Have you ever wondered why grandparents have so much more fun with their grandchildren than they did with their children? It’s the same reason why some organizations cut through crises like a knife through butter while others fall into total chaos – and sometimes collapse. It’s due to a phenomenon called Ashby’s Law of Requisite Variety, a concept conceived by late English psychiatrist W. Ross Ashby.
Let’s stay with the grandparent example for a minute, since I have as much experience with that as I do with compliance!
When a baby is born, it has just four basic needs; for now, let’s refer to these needs as disruptions, or better yet, perturbations. According to the Merriam-Webster dictionary, a perturbation is defined as follows:
“A disturbance of motion, course, arrangement, or state of equilibrium; especially: a disturbance of the regular and usually elliptical course of motion of a celestial body that is produced by some force additional to that which causes its regular motion.”
For our purposes, we are going to deal with the part of the definition that deals with a disturbance in a state of equilibrium – and if you hang with me for a few more paragraphs, you will see how this applies to the areas of compliance and compliance risk. So, back to our baby example. Those four perturbations that a parent experiences with a baby occur when the baby is hungry, tired, wet or sick. The good news is that most young adults have the requisite tools to deal with these issues. They can feed a baby, change a baby, put a baby to sleep, and take the baby to the doctor. It’s pretty simple, actually, and as long as these tools are in the young parent’s toolbox, equilibrium within the system is maintained.
To be more specific, Ashby’s law infers that the larger the variety of actions available in a control system, the larger the variety of perturbations for which it will be able to compensate. In more simple terms, for every perturbation there needs to be a response that can quell or counter that perturbation in order for the system to remain at equilibrium. So if a young parent, for example, cannot handle it when a baby cries, in essence he or she doesn’t possess the requisite tool to counter or quell that disruption, meaning the system (or the household, in this case) turns to chaos. I am pretty sure that most every parent understands that to which I am referring.
As a child grows older, the variety of perturbations or disruptions grows. Again, if you have ever been a parent, you understand where this is going. Toddlers have more disruptions than infants, and teenagers have even more and bigger disruptions. I am the father of four daughters, and when they hit the “relationship” years, the variety of perturbations definitely exceeded the tools I had to counteract them, and as a result, it was not uncommon in my house for chaos to reign.
But here I am today as a grandparent, and having gone through the experiences of raising my kids, I have amassed a figurative toolbox that is huge, and filled with a variety of “tools” that can easily quell any disruption that my grandkids can throw at me. As a result, because (as stated above) the variety of actions available to me is at least equal to the number of perturbations my grandchildren can create, I no longer live in the stress of chaos. In other words, life is grand!
Now, on to the point. In the world of healthcare, because of the complexities involved in both clinical iterations of treatments and regulations, there can be a seemingly infinite number of perturbations. For most tasks – such as dealing with patient visits, performing procedures and services, executing billing and collection operations, and attending to many other routine matters – we meet the threshold for Ashby’s law in that we have the requisite variety of tools necessary to deal with the majority of the critical perturbations.
This has major implications in many practical applications within a provider organization, including patient relations, HR, and other areas not related to compliance. Looking at compliance in particular, however, there are 12 or more auditing entities currently mining data from healthcare providers. Each, as listed in their various own mission statements, looks for different types of outliers, anomalies, aberrancies and other variances from what they may define as normal. Each, then, creates its own model to define the thresholds that stimulate an audit or review, and each component within that model could be considered as a perturbation. In CERT, for example, there are several major reasons for classifying a claim as having been paid in error. There’s insufficient documentation, improper coding, lack of medical necessity, etc. For insufficient documentation, for example, there are a number of thresholds that push a finding into that classification. CERT states that such a determination means that the provider did not include pertinent patient facts, such as the patient’s overall condition, diagnosis, extent of services performed, etc. Each of those factors, from a documentation perspective, may represent an individual disruption – while at the same time, together they represent another disruption. If we take Ashby’s law to heart, it means that for each of those disruptions, we need a counteractive tool to suppress the perturbation. In an audit situation, the initial request for records creates a perturbation, and our ability to respond will create an outcome that is either positive or negative. When an audited unit (a patient, claim, line, etc.) is found to be in error, having a qualified coder to argue qualitative points of the findings counters those disruptions to the degree that, whatever the outcome, chaos likely can be averted.
The bottom line is that any audit event creates many perturbations, and maintaining equilibrium within the system depends on our ability to meet each of those perturbations with a viable counteraction. It’s all about building a toolbox with as much variety as possible so that we are ready to deal with any possible disruption. Like with parenting, in most circumstances, the second child is easier than the first, and the third is easier than the first two (remember, I said in most circumstances, not all). Allegorically speaking, the second audit is usually easier to deal with than the first, and the third is normally easier than the first two. The problem with the latter is that not having the variety of tools to deal with the first audit can in some circumstances pretty much guarantee there won’t be a second or third, as you will be out of business.
So, if we accept that Ashby’s law is valid and that it applies in the audit environment, what can we do to mitigate the chaos that these perturbations often create? The simple answer is to build a toolbox with as much variety as you can, as quickly as you can; this is preferable in advance of the first audit. How do we do this? By attending conferences, reading articles, engaging consultants, getting training, and engaging in other activities that afford us the opportunity to be prepared as best we can. Unfortunately, things will happen for which we are totally unprepared. We won’t have a tool to counter every disruption. That’s pretty much a given, however, in the process of acquiring these tools, we become better at acquiring new tools – and when “black swan” events rear their ugly heads, we likely will have the experience and skill set necessary to develop the requisite tool in short order.
In summary, we should look to the U.S. Coast Guard as our example of Ashby’s Law. Their motto is “semper paratos,” meaning “always ready.” We should be, also.
About the Author
Frank Cohen is the senior analyst for The Frank Cohen Group, LLC. He is a healthcare consultant who specializes in data mining, applied statistics, practice analytics, decision support and process improvement.
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