The Heart of Complexity

The Heart of Complexity

Stories and Applications

Marilyn Rymer, M.D. - “Growing A Stroke Program, Chunk by Chunk”

The scenario

Stroke was a big issue at St. Luke's Hospital, because of the cardiac care. Cardiac care tends to create stroke issues. But there was no organized approach to stroke care.

How the program came together

The first step was to bring doctors from many disciplines together and ask if they thought a stroke program was necessary. Of course, it was necessary. But hearing the doctors say it was important. This created a mandate to do it.
Two teams were created: clinical and organizational. A good-enough vision was articulated, which was to "decrease incidences of stroke in our community." Note that the vision didn't necessarily include the hospital!
The teams identified specific areas that would require attention: the program; the people needed; the training; etc. The teams were very flexible in terms of who was on them. The team changed as needed.
Boundaries were important — first to affirm, then to breach. This leads to creativity. Traditionally, for example, there's a boundary between the neurologists and the internists. But there's also a broader boundary that embraces both of them. One can breach a boundary by drawing a wider boundary around two. Similarly, boundaries were breached between specialists, groups outside the organization, and the neurologists and ambulance companies.
So much came out of new connections — ambulance drivers, other hospitals. There were a lot of different relationships. Some really kicked in in a surprising way.
"We tried a lot of small things first... We didn't necessarily begin with trying to change the system."
"Complexity has given us permission. I used to think I wasn't being a very good leader in meetings, because of lack of decorum. But there is real energy and passion. That's why it hasn't lost steam.

What was created

One result was the SWAT team. It was found that one of the worst places to have a stroke is in the hospital. These strokes are usually identified the slowest. A process was developed in which nurses have only to identify neurological change. That's when they call a beeper for a nurse on the SWAT team. That nurse shows up and decides if action needed to be taken. So far, over 100 SWAT calls have been placed — probably 4 of which made a huge difference. Many others made a significant difference.
Stroke team meetings: They tend to be very noisy. There is a "good enough" agenda. "Stroke talk" is where difficult things are discussed, like trouble with certain doctors or communication problems. It stays there, without revealing confidences. People are free to bring up whatever is on their mind. There is obviously distributed control — it's not dominated by Marilyn.
Now, if it is known that a patient is coming, they can be in a CAT scanner within 5 minutes.
A system-wide anti-coagulation system is in the works. A stroke prevention and recovery clinic will be opened. So the boundary is broadening even more.

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