“A Health Care Application Story: The Politics of Change”
In which Jim Taylor presented an indepth case study of complexity principles at work.

• Because Taylor learned about complexity before it entered the mainstream, it became baggage for him. He was asked to behave in ways he realized no longer worked. “As with anything else that you internalize,” he said, “you can’t turn it on and off. It’s part of the way you do things.”
  

The scenario

• Before Taylor arrived, the University of Louisville Hospital had been managed commercially. Columbia/HCA recently left. Two hospitals in the area came together to form a not-for-profit company and won the contract to manage the University of Lousiville Hospital. It was a new environment of former competitors. Nobody knew how it would work.
  
  
• A priority became to integrate adult cancer services. Suddenly, the organization faced a bond offering, and the cancer integration issue became critical. Now, they needed to take this cancer integration plan to the public as part of the bond issue.
  
  
• Gareth Morgan was brought in as a consultant. “The mandate was to create a way to put together the three practices,” Morgan said. “Actually, everyone wanted to use the meeting as a way of putting their stakes in the ground. Each of them wanted to define how they would work together before they had discussed what working together would mean.”

• “Until this point, the group was caught up in its own attractor pattern,” Morgan noted. “Each participant wanted an integrated oncology program but wanted to build it on what they had. I got them to focus on the ‘buts,’ the contradictions that could be levers for change. I asked what would immobilize the integration. What about physician leaders in three organizations? What about the town and gown issues? Any of these issues could stop the effort in its tracks.”
  
  
• As a result, all participants saw the need for a different approach. Morgan suggested they take on these issues and find a creative solution.
  
  
• Their solution: “An oncology program without walls.” “We asked what it would look like,” he continued, “what the architecture might be. It emerged as an integrated oncology program where information systems would bring everything together. Then the group pushed it into a task force to work out the details.”
  
  
• For Morgan and Taylor, their 15% was to talk about what was blocking the participants from taking action on this idea. Once they reframed the issue, those participants were prepared to sign off.

• When the holidays came, the sense of urgency was lost. The task force fell victim to the old attractor of bringing in external consultants. The bond issue ended up not being so important.
  
  
• Taylor noted: “We later found we hadn’t uncovered all the buts. The most important one was whether the physicians would do it.”
  
  
• The lack of urgency gave people the opportunity to pull back and return to their old ways. The crisis was gone. They could return to how things were always done. Crisis had been a major key to change.

• Ultimately, physicians decided they weren’t willing to consolidate. However, they were willing to sit together and talk, willing to consider the need for change over time, to build a clearing house for information, to do education programs together.
  
  
• Taylor said: “We learned what was doable and what wasn’t. We’d taken one of major ‘buts’ and brought parties together to talk. We also avoided a major consultant study that wouldn’t have done anything. We’ve learned about a process that is useful in other areas. It enabled us to learn what was possible.”

• The termite mound metaphor suggests that you won’t do everything you begin. The oncology program got stopped. But other projects, like infectious and digestive disease programs, took off using the methodology used in the cancer program planning. This is classic emergence. The system is self-organizing. It’s a battle between a desired future and old attractors.

Copyright © 1999, VHA Inc. Permission
to copy for educational purposes only.