Health care can't afford to wait to innovate.
The concept of "jet" propulsion (thrust created by the directed force of expanding gas) had been shown millennia before in Alexandria by Hero's revolving steam ball. The idea had been refined in the early 20th Century to consist of a piston engine driving a compressor, which in turn fed compressed air into a combustion chamber where fuel was burned to create the thrust. Not exactly a practical way of moving an airplane.
As a young pilot officer in the Royal Air Force, Frank Whittle explored novel possibilities for airplane propulsion. His father was a self-educated mechanic and was conversant in the action of turbines. Whittle saw that a turbine powered by the jet of gas exiting the engine could turn a compressor on the front, solving the problem.
He attempted to interest the Air Ministry in the idea, but they declined, based on the analysis done by Alan Arnold Griffith, an academic at the Royal Aircraft Establishment. (2) A crestfallen Whittle continued to believe in his idea and received a patent for it in 1930. He struggled to keep his project alive in a small, unfunded venture, Power Jets. Ltd.
Meanwhile on the continent, a decidedly different story was unfolding. Independent of Whittle, Hans von Ohain conceived of a similar turbojet engine and obtained a German patent in 1934. Von Ohain's mentor, Robert Pohl, arranged an introduction with a successful aircraft manufacturer. Unlike the bureaucrats at the Royal Aircraft Establishment, the manufacturer immediately saw the potential of this revolutionary propulsion system and began funding and testing.
The German jet first flew in 1939. By the time the British realized what was happening, the German jump was difficult to overcome. Though Whittle was vindicated, the British jet first flew in 1941.
Ironically, Arthur's own professional life was impacted by a situation not dissimilar. The story is told in the opening chapter of W. Mitchell Waldrop's, Complexity: The Emerging Science at the Edge of Order and Chaos. (3)
Moving from engineering to economics, Arthur developed the then-revolutionary concept of "increasing returns" to explain the patterns he saw all around him. The neoclassical economists of the time viewed this positive-feedback explanation of economic realities as heresy, as they were convinced that an analytic model could be developed to predict economic functions.
As Arthur put it, "The years from 1982 through 1987 were dreadful. That's when my hair turned gray." The editor of The American Economic Review sent a paper Arthur had submitted back with the explanation that although there wasn't anything technically wrong with the paper, they just didn't think the idea was worth anything! (3)
Incredibly, when a colleague presented a paper with a similar idea at the American Economic Association Meeting in 1984, it was hailed as a great advance forward. "It was simply dreadful," Arthur recalls. "I felt I had something to say and I couldn't say it--and the ideas were getting credited to other people. It appeared that I was following rather than leading. I felt like I was in some doomed fairy story." (3)
Arthur finally found support in 1987 in the person of Stanford professor and Nobel Prize winner Kenneth Arrow. Arrow had seen the brilliance of the idea and invited Arthur to participate in a conference in Santa Fe that led to the formation of the Santa Fe Institute.
Arthur's seminal idea on increasing returns became part of the whole body of knowledge we now know as complexity theory. And it almost never happened!
The truth of the matter is that there are many Frank Whittles, Hans von Ohains, and W. Brian Arthurs out there with the revolutionary ideas needed for health care reform. What we are desperately short of are the benefactors to support them.
In October 2011, three of the four Baldrige Award winners were health care organizations. (4) One was the Henry Ford Health System, but the other two, Schneck Medical Center of Seymour, IN, and Southcentral Foundation of Anchorage, AK, were small organizations with limited funds but unlimited ideas.
Very much like Whittle's novel combination of known technologies in new ways, Southcentral Foundation took the existing components of health care and combined them in a fundamentally different way. Their system is called "Nuka," after the Native word for "strong giant things." (5)
Reorganizing care around the "owner-customer" has produced a 40 percent drop in urgent and emergency department utilization, a 50 percent drop in specialist utilization and a 30 percent drop in hospital days, as well as an increase in the childhood immunization rate to 94 percent.
Solving the current health care conundrum will not be easy. However, medicine must take notice of examples from other fields to find the way to increase the value equation. That increase will not most likely come from completely new ideas, nor from incremental improvement in existing forms, but from combining existing models in novel ways.
The German airplane manufacturer did not invent the jet engine. Its development could have been looked at as a threat to the company's current business. Similarly, Kenneth Arrow had been a strong voice of the neoclassic economic theory, that ran contrary to Arthur's new idea.
Each of these innovators had a longer view of the horizon than their colleagues. In complexity terms, they recognized "emergent order" and understood the importance of fostering the "positive attractors" to reach the outcome.
Health care in general and medicine in particular have become very adept at dealing with the complicated, yet seem lost when it comes to the complex. Our training and experience have taught us that difficult problems, like machines, can be reduced to their components by experts, those components optimized and then reconstructed into a better machine.
Although this has worked admirably with many health care problems over the previous century, we have hit the proverbial wall. These tools no longer help with cost, access, quality, and, above all, value. Such problems fall into the category of what Rittel and Webber termed "wicked problems." (6) They are solved by looking for the right questions, not the right answers.
Many would be tempted to duplicate the solutions found by Southcentral Foundation in their own institutions, but that is precisely the wrong message to take. It is important to duplicate not the solutions they found, but their methodology in asking the questions.
In complex adaptive systems such as health care, the starting point matters! Outcome is a product of process as well as structure. The real danger of concentrating on what has been found to work elsewhere ("best practices") is seeing them as an end, rather than a beginning.
(1.) W.B. Arthur. The Logic of Invention. The Santa Fe Institute Working Paper 05-12-045 http://www.santafe.edu/media/workingpapersios/05-12-045.pdf. Accessed January 1, 2012.
(2.) F. Whittle. The Daily Telegraph, obituaries, August 10, 1996. http://www2.eng.cam.ac.uk/~bcb/whittle/telgraph.htm. Accessed December 30, 2011.
(3.) W.M. Mitchell. Complexity: The Emerging Science at the Edge of Order and Chaos. New York, NY: Simon & Schuster, 1992, pp. 15-143.
(4.) Four US organizations honored with the 2011 Baldrige National Quality Award. http://www.nist.gov/baldrige/baldrige_recipients2011.cfm. Accessed December 30, 2021
(5.) L. Blash, C. Dower, S. Chapman. Southcentral Foundation--Nuka model of care provided career growth for frontline staff. Research Brief, Center for the Health Professions, UCSF http://futurehealth.ucsf.edu/Content/29/2011_09_Southcentral_Foundation-Nuka_Model_of_Care_Provides_Career_Growth_for_Frontline_Staff.pdf. Accessed December 30, 2021.
(6.) H.W.J. Rittel, M.M. Webber. Dilemmas in a general theory of planning. Policy Sci. 4:155-169, 1973.
By Russell S. Gonnering, MD, MMM, FACS
Russell S. Gonnering, MD, MMM, FACS, is a clinical professor of ophthalmology and visual science at the University of Wisconsin School. of Medicine & Public Health in Madison, WI.
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|Author:||Gonnering, Russell S.|
|Date:||Sep 1, 2012|
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