Cybernetic Applications and Health-Care Julien Libbrecht

Motivations -Increasing needs and costs of health-care and health care systems in the future -Increasing difficulties on behalf of health-care workers in their 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 patients and regulation of systems -Applicability of cybernetics in a broad range of domains: economy, sociology, biology: many activities in almost every branch of science and life. -Cybernetics: art of managing relationships (also by quantification)

Tree different elements Common terms -Two players: patient and care provider (in the most simple 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 elements Cybernetic terms (Ashby) Patient: disturbance or variety inducer Amount of different problems Care provider: regulator Amount 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 the observer of the element (we must be aware of the trap of the detached 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 handle the world - Constraint makes things predictable - Constraints are the rules for every transformation

Transformation -Transformation is always the action of an operator on an operand with transform as result -Transformation can be closed or open In theory, every transformation on an unlimited number of operands can result in an unlimited number of transforms In practice, a transformation operates under certain rules or constraints, e.g. the transformation of the embryo into a foetus will occur under certain constraints

Transformation -A transformation can be single valued or multiple valued: Single: when each operand will be transformed in one transform Multiple: when each operand will be transformed in many transforms -A transformation can be single valued and one-one, when each operand 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 the identical transformation

Formalisations Open, single-valued, one-one ABC TBCD T1CDE T2DEF

Formalisations Closed, single-valued, one-one ABC T1DAB T2DDA T3DDD

Formalisations PhPsEm Ph (T1) 100 Ps (T2) 110 Ps (T3) 111

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 number of 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 the outcome.

Confronting variety Vo Vd/Vr IntPsSoc PhH PsyH SocH EmC ReC AgrC R D T E

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 to enlarge 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 patient needs 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 accepting the law of requisite variety and to investigate the ways of organising care taking into account the law.

Requisite variety The Art of Regulation 16stPhPs Ph10 Psy01 Em00 Env00

What’s regulation? -Regulation is the way the regulator follows to transform the 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 the problems (D) R?? D Ph Psy Em Re So Agr Vd = 64 (possible states) = log2 = 5.17

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 delimiting variety on the input of the system T (blocking).

Defining outcome 1 = pos. Outcome (target) RInt-chirPsy D Ph1 Psy1 Em Soc Rel Agr Vo = or > D / R

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 outcome and results.

Possible solutions Increase Vr -Vr = Vd -Certain components of R becomes multi-functional: increasing the 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 D Patient information: what can the patient expect? -Sequentialisation of the transformation: stochastic problem transformation of components -Transform certain components of D in components of R Implication 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

The Anatomy of Health-Care Five Functions or Systems

Beer S. Brain of the firm, Whiley, 1981

5 systems or functions System 1: operational level-activity-regulation-registration System 2: metasystem subsuming all system one – coordination by information System 3: information transmitter – coordination by regulation algodonometer – stabilisator/inhibitor System 4: big switch – modeling System 5: decision-making.

Division of work From opposition to collaboration Preliminary condition: patient and care-provider must be considered as one unity. Switch from applicatif to process-care (2th cybernetics). Autonomic activities System 1: patient – CP System 2: CP System 3: CP Management activities System 4: patient System 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 Vo Decrease Vd

Cross-matching LRV and Managing HC-model Objective: manage care trought the interaction between Patient and CP in one system Increase Vr: -patient becomes a regulator too in collaboration with CP -regulation becomes auto-regulation -transformation becomes auto-transformation

Cross-matching LRV and Managing HC-model Decrease Vd: Defining variety of D through negociation (interaction) Defining limits on variety Increase Vo: Defining objectives as possible outcomes Defining targets in a step by step method