Insights (Essays)

Insights (Essays) January 2013

Fragmentation vs Collaboration

Hugh MacLeod and Janet Davidson


Today I am joined on the balcony by Janet Davidson, an international healthcare leader. The ghost is angry today. Before we can even begin our discussion on collaboration in healthcare we are interrupted by a voice dripping with sarcasm. Again comes the Ghost of Healthcare Despair. 

“Collaboration? Hah! You and your healthcare networks advance your own goals and agendas. You all seek preferential access to the policy and funding, decision-making process. You have an insatiable and escalating demand for funding, despite a lack of clear, uniform direction. Your attempts at re-designing whole systems are focused only on selected fragments that encourage a service delivery system that is provider and hospital centric. To the extent that the patient and his or her family are even acknowledged as important players in the system is notional at best. Good Luck on transforming the system.”

We are not out to assign blame. The way the system, if one can call it a system, is designed — the processes encouraged and the behaviors rewarded, intentional or not serve to deliver the only results they can. To achieve different results, the system needs to change. Reactive, insular decision making counteracts the attainment of health system goals. Downstream impacts of incremental service expansion and the introduction of new technologies are often uncoordinated and not well understood. Many in the system perceive themselves as being ‘different’ or ‘unique’ and seek special treatment. They believe themselves, therefore, to be excused or disqualified from any discussion of standardization. Some even go so far as to label standardization as “cook book medicine” when nothing could be further from the truth. But it serves as a good distraction.

This limits collaboration and communication with and among other providers and patients. Silo based providers plan and make their demands accordingly. From our view, the most common pattern in healthcare is fragmentation. The opposite of fragmentation is cohesion. To change, people must learn to preserve and transform the raw materials of fragmentation into new structures and processes and they must learn to work in new ways. To do this, the system must learn to look through a new lens towards the future. When an ‘old’ system increases its level of fragmentation, anxiety grows. Anxiety is inevitable when the value creating ability of structure is lost, while the intensity of demands remains high. This anxiety is the fear of collective, professional death. Individuals and organizations are loath to acknowledge this deeply felt reality and they respond with anger and despair. The need to preserve fragmenting structures at all cost, as a defense against this anxiety, even when they are maladaptive, is a compelling human need. Clinging to old structures and ways of doing things is not inherently bad and in health care it can serve as sober second thought. All too often we seem to rush towards restructuring with little thought given to what other things need to change. In fact, a common Canadian strategy seems to be “when all else fails, restructure”. No wonder consumers and patients are confused and while professionals are becoming increasingly jaded.

How can we as leaders create a culture that encourages cohesive future expression of intellect, passion, commitment and experience? How can we lead the development of a cohesive system that satisfies patient and consumer needs and expectations? We need to learn to stop worshipping the system as it presents itself now. It is only a tool, an evolving tool. With that understanding, the task becomes one of designing experiments to implement a strategy; then capturing stories of the change in patterns, structures and practical processes. Let the stories tell of what was created, what was preserved, and what was dismantled, and why. By repeating this process and documenting it, we will begin to see the way to create interconnection across the system. It is not through random, longitudinal studies or comparative benchmarking, not by policy, or trying to create economies of scale by ‘nesting’ systems within systems, although these are all important components.

Interconnection will grow by enabling the cohesive force of the healthcare system to flow, like a wind rushing through the system. To make best use of human and financial resources will require initiative, sensitivity, objectivity and courage. We may not have all the answers today, but if we have the proper balance of responsibility across the system, expressed through vision, values, courage, reality checks and ethics, we can begin a transformation journey. Transformation requires courage and leadership. Without it we are lost.

Collectively, we need to develop observation and listening skills. We need to suspend our reflex to impose structure on reality before we understand it. We must live our values. Components of culture include: norms, values, language, behaviour, leadership and stewardship. Such things influence everything from meaning and priorities to actions and emotions in a system like healthcare. Think of these components as mental maps. We are most comfortable with people who share the same mental maps. We are uncomfortable and feel vulnerable in situations where different assumptions operate, either because we do not understand what is going on, or worse, misperceive and misinterpret the actions of others. Organizations wanting to transform culture to include norms of personal responsibility, accountability, leadership and stewardship need to develop specific strategies and leveraged actions to accomplish this.

While many change management scholars claim it takes years to change corporate culture, there are ways to accelerate the process. Our current fiscal situation provides a ‘burning platform’ that demands new approaches for managing, leading and working in the healthcare system. It may take further challenges of this magnitude for the new normal to emerge, if we do not find more systematic and forceful ways to bring it forth incrementally. 

What will it take to get a critical mass of leaders to be open to learning and finding new solutions to old, ignored problems? Real-life leadership models are required. These must emerge from all sectors of the system and be based upon the principle of social proof that people look to others to determine appropriate behaviour. Transformational human behaviour can be contagious. Unfortunately, existing processes of social proof often encourage inappropriate behaviour that borders on unethical. When the top performer is singled out for public praise, yet is known to achieve questionable results, the message is that political, game playing behaviour is okay.

When the unwritten rules of the system accept manipulation, we all learn to play that way. In so doing people can and do harm one another. If we are to enjoy success in achieving the emerging vision for the healthcare delivery system, leaders will need to be able to let go. Forgive the angst caused by past challenges and be truly ready to manifest the new normal. Change management scholars tell us success can be achieved when we spend 100 percent of our time, energy and effort on those who are on board, knowing that the 30 percent on the fence will join them when they see clear benefits. We believe that is attainable in principle. If we can get at least 50 percent of the system aligned with our strategic approach in two years, we can be successful in achieving the four-year outcomes.

In addition to structure and culture, the final key component of the healthcare system is skills. Organizational skills must be aligned with strategies, structures and culture to achieve strategic outcomes. Skills are the fuel that powers transformational work.

Organizations and systems wishing to transform must invest in skills development for their people. How do we identify the skills required to achieve systemic transformation?

Individuals, teams and organizations need different types of skills. Technical skills, or skills at doing the work of the organization, are needed to run the organization and to identify redesign opportunities. Analytical skills help people to investigate and make sense of information, as well as identify leveraged actions. People skills are necessary to help individuals and groups get along and work together. Organizational and communication skills enable people to keep work moving effectively. But how do we best enable people to draw upon these skills? The most important moment in your life is the present one. Now is the time to look within, to determine the actions required to serve the highest values of our organizations.

Transformational skills emerge and collaborate with other skilled behaviour when people are truly present. There is no better time than now. No better place than here. If not now, when? Don’t Canadians now and in the future deserve better?

Next Week’s Guest on the Balcony of Personal Reflection: Dr. J. Kitts in a conversation titled: “Shaping Canadian Healthcare Alignment”. 

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(s)

Hugh MacLeod is CEO Canadian Patient Safety Institute. Janet Davison is Head of KPMG Global Healthcare Centre of Excellence. Prior to this appointment she was President and CEO of Trillium Health Centre


Robert Gordon wrote:

Posted 2013/01/25 at 07:38 AM EST

"We need to suspend our reflex to impose structure on reality before we understand it."

I strongly agree with the advice apparently carried with those words. On such occasions as these, I believe it is customary to offer some one-liner that will bring the main point to a peak of brilliant insight. But in this case, I must side with the sarcastic impatience of the ghost (whose little outbursts are a manifestation only of frustrated compassion).

It is difficult, humanly difficult, when REALLY understanding a system of the complexity of even one ER department is a task not yet completed, to have the intellectual self-discipline to withhold judgement until full understanding is attained. Of course, without understanding things properly, we are in danger of, we have proven repeatedly, that we are likely to do more harm than good unless we wait. All the cacaphony is of voices in competition or in defense, of self or of professionals or of patients. We must quell the hubbub before we can guard our minds to clear thought. But who will allow us to wait? No one. And last of all, least of all, ourselves. We want to, need to act!

So, we put one foot in front of the other. Do the very next thing. Acting gingerly. Long-term ineffectively. And hoping that someone else, perhaps someone we are not hearing from is giving some thought to, making some progress toward, really understanding.


Jennifer Jilks wrote:

Posted 2013/07/02 at 08:56 AM EDT

The key is to have all staff members buy into modern values, up-to-date strategies and techniques. But the most basic is education, and respect for the patient, sadly lacking in some who serve Canadian patients from physicians, to nurses, to organisations (CCAC) to PSWs.


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