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Aotearoa New Zealand is implementing a significant health reform agenda heralded as a “once in a generation” opportunity, derived from the Health and Disability System Review.[[1]] The reforms move us from delivering more healthcare activity and accepting unwarranted variation in care, to focusing on wellbeing and health outcomes and delivering services to meet people’s needs. Central to the reform agenda is the imperative to achieve equitable outcomes, particularly related to Māori, Pacific peoples, and disabled populations.

Arguably, previous major health reforms in the 1990s and 2000 have not effectively addressed inequalities, nor created an integrated, coordinated system.[[2]] In addition, these reforms have not meaningfully changed practice for most frontline clinicians. So, what needs to be different this time?

Today a range of complex global and local variables affect all aspects of our lives, including health. While change is a constant, COVID-19 has highlighted that we cannot predict the future precisely, and that we have complex challenges with few single causes or solutions.[[3]] Yet, large-scale change can happen rapidly. Globally, healthcare delivery systems are under increasing pressures from other factors including health workforce ageing and supply, consumer expectations, and climate change.

Healthcare is a complex adaptive social system (CAS). It has numerous agents including health service users, ministers, central agencies, national and community organisations and providers, healthcare professionals, educators, regulators… the list goes on. There are innumerable interactions amongst these agents (both people and organisations) who, through these interactions, learn and adapt, thereby constantly reshaping the system.[[4,5]]

Leadership and governance are building blocks of a well-functioning health system.[[6]] The multitude of largely Western definitions, and models related to these terms, highlight that there is no consensus or agreed taxonomy around their meaning. Given this, thinking in old models and roles of “management, leadership, and governance” can prove circular and ultimately unhelpful. The focus of this editorial is to reframe this thinking and consider the knowledge, mindset, and behaviours needed for leadership and governance of a CAS.

The correlation between effective leadership and overall performance is well established.[[7]] Here, it is worth considering the differences between complex and complicated systems, and the leadership skills needed for the respective systems. Much work has been done on this, and the Cynefin model and leadership framework is commonly used.[[8]] This model supports thinking about leadership and governance, and the approaches to take in the simple, complicated, complex, or chaotic domains.

In healthcare, an example that reflects the simple domain is taking a laboratory test and treating an infection. The simple domain—where cause and effect are clear—requires us to use best practice approaches. Leadership is supervisory—ensuring proper processes are in place. The danger is we apply this approach to complicated and complex problems, or continue with the same thinking when context changes.

The complicated domain—for example, management of surgery in an older adult with multiple co-morbidities—requires analysis or expertise, as there may be multiple appropriate responses available. However, it is still fact-based. Leadership is about bringing together expertise, listening to at times conflicting advice; to sense, analyse, and respond with good practice solutions. The danger here is “analysis paralysis” and experts overconfident in their solutions.

A complex system is not higher-order complicatedness; it is a fundamentally different kind of system requiring a different approach to leadership and governance. In complexity there is flux and unpredictability, no right answers, and many competing ideas. Examples in health include responding to rising national obesity rates. Here, there is a need for pattern-based leadership: ensuring diversity of input and interaction, and encouraging safe environments to test creative and innovative ideas, thereby allowing patterns to emerge. A danger is that leadership looks for facts rather than patterns using “complicated” approaches. As many of the challenges in this domain involve social determinants of health, both diversity of input and collaboration must be significant.

In chaos—for example, the early days of a pandemic—there is need for leadership to take control, to shift the system from chaotic turbulence where patterns cannot be discerned into complexity. Leadership needs to provide strong, direct communication, and enable the system to take advantage of opportunities and innovations that arise.

Although no role sits exclusively in a single quadrant, most clinical specialty-level work functions predominantly in the complicated domain, whereas organisational and national system-level challenges, such as achieving equity, sit in complexity. Clinicians are often assumed, on the basis of proven, tested clinical expertise and sometimes leadership in the simple or complicated domains, to have appropriate knowledge and skills when stepping into new organisational or national leadership or governance responsibilities. In transitioning to more system-level roles, we may default to applying our known, “complicated” knowledge and tools—an approach that could be inadequate, inappropriate, and have negative consequences.

We need to deliberately shift our approach by acquiring knowledge of complexity and systems science, and then applying this to the design and evaluation of interventions. We need an open, outward mindset that sees the world as interconnected and interdependent with dynamic, non-linear interactions, in which relationships are fundamental. We must accept and account for inherent uncertainty and unpredictability, understanding that interventions can have positive and negative impacts on the whole, and may not deliver the anticipated change.

A CAS leader accepts that there are no simple solutions, nor can they be solved by a single person. They are humble, admitting they do not know all the answers. They use networks and an inclusive, authentic sharing of power and knowledge—especially with those impacted—to identify patterns, ensure diversity of inputs and enable creativity to try local solutions for local contexts—always working to advance collective results. They know that solutions are not static, but may adapt further over time. A focus on individual or group interests and advancement will not bring about the required system change. Ultimately, rather than leadership being done to the system, the complex domain demands leadership through the system.[[7]]

A CAS has a few simple operating rules that become the system’s drivers and guidelines for all decision-making. In this complex domain, our shared health reform purpose to achieve the best equitable, culturally safe experiences and outcomes, at both whānau and population levels, becomes the system’s operating rule to determine our decisions. Governance in complexity must accept there are no best practice solutions that can be applied everywhere and be permissive within enabling constraints. It must be tight on accountability and responsibility for outcomes, but loose on the approaches to achieve them in different contexts. We need a greater risk appetite and tolerance for failure and for lessons to be learned. Equity needs to be the frame through which everything else is viewed, approached and evaluated. To do this, we must move beyond just cost-benefit and cost-effectiveness analyses, to instead prioritise “equity-effectiveness”.

As clinicians transition from direct patient-facing to system-level roles, we must be deliberate in requiring the appropriate expertise and behaviours, and providing access to training opportunities and pathways. We must ensure system leaders have the appropriate skill sets for the level of the system they work in, and that we support them to grow in these roles.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Iwona Stolarek: Independent Consultant, Wellington. Karina McHardy: Independent Consultant, Auckland. Lloyd McCann: CEO & Head of Digital Health, Mercy Radiology and Clinics & Healthcare Holdings Ltd, Auckland. Andrew Simpson: Independent Consultant, Wellington. Grant Howard: Intensivist, Department of Critical Care, Waikato District Health Board, Hamilton. John Robson: General Practitioner and Medical Administrator, Wellington.

Acknowledgements

Correspondence

Iwona Stolarek: Independent Consultant, Wellington.

Correspondence Email

authorISNZ@gmail.com

Competing Interests

Nil.

1) Health and Disability System Review. Health and Disability System Review – Final Report – Pūrongo Whakamutunga [Internet]. Wellington: HDSR; 2020 [accessed 22 January 2022]. Available from: https://systemreview.health.govt.nz/assets/Uploads/hdsr/health-disability-system-review-final-report.pdf

2) Cumming J, McDonald J, Barr C, et al. New Zealand health system review. Health Systems in Transition, Vol.4 No.2. World Health Organization; 2014.

3) Petrie N. Future trends in leadership development. Greensboro: Center for Creative Leadership; 2014.

4) Sturmberg JP. Health system redesign – how to make health care person-centered, equitable, and sustainable. Springer International Publishing AG; 2018.

5) Braithwaite J, Churruca K, Ellis LA, et al. Complexity Science in Healthcare – Aspirations, Approaches, Applications and Accomplishments: A White Paper. Australian Institute of Health Innovation, Macquarie University: Sydney, Australia. 2017.

6) de Savigny D, Adam T. editors. Systems thinking for health systems strengthening. World Health Organization; 2009.

7) McHardy K, McCann L. Shortfalls in clinical and health system leadership [Internet]. Intern Med J. 2015 Nov;45(11):1099-101. Available from: doi: 10.1111/imj.12901.

8) Snowden DF, Boone ME. A leader's framework for decision making. Harvard Business Review. 2007 November:68-76.

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

Aotearoa New Zealand is implementing a significant health reform agenda heralded as a “once in a generation” opportunity, derived from the Health and Disability System Review.[[1]] The reforms move us from delivering more healthcare activity and accepting unwarranted variation in care, to focusing on wellbeing and health outcomes and delivering services to meet people’s needs. Central to the reform agenda is the imperative to achieve equitable outcomes, particularly related to Māori, Pacific peoples, and disabled populations.

Arguably, previous major health reforms in the 1990s and 2000 have not effectively addressed inequalities, nor created an integrated, coordinated system.[[2]] In addition, these reforms have not meaningfully changed practice for most frontline clinicians. So, what needs to be different this time?

Today a range of complex global and local variables affect all aspects of our lives, including health. While change is a constant, COVID-19 has highlighted that we cannot predict the future precisely, and that we have complex challenges with few single causes or solutions.[[3]] Yet, large-scale change can happen rapidly. Globally, healthcare delivery systems are under increasing pressures from other factors including health workforce ageing and supply, consumer expectations, and climate change.

Healthcare is a complex adaptive social system (CAS). It has numerous agents including health service users, ministers, central agencies, national and community organisations and providers, healthcare professionals, educators, regulators… the list goes on. There are innumerable interactions amongst these agents (both people and organisations) who, through these interactions, learn and adapt, thereby constantly reshaping the system.[[4,5]]

Leadership and governance are building blocks of a well-functioning health system.[[6]] The multitude of largely Western definitions, and models related to these terms, highlight that there is no consensus or agreed taxonomy around their meaning. Given this, thinking in old models and roles of “management, leadership, and governance” can prove circular and ultimately unhelpful. The focus of this editorial is to reframe this thinking and consider the knowledge, mindset, and behaviours needed for leadership and governance of a CAS.

The correlation between effective leadership and overall performance is well established.[[7]] Here, it is worth considering the differences between complex and complicated systems, and the leadership skills needed for the respective systems. Much work has been done on this, and the Cynefin model and leadership framework is commonly used.[[8]] This model supports thinking about leadership and governance, and the approaches to take in the simple, complicated, complex, or chaotic domains.

In healthcare, an example that reflects the simple domain is taking a laboratory test and treating an infection. The simple domain—where cause and effect are clear—requires us to use best practice approaches. Leadership is supervisory—ensuring proper processes are in place. The danger is we apply this approach to complicated and complex problems, or continue with the same thinking when context changes.

The complicated domain—for example, management of surgery in an older adult with multiple co-morbidities—requires analysis or expertise, as there may be multiple appropriate responses available. However, it is still fact-based. Leadership is about bringing together expertise, listening to at times conflicting advice; to sense, analyse, and respond with good practice solutions. The danger here is “analysis paralysis” and experts overconfident in their solutions.

A complex system is not higher-order complicatedness; it is a fundamentally different kind of system requiring a different approach to leadership and governance. In complexity there is flux and unpredictability, no right answers, and many competing ideas. Examples in health include responding to rising national obesity rates. Here, there is a need for pattern-based leadership: ensuring diversity of input and interaction, and encouraging safe environments to test creative and innovative ideas, thereby allowing patterns to emerge. A danger is that leadership looks for facts rather than patterns using “complicated” approaches. As many of the challenges in this domain involve social determinants of health, both diversity of input and collaboration must be significant.

In chaos—for example, the early days of a pandemic—there is need for leadership to take control, to shift the system from chaotic turbulence where patterns cannot be discerned into complexity. Leadership needs to provide strong, direct communication, and enable the system to take advantage of opportunities and innovations that arise.

Although no role sits exclusively in a single quadrant, most clinical specialty-level work functions predominantly in the complicated domain, whereas organisational and national system-level challenges, such as achieving equity, sit in complexity. Clinicians are often assumed, on the basis of proven, tested clinical expertise and sometimes leadership in the simple or complicated domains, to have appropriate knowledge and skills when stepping into new organisational or national leadership or governance responsibilities. In transitioning to more system-level roles, we may default to applying our known, “complicated” knowledge and tools—an approach that could be inadequate, inappropriate, and have negative consequences.

We need to deliberately shift our approach by acquiring knowledge of complexity and systems science, and then applying this to the design and evaluation of interventions. We need an open, outward mindset that sees the world as interconnected and interdependent with dynamic, non-linear interactions, in which relationships are fundamental. We must accept and account for inherent uncertainty and unpredictability, understanding that interventions can have positive and negative impacts on the whole, and may not deliver the anticipated change.

A CAS leader accepts that there are no simple solutions, nor can they be solved by a single person. They are humble, admitting they do not know all the answers. They use networks and an inclusive, authentic sharing of power and knowledge—especially with those impacted—to identify patterns, ensure diversity of inputs and enable creativity to try local solutions for local contexts—always working to advance collective results. They know that solutions are not static, but may adapt further over time. A focus on individual or group interests and advancement will not bring about the required system change. Ultimately, rather than leadership being done to the system, the complex domain demands leadership through the system.[[7]]

A CAS has a few simple operating rules that become the system’s drivers and guidelines for all decision-making. In this complex domain, our shared health reform purpose to achieve the best equitable, culturally safe experiences and outcomes, at both whānau and population levels, becomes the system’s operating rule to determine our decisions. Governance in complexity must accept there are no best practice solutions that can be applied everywhere and be permissive within enabling constraints. It must be tight on accountability and responsibility for outcomes, but loose on the approaches to achieve them in different contexts. We need a greater risk appetite and tolerance for failure and for lessons to be learned. Equity needs to be the frame through which everything else is viewed, approached and evaluated. To do this, we must move beyond just cost-benefit and cost-effectiveness analyses, to instead prioritise “equity-effectiveness”.

As clinicians transition from direct patient-facing to system-level roles, we must be deliberate in requiring the appropriate expertise and behaviours, and providing access to training opportunities and pathways. We must ensure system leaders have the appropriate skill sets for the level of the system they work in, and that we support them to grow in these roles.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Iwona Stolarek: Independent Consultant, Wellington. Karina McHardy: Independent Consultant, Auckland. Lloyd McCann: CEO & Head of Digital Health, Mercy Radiology and Clinics & Healthcare Holdings Ltd, Auckland. Andrew Simpson: Independent Consultant, Wellington. Grant Howard: Intensivist, Department of Critical Care, Waikato District Health Board, Hamilton. John Robson: General Practitioner and Medical Administrator, Wellington.

Acknowledgements

Correspondence

Iwona Stolarek: Independent Consultant, Wellington.

Correspondence Email

authorISNZ@gmail.com

Competing Interests

Nil.

1) Health and Disability System Review. Health and Disability System Review – Final Report – Pūrongo Whakamutunga [Internet]. Wellington: HDSR; 2020 [accessed 22 January 2022]. Available from: https://systemreview.health.govt.nz/assets/Uploads/hdsr/health-disability-system-review-final-report.pdf

2) Cumming J, McDonald J, Barr C, et al. New Zealand health system review. Health Systems in Transition, Vol.4 No.2. World Health Organization; 2014.

3) Petrie N. Future trends in leadership development. Greensboro: Center for Creative Leadership; 2014.

4) Sturmberg JP. Health system redesign – how to make health care person-centered, equitable, and sustainable. Springer International Publishing AG; 2018.

5) Braithwaite J, Churruca K, Ellis LA, et al. Complexity Science in Healthcare – Aspirations, Approaches, Applications and Accomplishments: A White Paper. Australian Institute of Health Innovation, Macquarie University: Sydney, Australia. 2017.

6) de Savigny D, Adam T. editors. Systems thinking for health systems strengthening. World Health Organization; 2009.

7) McHardy K, McCann L. Shortfalls in clinical and health system leadership [Internet]. Intern Med J. 2015 Nov;45(11):1099-101. Available from: doi: 10.1111/imj.12901.

8) Snowden DF, Boone ME. A leader's framework for decision making. Harvard Business Review. 2007 November:68-76.

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

Aotearoa New Zealand is implementing a significant health reform agenda heralded as a “once in a generation” opportunity, derived from the Health and Disability System Review.[[1]] The reforms move us from delivering more healthcare activity and accepting unwarranted variation in care, to focusing on wellbeing and health outcomes and delivering services to meet people’s needs. Central to the reform agenda is the imperative to achieve equitable outcomes, particularly related to Māori, Pacific peoples, and disabled populations.

Arguably, previous major health reforms in the 1990s and 2000 have not effectively addressed inequalities, nor created an integrated, coordinated system.[[2]] In addition, these reforms have not meaningfully changed practice for most frontline clinicians. So, what needs to be different this time?

Today a range of complex global and local variables affect all aspects of our lives, including health. While change is a constant, COVID-19 has highlighted that we cannot predict the future precisely, and that we have complex challenges with few single causes or solutions.[[3]] Yet, large-scale change can happen rapidly. Globally, healthcare delivery systems are under increasing pressures from other factors including health workforce ageing and supply, consumer expectations, and climate change.

Healthcare is a complex adaptive social system (CAS). It has numerous agents including health service users, ministers, central agencies, national and community organisations and providers, healthcare professionals, educators, regulators… the list goes on. There are innumerable interactions amongst these agents (both people and organisations) who, through these interactions, learn and adapt, thereby constantly reshaping the system.[[4,5]]

Leadership and governance are building blocks of a well-functioning health system.[[6]] The multitude of largely Western definitions, and models related to these terms, highlight that there is no consensus or agreed taxonomy around their meaning. Given this, thinking in old models and roles of “management, leadership, and governance” can prove circular and ultimately unhelpful. The focus of this editorial is to reframe this thinking and consider the knowledge, mindset, and behaviours needed for leadership and governance of a CAS.

The correlation between effective leadership and overall performance is well established.[[7]] Here, it is worth considering the differences between complex and complicated systems, and the leadership skills needed for the respective systems. Much work has been done on this, and the Cynefin model and leadership framework is commonly used.[[8]] This model supports thinking about leadership and governance, and the approaches to take in the simple, complicated, complex, or chaotic domains.

In healthcare, an example that reflects the simple domain is taking a laboratory test and treating an infection. The simple domain—where cause and effect are clear—requires us to use best practice approaches. Leadership is supervisory—ensuring proper processes are in place. The danger is we apply this approach to complicated and complex problems, or continue with the same thinking when context changes.

The complicated domain—for example, management of surgery in an older adult with multiple co-morbidities—requires analysis or expertise, as there may be multiple appropriate responses available. However, it is still fact-based. Leadership is about bringing together expertise, listening to at times conflicting advice; to sense, analyse, and respond with good practice solutions. The danger here is “analysis paralysis” and experts overconfident in their solutions.

A complex system is not higher-order complicatedness; it is a fundamentally different kind of system requiring a different approach to leadership and governance. In complexity there is flux and unpredictability, no right answers, and many competing ideas. Examples in health include responding to rising national obesity rates. Here, there is a need for pattern-based leadership: ensuring diversity of input and interaction, and encouraging safe environments to test creative and innovative ideas, thereby allowing patterns to emerge. A danger is that leadership looks for facts rather than patterns using “complicated” approaches. As many of the challenges in this domain involve social determinants of health, both diversity of input and collaboration must be significant.

In chaos—for example, the early days of a pandemic—there is need for leadership to take control, to shift the system from chaotic turbulence where patterns cannot be discerned into complexity. Leadership needs to provide strong, direct communication, and enable the system to take advantage of opportunities and innovations that arise.

Although no role sits exclusively in a single quadrant, most clinical specialty-level work functions predominantly in the complicated domain, whereas organisational and national system-level challenges, such as achieving equity, sit in complexity. Clinicians are often assumed, on the basis of proven, tested clinical expertise and sometimes leadership in the simple or complicated domains, to have appropriate knowledge and skills when stepping into new organisational or national leadership or governance responsibilities. In transitioning to more system-level roles, we may default to applying our known, “complicated” knowledge and tools—an approach that could be inadequate, inappropriate, and have negative consequences.

We need to deliberately shift our approach by acquiring knowledge of complexity and systems science, and then applying this to the design and evaluation of interventions. We need an open, outward mindset that sees the world as interconnected and interdependent with dynamic, non-linear interactions, in which relationships are fundamental. We must accept and account for inherent uncertainty and unpredictability, understanding that interventions can have positive and negative impacts on the whole, and may not deliver the anticipated change.

A CAS leader accepts that there are no simple solutions, nor can they be solved by a single person. They are humble, admitting they do not know all the answers. They use networks and an inclusive, authentic sharing of power and knowledge—especially with those impacted—to identify patterns, ensure diversity of inputs and enable creativity to try local solutions for local contexts—always working to advance collective results. They know that solutions are not static, but may adapt further over time. A focus on individual or group interests and advancement will not bring about the required system change. Ultimately, rather than leadership being done to the system, the complex domain demands leadership through the system.[[7]]

A CAS has a few simple operating rules that become the system’s drivers and guidelines for all decision-making. In this complex domain, our shared health reform purpose to achieve the best equitable, culturally safe experiences and outcomes, at both whānau and population levels, becomes the system’s operating rule to determine our decisions. Governance in complexity must accept there are no best practice solutions that can be applied everywhere and be permissive within enabling constraints. It must be tight on accountability and responsibility for outcomes, but loose on the approaches to achieve them in different contexts. We need a greater risk appetite and tolerance for failure and for lessons to be learned. Equity needs to be the frame through which everything else is viewed, approached and evaluated. To do this, we must move beyond just cost-benefit and cost-effectiveness analyses, to instead prioritise “equity-effectiveness”.

As clinicians transition from direct patient-facing to system-level roles, we must be deliberate in requiring the appropriate expertise and behaviours, and providing access to training opportunities and pathways. We must ensure system leaders have the appropriate skill sets for the level of the system they work in, and that we support them to grow in these roles.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Iwona Stolarek: Independent Consultant, Wellington. Karina McHardy: Independent Consultant, Auckland. Lloyd McCann: CEO & Head of Digital Health, Mercy Radiology and Clinics & Healthcare Holdings Ltd, Auckland. Andrew Simpson: Independent Consultant, Wellington. Grant Howard: Intensivist, Department of Critical Care, Waikato District Health Board, Hamilton. John Robson: General Practitioner and Medical Administrator, Wellington.

Acknowledgements

Correspondence

Iwona Stolarek: Independent Consultant, Wellington.

Correspondence Email

authorISNZ@gmail.com

Competing Interests

Nil.

1) Health and Disability System Review. Health and Disability System Review – Final Report – Pūrongo Whakamutunga [Internet]. Wellington: HDSR; 2020 [accessed 22 January 2022]. Available from: https://systemreview.health.govt.nz/assets/Uploads/hdsr/health-disability-system-review-final-report.pdf

2) Cumming J, McDonald J, Barr C, et al. New Zealand health system review. Health Systems in Transition, Vol.4 No.2. World Health Organization; 2014.

3) Petrie N. Future trends in leadership development. Greensboro: Center for Creative Leadership; 2014.

4) Sturmberg JP. Health system redesign – how to make health care person-centered, equitable, and sustainable. Springer International Publishing AG; 2018.

5) Braithwaite J, Churruca K, Ellis LA, et al. Complexity Science in Healthcare – Aspirations, Approaches, Applications and Accomplishments: A White Paper. Australian Institute of Health Innovation, Macquarie University: Sydney, Australia. 2017.

6) de Savigny D, Adam T. editors. Systems thinking for health systems strengthening. World Health Organization; 2009.

7) McHardy K, McCann L. Shortfalls in clinical and health system leadership [Internet]. Intern Med J. 2015 Nov;45(11):1099-101. Available from: doi: 10.1111/imj.12901.

8) Snowden DF, Boone ME. A leader's framework for decision making. Harvard Business Review. 2007 November:68-76.

Contact diana@nzma.org.nz
for the PDF of this article

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