Equilibrium Does Not Foster Reform


Public services, like all other areas of human behaviour, develop local equilibria in order to function.  Equilibrium specifics will favor powerful participants, which in health care are physicians, hospitals and private insurers.  In public education the power rests with teachers, principals and central administrators.

System operations are rationally adapted to prevailing constraints and incentives which most often do not involve measures of user satisfaction or outcome quality.  Health care systems are rationalized and local equilibria established by the power players regardless of the cost, quality or value of outcomes to patients.  The same phenomenon is found in public education: local systems continue their usual functions in perfect equilibrium regardless of the actual students, their individual needs or their learning outcomes. It is often said of both hospitals and schools that these are great places to work if it weren’t for the users which are the patients or the students.

Equilibria are self-sustaining.  Systems reform does not occur until local equilibria are sufficiently destabilized.   This can occur with sector innovation, for good or ill, of sufficient magnitude to reset or re-rationalize the usual local functions.  Walk-in clinics with their changeable staffs have replaced more stable relationships with a primary care provider or team because they are accessible.  Destabilization also occurs when the institution loses the confidence of the public it serves.  This can be seen in the shuttering of long established neighborhood schools when those schools, their staff and administrators, are uninterested, incapable or insufficiently resourced to meet real student needs as the student population shifts.

System participants at all levels must become less complacent. All systems can be improved, all the time and at any level.  System participants must perceive continuous system improvement as part of their jobs not extra work.  Providers must also see system users as the center point of the system and all other pressures and constraints as secondary.  The purpose of public systems is, after all, to serve the users, not to employ the providers. That is a fundamental shift in attitude that would help providers participate positively and coordinate innovation action. 

Users also have responsibilities in the continuous improvement process for the systems they utilize.  They must take the time and trouble to understand how those systems are structured, how the incentives operate and what their options are at all points in their interaction with the system.  Users must know what their goals are in interacting with the systems. They must be clear about their needs in that interaction and ceaseless in their feedback about how those needs are being met.  For most systems users these are big challenges.  Imbalances in power and information between providers and users contribute to the challenge as do culture, language and communication skill differences. Systems dedicated to continuous improvement allocate resources to supporting their users to become full partners in achieving quality outcomes.  We all have a role to play and we all can do better.

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