Welcome to the balcony of personal reflection. Today I am joined by Hugh MacLeod.  We start our conversation by stating the obvious: there is no single healthcare transformation recipe. Transformation in attitude, understanding and behaviour is an experience. Real “transformation” reveals what is true now, the ideal solution to meet the evolutionary need in a system now and the pathway to what is universally true. The wise in many knowledge traditions say that “truth is multi-dimensional”; it contains and balances opposing forces. In the truth of a certain day, both day and night exist together in our world, where humanity experiences both at the same time. Suddenly, the Ghost of Healthcare Despair appears:

“Consider how you would answer the following questions: Is the future known or unknown? What causes an organization to move into the future? When transformative change occurs, what exactly is changing?

Great questions … Those who believe in control and prediction will think and act in very different ways from those who believe that the future is unknown and thus, unpredictable. Our sense is that many will believe that the future is both known and unknown. But, how is belief enacted in daily planning and decision-making? To answer this question, let’s take a look at three teleological approaches. Teleology explains a series of events in terms of goals or final purpose, and helps us to answer the question: “What causes an organization to become what it becomes?”

The current literature abounds with three teleological positions – rational, formative and transformative.

  1. Rational teleology: The basic assumption is that organizational movement is toward a known and predictable future. There is a strong belief that a known future arrives via various methods of control such as the use of established performance measures, rational analyses, plans, goals and actions of leaders and managers. There is no self-organization present, so stability and change are the result of choices made by autonomous human beings scrutinizing and planning on behalf of the organization. Motivation of the workforce is critical to realize the chosen aim and strategic goals. Statements of mission, vision and established universal values are essential so that all employees are singing from the same hymn book.
  2. Formative teleology: The assumption here is that movement is toward a future that is known or predictable by the interaction of a system’s related parts. The system self-organizes to reveal a predictable future. Time is from a given past toward a present. The future is recognizable from the past, and the past is carried forward in the present to the desired future. It is a deterministic view that realizes a future through the unfolding of the past into the present. Helping employees, thus the organization, realize their full potential assumes that the potential already exists in the form (employees). The final form (organization) is realized by the maturation of the agents’ selves or organizational identity that was already present.
  3. Transformative teleology: The assumption here is that movement to a future state is caused by the self-organization that occurs in the micro-interactions of organizational life in which each moment is influenced by previous moments. Each moment is a reconstruction of the past in the present accompanied by simultaneous continuity and change in the present as the future is continually under construction – an unknown and unpredictable future. The meaning of the past is reconstructed in the present, while at the same time the future is under continual construction. Time is non-linear.

Put yourself in the place of a spectator at a Stanley Cup playoff hockey game. You arrive full of confidence that your favourite team, which has had a good record of wins this year, will not disappoint you. All players on both teams are highly trained and skilled. Based on a close evaluation of tapes from previous games, coaches and players arrive convinced that they understand the strengths and weaknesses of the other team. Their analyses complete and a strategy determined, a game plan has been drawn. Coaches and players alike are well-prepared, having been instructed on all game strategies. Your challenge is to derive an awareness of where and how each of the three teleological positions is operative.

The idea of the game is that each player and team must navigate a way through the game that will guarantee a win. The win is obviously the desired outcome. The stakes are high as reputations are on the line. Money, energy and fan support are invested in achieving a win.

You are part of the crowd of spectators and have come to the game filled with confidence in your team. The rink represents the healthcare environment and the society that surrounds it. The way in which the game is played represents the assumptions, beliefs, behaviours and practices of healthcare players. The way the game is played out also represents various choices that need to be made by the actors within the action. Training, skill and expertise represent the past; the game represents the present; and the win at the other side of the game represents the desired future. The tactical plan developed prior to the game is the strategic map that will lead to the desired future. Three teleological positions or approaches are available to all players and their managers.

Teleology at Work

1. Rationalist teleology

In a rationalist teleological approach, attention is turned toward the team’s coaches/managers. These are the individuals who create the strategic maps for the players. They do this by analysis of previous games and by evaluation of each player’s skills and competencies as well as past performance. They move players around the map in a way that they, the rational decision-makers, deem necessary for winning. Before the game begins and as it progresses, decisions and choices about the game are the responsibilities of the coaches/managers. Therefore, any necessary changes in strategy are discussed with players before and during the game as a result of observations and conclusions made by the observant coaches/managers on the sidelines. There is no self-organization, and whether the team wins or loses is accredited to the coaches/managers. Loss is the fault of the coaches/managers for failing to adequately train and/or motivate their team. How often are coaches fired directly after a team loss?

The assumption is that those external to the action, as rational observers, can best determine the plans and actions necessary to win the game. Change is a result of rational choice. The problem is that the map may simply be wrong. Assumptions made at the beginning of the game cannot account for all the possible eventualities. Although the game is not what was expected, a rationalist approach may lead the coaches/managers to continue in spite of what is happening around the game and within the players on the ice. A rationalist approach trusts that if the players implement the plans and designs of their coaches/managers and team owners, the goal will be successfully reached.

2. Formative teleology

Within a formative approach, players will have been given the strategic map prior to the game. They will have done their homework, attended all pre-game coaching sessions and will have been given a strategy to follow. Like a rational approach, this approach is based on the past performance of your team, as well as the perceived performance of the other team.

Players will put their skates on and proceed to the ice with a belief that if the map/plan is correct, all that is required is that they unfold the plans and designs of the coaching team, follow the rules and principles of hockey and release their own potential, and then a win is assured. They may or may not have had input into the plan but, none the less, with their skill and training, they can quite competently bring the game home for the team and the fans. Whether the game is won or lost, formative teleology informs that the whole (game) is already contained within the rules of interaction of the parts in the macro-processes of repetition and iteration that will unfold the mature form of the game and the outcome.

A formative approach assumes that the team will self-organize within the game, repeating and adapting pre-given forms and strategies. Players will adapt their play but there will be no significant transformation of the strategies or the players. Consequently, the map could fail and the game will be lost. Losing may place the season in jeopardy for the team. The greater desired outcome – the Stanley Cup – will be out of reach. No doubt the players will be blamed, fired or traded.

3. Transformative teleology

A transformative approach is interested in everything that is happening in and around the ice rink – the players, coaches, spectators, ice conditions, temperature and so forth. Our players find themselves in a complex game situation where a map is useless. There are game rules and rules of conduct for fairness and safety, but due to the circumstances within the play, their pre-game map is insufficient. The outcome of the game is unpredictable and uncontrollable. The whole situation on the ice is self-organizing and non-determined. No one in the bleachers or on the ice knows how the game will be played out or what the final score will be.

The players are self-organizing according to the micro-interactions between, within and among them in the living present. Constraint as power and free will are inherent within their interaction and participation. There is also micro-diversity and fluctuations in how players experience and find meaning within the competition. Because constraint and freedom, articulated as conflict and cooperation, are simultaneously acting on the play action, the game is held within a paradox of stability and instability at the same time. Stacey et al. (2000) calls this “bounded instability,” while others refer to this as “the edge of chaos.”

No individual player or team of players is in control of the interaction; no individual player or team can decide or intend for others. In the heat of the action, no coach or manager is standing on the sidelines planning or controlling the event. The future of the game is continually under construction in the living present due to the political, social, physical and psychological freedom players bring to their micro-interactions and participation. The dynamic of the game is emergent within the context of micro-diversity and small fluctuations in play.

All players continually choose and intend for themselves in each lived moment at play. Being seasoned players, they recognize the emerging patterns of play; they differentiate between similarities and differences from other hockey games. The patterns that they are acting within are emergent, arising from all players’ continual interaction. And, these patterns of micro-interaction are continually forming and being formed by themselves. Essentially, all are engaged in a process of simultaneous intuitive and reflective practice: that is, they are sensing and reflecting on and in each play – participants and observers at the same time. Meaning, choice and intention all emerge in the living present. Therefore, teammates and teams are continually forming the game while being formed by it, perpetually constructing and reconstructing the future.

No one player can decide for another or for his team. But, the interplay of expertise, diversity, power, constraint and interaction has the potential to produce unexpected and often unwelcome outcomes. The centrality of self-organizing interaction causes new, novel variations to emerge within the game action and potentially the game of hockey itself.

As every player is choosing for himself alone within the play action, another paradox inheres: every player is simultaneously in a process of continuity and change, as are the teams, coaches/managers, spectators and game. In transformative teleology, continuity and change are occurring at the same time: that is, there is an opportunity for continuity or for transformation to a novel state, but without a guarantee. In essence, each player and team is in a place of potentiality wherein their individual and collective identities and differences are being continually expressed, but with no guarantee of continuity or transformation of those identities. If transformative change occurs, the players and the teams remain paradoxically the same, yet different. In transformative teleology, it is the player’s identity as well as the identities of the organization, spectator, team and environment that can change. The whole is not greater than the sum of its parts; the whole is different from the sum of its parts.

The process of transformation honours the paradox of simultaneous continuity and change. Again, there is an opportunity for transformative change but not a guarantee. For example, how many of us have survived traumatic events yet have remained unchanged in our basic values or ideology? We adapt to changing circumstances but tend to remain unchanged at the level of our core beliefs. Others, having endured similar events, become different people in that their basic assumptions have changed considerably. These people are simultaneously the same, yet different.

In closing, it is the potential for simultaneous continuity and change of one’s personal and organizational identities with their concomitant paradoxical nature that is changing when one manages in complexity. Complexity itself cannot be managed because it inheres in all of nature. One must be able to perceive, understand and manage within it – in other words, engage continually in reflexive and reflective practice in the living present.

Managing in complexity does not necessarily mean that rational and formative teleology, and the ideologies that support them, are without value. It means that managing within the paradoxical nature of all interconnection and participation (e.g., emergent creativity scientific method) is the competency required within the 21st-century. The capability to suspend the temptation to resolve paradox is difficult for western managers who have been schooled in a model of rationality and linear thinking about causality. However, difficulty need not prevent ongoing conversation and exploration of complexity. As we become increasingly aware of all aspects (visible and obscure) of organizational life, and if we can remain open, comprehending complexity can offer some of the most important learning of our lives.

Click here to see the First Series of Ghost Busting essays.

Click here to see essays from the Second Series: The Ghost of Healthcare Consciousness.

About the Author

Elizabeth Meuser, educator, care provider and manager. Hugh MacLeod, patient, consumer and concerned citizen

Acknowledgment

THANKS – A big thank you to Longwoods Publishing for allowing me the opportunity to share this essay series with you, as well as to all of my co-authors for their contributions. I’d also like to thank everyone who has come along on this journey. I sincerely hope these past 22 essays have resonated with you and will cause you to look at our healthcare system, and your place within it, in a new way.

References

Stacey, R., D. Griffin and P. Shaw. (2000). Complexity and Management: Fad or Radical Challenge to Systems Thinking.Routledge: London, UK.