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Motivations
-Increasing needs and costs of health-care and health care systems in the future
-Increasing difficulties on behalf of health-care workers intheir relation with patients: complexification and differentiation of relations, stress, burn-out, early exit,…
-Increasing demands in performance of the workers, the institutions and the system on macro-scale
Why cybernetics?
-Art and science of regulation and control
-Health-care is regulation of health-condition of patientsand regulation of systems
-Applicability of cybernetics in a broad range of domains: economy, sociology, biology: many activities in almostevery branch of science and life.
-Cybernetics: art of managing relationships (also by quantification)
Tree different elementsCommon terms
-Two players: patient and care provider (in the mostsimple form)
-Tree elements as basic system: Patient (D), care provider (R) and outcome (E)
-One desired outcome: patient’s health or health-stabilisation (idealised expectation)
Tree elementsCybernetic terms (Ashby)
Patient: disturbance or variety inducerAmount of different problems
Care provider: regulatorAmount of different responses
Outcome: amount of different results
Conceiving variety
-Each element has variety of a certain amount
-The amount of variety depends of both the element and theobserver of the element (we must be aware of the trap of thedetached observer: he does not exist)
-One’s variety is determined, it can be measured
-Measuring variety is the beginning of knowing it
-Knowing it is the beginning of handling it
Conceiving variety
-Variety reflects a state of a element at a certain moment
-The element will always be composed of parts or components that can change in function of time
-This element will be called a vector
-The components of the vector can have different values
-Change of the vector always means change of values
Variety and constraint
-Variety and constraint are intimately interlinked
-Variety without constraint is not conceivable
- Constraint sets a limit on variety and enables us to handlethe world
- Constraint makes things predictable
- Constraints are the rules for every transformation
Transformation
-Transformation is always the action of an operator onan operand with transform as result
-Transformation can be closed or open
In theory, every transformation on an unlimited numberof operands can result in an unlimited number of transformsIn practice, a transformation operates under certain rulesor constraints, e.g. the transformation of the embryo intoa foetus will occur under certain constraints
Transformation-A transformation can be single valued or multiple valued:
Single: when each operand will be transformed in onetransformMultiple: when each operand will be transformed in manytransforms
-A transformation can be single valued and one-one, when eachoperand corresponds with a different transform
-In all other cases they will be of the many-one type
-Another type of transformation (the most frequent one) is theidentical transformation
Variety and health-care
-Every patient is a vector with different possible values
-Every patient can have an infinite number of values
-Every care provider is a vector which can take a limited numberof values
-The variety of the outcome is the different possible values the outcome can take.
-The table T is the system (unit, hospital,…) which provides theoutcome.
The Law of Requisite Variety
-Only increasing variety of R can force down the variety of outcomes
-To force down the variety of outcomes, the variety in R must increase
Vo >or = Vd / Vr
-Only variety can destroy variety
-If we want the outcomes to take one value, the variety of R must be at last equal to that of D.
Variety of patients and care providers
-How to control the patient’s variety?
-The variety of patient needs is in most cases larger than the variety of care providers.
-The classic way of confronting variety of patient needs is toenlarge the variety of the care providers so that
Vd = Vr or
Vo = 0
The art of Regulation
-Care providers are in se regulators who transform patientneeds in one outcome: stabilisation, health,…
-The aim of cybernetic approaches consists in investigating the ways in which this regulation can be reached in the most effective way
-The most effective way to do this begins with acceptingthe law of requisite variety and to investigate the ways oforganising care taking into account the law.
What’s regulation?
-Regulation is the way the regulator follows to transformthe input of D into a certain range of desired outcomes.
-The only way for the regulator to do this is to fully take into account the variety of D.
-Without respect of the law, the regulator fails in his mission:suffering and decline of the whole system are the result.
Regulating health-problems
Three questions – three answers :
-Confronting patient’s problems = defining the set of problems
- When the patient’s problems are known, define the target: result
- How can we transform the problems in the target: desired Outcome?
Defining problems (D)
-Different aspects as components of one problem or vector
-Each component can have two possible values (0-1)
-Variety of the D-vector = 64 different states
-Describing patient’s problems = result of an interaction process
-Defining patient’s problems = first important step in delimitingvariety on the input of the system T (blocking).
Defining Outcome (E)
-Limiting outcome = enlarging R
-If outcome is limited to 1 value (1), Vr must be = Vd.
-Health-care is idealistic because it claims a limited set of outcomes
-Health care providers must be precise in formulating outcomeand results.
Possible solutionsIncrease Vr
-Vr = Vd
-Certain components of R becomes multi-functional: increasingthe competence of certain components of R.
-Increase the competence of R .
-R ‘s possibilities aren’t illimited
- Paradoxical with spcialisation
Decreasing D
-Division of D in different components
-Block Vd = selection in variety of components of DPatient information: what can the patient expect?
-Sequentialisation of the transformation: stochastic problemtransformation of components
-Transform certain components of D in components of RImplication of patients in the treatment.
-Clustering of different components
Increasing Vo
-Non-limiting the possible outcomes: compound target
-Non-defining the target
-Defining the possibile outcomes in function of Vr
5 systems or functions
System 1: operational level-activity-regulation-registration
System 2: metasystem subsuming all system one – coordinationby information
System 3: information transmitter – coordination by regulation algodonometer – stabilisator/inhibitor
System 4: big switch – modeling
System 5: decision-making.
Division of workFrom opposition to collaboration
Preliminary condition: patient and care-provider must be consideredas one unity. Switch from applicatif to process-care (2th cybernetics).
Autonomic activitiesSystem 1: patient – CPSystem 2: CPSystem 3: CP
Management activitiesSystem 4: patientSystem 5: patient - CP
Managing variety
-System 1: patient too assumes a regulation function.Enhance patients capabilities:
Increase Vr
-System 5: Define the target and objectives, evaluate and plan.
Increase VoDecrease Vd
Cross-matching LRV and Managing HC-model
Objective: manage care trought the interaction betweenPatient and CP in one system
Increase Vr:
-patient becomes a regulator too in collaboration with CP-regulation becomes auto-regulation-transformation becomes auto-transformation