Edgeware - Tales


Inter-Departmental Communication in a Large Hospital
The Challenges of South American Diplomacy

Bringing mental models to the surface as a technique for raising organizational understanding and progress on hospital wide improvement initiatives.

Told by: Paul Plsek

Illustration of:

  • metaphor
  • mental models
  • tune to edge



The CEO of the University of Louisville Hospital (ULH), Jim Taylor, is also a member of one of the VHA leadership groups exploring complexity science application. Jim asked Paul Plsek and Karen Wunderlin to facilitate a two-day retreat at which 14 managers from various hospital departments would come together to initiate specific improvement efforts within the hospital.


"We do not always need to introduce the formal language of CAS theory and tools. Often, it is enough to just do it. Understanding and action emerge."

As an ice-breaker exercise, Karen gave each participant an easel sheet, some colored markers, and 10 minutes to create a collage that they could use to introduce themselves. One element of the collage was to be a picture that "describes what it’s like to work at ULH." In other words, each group member was to create a metaphor of work life at ULH; although the term "metaphor" was never used.

Reflection: We do not always need to introduce the formal language of CAS theory and tools. Often, it is enough to "just do it." Understanding and action emerge, no matter what you call (or don’t call) the methods you are using. Indeed, sometimes the formal language of CAS theory and tools can be distracting and cause negative reactions among participants.

After all the introductions, we fed back to the group the patterns we saw emerging from the metaphors. There were several metaphors that spoke of boundaries and walls: a maze, the countries of South America (more about this in a moment). There were several pictures describing ups and downs: the stock market, volcanoes arising on an otherwise flat landscape. There were several chaotic conflict pictures: a tornado, a bee hive, arrows going in all directions, goats butting heads. Finally, there were several pictures which we termed "bittersweet:" a circus ("fun, but you have to put up with lots of clowns"), a dysfunctional family ("we know things are not right, but we never talk about it"), and the Titanic ("high hopes and lots of money lying now at the bottom of the ocean"). The group then spent over 40 minutes discussing these pictures. They realized that no one was happy with the status quo, but they had never talked about it in so rich a way before.

Brenda Zimmerman adds her reflection: One of the things that we know from CAS is that the independent agents are all responding to their own internal schema or mental models. The process used in this story surfaced not the "one true" metaphor, but the diversity of images that they were using (implicitly) to make sense of their work. One benefit from Paul’s intervention was that the participants learned to articulate their own schema and see others’ schemas.

The metaphor of South America attracted significant discussion. The group noted that the various countries in South America speak different languages (Spanish, Portuguese, various native dialects), have different styles of government (true democracies, dictatorships, mild forms of anarchy, military rule, etc.), and present different challenges to the tourist/visitor. Group members could clearly see analogies to the hospital’s departments, and the impact that this might have on patients and family members who had to navigate through the departments.

Tune to edge

Reflection: In this case, these are negative metaphors that the group wants to counter-act, rather than positive metaphors of a new way. Metaphor can be used in either a positive or negative sense; as long as it provides a new way of thinking about and seeing a situation.

"The implicit metaphor driving managers' behavior in the past was department as a fortress; protect your turf, protect your people, protect your professional discipline. What they learned through discussion was that they were mutually dissatisfied with this approach."

With the dialogue about these metaphors as a base, the group went on to a rather traditional and structured quality improvement workshop. The result of the workshop was that the group chose to work on specific improvement efforts in the areas of inter-departmental cooperation and providing better customer service.

Reflection: There is nothing particularly insightful about the issues that the group chose. These same two issues could easily have arisen from analysis of data, or through a recommendation by the outside consultants after a one-day organizational assessment. The key difference brought about by the use of metaphor within the group was that the metaphors provided a forum for having a discussion among the agents within the CAS that they had not had before. The implicit metaphor driving these managers’ behavior in the past was "department as a fortress;" protect your turf, protect your people, protect your professional discipline. What they learned collectively through the discussion was that they were mutually dissatisfied with this traditional approach. They now fundamentally think about and see the situation differently. This internalization and adoption of fundamentally new metaphors gives the CAS a new capacity for change. This new capacity would probably not have come about simply by injecting data or outsiders’ recommendations into the system, while retaining the old metaphors in the minds of the agents within the system. Successful metaphors often feel like a fresh breeze blowing from a new direction across the environment.

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Copyright 2001, Paul E. Plsek & Associates,
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