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Applying the "10 simple rules" of the institute of medicine to management of hyperbilirubinemia in newborns.

Arecent Institute of Medicine (IOM) report describes a chasm in health care quality that we must cross for patients to receive better care in the 21st century. The report calls for a “systems approach,” drawing on the rapid evolution of knowledge about complex adaptive systems.1 Understanding how complex adaptive systems work can give physicians insights to develop and modify health care systems. By describing a practical application of the ideas about complex adaptive systems to newborn care, we aim to help pediatricians prepare to lead in this field.

A complex adaptive system is a collection of individual agents who have the freedom to act, but because the agents are interconnected, action by any agent changes the context for other agents in the system. One familiar example is the buyers in a stock market. In the last century, it was usual to see organizations as mechanical systems: in mechanical systems, if we know what each part of a system does, we can predict perfectly how the whole will respond in a given situation. This is obviously not true of the stock market. A complex adaptive system may display sudden unpredictable shifts in behavior caused by interactions among agents. An essential first step in improving the US health care system is to recognize that its member organizations and individuals, with sublevels nested within and interconnected to each other, make up a complex adaptive system.

One of the key attributes of a complex adaptive system is that orderly behavior can emerge among many agents who are acting independently but who share a common drive. For instance, ants, driven to survive, create intricate buildings and foraging systems without any planning by a chief executive ant. So do humans. The citizens of New York City share a drive to eat; with no single individual …