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Stop Making Sense? Seeking Clarity in a Chaotic or Complex World

Section Editor(s): Ford, Eric W. PhD, MPH

doi: 10.1097/JHM-D-19-00159

Received July 24, 2019

Accepted July 24, 2019

There is a difference between chaos and complexity. Chaotic systems are driven by simple rules that, when applied repeatedly, tend to increase disorder. Moreover, chaotic systems are difficult to influence because the rules are fixed. Complex systems have multiple parts that interact to influence the environment. These features create system properties that can be observed and modeled. Several authors in this issue of the Journal of Healthcare Management find that the ideas used by people who study chaos theory are applicable to our healthcare system.

The Diversity and Inclusion column starts out with a classic example of chaos theory—the “butterfly effect.” Ernie W. Sadau, FACHE, and Tiffany Capeles describe how our implicit biases (yes, dear reader, we all have them) build up to diminish our organization’s adaptability and competitiveness over time. The solutions applied by Sadau, Capeles, and their colleagues at CHRISTUS Health create a change model that addresses the small features of decision-making that may accumulate in either a positive or negative way.

The Managing Risk column by consultants Simon Mawer and Barry Katz makes explicit references to complex systems—in particular, how design thinking can be used as a problem-solving tool in complex social and technical environments. The end-user focus of design thinking is consistent with other large-scale programs in healthcare today, such as patient-centered medical homes and accountable care organizations.

The empirical research article by Danielle J. O’Laughlin; Jennifer A. Bold, APRN, CNP, DNP; Darrell R. Schroeder; and Petra M. Casey, MD, looks at the professional satisfaction of advanced practice providers (APPs). They find that APPs who work in environments that are more complex achieve higher levels of professional satisfaction. It is gratifying to learn that the human condition contains the desire to both thrive and excel in challenging settings.

When I was an undergraduate, back in simpler times, two classes were required: Accounting 1 and Accounting 2. The professor who taught them joked that Accounting 1 was what you showed the Internal Revenue Service (IRS) and Accounting 2 was how you made money. The article by Darrell J. Gaskin, PhD; Bradley Herring, PhD; Hossein Zare, PhD; and Gerard Anderson, PhD, examines how hospitals report their charity care to the IRS and Centers for Medicare & Medicaid Services and seems to find the same vein of bookkeeping. I will not spoil the ending, but it is fascinating how small differences in government organizations’ definitions of charity care can lead to wildly different reporting norms.

The third article in this issue is a qualitative piece by Timothy Hoff, PhD, that looks into the sensemaking of frontline employees. Using comparative case design to study organizational phenomena is one of the most challenging ways to gain management insights. It requires numerous hours in practice settings, both interviewing and observing caregivers. Translating that fieldwork into findings that can be readily understood is one of the highest art forms in academic writing. Nobody in our profession today does a better job of this than Hoff. The sensemaking model, with roots in complexity theory, is one of the most important for understanding the U.S. healthcare system. Many different types of professionals must come together to make the system work, and to do that, they must arrive at a shared vision.

The article by Matthew DeCamp, MD, PhD; Vadim Dukhanin, MD; Lindsay C. Hebert; Sarah Himmelrich; Scott Feeser, MD; and Scott A. Berkowitz, MD, uses a novel methodology to look at how patients view participation on governing boards and advisory councils. The researchers conducted a free-text analysis of patients’ responses to elicit common themes around the topic—another form of sensemaking, in some regards. They found that patients want to be participatory, but making that happen is a complex problem.

So, what is the simple message I would like you to take away from all of these thoughts on chaos, complexity, sensemaking, and the way forward? I genuinely believe that the design-thinking school will have a significant impact on the way we deliver care, and for the better. A quote from graphic designer Paul Rand (1981) sums up my thoughts on the essence of design thinking:

Design is a way of life, a point of view. It involves the whole complex of visual communications: talent, creative ability, manual skill, and technical knowledge. Aesthetics and economics, technology and psychology are intrinsically related to the process.

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Rand P. (1981). Politics of design. In: Herdeg W. (Ed.), Graphis annual (pp. 233–235). Zurich: Graphis Press.
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