The Fix That Fails, And Worse

"Fixes that fail" - a delightful, euphonious and depressing phrase. Delightful because it is so useful. Euphonious because of alliteration and scansion. Depressing because it is so frequently true.

Never heard of "systems thinking?" It's time. Systems thinking is how you can make sense out of our modern world, and even have some influence on but not control over it.

Linear thinking sees a straight line from problem through action to outcome: start-middle-stop/end. With systems thinking, you see loops not lines. You recognize that problems generally have more than one cause, and actions always have multiple outcomes: short- as well as long-term; intended and unintended; obvious and hidden; with ripple effect. In systems thinking, the initial cause (#1) produces an action that has an effect on itself (cause #1) and by changing it, creates cause #2. Action #1 also has other effects, creating causes #3 and #4: the ripple effect.

Most of the problems we see in healthcare are actually the result of prior fixes that failed. Medicare was intended to give all Americans health insurance and was calculated to cost less than a fraction of 1% of GDP. Forty-seven million are currently without insurance and healthcare consumes over 15% of GDP. A fix that failed.

HMOs (health maintenance organizations) were supposed to maintain our good health and to reduce medical costs. Need I reiterate our current situation? HIPAA was supposed initially to give us portable (job-to-job) health insurance and later, to protect the confidentiality of our medical information. It does not assure portability and certainly was never intended to increase medical errors as well as escalate costs. Fixes that failed. Actually fixes that made things worse.

There are four reasons for fixes that fail or make things worse.
• No evidence before action
• Act on (treat) effects not causes
• Measure wrong outcomes or not measure outcomes at all
• No feedback or ineffective feedback

Fixes that fail apply just as much to your home and your work as to fixing the entire healthcare system. At work, suppose you find a department whose budget is out of alignment: expenses higher than can be justified by what they do. You reduce the budget - fire people; retire equipment; cancel activities - until the budget matches the revenue. Problem solved. This is how many businesses and most States fix their budgets.

Systems thinking shows how such budget "fixes" fail or generally make things worse. "Balancing" the Maintenance budget makes it unable to keep everything working and the output of other departments fall. Reducing the number of nurses in the Operating Room ultimately closes the OR. Cutting asthma prevention out of this year's State budget produces temporary balance but then increases next year's expenses because of more acute asthma attacks (that were not prevented). Systems analysis and production of ad hoc evidence would have prevented all these fixes that failed or made things worse.

Healthcare (and everything else) could benefit by systems thinking.