Marjorie Wiggins, Vice President of Nursing at Maine Medical Center,
a 650-bed hospital, recalls being in the emergency room on a busy night when patients seemed to be arriving by the dozens. The waiting room was filed. Nurses were unable able to move admitted patients. The emergency department might have to be shut down and patients might have to be diverted to another hospital. Yet records were showing 12 empty beds. What happened? All the housekeepers went to dinner at the same time to give a shower for one member of the staff.
Housekeepers returned to work, prepared rooms, and the threatened shut down and diversion were avoided. But the incident illustrates the extraordinary interdependence of all players in complex modern healthcare systems. One principle of complexity is nonlinearity—small things, like an unusual dinner hour, can have very large effects. Ms. Wiggins discussed the challenge of change and new roles for nurses in today's turbulent healthcare environment. She was one of the presenters at the July 12 -14 Plexus Institute conference at St. Joseph's College in Standish, Maine.
While conventional models have emphasized the role of experts, the partnership model adopted by Maine Medical Center emphasizes the strength of all agents and the mutual relationships of all involved in patient care. The idea, she explained, is that while the nurse as professional caregiver is the expert in some clinical information, "You, the patient, are the expert in you, your family, and your resources."
The concept has created many changes in practice. For instance, nurses traditionally prepared patient information reports for the next shift in a small room behind the nurses’ station. Under the partnership model, the shift change information is delivered at bedside, in the presence of patients and family members, and often with contributions from multiple medical providers. Patient safety checks often are done at the same time. The results, said Ms. Wiggins, include improved patient satisfaction and knowledge. In addition, careful and respectful language to patients and among staff is practiced and becomes habitual.
Studies have shown that patients often do not understand their medical conditions and medication, and patients who are not prepared to manage their own care are often readmitted to the hospital, Ms. Wiggins said. Preventable readmissions within 30 days of discharge waste billions of dollars every year. Using a redesigned discharge process, nurses double time spent preparing patients for discharge from eight to 16 minutes. Families are present when possible, and nurses explain medication, provide devices such as a pill box or alarm when necessary, and help uninsured patients find ways to get their medications. Another change allows families to be present, if the patient so desires, during "codes"--the emergencies when patients lives are in danger. "Dying is part of the life process," Ms. Wiggins observes, "but we often don't bring families in." For those fearing litigation, she added, law suits actually decrease when families are present, because they see that providers did all possible for their loved one.
Ms. Wiggins also described the new role of clinical nurse leaders (CNLs), master's degree level nurses who follow the most vulnerable patients through their entire hospital stays, keeping track of care and treatment during their interactions with countless people as they are moved from one department to another in a hospital. She said CNLs have improved patient care by seeing that patients get what they need, and they have saved money by identifying patterns that show some procedures and practices that don't help patients can be eliminated.Claire Lindberg, professor at The College of New Jersey School of Nursing
presented a brief primer on Complexity Science. She emphasized the interdisciplinary nature of the science, which has influenced scholarship in biology, economics physics, the social sciences, anthropology, management and mathematics, as well as nursing. Complexity is not one theory, she said, but many. Dr. Lindberg briefly described complex adaptive systems and complex responsive processes, as well as such central complexity concepts as self organization, emergence, and distributed control. For fuller treatment of this material, see the chapter she wrote with Curt Lindberg in On the Edge, Nursing in the Age of Complexity
, edited by Claire Lindberg, Curt Lindberg and Sue Nash.Bruce West, chief scientist in the Mathematical and Information Directorate of the Army Research Office
, talked about the history of ideas, the roots of complexity science, and the vital importance of understanding variability. One of his recent papers, Why Six Sigma Science is Oxymoronic, argues that eliminating variability is counterproductive in research environments and in human systems generally. The mathematician Carl Friedrich Gauss
(1777 – 1855) developed the law of averages that became the bedrock of all statistics we learned in school, Dr. West said, "and it is wrong.” At the end of the 19th Century, the economist and philosopher Vilfredo Pareto
asked new questions and looked at data in a new way. He discovered the power law distribution of income, and his work introduced a world view more consistent with the principles of complexity science. Mathematical and averages that create a "normal”
distribution curve work fairly well with a subject like human height, which has restricted intervals within a fairly small range. An "average" adult of five feet nine inches tall won't meet another adult twice his height, Dr. West explained. But he could easily meet someone with five times his income. (If Bill Gates were in a room with five minimum wage workers, the average of their incomes would be meaningless.) Income distribution, consumer behavior, weather systems and any system where outliers can dominate requires an understanding of power laws.
Dr. West gave several examples of how averages can distort reality. For instance, the "average” scientist has 3.2 published citations a year. But 35 percent of scientists have no citation, and 90 percent publish less than the average. The scientist who has 3.2 citations is actually in the top four percent for published citations.
Sixty years ago scientists began developing revolutionary ideas about the organization of living networks, he explained, and recent advances in complexity science have dealt mathematics of complex networks. He said complex systems are most robust when they are confronting problems they have evolved to solve. He spoke of, habituation, negative entropy, how two complex systems might influence each other, and the need for more scientific exploration of complexity science. The "take home” message, he advised conference goers, is that the best way to influence complex networks is not direct force or dominant authority. The best influence can be delicate and direct, he said, but the influence must match the network in complexity.
Dr. West has written scores of papers, journal articles and books. His book Where Medicine Went Wrong
explores how misuse of averages in human physiology have delayed understanding the role of variability in healthy human systems. Lack of variability, he has asserted, leads to the morgue.