officers or chief executive officers, are the best ones to lead change. But more profound change is clearly needed.

An adequate characterization of the health care system is needed to identify opportunities for improvement. There are three types of systems: simple, complicated, and complex. A simple system follows a standard recipe to yield results. A complicated system involves combining multiple subsystems and can be recreated by following the same procedures (e.g., sending a rocket to the moon). A complex system is made up of multiple subsystems, but each application is unique (e.g., raising a child). Health care is sometimes mischaracterized as a complicated system. In reality, health care is a complex system, and the spread of improvement both inside and outside health care is complex as well, Plsek said.

Much is known about complex adaptive systems and spread of innovations within such systems,1 Plsek said, referencing the work of Trish Greenhalgh (Greenhalgh et al., 2004; Plsek and Greenhalgh, 2001) and others. Spread of improvement and innovation within a complex system combines characteristics of the innovation itself, characteristics of the system, characteristics of the people adopting the innovation, and characteristics defining the context of the system. Plsek pointed out that while there are many characteristics of complex systems, three that are particularly important in understanding how improvements spread are the nature of relationships and coordination; attractors, described as the underlying motivating factors for the behaviors we observe in ourselves and others; and the interactions among structures, processes, and patterns.

The first characteristic of complex systems is that relationships and coordination are often more important than the parts of a system, Plsek said. Management expert Henry Mintzberg identified six basic mechanisms of coordination in organizations: mutual adjustment, direct supervision, standardization of work processes, standardization of outputs, standardization of skills/professions, and standardization of norms (Mintzberg, 1989). The particular mechanisms driving health care are the standardization of skills/professions, mutual adjustment, and standardization of norms. Professional organizations—the term Mintzberg uses to describe health care, law firms, and other such entities—coordinate naturally through professional standards such as education and regulation, at the heart of which is


A complex adaptive system is a collection of individual agents that have the freedom to act in ways that are not always predictable and whose actions are interconnected such that one agent’s actions changes the context for other agents (IOM, 2001).

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