"Another Way to Think"
Creating environment for organizational change and new models for community health
Story from Debbie Zastocki, Sr. VP, Clinical Services, Chilton Memorial Hospital
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 todays 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 theyd 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.
I realized that forest fires clear the ground for new growth-that new growth is almost
impossible without some destruction, Id 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
"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 cant 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.
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."
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 Id
learned with the task force, I began setting up cross-departmental teams to create value
as our patients recognized it. Wed 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.
wed 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 shouldnt 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.
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, wed 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. Theyre excited. They come up with action items.
Theres a feeling that theyre genuinely excited about what were 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 were working
at first were looking for bureaucracy and certainty. They wanted us to map out the next 25
steps in the process.
course, its new territory, so theres no way to map out what will happen.
Instead," she says, "weve 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.
"Well have to support
people who want to know more, to work in alternative modes and see what evolves-that is,
well have to let community health care self-organize. In the end, were likely
to have a network of interacting agents-consumers, health providers, other resources-and
well see some very interesting experiments."
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.
a result, Zastocki feels its extremely important to find techniques for containing
the anxiety thats inevitable when theyre working outside comfortable,
predictable areas. One technique shes found useful is metaphor, such as explaining
creative destruction with the metaphor of the forest fire. Another is the spider plant.
"A spider plant
doesnt plan or control its growth," she says. "It grows by
self-organization until it reaches a point where its 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
theyre 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, were living things, just like the
spider plant. So if the spider plant can do it, why cant we?"
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