Edgeware - Tales


"What We Could Be Doing Together"

Building new relationship with primary care physician group and planning for clinical quality improvement.

A Story from James Dwyer, VP, Medical Affairs, Memorial Hospital of Burlington County
Told by: Ken Baskin, Brenda Zimmerman and Curt Lindberg

Illustration of:

  • complexity lens
  • generative relationships
  • shadow system
  • chunking
  • good enough vision

Complexity lens



"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."


"It was reassuring to hear people talk about all the things that were out of our control. After all, in health care we're working with complex systems where no one can be fully in control... it made me comfortable to hear a scientific explanation of why that was true."

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.

"In 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."

As 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.

"One day, several doctors and nurses got to talking in the cafeteria about how some of their patients weren't getting anticoagulant quickly enough. so one physician ended up forming a team. This group was part of the hospital's shadow system."

"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."

Shadow system

Another 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 needed innovation.

"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.

"I'm convinced that we can't plan and create a complete system. Rather we need to develop it in components, from the bottom."

In some ways, Dwyer believes this community-based parish effort points to what could be happening to the emerging health care system.

"It's obvious that the system has become too conscious of costs, rather than quality," he points out. "The negative reaction of the public is beginning to reverse this trend, and there are a number of signs about what could emerge.

Good enough vision

"A 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."

Such 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.


"For 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 system.

Rather we need to develop it in components, from the bottom. We have to look to connect and make things more complex and adaptive. "No one organization can do everything. We need to take the best out of each organization and create a network that can continue to shift and adapt."


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