"Another Way to Think"

Creating environment for organizational change and new models for community health

A Story from Debbie Zastocki, Sr. VP, Clinical Services, Chilton Memorial Hospital
Told by: Ken Baskin, Brenda Zimmerman and Curt Lindberg

Illustration of:

• metaphor
• min specs
• reflection
• tune to edge
• Stacey matrix
• clockware/swarmware
• complexity lens
• generative relationships
  
  

Principles
Complexity lens

"I’ve found complexity theory valuable because it can help people develop a different way to think about what we do," says Debbie Zastocki, SVP, Clinical Services, Chilton Memorial Hospital. "Most of us learned about management in a world that seemed more stable. Faced with today’s rapid change, we need a different approach, like the one complexity gives us.

"For example, as we began to redesign procedures at Chilton Memorial, I was astounded at how hospital staff reacted to the changes we made. It was as if they felt they’d personally failed because we were creating new ways to do our jobs. But once we started talking about some of the ideas from complexity theory, creative destruction, for example, we developed a different framework for thinking about what we were doing.

"Until I realized that forest fires clear the ground for new growth-that new growth is almost impossible without some destruction, I’d always thought of forest fires as purely destructive," she adds. "Applying creative destruction to our restructuring helped some staff members refocus on what we were doing to ensure the future of our hospital."

Zastocki explains that her interest in this kind of thought had been stimulated before she was asked to work on the VHA complexity task force.

"About two years ago, I attended the Wharton nurse executive program," she notes. "We talked about "managing the space-in-between-that is, the areas where you can’t manage with clear-cut procedures. At the time, most of us understood it was important, but we had trouble getting our minds around what the "space-in-between" was.

Aides
Stacey matrix
Min specs

"Working with the complexity task force finally cleared that up for me. Ralph Stacey talks about processes being certain or uncertain and having a high or low degree of agreement about them," Zastocki continues. "Processes that are certain with a high degree of agreement are easy to manage with standard procedures. We know what the outcomes have to be and how to reach them. But processes that are certain with low agreement or uncertain with high agreement are-I think-the spaces-in-between."

As an example, she cites the procedural redesign at her hospital.

"We all agreed on the minimum specs-we wanted high quality, value-added and cost-effective care that met the needs of our patients. We were uncertain about how to perform that redesign. That," Zastocki emphasizes, "was the space-in-between, and learning how to manage it has, for me, really been what this work with the complexity task force was about.

"Using what I’d learned with the task force, I began setting up cross-departmental teams to create value as our patients recognized it. We’d always assigned tasks such as drawing blood, handling meal trays or cleaning to people in separate departments. Their work was scheduled by their departments, regardless of how the patients might feel about it. Now," she adds, "we were reorganizing these tasks on the patient care units, working together creatively to serve our patients."

The odd thing, Zastocki points out, is that her staff people seemed to feel intimidated by the new procedures they developed, even when they were far more successful, for both staff and patients.

"Part of the problem seemed to me that most of us, myself included, had such a control-oriented, mechanistic idea of what we were doing," she explains. "We were uncomfortable with letting new procedures emerge through self-organization. We really wanted to have every step of the way planned out. Some people even seemed to believe that in letting go of traditional control we were destroying quality.

Principles
Clockware/
swarmware

"Once we’d created an innovative way of doing things, our staff wanted to get out of the space-in-between and return to certainty and agreement. I was surprised it took that pathway. But maybe I shouldn’t have been so surprised," Zastocki admits. "There is a need for clockware after swarmware."

Her participation in the VHA complexity task force had given her an advantage in integrating this new way of thinking about how to manage.

Aides
Reflection

"At first learning about complexity was a mental exercise," she says. "I needed to be challenged to make it more than just theory. As we talked about these issues, like letting go of control, over time, we’d begin asking questions like, "How are you conducting meetings?" or "How have you approached projects to encourage self-organization?" And I saw that I was verbalizing the new ideas, but living in the old world. I called what I was doing coaching, but I was actually controlling.

"The lessons I was learning were a form of personal self-emergence and self-organization. I disbanded some meetings and recrafted the way we did things. Now, we've changed nursing and patient care council management. I have a nursing council and a practice council that staff run. They’re excited. They come up with action items. There’s a feeling that they’re genuinely excited about what we’re doing.

The next step, she believes, is to help community groups engage in this emergent, self-organizing type of behavior.

"We believe we need to build a community-based model of health. Many of the community people we’re working at first were looking for bureaucracy and certainty. They wanted us to map out the next 25 steps in the process.

Principles
Tune to edge

Aides
Generative relationships

"Of course, it’s new territory, so there’s no way to map out what will happen. Instead," she says, "we’ve used the principles of complexity theory to guide our collaboration."

For example, the steering committee pulled together the widest diversity of people possible so that whatever emerged would come from the broadest base in the community. Members included clergy, family practice attorneys, people from the schools and business, others from mental health services, a local college and an insurance company. And because it was both self-selecting and self-organizing, the energy level has continued high and 90 percent of those who started two years ago are still on the steering committee.

"Each of the sub-groups that has developed from the core group has evolved differently" Zastocki continues. "For instance, the group dealing with depression developed a ‘gatekeeper’ model. They asked who would be likely to know about people in the community with this problem. The answer was that it might be a clergy person or a hairdresser of a bartender. So the group is working on strategies to make resources available to these people.

"What the group is beginning to evolve is the model of healthcare without walls," she notes. "People should be able to draw on health care resources and support wherever they naturally come together. We will need to work in low certainty/low agreement activities.

"We’ll have to support people who want to know more, to work in alternative modes and see what evolves-that is, we’ll have to let community health care self-organize. In the end, we’re likely to have a network of interacting agents-consumers, health providers, other resources-and we’ll see some very interesting experiments."

The key to making this approach work, Zastocki has come to believe, is the ability of people to continue operating outside a high certainty/high agreement.

"We’ve had challenges operating in the uncertain areas because people involved found it difficult to stay in this some times uncomfortable zone," she explains. "When we’ve been able to contain the resulting anxiety, we’ve been able to excite a degree of commitment beyond anything we’d expected. When we haven’t, it seems the group needs to stop and regroup almost every time they try something new."

Aides
Metaphor

As a result, Zastocki feels it’s extremely important to find techniques for containing the anxiety that’s inevitable when they’re working outside comfortable, predictable areas. One technique she’s found useful is metaphor, such as explaining creative destruction with the metaphor of the forest fire. Another is the spider plant.

"A spider plant doesn’t plan or control its growth," she says. "It grows by self-organization until it reaches a point where it’s ready to throw off a shoot. Then the shoot grows through self-organization, maybe not exactly the same as its parent, but according to its own way of developing. And the process goes on and on, until you can have a very sophisticated, very complex structure-all without control or planning.

"This is a powerful way of helping people contain their anxiety," Zastocki adds. "Whether they’re engaged in redesigning hospital processes by evolution or stimulating the emergence of a completely new community model of health care, the spider plant shows that it can happen-that it does happen. And, after all, we’re living things, just like the spider plant. So if the spider plant can do it, why can’t we?"

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