Thursday, November 17, 2022

A Road Map for Reducing Diagnostic Errors in Healthcare

A recent article* about how to reduce diagnostic errors in healthcare caught our attention, for a couple of reasons.  First, it describes a fairly comprehensive checklist of specific practices to address diagnostic errors, and second, the practices include organizational culture and reflect systems thinking, both subjects dear to us.  The checklist’s purpose is to help an organization rate its current performance and identify areas for improvement.

The authors used a reasonable method to develop the checklist: they convened an anonymous Delphi group, identified and ranked initial lists of practices, shared the information among the group, then collected and organized the updated rankings.  The authors then sent the draft checklist to several hospital managers, i.e., the kind of people who would have to implement the approach, for their input on feasibility and clarity.  The final checklist was then published.

The checklist focuses on diagnostic errors, i.e., missed, delayed, or wrong diagnoses.  It does not address other major types of healthcare errors, e.g., botched procedures, drug mix-ups, or provider hygiene practices.

The authors propose 10 practices, summarized below, to assess current performance and direct interventions with respect to diagnostic errors:

1.    Senior leadership builds a “board-to-bedside” accountability framework to measure and improve diagnostic safety.

2.    Promote a just culture and create a psychologically safe environment that encourages clinicians and staff to share opportunities to improve diagnostic safety without fear of retribution.

3.    Create feedback loops to increase information flow about patients’ diagnostic and treatment-related outcomes after handoffs from one provider/department to another.

4.    Develop multidisciplinary perspectives to understand and address contributory factors in the analysis of diagnostic safety events.

5.    Seek patient and family feedback to identify and understand diagnostic safety concerns.

6.    Encourage patients to review their health records and ask questions about their diagnoses and related treatments.

7.    Prioritize equity in diagnostic safety efforts.

8-10.    Establish standardized systems and processes to (1) encourage direct, collaborative interactions between treating clinical teams and diagnostic specialties; (2) ensure reliable communication of diagnostic information between care providers and with patients and families; and (3) close the loop on communication and follow up on abnormal test results and referrals.

Our Perspective

We support the authors recognition that diagnostic errors are difficult to analyze; they can involve clinical uncertainty, the natural evolution of diagnosis as more information becomes available, and cognitive errors, all exacerbated by system vulnerabilities.  Addressing such errors requires a systems approach.  

The emphasis on a just culture and establishing feedback loops is good.  We would add the importance of management commitment to fixing and learning from identified problems, and a management compensation plan that includes monetary incentives for doing this.

However, we believe the probability of a healthcare organization establishing dedicated infrastructure to address diagnostic errors is very low.  First, the authors recognize there is no existing business case to address such errors.  In addition, we suspect there is some uncertainty around how often such errors occur.  The authors say these errors affect at least 5% of US adult outpatients annually but that number is based on a single mini-meta study.**

As a consequence, senior management is not currently motivated by either fear (e.g., higher costs, excessive losses to lawsuits, regulatory sanctions or fines, or reputational loss) or greed (e.g., professional recognition or monetary incentives) to take action.  So our recommended first step should be to determine which types of medical errors present the greatest threats to an institution, how many occur, and then determine what can be done to prevent them or minimize their consequences.  (See our July 31, 2020 post on Dr. Danielle Ofri’s book When We Do Harm for more on medical errors.)

Second, the organization has other competing goals demanding attention and resources so management’s inclination will be to minimize costs by simply extending any existing error identification and resolution program to include diagnostic errors.

Third, diagnosis is not a cut-and-dried process, like inserting a catheter, double-checking patients’ names, or hand washing.  The diagnostic process is essentially probabilistic, with different diagnoses possible from the same data, and to some degree, subjective.  Management probably does not want a stand-alone system that second guesses and retrospectively judges doctors’ decisions and opinions.  Such an approach could be perceived as intruding on doctors’ freedom to exercise professional judgment and is bad for morale.

Bottom line: The checklist is well-intentioned but a bit naïve.  It is a good guide for identifying weak spots and hazards in a healthcare organization, and the overall approach is not necessarily limited to diagnostic errors.   

*  Singh, H., Mushtaq, U., Marinez, A., Shahid, U., Huebner, J., McGaffigan, P., and Upadhyay, D.K., “Developing the Safer Dx Checklist of Ten Safety Recommendations for Health Care Organizations to Address Diagnostic Errors,” The Joint Commission Journal on Quality and Patient Safety, No. 48, Aug. 10, 2022, pp. 581–590.  The Joint Commission is an entity that inspects and accredits healthcare providers, mainly hospitals.

**  Singh, H., Meyer, A.N.D., and Thomas, E.J., “The frequency of diagnostic errors in outpatient care: estimations from three large observational studies involving US adult populations,” BMJ Quality and Safety, Vol. 23, No. 9, April 2014, pp. 727–731.

Thursday, September 22, 2022

Culture in the Healthcare Industry

A couple of articles recognizing the importance of cultural factors in the healthcare space recently caught our attention.  The authors break no new ground but we’re reporting these articles because they appeared in a couple of the U.S.’s most prestigious medical journals.

We begin with an opinion piece in The Journal of the American Medical Association (JAMA).*  The authors’ focus is on clinician burnout (which we discussed on Nov. 6, 2019) but they cite earlier work on the importance of quality and culture in the healthcare workplace, including “the culture changes needed for effective teamwork and optimizing the authentic voice of every team member. . . . [and examining] the consequences of medical hierarchy and inequity.”  

One of the references in the JAMA piece is an earlier article by two of the authors in The New England Journal of Medicine.**  This article discusses how the National Academy of Medicine (NAM) and its predecessor entities have influenced the trajectory of the discussion of healthcare effectiveness, starting by documenting the wide scope of inappropriate care prescribed to patients, i.e., the overuse of ineffective medical practices.  Their seminal 1999 report, “To Err Is Human,” estimated that 44,000 to 98,000 Americans die in hospitals each year because of medical errors.  

Their 2001 report, “Crossing the Quality Chasm,” defined a framework for healthcare quality with six dimensions: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity.  In practice, the quality of healthcare services has improved since then in several specific areas, e.g., reduced rates of acquired infections, but “wholesale, systemic improvement in quality of care has proven difficult to bring to scale.”  We wrote about the lack of progress on Nov. 9, 1920.  One significant ongoing problem is that efforts to increase provider accountability, e.g., ascertaining if providers are delivering appropriate care, has resulted in a negative impact on clinicians’ morale.  “The United States has yet to find for health care the wisest balance between accountability, which is critical, and supports for a trusting culture of growth and learning, which, as the NAM asserts, is the essential foundation for continual improvement.”

Our Perspective

None of this information is new.  What is worth noting is how cultural aspects have become important topics for discussion at the highest levels of healthcare policy. 

If you have been following our healthcare posts on Safetymatters, you know we have discussed the challenges and the progress, or lack thereof, in reducing errors and increasing effectiveness.  We have emphasized the role of a strong safety culture in the delivery of high quality services.  Click on the healthcare label to see all of our related posts.

Healthcare has a long way to go to catch up with other industries that have integrated high levels of safety and quality into their daily operations.  To illustrate healthcare’s current position, we will repurpose a recent McKinsey article on corporate ESG (Environment, Social, Governance) attributes.***  McKinsey uses a 3-category framework (Minimum, Common, and Next level practices) to describe a business’s ESG character.  For our purposes, we will replace ESG with safety and quality (S&C), and excerpt and adapt specific attributes that could and should exist in a healthcare organization.

Minimum practices – focus on risk mitigation and do no harm measures

•    React to external social-legal-political trends
•    Address obvious vulnerabilities
•    Meet baseline standards
•    Pledge to minimal commitment levels

Common practices – substantive efforts, more proactive than reactive

•    Track major trends and develop strategies to address them
•    Identify strengths and use them to move toward S&C goals
•    Comply with voluntary standards and perform above average
•    Engage with stakeholder groups to understand what matters to them

Next level practices – full integration of S&C into strategy and operations

•    View S&C as essential components of overall strategy
•    Link clearly articulated leadership areas with S&C goals
•    Embed S&C in capital and resource allocation
•    Tie S&C to employee incentives and evaluations
•    Ensure that S&C reports cover the entity’s full set of operations

Our judgment is that most healthcare entities, especially hospitals, demonstrate minimum practices and are trying to get ahead of the curve by implementing some common practices.  Some entities may claim to be using next level practices, but these are generally narrow or limited efforts.  The industry’s biggest challenge is getting the entrenched guilds of doctors and nurses, accustomed to working in protective silos, to fully embrace increased accountability.  At the same time, senior management must create, maintain, and manage a non-punitive work environment and a just culture.

*  Rotenstein, L.S., Berwick, D.M., and Cassel, C.K., “Addressing Well-being Throughout the Health Care Workforce: The Next Imperative,” JAMA, Vol. 328, No. 6 (Aug. 9, 2022), pp. 521-22.  Published online July 18, 2022.  JAMA is a peer-reviewed journal published by the American Medical Association.

**  Berwick, D.M., and Cassel, C.K., “The NAM and the Quality of Health Care — Inflecting a Field,” The New England Journal of Medicine, Vol. 383, No. 6 (Aug. 6, 2020), pp. 505-08.

***  Pérez, L., Hunt, V., Samandari, H, Nuttall, R., and Bellone, D., “How to make ESG real,” McKinsey Quarterly (Aug. 2022).

Friday, July 29, 2022

A Lesson from the Accounting Profession: Don’t Cheat on the Ethics Test

SEC Order

Accounting, like many professions, requires practitioners to regularly demonstrate competence and familiarity with relevant knowledge and practices.  One requirement for Certified Public Accountants (CPAs) is to take an on-line, multiple-choice test covering professional ethics.  Sounds easy but the passing grade is relatively high so it’s not a slam dunk.  Some Ernest & Young (EY) audit accountants found it was easier to pass if they cheated by using answer keys and sharing the keys with their colleagues.  They were eventually caught and got into big trouble with the U.S. Securities and Exchange Commission (SEC).  Following is a summary of the scandal as it evolved over time per the SEC order* and our view on what the incident says about EY’s culture.

During 2012-15, some EY employees were exploiting weaknesses in the company’s test software to pass tests despite not having a sufficient number of correct answers.  EY learned about this problem in 2014.  In 2016, EY learned that professionals in one office improperly shared answer keys.  EY repeatedly warned personnel that cheating on tests was a violation of the firm’s code of ethics but did not implement any additional controls to detect this misconduct.  The cheating continued into 2021.

In 2019 the SEC discovered cheating at another accounting firm and fined them $50 million.  As part of the SEC’s 2019 investigation, the agency asked EY if they had any problems with cheating.  In their response, EY said they had uncovered instances in the past but implied they had no current problems.  In fact, EY management had recently received a tip about cheating and initiated what turned out to be an extensive investigation that by late 2019 “confirmed that audit professionals in multiple offices cheated on CPA ethics exams.” (p. 6)  However, EY never updated their response to the SEC.  Eventually EY told the Public Company Accounting Oversight Board (PCAOB)** about the problems, and the PCAOB informed the SEC – 9 months after the SEC’s original request for information from EY.

In the U.S., the relationship between government regulators and regulated entities is based on the expectation that communications from the regulated entities will be complete, truthful, and updated on a timely basis if new information is discovered or developed.  Lying to or misleading the government, either through commission or omission, is a serious matter.

Because of EY’s violation of a PCAOB rule and EY’s misleading behavior with the SEC, the company was censured, fined $100 million, and required to implement a host of corrective actions, summarized below.

Review of Policies and Procedures

“EY shall evaluate . . . the sufficiency and adequacy of its quality controls, policies, and procedures relevant to ethics and integrity and to responding to Information Requests” (p. 9)  In particular, EY will evaluate “whether EY’s culture [emphasis added] is supportive of ethical and compliant conduct and maintaining integrity, including strong, explicit, and visible support and commitment by the firm’s management” (p. 10)

Independent Review of EY’s Policies and Procedures

“EY shall require that the Policies and Procedures IC [Independent Consultant] conduct a review of EY’s Policies and Procedures to determine whether they are designed and being implemented in a manner that provides reasonable assurance of compliance with all professional standards . . . . EY shall adopt, as soon as practicable, all recommendations of the Policies and Procedures IC in its report. . . . EY’s Principal Executive Officer must certify to the Commission staff in writing that (i) EY has adopted and has implemented or will implement all recommendations of the Policies and Procedures IC in its report . . .” (pp. 10-12)

Independent Review of EY’s Disclosure Failures

“EY’s Special Review Committee shall require that the Remedial IC conduct a review . . . of EY’s conduct relating to the Commission staff’s June 2019 Information Request, including whether any member of EY’s executive team, General Counsel’s Office, compliance staff, or other EY employees contributed to the firm’s failure to correct its misleading submission.” (p. 12)  Like the Policies and Procedures review, EY must adopt the recommendations in the Remedial IC Report and EY’s Principal Executive Officer must certify their adoption to the SEC.

Notice to Audit Clients, Training, and Certifications

“Within 10 business days after entry of this Order, EY shall provide all of its issuer audit clients and SEC-registered broker-dealer audit clients a copy of this Order. . . . all audit professionals and all EY partners and employees who, at any time prior to March 3, 2020, were aware (i) of the Division of Enforcement’s June 19, 2019 request, (ii) of EY’s June 20, 2019 response, and (iii) that an employee had made a tip on June 19, 2019 concerning cheating shall complete a minimum of 6 hours every 6 months of ethics and integrity training by an independent training provider . . . . EY’s Principal Executive Officer shall also certify that the training requirements . . . have been completed.” (pp. 14-15)

Our Perspective

A company’s culture includes the values and assumptions that underlie daily work life and influence decision making.  What can we infer about EY’s culture from the behavior described above?

First, what managers did after they discovered the cheating – issuing memos and waving their arms – did not work.  Even if EY terminated some employees, perhaps the worst offenders or maybe the least productive ones, EY did not make their testing process more robust or secure.

Second, senior leadership has not suffered from this scandal.  There is no indication any senior managers have been disciplined or terminated because of the misconduct.  The head of EY’s U.S. operations left at the end of her 4-year term, but her departure was apparently due to a disagreement with her boss, EY’s global chief executive. 

Third, there has been no apparent change in the employees’ task environments, e.g., their workload expectations and compensation program.

Conclusion: EY management tolerated the cheating because their more important priorities were elsewhere.  It’s safe to assume that EY, like other professional service firms, primarily values and rewards technical competence and maximizing billable hours.

We see two drivers for possible changes: the $100 million fine and the mandated review by “Independent Consultants.”  (EY’s self-review will likely be no more useful than their previous memos and posturing.)

What needs to be done? 

To begin, senior leadership has to say fixing the cheating problem is vitally important, and walk the talk by adjusting company practices to reinforce the task’s importance.  Leadership has to commit to a company corrective action program that recognizes, analyzes, and permanently fixes all significant company problems as they arise – not after their noses are rubbed into action by the regulator.  

In addition, there have to be visible changes in the audit professionals’ task environment.  The employees need to get work time, in the form of unbilled overhead hours, to prepare for tests.  The compensation scheme needs to add a component to recognize and reward ethical behavior – with clients and internally.  The administration of ethics tests needs to be made more secure, on a par with the accounting exams the employees take.

*  Securities and Exchange Commission, Other Release No.: 34-95167 Re: Ernst & Young LLP (June 28, 2022).  All quotes in our post are from the SEC order.  There is also an associated SEC press release.

**  The Public Company Accounting Oversight Board establishes auditing and professional practice standards for registered public accounting firms, such as EY, to follow in the preparation of audit reports for public companies.  PCAOB members are appointed by the SEC.

Monday, June 6, 2022

Guiding People to Better Decisions: Lessons from Nudge by Richard Thaler and Cass Sunstein

Safetymatters reports on organizational culture, the values and beliefs that underlie an organization’s essential activities.  One such activity is decision-making (DM) and we’ve said an organization’s DM processes should be robust and replicable.  DM must incorporate the organization’s priorities, allocate its resources, and handle the inevitable goal conflicts which arise.

In a related area, we’ve written about the biases that humans exhibit in their personal DM processes, described most notably in the work by Daniel Kahneman.*  These biases affect decisions people make, or contribute to, on behalf of their organizations, and personal decisions that only impact the decision maker himself.

Thaler and Sunstein also recognize that humans are not perfectly rational decision makers (citing Kahneman’s work, among others) and seek to help people make better decisions based on insights from behavioral science and applied economics.  Nudge** focuses on the presentation of decision situations and alternatives to decision makers on public and private sector websites.  It describes the nitty-gritty of identifying, analyzing, and manipulating decision factors, i.e., the architecture of choice. 

The authors examine the choice architecture for a specific class of decisions: where groups of people make individual choices from a set of alternatives.  Choice architecture consists of curation and navigation tools.  Curation refers to the set of alternatives presented to the decision maker.  Navigation tools sound neutral but small details can have a significant effect on a decider’s behavior. 

The authors discuss many examples including choosing a healthcare or retirement plan, deciding whether or not to become an organ donor, addressing climate change, and selecting a home mortgage.  In each case, they describe different ways of presenting the decision choices, and their suggestions for an optimal approach.  Their recommendations are guided by their philosophy of “libertarian paternalism” which means decision makers should be free to choose, but should be guided to an alternative that would maximize the decider’s utility, as defined by the decision maker herself.

Nudge concentrates on which alternatives are presented to a decider and how they are presented.  Is the decision maker asked to opt-in or opt-out with respect to major decisions?  Are many alternatives presented or a subset of possibilities?  A major problem in the real world is that people can have difficulty in seeing how choices will end up affecting their lives.  What is the default if the decision maker doesn’t make a selection?  This is important: default options are powerful nudges; they can be welfare enhancing for the decider or self-serving for the organization.  Ideally, default choices should be “consistent with choices people would make if they all the relevant information, were not subject to behavioral biases, and had the time to make a thoughtful choice.” (p. 261)

Another real world problem is that much choice architecture is bogged down with sludge - the inefficiency in the choice system – including barriers, red tape, delays, opaque costs, and hidden or difficult to use off-ramps (e.g., finding the path to unsubscribe from a publication).

The authors show how private entities like social media companies and employers, and public ones like the DMV, present decision situations to users.  Some entities have the decider’s welfare and benefit in mind, others are more concerned with their own power and profits.  It’s no secret that markets give companies an incentive to exploit our DM frailties to increase profits.  The authors explicitly do not support the policy of “presumed consent” embedded in many choice situations where the designer has assumed a desirable answer and is trying to get more deciders to end up there. 

The authors’ view is their work has led to many governments around the world establishing “nudge” departments to identify better routes for implementing social policies.

Our Perspective

First, the authors have a construct that is totally consistent with our notion of a system.  A true teleological system includes a designer (the authors), a client (the individual deciders), and a measure of performance (utility as experienced by the decider).  Because we all agree, we’ll give them an A+ for conceptual clarity and completeness.

Second, they pull back the curtain to reveal the deliberate (or haphazard) architecture that underlies many of our on-line experiences where we are asked or required to interact with the source entities.  The authors make clear how often we are being prodded and nudged.  Even the most ostensibly benign sites can suggest what we should be doing through their selection of default choices.  (In fairness, some site operators, like one’s employer, are themselves under the gun to provide complete data to government agencies or insurance companies.  They simply can’t wait indefinitely for employees to make up their minds.)  We need to be alert to defaults that we accept without thinking and choices we make when we know what others have chosen; in both cases, we may end up with a sub-optimal choice for our particular circumstances. 

Thaler and Sunstein are respectable academics so they include lots of endnotes with references to books, journals, mainstream media, government publications, and other sources.  Sunstein was Kahneman’s co-author for Noise, which we reviewed on July 1, 2021.

Bottom line: Nudge is an easy read about how choice architects shape our everyday experiences in the on-line world where user choices exist. 


*  Click on the Kahneman label for all our posts related to his work.

**  R.H. Thaler and C.R. Sunstein, Nudge, final ed. (New Haven: Yale University Press) 2021.

Thursday, March 31, 2022

The Criminalization of Safety in Healthcare?

On March 25, 2022 a former nurse at Vanderbilt University Medical Center (VUMC) was convicted of gross neglect of an impaired adult and negligent homicide as a consequence of a fatal drug error in 2017.* 

Criminal prosecutions for medical errors are rare, and healthcare stakeholders are concerned about what this conviction may mean for medical practice going forward.  A major concern is practitioners will be less likely to self-report errors for fear of incriminating themselves.

We have previously written about the intersection of criminal charges and safety management and practices.  In 2016 Safetymatters’ Bob Cudlin authored a 3-part series on this topic.  (See his May 24, May 31, and June 7 posts.)  Consistent with our historical focus on systems thinking, Bob reviewed examples in different industries and asked “where does culpability really lie - with individuals? culture? the corporation? or the complex socio-technical systems within which individuals act?”

“Corporations inherently, and often quite intentionally, place significant emphasis on achieving operational and business goals.  These goals at certain junctures may conflict with assuring safety.  The de facto reality is that it is up to the operating personnel to constantly rationalize those conflicts in a way that achieves acceptable safely.”

We are confident this is true in hospital nurses’ working environment.  They are often short-staffed, working overtime, and under pressure from their immediate task environments and larger circumstances such as the ongoing COVID pandemic.  The ceaseless evolution of medical technology means they have to adapt to constantly changing equipment, some of which is problematic.  Many/most healthcare professionals believe errors are inevitable.  See our August 6, 2019 and July 31, 2020 posts for more information about the extent, nature, and consequences of healthcare errors.

At VUMC, medicines are dispensed from locked cabinets after a nurse enters various codes.  The hospital had been having technical problems with the cabinets in early 2017 prior to the nurse’s error.  The nurse could not obtain the proper drug because she was searching using its brand name instead of its generic name.  She entered an override that allowed her to access additional medications and selected the wrong one, a powerful paralyzing agent.  The nurse and other medical personnel noted that entering overrides on the cabinets was a common practice.

VUMC’s problems extended well beyond troublesome medicine cabinets.  An investigator said VUMC had “a heavy burden of responsibility in this matter.”  VUMC did not report the medication error as required by law and told the local medical examiner’s office that the patient died of “natural” causes.  VUMC avoided criminal charges because prosecutors didn’t think they could prove gross negligence. 

Our Perspective

As Bob observed in 2016, “The reality is that criminalization is at its core a “disincentive.”  To be effective it would have to deter actions or decisions that are not consistent with safety but not create a minefield of culpability. . . .  Its best use is probably as an ultimate boundary, to deter intentional misconduct but not be an unintended trap for bad judgment or inadequate performance.”

In the instant case, the nurse did not intend to cause harm but her conduct definitely reflected bad judgment and unacceptable performance.  She probably sealed her own fate when she told law enforcement she “probably just killed a patient” and the licensing board that she had been “complacent” and “distracted.”   

But we see plenty of faults in the larger system, mainly that VUMC used cabinets that held dangerous substances and had a history of technical glitches but allowed users to routinely override cabinet controls to obtain needed medicines.  As far we can tell, VUMC did not implement any compensating safety measures, such as requiring double checking by a colleague or a supervisor’s presence when overrides were performed or “dangerous” medications were withdrawn.

In addition, VUMC’s organizational culture was on full display with their inadequate and misleading reporting of the patient’s death.  VUMC has made no comment on the nurse’s case.  In our view, their overall strategy was to circle the wagons, seal off the wound, and dispose of the bad apple.  Nothing to see here, folks.

Going forward, the remaining VUMC nurses will be on high alert for awhile but their day-to-day task demands will eventually force them to employ risky behaviors in an environment that requires such behavior to accomplish the mission but lacks defense in depth to catch errors before they have drastic consequences.  The nurses will/should be demanding a safer work environment.

Bottom line: Will this event mark a significant moment for accountability in healthcare akin to the George Floyd incident’s impact on U.S. police practices?  You be the judge.

For additional Safetymatters insights click the healthcare label below.


*  All discussion of the VUMC incident is based on reporting by National Public Radio (NPR).  See B. Kelman, “As a nurse faces prison for a deadly error, her colleagues worry: Could I be next?” NPR, March 22, 2022; “In Nurse’s Trial, Investigator Says Hospital Bears ‘Heavy’ Responsibility for Patient Death,” NPR, March 24, 2022; “Former nurse found guilty in accidental injection death of 75-year-old patient,” NPR, March 25, 2022.

Wednesday, February 2, 2022

A Massive Mental Model: Lessons from Principles for Dealing with the Changing World Order by Ray Dalio

At Safetymatters, we have emphasized several themes over the years, including the importance of developing complete and realistic mental models of systems, often large, complicated, socio-technical organizations, to facilitate their analysis.  A mental model includes the significant factors that comprise the system, their interrelationships, system dynamics (how the system functions over time), and system outputs and their associated metrics.

This post outlines an ambitious and grand mental model: the recurring historical arc exhibited by all the world’s great empires as described in Ray Dalio’s new book.* Dalio examined empires from ancient China through the 20th century United States.  He identified 18 factors that establish and demonstrate a great society’s rise and fall: 3 “Big Cycles,” 8 different types of power an empire can exhibit, and 7 other determinants.

Three Big Cycles 

The big cycles have a natural progression and are influenced by human innovation, technological development, and acts of nature.  They occur over an empire’s 250 year lifetime of emergence, rise, topping out, decline, and replacement by a new dominant power.

The financial cycle initially supports prosperity but debt builds over time, then governments accommodate it by printing more money** which eventually leads to a currency devaluation, debt restructuring (including defaults), and the cycle starts over.  These cycles typically last about 50 to 100 years so can occur repeatedly over an empire’s lifetime.

The political cycle starts with a new order and leadership, then resource allocation systems are built, productivity and prosperity grow, but lead to excessive spending and widening wealth gaps, then bad financial conditions (e.g., depressions), civil war or revolution, and the cycle starts over.

The international cycle is dominated by raw power dynamics.  Empires build power and, over time, have conflicts with other countries over trade, technology, geopolitics, and finances.  Some conflicts lead to wars.  Eventually, the competition becomes too costly, the empire weakens, and the cycle starts over.

Dimensions and measures of power

An empire can develop and exercise power in many ways; these are manifestations and measures of the empire’s competitive advantages relative to other countries.  The 8 areas are education, cost competitiveness, innovation and technology, economic output, share of world trade, military strength, financial center strength, and reserve currency status.

Other determinants

These include natural attributes and events, internal financial/political/legal practices, and measures of social success and satisfaction.  Specific dimensions are geology, resource allocation efficiency, acts of nature, infrastructure and investment, character/civility/determination, governance/rule of law, gaps in wealth, opportunity and cultural values.

The 18 factors interact with each other, typically positively reinforcing each other, with some leading others, e.g., a society must establish a strong education base to support innovation and technology development.  Existing conditions and determinants propel changes that create new conditions and determinants.

System dynamics

Evolution is the macro driving force that creates the system dynamic over time.  In Dalio’s view “Evolution is the biggest and only permanent force in the universe . . .” (p. 27)  He also considers other factors that shape an empire’s performance.  The most important of these are self-interest, the drive for wealth and power, the ability to learn from history, multi-generational differences, time frames for decision making, and human inventiveness.  Others include culture, leadership competence, and class relationships.  Each of these factors can wax and/or wane over the course of an empire’s lifetime, leading to changes in system performance.

Dalio uses his model to describe (and share) his version of the economic-political history of the world, and the never-ending struggles of civilizations over the accumulation and distribution of wealth and power.  Importantly, he also uses it to inform his worldwide investment strategies.  His archetype models are converted into algorithms to monitor conditions and inform investment decisions.  He believes all financial markets are driven by growth, inflation, risk premiums (e.g., to compensate for the risk of devaluation), and discount rates.

Our Perspective

Dalio’s model is ambitious, extensive, and complicated.  We offer it up an extreme example of mental modeling, i.e., identifying all the important factors in a system of interest and defining how they work together to produce something.  Your scope of interest may be more limited – a power plant, a hospital, a major corporation – but the concept is the same.

Dalio is the billionaire founder of hedge fund Bridgewater Associates.  He has no shortage of ego or self-confidence.  He name-drops prominent politicians and thinkers from around the world to add weight to his beliefs.  We reviewed his 2017 book Principles on April 17, 2018 to show an example of a hard-nosed, high performance business culture. 

He is basically a deterministic thinker who views the world as a large, complex machine.  His modeling emphasizes cause-effect relationships that evolve and repeat over time.  He believes a perfect model would perfectly forecast the future so we assume he views the probabilistic events that occur at network branching nodes as consequences of an incomplete, i.e., imperfect model.  In contrast, we believe that some paths are created by events that are essentially probabilistic (e.g., “surprising acts of nature”) or the result of human choices.  We agree that human adaptation, learning, and inventiveness are keys to productivity improvements and social progress, but we don’t think they can be completely described in mechanical cause-effect terms.  Some system conditions are emergent, i.e., the consequence of a system’s functioning, and other things occur simply by chance. 

This book is over 500 pages, full of data and tables.  Individual chapters detail the history of the Dutch, British, American, and Chinese empires over the last 500 years.  The book has no index so referring back to specific topics is challenging. Dalio is not a scholar and gives scant or no credit to thinkers who used some of the same archetypes long before him.

We offer no opinion on the accuracy or completeness of Dalio’s version of world history, or his prognostications about the future, especially U.S.-China relations.

Bottom line: this is an extensive model of world history, full of data; the analyses of the U.S. and China*** are worth reading.


*  R. Dalio, Principles for Dealing with the Changing World Order (New York: Avid Reader Press) 2021.

**  If the new money and credit goes into economic productivity, it can be good for the society.  But the new supply of money can also cheapen it, i.e., drive its value down, reducing the desire of people to hold it and pushing up asset prices.

***  Dalio summarizes the Chinese political-financial model as “Confucian values with capitalist practices . . .” (p. 364)