A Complexity Tool Box


		A Complexity Tool Box: A story from James Roberts, M.D., Senior Vice President, VHA Inc. Told by: Ken Baskin Illustration of: emergence self organization good enough vision Stacey matrix clockware/ swarmware paradox "Edward Wilson talks about biological systems and how centuries of evolution have affected the way we work," explains Jim Roberts, a senior VP at VHA’s Dallas Headquarters. "Complexity theory gives us a better feeling for those biologically based ways of working together. The more I’ve studied ideas like self-organization and emergence, the more I’ve seen them operating in groups at work," he adds. "So the question, for me, is how these ideas can help us provide better health care service." A physician with experience in measuring quality for public health service and the Joint Commission of Accreditation of Healthcare Organizations, Roberts came to VHA in part to examine how physicians can be more effective in their leadership roles. "Physicians serve a variety of leadership roles," he notes. "We serve as senior executives, medical directors, vice presidents for medical affairs or senior physicians in member organizations. However, few of us have backgrounds in health system organization or general business, except for our small practices. On top of that, med school gives us a culture of autonomy and individual responsibility, as opposed to the team-orientation we need for many leadership roles. "What I found from the time I started studying complexity theory with Curt Lindberg about three years ago, is that it gives us a series of tools to help make health care work better."
Principles Good enough vision		Specifically, Roberts has been experimenting with complexity theory tools in building a Physician Leadership Network across the VHA system. "The idea, the shared aim that holds us together, has been to create connections so that physician leaders throughout our system can learn from each other," he says. "What we’ve found so far is that these tools are effective, that they do seem to reflect the way people work much better than our old bureaucratic ways." Roberts warns that these tools are less "tangible" than those provided by Total Quality Management. Control charts, for example, give you formulas for calculating whether systems are in control. The tools of complexity theory are more the products of close observation of the way people and systems behave.
Aides Stacey Matrix		Nonetheless, they’ve enabled the team working to build the leadership network to make major strides. Some of the tools are relatively simple and concrete. For instance, Roberts has begun mapping projects on Ralph Stacey’s four-square grid according to the level of agreement ("close to" vs. "far from") and the degree of certainty ("close to" vs. "far from"), on the horizontal axis in order to help think through how they should be addressed. "One of the challenges physicians in leadership positions face is how to allocate our time," he explains. "So, my clinical leadership team has begun mapping tasks on Stacey’s grid to get a better idea of which tasks we should focus on.
Principles Clockware/ swarmware		"For example, tasks in the lower left [close to agreement/close to certainty] are likely to be stable procedures that lead to a product or service in the later stages of its life cycle," Roberts continues. "So it makes sense to delegate those tasks. Tasks in the middle, on the other hand, with a good bit of instability, are likely to lead to a product or service in the earlier stages of its life cycle. So it makes sense for me, as a leader, to pay more attention to issues like customer feedback and what our competitors are doing." Other tools seem more abstract, at first. Roberts recommends the ideas of coevolution, self-organization and emergence to help managers understand the way groups naturally work together when they need to respond to rapid change. "These terms seemed to refer to separate experiences," he notes. "But the more I saw them in action, the more I realized they combine to describe the same phenomenon." Coevolution refers to the way units in a complex adaptive system (CAS) must continually respond to changes in their environments and, in responding, further change those environments; self-organization describes how units in a CAS can respond to changes and cooperate with others without being told what to do; emergence refers to the way often-unexpected new developments appear as units in CASs respond to change. "When you give a group of people a problem and allow them to self-organize, to solve it in a way that makes sense to them," Roberts says, "they’ll explore the environment and decide on an action that will respond to—that is, coevolve with—their environment. In this process, the most amazing, and unexpected, products emerge. "That’s what happened with some members working on our Physician Leadership Network," he adds. "They came to the conclusion that we needed a comparative data base of physician practices. That need emerged spontaneously. It wasn’t in anyone’s vision of what we needed. If we had given them detailed instructions on what they were to do, they probably would never have considered it. But because the people working on our needs in this project were self-organizing, free to discover what they needed, they could recognize the unanticipated and let it emerge.
Aides Ecocycle		"As they built the data base, the relationship between VHA’s Dallas headquarters, our regional offices and the physicians we worked with began to change. We all had to coevolve, and we’ll continue to coevolve. As long as people have shared aspirations, coevolution will generate new ways of meeting their needs. So products aren’t going to have life cycles anymore. The life cycle will be forever."
Principles Paradox		Roberts has also used some complexity theory tools to accelerate the change process. Gareth Morgan’s ideas about leveraging paradox as a catalyst for these new, coevolving systems was especially helpful. "When a group of people begin working on a project, they usually have points of internal conflict," he explains. "With these yes/but points, they may, for example, be excited about finding new ways to solve long-standing problems. They may also feel uncomfortable that their solutions will change the ways they’ve always been successful. "Morgan suggests the group articulate these paradoxes as quickly as possible, surface them early and honestly. By recognizing their points of discomfort, they can address and defuse them and move ahead more quickly with their solutions," Roberts adds. As an example, he points to the team that recognized the Physician Leadership Network required a data base of physician practices."Our group was looking for the paradoxes that would speed development of the network," he notes. "We realized how difficult it would be to connect physicians if we didn’t know who they were and what their challenges were. How could we learn this information quickly? The answer that emerged was a strong data base. So, by looking for the issue we were most uncomfortable with—the issue it would have been easiest to avoid, as we might have five years ago—we got the leverage to make a major step forward. "We’ve even got evidence that the data base was the right point to begin from. Since we started working on it, we’ve continued to get feedback reinforcing how valuable it could be."
Principles Clockware/ swarmware		Beyond his use of complexity theory to develop a management tool box, Roberts has also found it helpful in thinking about the future of health care and what that can mean for VHA’s member hospitals. "It’s clear to me that managed health care isn’t working," he notes. "I heard one HMO executive say, ‘Doctors are workers on an assembly line. If they quit, we’ll get some new ones.’ Health care isn’t that easy. People aren’t machines. Nobody likes being treated that way. "So you see a lot of our customers interested in alternative medicine," Roberts continues. "One senior physician I know is hanging it up. He can’t deal with all the angry doctors anymore. It’s a real tragedy. This guy makes a major contribution, but he can’t take it anymore."
Aides Min Specs		Much of the problem, as Roberts sees it, is the current system’s emphasis on the old model of health care as repairing illness. But he sees a new system emerging in the coevolution of a partnership between customers and health care providers. "We need to engage a partnership with our fellow human beings to serve and improve health, prevent illness, and provide comfort," he says. "This idea of coevolving with our customers is one of the most powerful ideas around today. It’s forced me to think about the barriers to us really working together, coevolving. How do we blur the distinctions between providers, customers and suppliers? After all, we’re all in this together. "Many of the issues that effect us most—tobacco and alcohol, drugs and violence, for example—are life-style and social policy issues," Roberts adds. "Where are the paradoxes that can serve as leverage points for bringing together health care providers and schools, police and social service agencies and government? "President Clinton’s ideas about a strong, centrally run system won’t work. It’s the right problem but the wrong solution. It’s command-and-control when we need new answers to emerge. And maybe that’s the biggest contribution complexity theory can give us—the tools to help tease out a new community partnership model of health care."
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