Díaz Carlos Alberto.
Professor. Director of specialization in economics and health management. ISALUD University.
Hospitals are complex companies of services, because they are governed by paradigms of complexity and nonlinear behaviors of their members, of the patients and also of their illnesses, and they are also four companies in one: the clinic, the industrial, the hotel and the teaching.
The principles that rules this kind of organizations are dialogic, holistic and recursion, mainly because what the patient demands is not what he needs, subject to uncertainty and confidence. In each person who receives health attention you see the rest of the hospital that is behind and the final product becomes a health-producing loop L that return to the community[i][ii][iii][iv],[v] ,[vi]
In addition hospitals are complex because they are the conjunction of five groups of participants with their respective technical and social domains, which are: doctors, nurses, administrative technicians, patients and their families, representatives of the owners or Owners themselves. What makes it even more difficult is that real patients have multiborbidity and chronic pathologies, so the health care is not a single medical consultation but a series of them, with hospitalizations, medications and special requirements.[vii]
Health organizations have six constituent parts: strategic summit, middle management (that transform order flows into workflows), operational core, technostructure, support staff and culture, all governed by the principle of “adhocracy”, that is defined as a flexible and adaptable form of organization with lack of formal structure where the specialized multidisciplinary teams are grouped by functions. The operational core is the clinical care and its actors seek their self-fulfillment as individuals and also promote self-organization, which should be channelled by the "empowerment" and alignment of the specific objectives of the services, with the institutional and strategic, for a quality servuction.
The services are produced in an internal work matrix where there is a maximum of interactions, interdependence and interdisciplinarity, where agents buy in order to improve the health of patients and then the internal suppliers satisfy the requirements using the information, the logistic and the functionality of the structure.
On the other hand, the complexity[viii] it is also due to the presence of contradictory dual pairs between the interests of the different groups involved.
We have to think of hospitals as complex adaptive systems[ix][x][xi][xii][xiii]since clinical practice, organization, information management, research, education and professional development are interdependent, built in an environment with multiple self-adjustments and interacting systems. In this context, individuals are the social actors of the hospital and have freedom of action, but their actions have impacts on the rest of the environment, even in the same group and what it is more many times behaviors are not predictable and small modifications can make great changes.
In general, adaptive systems operate out of equilibrium, stability, and constancy; they are open, but they have different levels of aggregation inside, in a fractal form, and its competitive advantages are also the arrays, networks, hierarchies, continuity of attention and information systems alerts. The science of adaptive complex systems, therefore, provides important concepts and tools to meet the challenges of the 21st century.[xiv] [xv]
In complex systems, unpredictability and paradox are always present, and as such some things will remain unknown. Resolving should be replaced by a dynamic, emergent, creative and intuitive vision of the world to offer a comprehensive and integrated medical care[xvi] service, based on the continuity of care and performance-based services.
Summarizing the previous concepts:
The hospital is open and continuously exchanges information with the environment, with the community and its affiliates, with the patients it attend and their family, and also with the workers and financiers. This affects the circulation and increases the interests linked to whoever provides the best service or improves the functional utility. It is an organization of intensive work immersed in a competitive, changing and hostile market that does not admit another form of work that is not the excellence and the efficiency in the quality of the services and the security of the patients.
The hospital must be continuously developed to provide the population that needs information, maintaining its legitimacy and establishing its area of influence, its programmatic area and is socially justified.
Open medical systems require:
They cannot or should not function as closed systems, which only respond to the designs of the offer. Open systems like this can leverage, select, process media information and become into more complex systems, such as services, results, responses, changes in life habits, people’s relationship with their society and the environment. [xvii][xviii] [xix] [xx] [xxi]
The boundaries in adaptive systems are diffuse rather than rigid. The registry can change and the agents can be at the same time members of several sub-systems. In mechanical systems instead, the limits are fixed and they are well defined. Therefore, in health organizations such as hospitals, we must bear in mind that other domains, other social systems, can be affected and we must produce corporate responses as a reaction.
The concept of service component architecture (SCA) is based on the idea that company function is provided as a series of services, which are assembled together to create solutions that serve a particular need. In the case of Hospitals the services are health care (including physically, mentally and social care) and the need it is to improve the patient conditions and his environment as well.
In a SCA, the agents respond to the environment through the use of internalized rules that lead to action and influenced for example by the complex medical industry, corporations, scientific associations and their representatives: medical circles, Association of Anesthetists, of Traumatologists, of neurosurgeons, etc. These internal rules do not have to be shared, explicitly, or even logically perceived by another agent as contradictory[xxii] [xxiii][xxiv]
The behaviors of the institutional actors in the complex systems arise from the interaction of the agents with the care services, the cost centers, the medical attention, nursing, administrative, cleaning groups, which focus on protagonist and interact in matrix networks, where some are buyers and other domestic suppliers or vendors. Buyers do it on behalf of the patients, against a range of options, which should be explicit in a coherent diagnosis and treatment plan that reduces the gap between effectiveness, effectiveness, efficiency and cost minimization. [xxv]
The observable results, when the value chain is strengthened, are more than just the sum of the parts. The properties of hydrogen and oxygen atoms cannot be combined simply to consider the noise or the brightness of a stream. The results arises from the productive interaction of nurses, kinesiologists, plant physicians, interconsultors. The inability to account for surprise, creativity and emerging phenomena is the main flaw in reductionist thinking.[xxvi]
Health in this analysis arises from a different topography, a different look, with an internal dynamic, and from non-causality, non-linearity, without tendency to balance and prediction. Health from complex adaptive systems would have five components or areas of manifestation: Biological, technical-scientific, social, the emerging global structure, life itself.
The management leadership of complex adaptation systems requires managers who know the mission of the company and the strategic objectives, who are responsible and who materialize the ideas and projects of the services, who offer alternatives and are good at listening, understanding, collaborate with the teams, co-participate in the successes and contain the groups in the crisis.
Managers should demand and give the example, recognize and identify the paradoxes of the middle managers, the personnel services, the technostructure, the strategic summit and the operational core. They also must be present and dedicated continuously, identifying the value of people and adapting to the changes. It is not easy to be a manager in complex adaptive systems and help others to make decisions, because there are always new balances and process changes that must be adapted. They also know that tension will exist which is part of the “Flux Tendu” logistics of the system. What aggravates this fact is that complex health systems interact with other complex systems that increase tension. In social systems, the seemingly opposing forces of competition and cooperation often work together in positive competition, which can improve collective performance. [xxvii] [xxviii]
Those who integrate or perform executive functions in hospitals must learn how to compete, knowledge of complexity and complex thinking, their paradigms, chaos, changing population needs and the risk of system sustainability in the immediate future. They must also manage instability and uncertainty, avoid control management and train members to work as a team, have the ability to self-organize into matrix production schemes. Managers must form more horizontal organizations, where knowledge is not the only element that hierarchizes, but fundamentally those that lead and define what will be the strategic processes of the organization. it is always necessary to keep in mind that patients are increasingly complex, explained by multimorbidity and polypathology. The drugs that we use immunomodulated with their action responses, and the correction of a physiopathological phenomenon, can generate unknown reactions, which puts us before a more complex universe, such as the organization itself.[xxix] [xxx] [xxxi] [xxxii]
A profession is a specialized activity within society, which constantly needs to detect trends, see needs, and question beliefs to generate value and satisfy a social need, which in our professional field are: Patients and citizens, health professionals, doctors and nurses, non-medical technicians and the whole health system.
[i]Bohórquez Arévalo L E. The business organization as a complex adaptive system. Management studies 2013.29.258-265
[ii]Begun JW. Zimmerman B. Dooley K. Health Care Organizations as Complex Adaptive Systems. June 15.2002. University of Minnesota. http://adaptknowledge.com/wpcontent/uploads/rapidintake/PI_CL/media/Begun_Zimmerman_Dooley.pdf
[iii]Tarride MY. Towards the Constitution of a complex public health. Rev Chil Public health 2005. Vol 9.3. 160-174.
[iv]Díaz CA. The modern Sanitary Enterprise 2. ISALUD editions. Buenos Aires.
[v] Barasa EW. Molyneux S. English M. Cleary S. Hospital as complex adaptive systems: a case study for factors influencing priority setting practices at the hospital level in Kenya. Social Science & Medicine. 2017.174.104-112
[vii] Blumenthal D. Chernof B. Fulmer T. Lumkin J. Selberg J. Caring for High-Need, High Cost Patients An Urgent Priority. New Eng J Med 2016. 909-911.
[viii]Fajardo-Ortiz G. Fernández Ortega MA. Ortiz Montalvo A. Olivares Santos RA. The dimension of the paradigm of complexity in health systems. Surgery and surgeons 2015. 83.81-86
[ix]Holden LM. Complex adaptive systems: concept analysis. JAN. 52.6.2005.651-657
[x]Stumberg JP, O´Halloran DM. Martin CM. People at the centre of complex adaptive health system reform perspective. Medical Journal of Australia. 2010. 193.8.474-478
[xi]Sturmberg JP, O’Halloran DM, Martin CM. Understanding health system reform—a complex adaptive systems perspective. J Eval Clin Pract. 2012; 18(1):202–208.
[xii]Lipsitz LA. Understanding Health Care as a Complex System: The foundation for unintended Consequences. JAMA. 2012. 308.3.243-244
[xiii]Martínez García M. Hernández Lemus E. Health Systems as Complex Systems. American Journal of Operations Research 2013. 3.113.126
[xiv] P. E. Plsek and T. Greenhalgh, “The Challenge of Complexity in Health Care,” British Medical Journal, Vol. 323, No. 7313, 2001,
[xv] Kannampallil TG. Schauer GF. Cohen T. Patel VL. Considering complexity in health care system. Journal of Biomedical Informatics. 2011.44.943-947.
[xvi]Tsasis P. Evans JM. Owen S. Reframing the challenges to integrated care: a complex-adaptive systems perspective. International Journal of Integrated Care. 2012. 12. 1-11
[xvii] Hock Lee K. The hospitalist Movement – a Complex Adaptive Response to Fragmentation of Care in Hospitals. Ann Acad Med Singapore 20122008;37:20-30
[xviii] Toro-Palacio LF, Ochoa-Jaramillo FL. Salud: un sistema complejo adaptativo. Rev Panam Salud Publica. 2012;31(2):161–5.
[xix] Patiño JF. Oncología, Caos y sistemas adaptativos complejos. Revista colombiana de Cancerología. 2004.
[xx] Ratnapalan S. Uleryk E. Organizational Learning in Health Care Organizations. Systems 2014. 24-33- doi:10.3390/systems2010024
[xxii] Toro-Palacio LF, Ochoa-Jaramillo FL. Salud: un sistema complejo adaptativo. Rev Panam Salud Publica. 2012;31(2):161–5
[xxiii] McDaniel Jr. RR. Lanham HJ. Anderson RA. Implications of complex adaptive systems theory for the design of research on health care organizations. Health Care Manage Rev 2009.34.191-199.
[xxiv] M. Martínez-García and E. Lemus, “Health Systems as Complex Systems,” American Journal of Operations Research, 2013. Vol. 3 No. 1, 113-126.
[xxv] Sturmberg JP. O´Halloran DM. Marti CM. People at the center of complex adaptive health systems reform. MJA. 2010.193.474-478
[xxvi] Notarnicola I. Petrucci C Barbosa MR. Giorgi F. Stievano A. Rocco G. Lancia L. Complex adaptive systems and their relevance for nursing: an evolutionary concept analysis. International Journal of Nursing Practice. February 2017.
[xxvii] Sturmberg J. Person-centered Medicine from a Complex Adaptive Systems Perspective. European Journal for Person centered Healthcare. 2014. 2.1
[xxviii] Ellis BS. The Value of Systems and Complexity Thinking to Enable Change in Adaptive Healthcare Organisations, Supported by Informatics 02 March 2016217-229 Chapter 2. Springer
[xxix] Meyer Junior V. Pascucci L. Implementing Strategies in complex systems: Lessons from Brazilian Hospitals. Brazilian Administration Review. BAR. 9. 2.19-37.2012.
[xxx] Park S. Smith J. Healthcare Organizations as complex adaptive Systems. 2016.
[xxxi]The Health Foundation Inspiring Improvement. Evidence scan: Complex adaptive systems. August 2010.
[xxxii] Levy P. Adapting Process-Improvement Techniques in an Academic Medical Center. The Bridge. Health care. Spring 2008. 6-11