Ant hills, intercellular communication, human interaction… all consist of complex networks that cannot be described linearly (are high-dimensional), nor can they be easily understood or modeled. The study of such complex systems can be applied to a plethora of subjects, and Mark Smith, MD and Craig Feied, MD decided to apply complex system theories to, what else, the Emergency Room:

The Emergency Department as a Complex System – Mark Smith, MD and Craig Feied, MD

The Emergency Department (ED) system, as simply as possible, is an enclosed system comprised of the entrance and exit of patients. It gets more complicated when it comes to the details of each medical condition and treatment, the transfers of patients between people and rooms, the tests done, the paperwork… every minor decision that is made and unexpected event that occurs will completely change the path of a patient, and no two paths are ever the same. When picturing this, I think of random fractals, in which anything can happen as it grows into a complex, irregular, and multi-dimensional image.

 The ED may be more of a system of processes than a network, although it is possible to think about it like the networks we talk about in class. The nodes could be possible events that occur, and the edges would be the paths that patients may follow. Some nodes would be passed through often (everyone has to fill out forms), whereas rare accidents can call for a one-of-a-kind treatment that will only be on one patient’s path. Of course this web of events would be huge, as think about all the possible things that may happen in the ED. So perhaps we could think of it more as a sequence that is being created, where one thing leads to the next in a directed graph of events.

As in several of the networks discussed in class, the ED system is rich and complex, and often paradoxical. Similar to Braess Paradox in which an extra road increases travel time and decreases productiveness, the more complex the ED system is, the worse its operating state. It is important in an ED that there are not too many people to go through, or too many tests to be done. The ED system goes further beyond this paradox as it is to amazingly able to move between order and chaos and back again, often because of one seemingly-insignificant factor. An ED is sometimes a state of chaos when there are too many patients and too little organization. Yet sometimes this chaos will switch to a beautiful order; this is not order in the sense of calmness, but order that Smith and Feied refer to as “a humming complexity, a room resonance,” in which so much is happening but it all seems to be working well together as intended. This is the way of many complex systems and networks, in which one change or addition can either fix or completely disrupt the workings of the system.

In Smith’s and Feied’s attempt to train this beast that is the ED system according to the concept of complex systems, they offer several interesting theories. The main idea is increasing simplicity, which relates to the idea that less is better. As in most systems that need optimization, it is better to have less connections or steps. For example, in the case of the ED, the process of testing a patient’s blood can be reduced from 8 to 3 steps, reducing the nodes and the length of connections necessary.

In class we talked about the strength of connections, as well as their direction. Smith and Feied suggest that we use both of these as applied to the ED. They suggest that it is important to put value to each of the processes in ED care so as to better evaluate quality. This gets complicated, however, since some of the process scores need to be high (e.g. patient satisfaction, revenue, reputation), whereas some need to be low (e.g. turnaround time, complaints, costs, violations). They also suggest that each process needs a feedback loop that goes in the reverse direction of each process to check for error, making each process connection a two-way connection. This is much better than a global system of error identification that simply analyzes the end, rather then every step in between. Local evaluating connections allow for increased quality and awareness of places for improvement. If we were actually able to map out a particular ED, we could analyze the values of each connection with the feedback loops and find ways to improve various paths through the system.

There are some final ideas offered by Smith and Feied that I find very interesting. Their 80/20 rule states that putting in 20% of the effort required will bring about 80% of the return, so often it is important to avoid burdensome perfectionism and focus on small but significant change. This relates to their 85%/15% rule, which says that for a complex system it is important to find the most important 15% to change, as this is really the most you can conquer at a time. But as mentioned earlier, just a 15% change when done right can affect the system as a whole in just the right way. This is an interesting statement, and one that can probably be applied to many issues beyond the ED. When optimizing any system, it may be helpful to be in the pessimistic mindset that one can only affect a small portion of the entire problem, yet it is important to put as much as possible into that small portion because that makes all the difference.

Mapping out any network or system can often lead to clarity and show potential improvement sites. In the study of networks we like to believe that this is always the case, that we can visualize and understand any system of connections. Yet complex systems make things much more interesting, particularly when we are looking at a system such as an Emergency Department, where optimization can save money, time, and most importantly, lives.