Delays create oscillations. These oscillations often are made worse by managers’ attempts to control them. The trick is to be aware that all oscillations are due to delays in feedback, then finding the delay and changing it. I once heard the CEO, Bob Galvin, of Motorola say that “Quality is Cycle-Time”. I am sure he meant something different than system dynamics teaches us but his emphatic admonition resonated. We must at a minimum avoid making things worse. We can avoid putting more force into control which amplifies the oscillation. Instead look for ways to address the delay itself. Simple rule: if you cannot change the delay, don’t push harder.


Stocks dominated by positive feedback loops change dramatically–getting bigger faster or getting smaller faster–bust or collapse. If you care about the long term outcome, rather than only short term gain taking, then it makes sense to find ways to slow the rate of change as well as to introduce balancing loops (negative feed back loops) to keep the stock and the system within sustainable ranges.


Some entrepreneurial  medical system leaders would suggest that they should be the main economic beneficiaries of improvements in healthcare delivery. Clearly the customer and society should be the main economic beneficiaries since they pay the current excess costs and they have paid for medical research, education and economic protection of professionals.

That said, it makes sense to provide effective incentives to providers to make changes in the way the operate.


Environmental hazards are noted to account for 5% of adverse health events. Most environmental hazards are related to socioeconomic status and are therefore amenable to improving the social determinants of health that determine economic status.


While perfect medical care has the ability to improve health or reduce unnecessary deaths by 10%, improved health behaviors have a potential for four times that impact. So the question, how do people change their behaviors, begs an answer. That question is worth four times as much all medical research!

Redesign Primary Care Practices for Efficiency

Much has been clarified about how to do this for primary care and less so for speciality offices. This domain of experience and knowledge is called IDCOP (Idealized Design of Clinical Office Practice). This approach requires discipline, commitment, and ongoing management. Small offices run for and by the provider often cannot manage the ongoing discipline, commitment and management.

Dartmouth promotes “Clinical Microsystems”. In addition to these predecessors, many are now promoting Primary Care Medical Homes.

Some of us are quite focused upon the primary care physician in the belief that they can play the transformative role in health care.

It is important to understand the limits of these kinds of changes on the overall outcomes of healthcare system–for instance on the triple aim goals of cost, population health and experience of care.

Provide Adherence Support for Routine Care

Providing diagnosis and/or treatment is different from providing support of the individual’s choices and behaviors. Considering the difference, we should consider how best to provide the support services.


Since foundations are in the business of providing funds for social projects it is natural for communities to look to foundation funding of health system transformation. This is a dangerous way to fund anything that must be reliable and sustainable.

There is an active pursuit of grant-making for social change. Even the White House is promoting this approach.