Learning from New Zealand

Sofia Ramirez

So, David, Dr. Swanson got this really fascinating message the other day. It was from Dr. Sharen Paine, a researcher in New Zealand.

David Caldwell

From New Zealand? Do you they know each other?

Sofia Ramirez

Not at all! That’s the thing. Total surprise. She reached out and said, "Hey, would you read this academic paper we just published?"

David Caldwell

Oh, come on, Sofia. That sounds… intense. Academic papers are not exactly light reading.

Sofia Ramirez

I know, right? But honestly, this one caught my attention. It’s about how we can embed systems thinking into transforming healthcare. And the model they explored, called the Viable System Model, is so interesting. I had never really heard of it before.

David Caldwell

Neither have I. And honestly, systems thinking? It always sounds like this abstract, nerdy thing that only researchers care about. Sell it to me, Sofia—why should I, or our listeners, care?

Sofia Ramirez

Fair point, David. Here’s the deal. The United States health system, as you know, is complex and not exactly, um, functional all of the time. There’s a lot of room for improvement in how we tackle not just healthcare but health itself. Systems Thinking could help guide us to make smarter changes, especially for equity and efficiency.

David Caldwell

Okay, I’m intrigued. And I’ll admit, we Americans are often pretty bad at learning from what other countries are doing. But New Zealand sounds like an unlikely teacher. I mean, what makes their health system something we should pay attention to?

Sofia Ramirez

Good question. And yes, while every country’s system has its own path to tread, New Zealand’s approach offers lessons—it’s like a crash course in what could work or fail when you try applying systemic transformation. So today, we’ll dig into those lessons, plus the model itself, to see how it could apply here.

David Caldwell

Let’s also talk about this podcast experiment. You, me, the listeners—what are we really building here?

Sofia Ramirez

Great pivot, David. Let’s talk about why this show might actually matter to people out there. First, as today’s episode highlights, this isn’t just us talking, right? We want the podcast to be responsive and relevant, adaptive even. If our listeners have ideas or questions, we’ll dive into those. Use their curiosity to shape future episodes.

David Caldwell

Right, and we’re not just pulling stuff from the sky. Dr. Swanson is balancing clinical work, public health research, and let’s not forget, writing a book.

Sofia Ramirez

He brings a variety of lenses - clinical, public health, systems thinking, and history - to transformational change. And, let’s be fair, you, David, bring a fresh perspective, with that “why don’t things work” curiosity people can relate to.

David Caldwell

Flatter me all you want, I’ll take it. But in all seriousness, the big selling point here is that this podcast isn’t tied up in bureaucracy, financial sponsorships, or groupthink. We’ve got no agenda other than making sense of these big, hairy problems.

Sofia Ramirez

Exactly. And to wrap this up before we dive into New Zealand, let me shout out Debbie Kantor, a nurse practitioner who commented on LinkedIn. She agreed with something we said in a past episode: healthcare scope of practice should be about competence, not degrees or titles. Clinical judgment and analytical skills matter way more than credentials.

David Caldwell

Totally. Alright, where do we start unpacking this Viable System Model thing from New Zealand?

Sofia Ramirez

Alright, David, let’s pick up from where we left off and start unpacking this. One of the reasons New Zealand is such an interesting case study is their approach to tackling preventable conditions—things like obesity and cardiovascular disease. But here’s the twist: Māori and Pasifika populations often experience significantly worse health outcomes compared to others, which brings us to the equity challenges that resonate worldwide, including in the United States.

David Caldwell

So socioeconomic inequities are in the mix there too, just like here?

Sofia Ramirez

Exactly. But here’s where it differs. New Zealand’s health system is centrally structured, meaning the government plays a bigger role in funding and delivering services. It’s not perfect, of course—they still struggle with funding gaps and workforce shortages. But the central system allows them to organize public health initiatives that target these inequities in a more coordinated way.

David Caldwell

Wait, more coordinated than anything we’ve got going on here? How so?

Sofia Ramirez

Well, in the United States, healthcare operates more like a business. We’re driven by profits. New Zealand, on the other hand, focuses on fairness. Not to say money doesn’t matter, but equity holds more weight there. For example, their nationwide health strategies emphasize access to primary care as a right, not a privilege. If you’re in a rural area, they’ll try to bring the care to you—clinics, mobile units, that kind of thing.

David Caldwell

So, like, the opposite of "if you can pay, you get treated." It’s a whole mindset shift.

Sofia Ramirez

It really is. And it’s not just about healthcare. David, health is broader than that. It’s housing, education, transportation—things that shape whether or not people even need a doctor. New Zealand seems to get that with their public health campaigns. They actively link better living conditions to better outcomes.

David Caldwell

That feels… idealistic. I mean, how do you square all this with your earlier point about New Zealand’s imperfections?

Sofia Ramirez

Fair question. Despite the positives, they’re still bogged down by some bureaucratic inefficiencies and a general difficulty adapting quickly to changing demands. Think about how the pandemic forced everyone to pivot—New Zealand’s system did OK, but it wasn’t immune to delays or bottlenecks.

David Caldwell

Hmm, like no system’s perfect. They’ve got lessons for us, but only if we’re willing to learn, right?

Sofia Ramirez

Exactly. It’s not about copying them, but seeing what aligns with our values. What if we prioritized equity the way they do, while also improving efficiencies to fit our own scale? It’s an open question, but one worth asking.

Sofia Ramirez

So, David, building on what we’ve discussed about equity and systemic organization, let’s dive into what this Viable System Model, or VSM, actually is. First introduced by Stafford Beer in the 1970s, it’s a framework designed to help organizations navigate and adapt to complex environments. And let’s be honest, our health system embodies complexity, doesn’t it?

David Caldwell

So, it’s basically a survival guide for systems? Sounds... intense. What does it look like in practice?

Sofia Ramirez

Great takeaway, and yes, it’s intense, but also practical. The VSM divides an organization into five key subsystems—each with its role in keeping the system viable. There’s governance, planning, resource management, coordination, and operational delivery. And they all need to communicate and function in balance for the system to adapt and improve.

David Caldwell

Okay, wait. Five subsystems? That’s a lot to juggle. I can barely keep two apps coordinated on my phone without them crashing.

Sofia Ramirez

I hear you. What’s cool is that it’s not about micromanaging everything. It’s about understanding how these components connect. For example, governance, or what they call “System 5,” sets the purpose and values. If you don’t have a clear purpose, you end up with, well, chaos. Sound familiar?

David Caldwell

Oh, absolutely. Governance seems like corporate speak for "who's really in charge." And for us, that’s… no one?

Sofia Ramirez

Exactly! That’s part of the problem in the U.S. We’ve got layers of decision-makers, but no unified governance. New Zealand used the VSM to diagnose similar gaps in their healthcare delivery. Specifically, their ophthalmology services were struggling under fragmented IT systems, unclear operational roles, and communication breakdowns.

David Caldwell

I’ve gotta ask, though. How did diagnosing all that actually help? Did they just make a list and call it a day?

Sofia Ramirez

Not at all. Diagnosing was just step one. They rebuilt operational clarity by defining service standards—things like how care should be delivered and monitored. Then, they created feedback loops so problems could be spotted and fixed quickly. That’s where the "learning health system" comes in.

David Caldwell

Feedback loops… like building in a way to immediately see what’s working and what’s not?

Sofia Ramirez

Yes, exactly. Think about it like this: if your car dashboard didn’t tell you your gas was running low, you’d end up stranded. These feedback systems give real-time data to correct course before things spiral.

David Caldwell

Ah, so it’s preventive maintenance for a health system. But… that sounds expensive. I mean, IT upgrades, new processes. How realistic is it to implement that here?

Sofia Ramirez

You’re right—it’s not cheap upfront. But the savings come from avoiding costly failures later. For example, their ophthalmology pilot showed improvements in efficiency, like shorter wait times and better resource allocation, simply by aligning their systems. The VSM gave them the tools to think ahead.

David Caldwell

That’s compelling. But isn’t it risky to implement something this big without overwhelming people—or failing entirely?

Sofia Ramirez

Oh, it’s risky. But they started small—a single specialty service. That way, they learned what worked without upending the entire system. The lesson for us? Targeted pilots can drive change without creating chaos. Start small, but think big.

David Caldwell

And it’s not like we’re starting from scratch. Everyone talks about how disjointed our system is—maybe this could help us patch the cracks.

Sofia Ramirez

Exactly. It’s about designing a system that learns, adapts, and actually serves its purpose. So, next up—what makes a health system truly "learning"?

Sofia Ramirez

Alright, David, building on that idea of designing a system that adapts and learns, let’s dive into what a learning health system actually is—you know, beyond the buzzwords. It’s not just hospitals and doctors. It’s all the moving parts that influence health—people, organizations, technology, you name it.

David Caldwell

So, like, everything?

Sofia Ramirez

Pretty much! Imagine education programs that teach kids about healthy eating, community organizations offering fresh produce, or even workplaces encouraging mental health breaks. It’s all interconnected, and when the system learns—meaning it can assess itself, adapt, and improve—it works better for everyone. And Peter Senge—you’ve heard of him, right?—

David Caldwell

The systems guy? Yeah, didn’t he write seriously long books?

Sofia Ramirez

Yes, but trust me, his work applies here. He talks about how learning organizations are constantly evolving, how they reflect on themselves to grow. A learning health system is just that idea but on steroids.

David Caldwell

Okay, so, like a self-driving car that learns as it goes? But our system feels more like… well, one of those jalopies you gotta push-start down the hill.

Sofia Ramirez

That’s not a bad metaphor, actually. Our system does learn in certain ways, but it’s far from efficient or healthy. For example, med students memorize insane amounts of material that they rarely use, or coders document patient visits to maximize payments—even if it has nothing to do with improving health outcomes.

David Caldwell

Ah, so we’re learning, just not the right lessons?

Sofia Ramirez

Exactly. Or take surgeons getting trained to perform procedures faster—sometimes at the expense of asking whether those surgeries are even necessary. And public health? We’re great at piecemeal projects, but rarely do they tie back to broader goals. It’s fragmented learning instead of cohesive growth.

David Caldwell

Alright, so what would relentless learning look like? For real, what’s the ideal here?

Sofia Ramirez

It’s a system where feedback is baked in. Where data from everyday patient experiences flows back into the system to highlight what’s working—and what’s not. It’s about building a culture where every layer of the system, from the front desk to policymakers, sees learning as constant and essential, not just something you check off a list.

David Caldwell

That feels so… un-American, honestly. I mean, we love quick fixes, don’t we?

Sofia Ramirez

Well, that’s the challenge, David. It’s rewiring our approach to see value in thoughtful, ongoing improvement. And here’s the kicker—imagine if all that energy we put into gaming the system or chasing profits was redirected toward health outcomes, fairness, and efficiency.

David Caldwell

Oof, that’s a big shift. But I like where this is going. So, what’s next—how do we tackle profit motives that get in the way of all this?

David Caldwell

So, Sofia, since we’re talking about profit motives, let’s dig into the bigger question—money. It’s like the whole system runs on dollars first, health second. How do we even start shifting that balance?

Sofia Ramirez

David, you’re spot on. The U.S. health system is undeniably profit-driven. Hospitals view procedures as revenue. Insurance companies focus on reducing payouts, not necessarily improving outcomes. It's a system that incentivizes treatment episodes rather than health itself. Take this—preventing diabetes doesn’t bring in as much revenue as managing diabetes complications over time. But what if our primary goal was health, not profits?

David Caldwell

Wait, hold up. Are you saying we... don’t actually profit from making people healthier?

Sofia Ramirez

Not under the current model, no. The more someone stays sick, the more treatments they require, and that’s where the dollars flow. But flipping this system—to value prevention and health—means a total rethink. Picture this: Instead of paying for hospital visits, what if insurers rewarded communities where chronic disease rates dropped?

David Caldwell

Okay, I love the idea, but I can hear critics already saying, "Who's paying for all this prevention stuff?"

Sofia Ramirez

That’s fair. But what the critics don’t always acknowledge is that prevention can save money in the long run—reducing hospitalizations, emergency treatments, even lost productivity. Countries like New Zealand are proving that focusing on equity and health outcomes ultimately brings costs down. But let’s dig deeper here: equity isn’t just an abstract goal. It’s a pressing need in our system.

David Caldwell

Right. And equity hits home for me personally, you know? My mom worked crazy hours to make ends meet, and I think about families like hers who’ve always been on the outside looking in.

Sofia Ramirez

Exactly, David. Families like yours—and many others—experience our system’s deep inequities. Communities of color, rural populations, even women—these groups face higher barriers to care and worse outcomes. Did you know Black Americans are more likely to die from preventable conditions like heart disease, even when controlling for income? It’s a stark reminder that fairness in health isn’t just about money. It’s systemic.

David Caldwell

So, fixing equity isn’t a "nice-to-have," it’s foundational. How do we even start to tackle something this huge, though?

Sofia Ramirez

One key way is collaboration. Health doesn’t happen in isolation. Policies around housing, education, and nutrition directly impact outcomes. But here’s the catch—our current model treats these as separate silos. If the U.S. health system is ever going to be fairer, we need cross-sector partnerships.

David Caldwell

Alright, but let’s make this real. Like, what does cross-sector collaboration even look like?

Sofia Ramirez

Great question. Imagine this: A city government teams up with healthcare providers and local schools. The schools add nutrition education; the providers bring mobile clinics to underserved areas; and housing programs reduce mold infestations, cutting asthma rates. Together, they tackle interconnected issues that one sector couldn’t fix alone.

David Caldwell

That sounds… ambitious. Do we know if this actually works, though?

Sofia Ramirez

It does. Look at examples from places like New Zealand. Their public health campaigns actively link housing quality to health outcomes, and we’re seeing measurable improvements. Collaboration isn’t just feel-good—it’s effective. But here in the U.S., progress requires a willingness to align our systems and agree on shared goals.

David Caldwell

And here’s where I imagine some big structural change has to come in, right? Like, you need a roadmap for this kind of realignment?

Sofia Ramirez

Exactly, David. This is where frameworks like the Viable System Model come into play. It offers a guided way to analyze and adapt these interconnected pieces. Implementing it won’t be easy, but it might be our best hope for embedding fairness, health, and efficiency into the core of how we operate.

David Caldwell

Okay, so we’re getting into VSM now. Let’s break that down, because I can already feel my head spinning.

Sofia Ramirez

David, picking up where we left off, let’s dive into how we transition from understanding the Viable System Model, or VSM, to actually using it in the U.S. healthcare system. What are the specific steps we need to take to make this framework a reality?

David Caldwell

Yeah, because I think at this point, people get the idea that the system is broken. But theory—especially models—has a way of feeling, I don’t know, disconnected. How do you make it something real and practical?

Sofia Ramirez

Fair point. One way to think about it is like a diagnosis. The VSM helps us understand where a system is falling apart—whether it’s a communication breakdown, inefficient resource allocation, or something else entirely. And once the gaps are clear, you rebuild—just like in New Zealand, where the VSM helped them streamline their ophthalmology services. But instead of one department, here, we could begin with larger-scale pilots.

David Caldwell

Okay, but Sofia, where do we even start with a system this massive? I mean, our healthcare system is like this sprawling octopus—tentacles everywhere.

Sofia Ramirez

You’re right that it’s overwhelming. That’s why we start small, with manageable pieces. For example, let’s take diabetes prevention programs. New Zealand’s approach focused on aligning systems—primary care, data analytics, and community outreach—to tackle specific problems. We could experiment with something similar here. A VSM pilot might integrate clinics, schools, and data systems to zero in on at-risk populations and scale up from there.

David Caldwell

Alright, I get the concept, but what about funding? I can already hear people asking where the money’s coming from for connected IT systems, training, and all this coordination.

Sofia Ramirez

It’s not cheap, David, no doubt about that. But consider this: the costs we’re spending now on inefficiencies, readmissions, and chronic disease complications dwarf what prevention and better systems would cost in the long run. One study even projected billions in savings if we reduced emergency room visits tied to gaps in primary care. We’re already spending the money—it’s just not going to the right places.

David Caldwell

Okay, but pivoting doesn’t just take money, does it? It feels like there’s a cultural barrier, too. Like, how do you convince people—especially providers and insurers—to rethink their roles?

Sofia Ramirez

Exactly. It’s not just a technical overhaul; it’s about changing how we view and value health. When New Zealand piloted these ideas in ophthalmology, they didn’t just jump to solutions. They involved everyone—clinicians, administrators, even patients. That’s the power of feedback loops. Providers saw results—like shorter wait times and more reliable IT systems—and that reinforced the value of working as a cohesive system. What we need here is transparency and collaboration, not directives from the top down.

David Caldwell

Collaborate more. Got it. But I’m still stuck on how we’ll know if this kind of shift is actually working. Is there a way to measure progress without waiting decades?

Sofia Ramirez

Totally. Think of real-time dashboards that track outcomes like wait times, chronic disease rates, or even patient satisfaction. In New Zealand, they analyzed whether their VSM-inspired changes actually reduced bottlenecks and improved efficiency. In the U.S., we could use the same principles to build systems that give us actionable data instantly, not ten years down the line.

David Caldwell

And let me guess—this is the part where you plug data-driven policy reform?

Sofia Ramirez

You know me well! But seriously, data matters. Without solid, real-time evidence, decision-makers can’t fix what’s not visible. Take something like the public health response to COVID—without updated case rates and hospital data, some states were flying blind. And on an operational level, that’s what the VSM fixes—making the data flow in ways that help us adapt and act faster.

David Caldwell

So, basically, instead of patchwork solutions, the idea is to build a foundation where the system fixes itself?

Sofia Ramirez

Yes! That’s what a viable system does. And David, let me give you a quick example. Recently, I was speaking to a social worker in Denver trying to coordinate care for a patient leaving the hospital. She spent over 30 minutes on hold because the insurance provider’s system didn’t “talk” to the hospital’s billing department—it was like stepping into the 1990s. Imagine a VSM-inspired system where communication gaps like that simply don’t exist. That’s the direction we could take if we’re serious about systemic integration.

David Caldwell

Whoa, Sofia—that kind of integration feels so far away. But man, wouldn’t it be something.

David Caldwell

Sofia, that example about the social worker in Denver stuck with me—it’s like a perfect snapshot of why the system feels so broken. This conversation has been, well, eye-opening, and that feels like an understatement. We started with this intimidating-sounding Viable System Model and ended up exploring what it really takes to rethink health, not just healthcare.

Sofia Ramirez

You’re right, David. It’s not just about changing what happens in hospitals or clinics—it’s about mobilizing an entire system to prioritize health outcomes, fairness, and, yes, efficiency. And we’re all part of that system—patients, policymakers, communities.

David Caldwell

It’s a lot to wrap your head around, honestly. But what stood out to me is this idea of starting small, you know? Running pilots—not getting overwhelmed by the scale of the problem. It’s such a simple idea, but somehow, it feels revolutionary.

Sofia Ramirez

Exactly. Change doesn’t have to be perfect or massive right away. It just has to move us in the right direction. And that’s why frameworks like the VSM are so useful—they provide clarity on where to focus our efforts, even if we're starting small. There are lots more systems and complexity models and tools out there and experts that know about them. Our health system needs to tap much more into the world of complex systems.

David Caldwell

So, for our listeners out there—health professionals, policymakers, maybe even a few curious tech geeks like me—what’s the one thing you hope they take away from this episode?

Sofia Ramirez

I’d say this: don’t underestimate the power of systems thinking. It’s not just academic jargon. It equips us to identify leverage points in a broken system and apply real solutions that matter. If we start asking "How can this system learn and adapt?" instead of just "How can I fix this problem today?" we’ll take health transformation to a whole new level.

David Caldwell

And that’s something anyone can get behind. So, thank you, Sofia, for breaking down this really complex, but seriously important, topic. I think you’ve got me convinced—we can’t ignore this stuff anymore.

Sofia Ramirez

Thanks, David. And thanks to our listeners for joining us on this journey. Please keep asking the tough questions, and sending them our way. Let's keep learning together, and keep pushing for change. Because honestly? That’s how transformation happens.

David Caldwell

Couldn’t agree more. Let’s do it. And with that—

Sofia Ramirez

And with that, we’re wrapping up today’s episode. Stay curious, stay engaged, and take care of each other. See you next time.