraints; decide how to exploit the constraints; subordinate everything else to the above decision; and then elevate the system’s constraint. If, in the previous steps, a constraint has been broken, return to Step One, but don’t allow inertia to cause a system’s constraint.
So, how is the swarm theory instrumental to the healthcare setting?
Responsible, effective healthcare delivery must put patients at the center of the model. Healthcare must move on with process improvement, but must move beyond mechanical, technological, and manufacturing-like applications. The swarm theory allows us to apply lean process improvement principles in a complex, patient-centered system. In order for lean principles to work, micromanagement must be thrown out with the bathwater, thus allowing for overall system and patient experience (think “satisfaction”) improvement. However, it bears repeating that we must not liken lean principles to Toyota-esque assembly. In order for improvement to truly enhance the patient experience, all levels of leadership must buy into the theory, and it calls for physicians to lead the charge. Therefore, we must consider the entire patient experience, from the emergency department to physician interaction, from nursing to pharmacy, from housekeeping to lab, from admission to transportation. The role of leadership is to articulate a compelling vision and communicate strategic goal categories, while also prioritizing those categories. Guide and support the team in a targeted, focused approach to improvement work.
But it doesn’t stop there. Leadership plays a dual role, and its importance cannot be understated. Again, responsible leadership establishes a learning culture, rather than a culture of judgment. Attack the process, not the people, by creating an execution-driven, accountable atmosphere. Leadership is a fluid skill, and it must guide the conversation, occasionally choosing among competing options. Successful implementation/execution of even the best of ideas requires an innovative (for healthcare particularly) approach and mentality (which brings us back to the swarm theory).
Remember that the swarm theory centers on a collective body of individuals acting independently with a shared, or common, purpose. It’s a group mindset organized by shared objectives to create a meaningful pattern of achievement. Understanding the goal categories allows the collective/coordinated action to succeed, driven by local leaders who are adaptable, evolvable, resilient, and sensitive to current and local conditions. The sometimes messy power of complexity requires the unprejudiced growth and unguided learning achieved by the network approach with a shared, or common, purpose and goal-achieving actions.