Aussie health informatics specialist Enrico Coiera has published a really useful paper on why change is so hard to achieve in health systems (June 23rd British Medical Journal, BMJ 2011; 342:d3693) - and by definition in all complex systems, including yours.

According to Coiera "Health systems around the world are struggling to find effective ways to make clinical practice safer, more effective, and evidence based", and "It is a conundrum, and a source of deep frustration, that health systems seem so resistant to change. Safety and quality initiatives struggle to make care safer for patients. Restructuring ... seems to achieve little. Evidence based recommendations and standards pile up unheeded or poorly enacted."

Anyone who deals with health systems knows this to be true. And if you've been around as long as I have (four terms as a member of the Southern DHB), you'll agree with Coiera: who we blame depends on where we stand. "We make culprits of clinical culture, policy, politics, or the vested interests of industry."

But, he asks, what if all of those diagnoses are wrong? What if inertia is a fundamental, inevitable property of all health systems? If that's true, and we don't account for it, we will never create the safer, more effective, and resilient health systems we all strive for.

Coiera identifies two sorts of inertia - clinical and systems. It's tempting but wrong to blame the clinicians for clinical inertia, because it has other causes. Mostly about making suboptimal decisions to satisfy competing demands - a process called satisficing. Satisficing is at odds with evidence-based models of care, doesn't sit well with interventions that target particular behaviors, and subverts initiatives that focus on 'putting the patient first'. Imposing more rules - the standard approach to suboptimal behaviour - also means that compliance will eventually approach zero. A wealth of standards leads to a poverty of their implementation.

Inertia is also seen in slow progress with patient safety initiatives and the limited effectiveness of restructuring. So is it just a manifestation of a more general system inertia, Coiera wondered? Originally blamed on administrative and political decision making - on people - systems inertia is increasingly understood to be caused by the systems themselves.

Health systems also become more complex over time, because of effects such as changes in staff, breakdowns, miscommunication, and workarounds - as well as the accumulation of rules and standards. And because policy makers and managers introduce new or improved processes while not dismantling the old ones.

Inertia, complexity and reform
Recognising inertia has implications for how we interpret attempts to reform health systems. Rather than a negative and willful reaction, inertia is a natural behaviour of systems - a rational response when individuals and organisations have to satisfice. Systems constrained with competing demands and starved of resources simply don't have the capacity for new interventions.

This means that for change to stick there must first be a reduction in complexity. For example, we might need to retire old standards to free clinicians up to adopt new ones, or supply new resources to meet additional demands. System change requires coherent actions that both build and destroy.

The idea of creating a "bundle" - a set of clinical actions with a reinforcing internal logic - is also gaining traction. Once commenced, the whole bundle must be completed, with limited opportunity to avoid individual steps because of competing demands. Bundling might also help us 'right size' system change.

As a systems thinking advocate, I hear some familiar and general themes emerging from between the lines in Coiera's paper, especially in his final words of caution. Death 'by design' is not excision, he says: removing unwanted processes in a health system after the fact, and without a whole of system approach, is likely to have many unanticipated and unpleasant consequences.
That too is the nature of systems.