Lessons from the Edge

Health Care Stories

In which participants learned first-hand of health-care efforts and successes from a complexity perspective

(With Linda Rusch, VP, Patient Care Services, Hunterdon Medical Center)

• Linda Rusch asked some nurses what they thought about going into the community and participating in the local Shad Festival. Unpredictably, the nurses jumped at the chance, soon looking beyond their roles as nurses in the hospital. Some of the things they do now:
  
  
  • They participate in four local festivals.
    
    
  • They sponsor an OR “community day.”
    
    
  • Maternity nurses contacted local prosecutors and became active in domestic violence, even helping to set up a shelter
    
    
    
• Rusch emphasized that she merely acted as a “context maker.”
  
  
• The new context was that nurses who once focused on their own educational needs began thinking in terms of educating the patient and working in the community.
  
  
• This is an example of using one’s 15%, of management by nudging.

(With Stephen Larned, MD, Vice President, Medical Affairs, Maine Medical Center)

• Steve Larned discussed his use of the Stacey Matrix as it related to the merger between his allopathic teaching hospital and an osteopathic teaching hospital.
  
  
• People at both hospitals wanted to lessen their anxiety by reducing issues in the middle of the diagram and moving to the lower left. They were thinking in terms of win/lose.
  
  
• Larned kept pulling them back to the middle. By staying out of equilibrium, they were able to learn and work together in an entirely new way. They soon stopped fighting over old issues.

(With Deborah Zastocki, RN, EdM, Sr. VP, Clinical Services, Chilton Memorial Hospital)

• Using complexity principals, Deborah Zastocki’s hospital identified and met mental health needs of the community
  
  
• The committee could not focus on finding innovative solutions until they addressed internal issues of trust. Zastocki worked to resist the temptation of pulling down complex issues into the lower left of the Stacey Diagram.
  
  
• She further facilitated the process with Morgan’s spider plant metaphor. This helped self-selected pods to “sprout” and develop unconventional strategies for addressing mental health problems through “gatekeepers” the group identified. This played out in innovative ways:
  • Instead of identifying mental health needs only through clergy and attorneys (the traditional way,) they also formed relationships with bartenders and hair stylists, who provided feedback on where the community needed help.

• 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.”

(With Richard Weinberg, MD, VP Network Development, Atlantic Health System)

• Richard Weinberg used complexity theory to facilitate the merger between physician organization (PO) and a primary care IPA. Relationships between the two groups were deteriorating. Weinberg brought representatives from both groups together for regular conversations. In these meetings, he had them:
  • talk over issues of distrust and agreement;
  • set minspecs
  • focus on what they had to do to have the “best” successor organization
  • form a good-enough vision of the new attractor
    
    
• Progress stopped over the issue of choosing a financial partner, as members of the IPA retreated to their old attractor. Rather than having the PO deliver an ultimatum, as a more conventional approach might suggest, Weinberg kept communications open. He let members of the IPA know when the PO was preparing to choose its financial partner; yet he did not pressure IPA members. He left them free to do what they wanted. As a result, in a sudden, unexpected move, the IPA voted to join the new organization.
  
  
• The combination of building a strong vision of the new attractor and allowing people to make up their minds without coercion appears to have flipped the context so that the desired result “just happened.”

(With Martha Dawson, RN, Sr. Nursing Director, University of Louisville Hospital)

• The Challenge: The University of Louisville Hospital is a historically bureaucratic institution, with a traditional top-down approach, central power of control and little tolerance for true creativity. There are thick manuals, but few rules.
  
  
• Complexity science was combined traditional management approaches to move the hospital into a new system that embraces creativity, risk taking, learning, and an empowered work force.
  
  
• Martha Dawson spent a lot of time trying to influence how information flows in the system: through leadership meetings, unit level staff meetings, asking front-line to meet with her one on one, restructuring committees to include staff (versus being all management,) meeting with physicians, and meeting with community leaders.
  
  
• Some of the complexity aides she and Jim Taylor have used or discussed are minimum specifications, reflection, generative relationships, wicked questions, and Stacey’s agreement and certainty matrix.
  
  
• Martha reflects “I have no idea whether I am doing the right thing, but that’s what I like about this concept; there is no how to, right way or wrong way. You just let things happen and facilitate in a natural way. Today, the new administrative leaders have a different, positive style of leading — and that environment feels different.”

(With Martin Merry, MD, Independent Physician Consultant)

• Martin Merry told a story about a medical staff committee charged with developing recommendations for improving the effectiveness and structure of the medical staff organization.
  
  
• Initial efforts followed a conventional approval process — basically, the development of a plan based on an outside expert’s advice (i.e., copy what had been done elsewhere.) This led to little progress.
  
  
• The committee asked Martin Merry for some advice. He observed that the issues they were addressing were in Stacey’s middle zone – “not close to certainty and agreement” (where an expert’s prescriptions might work.) He suggested a retreat process based upon a few simple rules (like “increase information flow about what was happening in the health care environment; no central control; facilitation in a way which enables all to participate and diverse viewpoints to be heard.”)
  
  
• The results were some breakthroughs that the committee had a hard time believing — like “we need full time physician leadership” (after they had resisted the concept for years); and “we need to work more – not less – with administration and the board.” (Before the staff had been convinced it needed to wrest more control for the physicians.)

(With Mary Ann Keyes, VP of Nursing Affairs; Philip Brown, Sr. VP and COO; and Robert Bayly, MD, Director of Critical Care Systems; Muhlenberg Regional Medical Center)

• How can leaders facilitate the embracement of complexity concepts into the organization’s culture? Leaders at Muhlenberg shared their answers to this compelling question. Some principles they shared are:
  
  
• Just do it! Rather than trying to design a whole solution, take a little thing and do something about it. Real change occurs in incremental steps. Call it a pilot. Begin a little experiment in a small corner of the organization. If it works, nurture its adoption and emergence in other part of the organization.
  
  
• Trust each other — and yourself. Spend time with your team. Learn to really listen and hear. Get clear on what the overall direction is.
  
  
• Give up control, but give direction. Get comfortable with muddling through. You can’t know every answer now, and many answers will become clearer down the road. Trust that the best decision will be made, and learn to appreciate ambiguity.
  
  
• Generate many options. If it doesn’t feel right and simple, step back and look for what is emerging. Don’t force fit. Follow your instincts. As a leader, be willing to let the staff struggle and work out the plan. You don’t have to abdicate your power, nor do you have to abandon your people. Continue to focus on what matters, provide resources and allow experimentation.

(With Al Herzog, MD, VP, Medical Affairs, Hartford Hospital)

• Dr. Herzog told of Hartford’s plan to develop an office-based clinical information system with an electronic medical record (EMR). The EMR would link with the office practice management system. Both CIMS and practice management IS would be linked with healthcare IS system. The work is still in progress.
  
  
• Complexity science concepts were used in the project’s development and discussion. Principles included:
  
  
• Start with minimal specs. (Start with a design consisting of 1/2 page.)
  
  
• Make use of creativity from interaction of a complex adaptive system.
  
  
• Work with high leverage paradoxes (i.e., the need to collaborate vs. inherent reluctance to share data.)
  
  
• Build a “good enough” model. (The “perfect” model does not exist) •Direction will emerge from action and interaction.
  
  
• Always pay attention to the shadow system. (The clinician users’ input is key.)

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