A Message from the Guest Editor

This edition of Healthcare Management Forum is broadly focused on behavioural health, a topic that was identified as part of a collaboration with the American College of Healthcare Executives. Both organizations are publishing editions of their journals in November on this subject; you’ll want to read Healthcare Management Forum and the Journal of Healthcare Management for a robust group of articles.

As leaders, we have all experienced that human behaviour at the micro, meso, and macro level, has been a key factor in some of our greatest triumphs and our biggest failures. Seemingly logical, evidence-based programs can fail because of user, client, or patient mistrust, such as was seen during the considerable community push back against COVID-19 vaccines and control measures during the pandemic. Remarkable improvements can be achieved in difficult conditions when those involved truly become engaged in the improvement process. As management consultant Karen Phelan wrote in her 2013 book, Sorry I Broke Your Company, “We have been led to believe…that businesses are logical and run by the numbers and that their models and theories will provide step-by-step instructions on how to succeed, but businesses are people—irrational, emotional, unpredictable, creative, oddly gifted, and sometimes ingenious people who don’t operate according to the theories.” Simply put: ignore the impact of behaviour at your peril when trying to make changes to the status quo.

For all its science, logic, and love of processes, timelines, milestones, and flowcharts, healthcare delivery relies on imperfect people working in different environments, and in different groups with sometimes opposing goals, to do the work. Healthcare is considered a complex adaptive system: such a system is composed of sub-groups that make independent iterative decisions on how to behave, the sub-groups interact with each other, often in unpredictable and immeasurable ways, and whose sum is greater than the individual parts.

Working in complexity requires different approaches as explained by Nason, who posits that the lack of significant healthcare improvement is at least partially because we continue to try to apply rules and processes more appropriate for complicated industries, such as Lean Six Sigma, in the hopes that it will provide some order and simplification to a world that often feels beyond our control. As Nason explains, while there are parts of the healthcare system that will be helped by such tools, complex systems require a focus on human behaviour, relationships, interactions, and organizational culture, not to mention leadership comfort with ambiguity and frontline worker empowerment. It requires “adaptive leadership” as described by Heifetz and others, an approach that is often counterintuitive to health leaders.

Viewed from a complexity lens, it should be clear why physician leadership development training is so important to enabling healthcare system change, given the influential role physicians occupy in modern healthcare systems. Sakelaris and co-authors qualitatively describe the positive impact of 10 years of physician leadership education at Sauder Executive Education on the British Columbia healthcare system. This is something I know well; I am a lecturer in complexity science in that program.

Writing about physician engagement from the East Coast, Brown stresses not only the importance of engagement, but provides strategies of how to engage. Key to these strategies are acknowledging physicians’ unique place in the healthcare system such as remunerating them for lost clinical time, and being explicit about the need for physician input, even at a high level when choosing what priorities to work on (it is not a “nice to have” but rather a “must have”). Brown stresses the importance of engagement and ownership over “buy-in”—a term that implies getting physicians to get on board with someone else’s idea and on someone else’s timeline.

Moving from doctors in the system to patients and communities, Lofters shows the benefits of community engagement and the use of community champions in HPV screening using self-sampling. This approach acknowledges the cultural gap between physicians the community and provides local, culturally acceptable role models rather than attempting to improve compliance with the traditional system through education and reminders. Again, the logic behind HPV screening being an important strategy to prevent cervical cancer is scientifically unassailable; however, the impact of cultural and behavioural factors will either facilitate adoption or ensure failure.

The COVID-19 pandemic drew attention to the barriers facing foreign trained workers to working in Canada. Baumann and co-authors write about the many barriers preventing internationally educated nurses being integrated in Ontario’s healthcare system, the vast majority of which are imposed by our healthcare system, ironically at a time of severe healthcare worker shortages. As Canada knocks down its barriers to employing foreign trained workers, we will also have to be cognizant of the potential “ripple effects” such as the impact on Canadian training programs and a potential increase in racist behaviours in our system.

Bond discusses the impact of the COVID-19 pandemic, as a “big event disruption,” on modern healthcare. Such external threats have the potential to nudge complex adaptive systems in different directions, including enabling the adoption of new approaches and technologies that might otherwise have been stalled prior to the event. As has often been said during the pandemic, never let a good crisis go to waste, and paradoxically although much attention has been paid to how the pandemic worsened healthcare, some issues such as virtual care have actually been improved.

Lee and co-authors show how a seemingly straight-forward clinical pathway, specifically a referral for complex gastrointestinal surgery, is quite complex. They identified 15 individual queues faced by patients, far more than might be apparent at the outset, and highlighted the importance of interactions between different components and individuals in the system. One can readily see how surgical queues differ from those in industry, such as a factory assembly line, where processes and components are the same each time, and success is not nearly so dependent on human behaviour and preference.

Global climate change is a frequently cited example of emergence in a complex adaptive system. Aboueid and co-authors dive into the barriers and enablers to implementing sustainable practices in healthcare, and show just how complex the issue is, with human behaviour and knowledge, infrastructure, public awareness, and political regulations and priorities all playing a role. They call for a clear leadership vision and a collaborative approach that recognizes the complexity of the issue.

Finally, Hemphill and co-authors describe a quality improvement initiative in long-term care that bears the hallmarks of a successful complexity-informed process, namely the engagement of those “touching the problem” such as residents, families and healthcare providers and the iterative plotting of ways forward through facilitation. As with the work of Bond mentioned above, this initiative was prompted by the experience of the long-term care community during the COVID-19 pandemic.

Hopefully, it is clear how seemingly disparate topics such as leadership training to HPV screening to surgical referrals and others, are all united by the requirement to lean into the complexity of the challenge. I suspect that many of us have historically viewed human behaviour as an obstacle to be overcome, yet as this edition illustrates, engaging in the complexity of behaviour can often lead to a better healthcare system.