Donella Meadow’s, in her 12 Leverage Points, gave us some of the clearest perspective on how to influence a complex system like US health care. Let’s explore Donella Meadow’s insights, as they apply to health and the healthcare system. In my opinion she added humanity and spirituality (or at least meaning) to system dynamics.
Her 12 leverage points, in reverse the order that she published them, are listed here and then discussed in the context of health and healthcare. From the most powerful to the least powerful:
Here I have made a first pass at connecting the Rippel Foundation’s Rethink Health system dynamics model levers to Donnela Meadows 12 Leverage Points. The reason I am doing this is to both highlight the relative impact of each health care lever and to highlight the need for different strategies to “implement” the levers. There is not much mechanical about her first four foundational high leverage points: paradigms, mindsets, goals, and organizing/self-organizing.
Notice that the power of the leverage points (the way I have organized them) is highest at #1 and progressively decreases until # 12. You may notice that most of our attention and effort is at #12, which is problematic.
The three green levers are existential. I think that Dialogue is a foundational communication method/strategy for the “existential” system leverage points.
The three blue levers are political. I think that both Community Organizing and Ostrom’s governance of common pool resources as foundational communication method/strategy for the “political” system leverage points.
The three yellow levers are very interesting and responsible for the counter-intuitive nature of complex nonlinear dynamic systems. These are seldom understood and seldom taken into account. I think the community conversations grounded in the Rippel system dynamics model are foundational for the “counter-intuitive and non-linear” system leverage points.
The three orange levers are linear, more commonly understood levers used by some of our our best business thinking–lean, Toyota production system, six sigma. Unfortunately, they are puny and often irrelevant if the lower lever pushed in the wrong direction. For intractable problems the lower levers are almost always pushed in the wrong direction! I think that Lean / TQM / IHI-like interventions are useful methodologies for the the day-to-day business operational level. A3 thinking and problem solving is my favorite and I think that Cindy Jimmerson’s Lean Healthcare West is a very good resource.
From most powerful to least powerful.
“Transcending paradigms may go beyond challenging fundamental assumptions, into the realm of changing the values and priorities that lead to the assumptions, and being able to choose among value sets at will.
Many today see Nature as a stock of resources to be converted to human purpose. Many Native Americans see Nature as a living god, to be loved, worshiped, and lived with. These views are incompatible, but perhaps another viewpoint could incorporate them both, along with others.”
Its goals, structure, rules, delays, parameters. A society paradigm is an idea, an unstated assumption that everyone shares, thoughts, or states of thoughts that are sources of systems. Paradigms are very hard to change, but there are no limits to paradigm change. Meadows indicates paradigms might be changed by repeatedly and consistently pointing out anomalies and failures to those with open minds.
A current paradigm is “Nature is a stock of resources to be converted to human purpose”. What might happen to the lake were this collective idea changed ?
Changes every item listed below: parameters, feedback loops, information and self-organization.
A city council decision might be to change the goal of the lake from making it a free facility for public and private global use, to a more tourist oriented facility or a conservation area. That goal change will effect several of the below leverage points : information on water quality will become mandatory and legal punishments will be set for any illegal polluted effluent.
Self-organization describes a system’s ability to change itself by creating new structures, adding new negative and positive feedback loops, promoting new information flows, or making new rules.
For example, microorganisms have the ability to not only change to fit their new polluted environment, but also to undergo an evolution that make them able to biodegrade or bio-accumulate chemical pollutants. This capacity of part of the system to participate to its own eco-evolution is a major leverage for change.
Such as incentives, punishment, constraints. Pay attention to rules, and to who makes them.
For example, a strengthening of the law related to chemicals release limits, or an increase of the tax amount for any water containing a given pollutant, will have a very strong effect on the lake water quality.
Rules that change a negative feedback loop can slow down a process, tending to promote stability. The loop will keep the stock near the goal, thanks to parameters, accuracy and speed of information feedback, and size of correcting flows. For example, one way to avoid the lake getting more and more polluted might be through setting up an additional levy on the industrial plant based on measured concentrations of its effluent. Say the plant management has to pay into a water management fund, on a weekly or monthly basis, depending on the actual amount of waste found in the lake; they will, in this case, receive a direct benefit not just from reducing their waste output, but actually reducing it enough to achieve the desired effect of reducing concentrations in the lake. They cannot benefit from “doing damage more slowly” — only from actually helping. If cutting emissions, even to zero, is insufficient to allow the lake to naturally purge the waste, then they will still be on the hook for cleanup. This is similar to the US “Superfund” system, and follows the widely accepted “polluter pays principle”.
Who does and does not have access to what kinds of information. Information flow is neither a parameter, nor a reinforcing or slowing loop, but a loop that delivers new information. It is cheaper and easier than changing structure.
For example, a monthly public report of water pollution level, especially nearby the industrial release, could have a lot of effect on people’s opinions regarding the industry, and lead to changes in the waste water level of pollution.
A positive feedback loop speeds up a process. Meadows indicates that in most cases, it is preferable to slow down a positive loop, rather than speeding up a negative one.
The eutrophication of a lake is a typical feedback loop that goes wild. In a eutrophic lake (which means well-nourished), lots of life can be supported (fish included). An increase of nutrients will lead to an increase of productivity, growth of phytoplankton first, using up as much nutrients as possible, followed by growth of zooplankton, feeding upon the first ones, and increase of fish populations. The more nutrients available there is, the more productivity is increased. As plankton organisms die, they fall at the bottom of the lake, where their matter is degraded by decomposers. However, this degradation uses up available oxygen, and in the presence of huge amounts of organic matter to degrade, the medium progressively becomes anoxic (there is no more oxygen available). Upon time, all oxygen-dependent life dies, and the lake becomes a smelly anoxic place where no life can be supported (in particular no fish).
Relative to the impacts they are trying to correct against. A negative feedback loop slows down a process, tending to promote stability. The loop will keep the stock near the goal, thanks to parameters, accuracy and speed of information feedback, and size of correcting flows.
For example, one way to avoid the lake getting more and more polluted might be through setting up an additional levy on the industrial plant based on measured concentrations of its effluent. Say the plant management has to pay into a water management fund, on a weekly or monthly basis, depending on the actual amount of waste found in the lake; they will, in this case, receive a direct benefit not just from reducing their waste output, but actually reducing it enough to achieve the desired effect of reducing concentrations in the lake. They cannot benefit from “doing damage more slowly” — only from actually helping. If cutting emissions, even to zero, is insufficient to allow the lake to naturally purge the waste, then they will still be on the hook for cleanup. This is similar to the US “Superfund” system, and follows the widely accepted “polluter pays principle”.
Relative to the rate of system change. Information received too quickly or too late can cause over- or under-reaction, even oscillation.
For example, the city council is considering building the waste water treatment plant. However, the plant will take 5 years to be built, and will last about 30 years. The first delay will prevent the water being cleaned up within the first 5 years, while the second delay will make it impossible to build a plant with exactly the right capacity.
Such as transport networks, population age structures. A system’s structure may have enormous effect on operations, but may be difficult or prohibitively expensive to change. Fluctuations, limitations, and bottlenecks may be easier to address.
For example, the inhabitants are worried about their lake getting polluted, as the industry releases chemical pollutants directly in the water without any previous treatment. The system might need the used water to be diverted to a waste water treatment plant, but this requires rebuilding the underground used water system (which could be quite expensive).
Relative to their flows.
Such as subsidies, taxes, standards. Parameters are points of lowest leverage effects. Though they are the most clearly perceived among all leverages, they rarely change behaviors and therefore have little long-term effect.
For example, climate parameters may not be changed easily (the amount of rain, the evapotranspiration rate, the temperature of the water), but they are the ones people think of first (they remember that in their youth, it was certainly raining more). These parameters are indeed very important. But even if changed (improvement of upper river stream to canalize incoming water), they will not change behavior much (the debit will probably not dramatically decrease).