Reconceiving Design without Redesigning

Mary Anne Keyes, vice president of patient care for Muhlenberg Medical Center, talked about working with her people to create "Express Admissions". The hospital wanted to reduce the time patients spent in the admission process, to make it a faster, more convenient experience. The process of admissions tended to be complicated, taking up hours of the patients’ time and demanding visits from different hospital staff members and travel to several hospital departments.

"In the past, when managers have tried to implement change, they’d find themselves wasting energy fighting off resistors who felt threatened. Complexity science suggest that we can create small, non-threatening changes that attract people, instead of implementing large-scale change that excites resistance. We worked with the attractors."

So Keyes set out to create attractors. She brought together a "little group" of doctors and nurses interested in streamlining the process. She gave them one basic rule: All the admissions work must be done within an hour of the patient coming into the hospital.

"Keyes set out to create attractors. She brought together a little group of doctors and nurses interested in streamlining the process. She gave them one basic rule: All the admissions work must be done within an hour of the patient coming into the hospital."

The group set up a pilot for elective medical-surgical patients. That would keep the pilot to a manageable size and minimize resistance. They staffed an area with additional nurses who gave the newly admitted patients concentrated attention to ensure they got all their initial tests completed within an hour. It worked.

"Patients loved it," Keyes pointed out. "Doctors loved it. In fact, the doctors liked it so much that they kept asking for additional services. And whenever they called, the nurses would say they could do it. Pretty soon, this was an area where doctors could get both in-patients and out-patients taken care of quickly, whatever they needed. We’ve even included pre-authorizing insurance and scheduling. It’s a ‘can do’ area." This project spawned similar projects throughout the hospital.

These projects show why Keyes believes that complexity science is so practical. They start small; so small there’s no big initial expense, and they don’t create a lot of resistance. They prove themselves in action, and what doesn’t work is thrown away. They’re designed by the people who perform them; so there’s no resentment at having procedures imposed.

Keyes admits there can be problems with this style of management. "For anyone trained in traditional management, it’s all counter-intuitive," she noted. "It means you have to let go of control and trust that, given information and freedom, the people who work for you can come up with solutions at least as good as the ones you’d develop."

One of the keys to Kopicki’s success is giving up centralized control and even centralized knowledge. He said there are times when he simply doesn’t know what is happening in the hospital.

"I guess the really incredible thing for the CEO, and what I’ve learned is the toughest thing, is to give up control. You can say it and talk about it, but you don’t know it until you start doing it, until things start happening in an organization that you never heard about and they weren’t successful and you have this instinct to say, ‘Who the hell authorized that?’ ... You have to give permission to make mistakes if you want experimentation." (Kopicki)

There are many initiatives underway simultaneously and he knows he is not aware of them all. Not all are successful, but the learning is happening faster and the positive stories far outnumber the failures. Keyes talked about how they also learned about reflection in real time so that when something goes awry you can adjust it. The adaptation is happening within projects as well as between projects.

Keyes has been a major influence on complexity thinking at Muhlenberg. She has been a student, teacher and co-learner with Kopicki. They are part of a learning community in the hospital studying complexity. Two of the major impacts for Keyes has been her capacity to act by using attractors and small ‘do-able’ projects. She uses Gareth Morgan’s ideas of the 15% solutions. She encourages her staff to experiment and learn from their actions. She does not take credit for their ideas and has the humility to state that they may have better ideas. She trusts them to be creative, implement their ideas and keep the patients at the Center of all their initiatives.

Keyes also demonstrated in this story and others her use of minimum critical specifications. The admissions project had a clear set of minimum standard that had to be satisfied. Beyond that, it was up to the participants. This freed them to find creative solutions within the boundaries created by the minimum specifications. This approach allowed for unplanned solutions to emerge.

Both have learned to be patient with emergence. Kopicki said at times he has "to grit his teeth" when he sees something happening that he could have done better. One of their intervention strategies is not to intervene at all. They have been surprised over and over with how quickly "learning from doing" happens with the staff. They make mistakes or try things that don’t go as planned. They learn from them without being told by a supervisor what went wrong. The staff make the corrections or adjustments and carry on with the experiments. The feedback loops are within the system - the individuals act, reflect and adjust on their own without going through the bureaucracy for permission. Paradoxically, Kopicki and Keye’s patience has resulted in faster than expected outcomes on many projects.