"What We Could Be Doing Together"
Building new relationship with primary care
physician group and planning for clinical quality improvement.
Story from James Dwyer, VP, Medical Affairs, Memorial Hospital of Burlington County
"In the end,
complexity theory makes you ask what projects make sense in the world you live and work
in," says Jim Dwyer, VP, Medical Affairs, Memorial Hospital of Burlington County.
"As an administrator, I've always gone into planning sessions with a clear idea of
what the outcome should be. But since I've been studying complexity, I'm open to more
ideas. I don't need to have all the answers, so I'm willing to draw on the experience of
anyone who can help ensure the best results."
This sense that he didn't have to be in
total control, because no one could be, attracted Dwyer to complexity studies from his
earliest work with the New Jersey VHA task force.
"It was reassuring to hear people talk about all the things that
were out of our control," he notes. "After all, in health care we're working
with complex systems where the future is sometimes unidentifiable, and relationships
aren't necessarily permanent. No one can be fully in control of those kinds of situations,
and it made me comfortable to hear a scientific explanation of why that was true."
Dwyer cites the concept of "generative relationships" as one
that makes him more flexible and, therefore, more effective.
the past," he says, "if I were trying to develop a partnership with another
physicians' group, I'd try to bring other people around to the right way-that is, my
way...of seeing things. With generative relationships, on the other hand, I begin by
showing them what we could be doing together. Then we define what we're both comfortable
with and let the relationship grow from there."
an example, Dwyer points to the discussion his hospital recently had with a primary care
group that has a standing relationship with another hospital in the county.
"They initiated the discussion
because they were interested in the network of physicians we've been building," he
says. "As we talked, they expressed some fears about having to accommodate the
management systems and protocols we'd already begun developing. A couple of years ago, I
might have tried to convince them that our systems really were the best. But that doesn't
seem necessary anymore. So I explained that they didn't have to use our systems, that we
could work together in whatever way was best for them.
"Once we demonstrate that we can
work together, and they experience how much they have to gain in the process, we can let
the relationship grow. Our relationship doesn't have to appear all at once. It's a lot
more comfortable for everyone if we let it emerge, let it generate itself."
idea from complexity theory that Dwyer believes has made him more flexible is Ralph
Stacey's "shadow system." Stacey notes that most organizations have a dominant
system responsible for making day-to-day operations work. They also have a shadow system
that plays with innovations that might replace those of the dominant system. Stacey
explains that, in markets changing as quickly as health care, it's important for
management to be able to tap the potential contributions of the shadow system. Dwyer
learned the importance of being able to tap this shadow system with the quality process
hospital management put together in 1996.
"We had this formal mechanism for approving quality improvement
projects," he notes.
"We needed it because projects were being pursued without any idea
of whether the effort needed for them would be worth the value they produced.
Unfortunately, the process became so difficult and took so much time, people were losing
their enthusiasm over worthwhile projects." The dominant system was discouraging
"Then, one day, several doctors and nurses got to talking,
probably in the cafeteria, about how some of their patients weren't getting anti-coagulant
quickly enough. So one physician researched the problem and ended up forming a team-I was
asked to participate-to study the problem and how other hospitals were handling it. We
ended up creating a procedure to ensure that anti-coagulants were administered more
effectively," Dwyer added.
This group was part of the hospital's shadow system. Everything its
members did was outside the official quality program. When Dwyer and other members of the
dominant quality structure discussed what had happened, they decided to re-examine the
official quality program.
"Basically, we decided to turn the structure upside-down," he
says. "We created lots of opportunities for people to generate projects and
restructured our quality program to support them. As experts, we can help them identify
their needs and help them get the data and support they need. But we expect we'll see a
lot more important projects because we've found a way to tap the shadow system."
Dwyer's even been able to extend this idea of shadow systems outside
the hospital and into his community.
"I'd noticed that managed care had cut down on utilization of our
resources, and that many people were suffering because of it," he explains. "At
the same time, many people in health care are willing to give their time to help those who
were suffering. To connect those with resources and those who needed them, my local parish
created a health ministry to catalogue available resources and connect those resources
with the people who need them.
"Sometimes it's as simple as pointing people in the right
direction or holding their hands. But the idea is straight out of complexity theory:
Develop a shadow system to connect the people that the dominant structure has overlooked
to resources that this shadow system can now make available," Dwyer adds.
In some ways, Dwyer
believes this community-based parish effort points to what could be happening to the
emerging health care system.
year and a half ago, I was at a VHA session where a consultant, Gus Jaccaci, indicated
that we're moving toward a more community-oriented approach that will focus on
illness-prevention," Dwyer says. "This kind of community-based model would give
people a significant role in managing their own health, responsibility would be spread out
across the community."
a system would favor the kind of generative relationships that Dwyer has begun building.
"The Columbia/ HCAs of the world have driven a wave of hospital
mergers that have downsides they never thought about," he explains. "Our
approach is to serve the community by creating relationships that allow partnering
organizations to benefit mutually, yet retain their identities.
me, this is the fun part of health care," Dwyer continues. "How can we develop
relationships that will develop a healthier community, rather than merely a fatter bottom
line? I'm convinced that Curt [Lindberg] is right-that we can't plan and create a complete
All Components of Edgeware Tales
(except where otherwise indicated)