Insights March 2013

Ghost Busting: Feedback on the Essay Series

Ghost Busting Feedback

As at March 5, 2013 | Series went live January 09, 2013 at 11:00 EST

[The following material has not been edited. We have removed the correspondents’ names but any content that might identify the authors has been left untouched. The complete series can be found here.]

Personal e-mails to Hugh MacLeod

There are 16 e-mails that simply say "THANK YOU".

“I hope this note finds you well and you are surviving the challenges of what has been a more traditional Canadian winter. I have read the Ghost Busting articles with interest and wondered if an article such as I have attached would be one that might, with the appropriate amount of work from you or whoever helps with edits etc., be a possible future Ghost Busting topic? I look forward to your comments.”

“Thanks Hugh. Excellent journey in front of us, looking forward to the series!”

“Thank you, thank you, thank you for writing this article! I was moved to tears reading it because it is the first thing I have seen that really identifies the issue of health care in Canada. As a front line manager of I have been observing how we pass the buck and blame others. I try very hard to ask critical questions from a learning perspective but those questions are not always appreciated. In fact, on several occasions I have been told by my staff and co-workers that if I do not keep my mouth shut I risk being fired. My response has always been that if requiring this organization to live up to its espoused values means I will be fired it is a price I am willing to pay. At the risk of not being humble, firing people like me will put healthcare and patients at much greater risk. I see so many fabulous people in healthcare and the culture has kept them quiet because they are afraid of repercussions. As someone who often feels like they banging their head against a brick wall”

“Thanks Hugh for orchestrating this, long overdue, time to place truth on the table and create honest conversations”

“Saw and read the Kirby one yesterday. Excellent!”

“Thank you for doing this…the timing is perfect”

“Hi Hugh, Must have been one heck of a late night! Great article and glad you penned it. Continuing to lead with our chin. We still have our share of Ghosts of Healthcare Despair. I’ll send them your article. The good news is we also have more and more new chins with us every day. Attached is a recent example I still remember my first days back in January 2006 and your pep talk about being provocative and pushing these kinds of questions every day. If you’re ever out this way, please give me a call and we can do lunch. Would be great to see you again.”

“Hi Hugh. Happy New Year. This is a great idea. Would you like us to put a link into our next e-newsletter Communiqué?”

“Good stuff, Hugh! Looking forward to the reads and stimulation!”

“Great work -- very impressive.”

“What a diverse, novel idea, to entice nurses and co-workers to explore health care changes; and the care we provide. I have been lucky as I have had the pleasure of nursing for nearly 35 years and I have seen numerous changes in the focus of health care; Some changes were good, others were not great. When a governing body can accept a certain focus of care is not working; and invites ideas for change, miraculous things occur. The management need to be willing to listen, staff need to be able to be heard. Everyone needs to know their ideas have value. If we ask nurses to design a wing in a hospital, honestly listen to him/her as to where sinks and isolation rooms should be located. Even storage and stock supplies come down to simple ergonomics. Housekeepers lifting heavy buckets of duty water over a three inch lip on a floor splash drain, would offer better suggestions than those laid out on the master draft. Envisioning change is being able to see past the here and now, it’s a plan for the greater good, to save time or money. Or, to share floor space with other departments while a new wing is built. We have just opened a world renowned high school, everything is computerized, no chalkboards, or brushes. The building is geo- thermal and sells electricity back to the town, as it creates more than it uses .Exercise bikes, and treadmills generate electricity when ridden by the students. The students and teachers have access to the internet, other schools around the world, research facilities, labs and electron microscopes to see the stars. Our healthcare has changed so much that in the future more doctor’s will educate and lecture in operating rooms with students at the university miles away. We have advance so quickly in the last 40 years in health care, the only way to continue is forward, we must follow our standards and ethics to provide holistic therapeutic care. I look forward to your teaching sessions and discussions, as we learn through sharing knowledge.”

“Hello Mr. MacLeod, I just wanted to thank you for sharing The Ghost of Healthcare Despair through the CPSI newsletter – what a remarkable essay. It’s true that we have a somewhat disparate and dysfunctional healthcare system in Canada but there is hope… Working in patient safety allows me to see the possibilities you allude to in your essay. I see administrators and managers who lead with courage and grace and staff and physicians who bring compassion and skill to the bedside, all with a common calling to be of greater service to those in need.”

“Thanks and keep up the great work at CPSI!”

“I really enjoyed your essay, it was brilliantly written, and a bit of a kick in the b*** that some of us need to realize that if we want to be part of the solution, we must stop being part of the problem. Thanks again.”

“Thank you for illuminating the shadows and naming the fears.”

“Good Afternoon Hugh, I definitely enjoyed todays article. Very Bold – yet aligned with the two lessons learned from every health technology conference I have ever attended since 2003: Leadership is key, Involve the Users (clinical and front line)..It all boils down to the courage to think differently about change to accomplish what needs doing.”

“Thank you for your essay! I have heard you speak…your essays follow the same script… honesty with a respectful touch.”

“Hi Hugh, Just wanted to let you know I thought your Longwoods Essay, The Ghost of Healthcare Despair, was brilliant. I love how you wrapped up your commentary in a parable and incorporated the greats – Ghandi and Tommy Douglas in one article – wow! I can hardly wait for the next one.”

“Hi Hugh, I love this essay on the need for courage in leaders in healthcare today”

Well done Hugh! Congratulations!”

“I agree, we all know what needs to be done, we must develop the “will” to do it, hopefully your essays we get people focused on doing the right thing.”

“Time for all to let go of the Ghosts that hold them back.”

“Long overdue, a move away from theory to truth and shadows we all carry”

“Hugh, very bold…a much needed and honest conversation.”

“I look forward to the whole series…a must read for leaders”

“You have never been afraid to speak truth, time for others to step up”

“Hello, topics by Macleod and his colleagues really interests me, but I amerais whether it would be possible to have it in French Thank you very much for your cooperation”

“Hi Hugh, Great article. Glad you are still writing! Look forward to the full series.”

“All about changing behaviour and mindsets..lets pray these essays provide the courage.”

“Dear Hugh, Love the essays. I would love to co-author with you.”

“Hi, I love the concept…have many ideas for a future co-authored piece.

“If Mr. Macleod is still looking for any co authors I have worked in health care for over twenty years, have been a nurse in acute care, worked in leadership and have gone onto become a Nurse Practitioner in BC, not an easy task and still not, I would be very interested in working with him on an article. There are certainly several articles and topics that can be discussed including the position of a medical ombudsperson, use of acute and long term services and the funding of each, Canadians perceptions and uses of health care and the systems inability to individualize care or think outside the box to better meet the needs of Canadians and improve their safety as they move through the system. Please contact me if this would be possible as I think it would be a potentially excellent collaboration. I have included my CV in case this is of interest. “

“Absolutely awesome work and congratulations to you, Hugh, and all who had a hand in this endeavour.”

“Thanks Hugh. Extremely well done”

“I think the essay concept is a great way to get various messages out about changes that are necessary in the health world.”

“We talk a good talk, we convince ourselves on paper how great we are, I hope this series prompts honest reflections from the balcony”

“Only the best from Hugh. Fabulous stuff.”

“How often have we seen structure as the answer…time to focus on leadership and relationships.”

“That is excellent stuff. Happy New Year to you!!!”

“Just to let you know I really enjoy reading your Ghost Essays. They provide food for thought and honest reflections.”

“Love the essay concept, I hope this gets serious traction.”

“I hope you are getting great responses. You have started a conversation.”

“Thanks Hugh for doing this, long overdue.”

“I have bookmarked Longwoods Ghost Busting Essays, looking forward to the journey you are taking us on.”

“Love the Essays, Looking forward to my Tuesday updates, keep them, coming.”

“I just read this excellent piece. Wow! I saw a number of people/players. I wonder if they will see themselves-or if they will even bother reading the essays. Thank you for the spotlight on healthcare.”

“Hi Hugh, I just came home from presenting to a large physician group who invited me to help them identify priorities as to how they can do things better based on all the information for their health region. I went in so excited!! One hour later, I realized that in the room was 2 camps of individuals...those that really focused on the outcomes the population was achieving based on how well the sectors of care were collaborating for the patients' benefit and then the ...MINOR FEW...who questioned the data, particularly in their specialty area..focusing on 1 or 2 indicators instead of the many indicators which pointed to some key common priorities. I was exhausted from dealing with a few at the cost of the many...I persevered with the hope that if I did anything...I would try to help break down some silos and encourage collaboration to rally around the citizen outcomes from prematurely dying from a condition that could have been better treated or prevented in this health region. I walked away not knowing how I felt about this experience...Upon sitting reading my emails, I came across yours, and read your article on Fragmentation vs Collaboration and my feelings about the experience were clearer. I think the feelings I walked out with were of helplessness but after the article I think they were of hopefulness that instead of focusing on the couple naysayers to changing...I focused on the fact that they had invited me to help them with changing.....It will be a challenging road...but we can't let a few prevent the road for many!! Thank you for your article!!’

‘On January 2nd my Mom in Law was brought by stars to Edmonton by plane. THANK YOU STARS! BUT She was on oxygen and drip lines when she was brought into the Grey Nuns where she was unhooked from all Stars equipment and they left. We were told her chances were slim as she had an Aortic aneurysm. My question is why (after waiting for an hour and a half for the plane to arrive) wasn't the specialist at the hospital waiting???This specialist still wasn't there when we left after she died!!Hours later.! This was only one of my complaints in how this was handled. She was not given Oxygen after the Stars unhooked their equipment and why were the drip lines on poles never hooked up to her. All they did was push us into a family room where we couldn't see how little they were doing to save her.!!! I walked up and down the hall and they stood in there but DID NOTHING FOR HER! To say the family are pissed is a real understatement! If she had even been given water on a cloth to wet her lips, I would feel that she had some care. She repeatedly asked for water which after my Dads heart attacks, I understand they couldn't give as she was slated for surgery, but wetting her lips with a cloth may have comforted her a little. A statement on Global news this morning stating that 2/3 of Albertans are satisfied with health care where did they dig up that amount. Alberta doesn't make health

“Your essays are making a difference”

“I look forward to my jolt of reality every week”

“ I love the idea of the Ghost and the critic and co-authorship, I would love to join you on the balcony.”

“ A great blend of harsh truth and hope.”

“Thanks for the balcony of reflection..To make lasting progress we must understand a look at where we are today.”

“ I hope the policy makers and CEOs, and Board Chairs read these essays, they should be a must read.”

“You are creating a new discussion that I hope will test the assumptions we hold.”

“Thank-you very much for your latest essay, 'Shaping Canadian Healthcare Alignment'. I have just finished reading it and am left both encouraged and refreshed by the clear and forthright way in which you have addressed the current fundamental challenges/obstacles to the meaningful and sustained reform of our Health Care 'System'. By way of introduction, I should mention that. However, as a result of a long and arduous struggle with the health care system in Ontario, over a period of about 10 years, I am not new to its numerous 'difficulties' and 'challenges' -- at least, from a patient/family point of view. (However, I appreciate that the view from inside the system may very well be different.)Also, as a result of what I learned and achieved in the process of advocating for my late father's proper hospital care over a period of about 5 years, and as a way of honouring and giving meaning to my father's experience and death, I am committed to sharing and seeking the wide implementation of various protocols and strategies that I used to significantly improve my father's quality of care in hospital. (Subject to appropriate verification of efficacy, of course.)Now, so that the reasons for my passion regarding health care reform might be better understood, I should explain that my father was admitted to hospital on two occasions during the last 5 years of his life; and, in both instances, the admissions were for relatively minor issues -- with each expected to require about 2 weeks of hospitalization However, due to numerous hospital-acquired infections, various adverse(toxic) effects of medications and ongoing hospital errors, he ended up spending most of the last five years of his life in hospital -- at great, but completely avoidable, human and financial cost to all involved. (Please understand that, though my father clearly bore the overwhelming majority of the human cost of what happened, our entire family was also deeply affected. And, though some may be surprised to hear me say this, I believe that his health care providers were also negatively affected by the experience.) And, given that the issues that I wish to address are related to the various more fundamental issues that you have addressed in your essay, I thought it might be helpful to also share my thoughts with you. Therefore, if you are agreeable, I would be more than pleased to do so. I very much look forward to hearing back from you, and to beginning a meaningful discussion about how some of the major obstacles to significant and sustained health care reform in Canada might be addressed.”

“Speaking the truth is rare, we at the front line are searching for this.”

“Wonderful essays, congratulations to you and your co-authors.”

“Well done, have been reading with interest these short essays.”

“Will you be publishing patient safety thoughts as well in the future, love to be involved.”

“Very informative essays, keep them coming.”

“Challenging assumptions (as you say in your latest article) without alienating one's audience is something we clearly need to explore. It requires that internally-contradictory combination of "strong but nuanced leadership".

“I just wanted to let you know that I found your Longwoods blog on “Shaping Canadian Healthcare Alignment” to be brilliant. I am a US Health and Aging Policy/Congressional Fellow this year in the heart of political dysfunction. I am doing some work for Rep. Jim McDermott, now ranking member of the House Ways and Means Committee, who is a supporter of single payer models of coverage. I sent him and his chief of staff a link to your blog, which nicely illustrated though different systems, reform is still challenging. I also shared with the other 2012-2013 fellows.”

“I am a part time student at the University of Ottawa Masters in Healthcare Administration program. We are in the midst of studying governance in healthcare, and have examined different models of regionalization in various provinces across Canada. This morning, I had an opportunity to read your recent essay with Dr. Jack Kitts entitled “Shaping Canadian Healthcare Alignment”. In the article, you make the following statement: Implications of provincial and regional variations in healthcare spending suggests that a significant % of current healthcare spending is devoted to services that provide no apparent health benefit and in fact, may be harmful. This certainly caught my attention, as it underscores the different approaches to health across the country, and may be impacted by the various approaches to governance in provincially or regionally-associated boards. Do you believe that the boards are impacting the decisions to spend money on practices that are of little benefit, or worse, are causing harm to Canadians? If so, how can this be evaluated so that corrections to the systems can be made? If not, what would be the driving forces? Thank you for your time in considering my questions.”

“I like the style of these essays, they are to the point and get you to pause and reflect. Thanks”

“Hugh, thank you for all of these essays…they are, in fact, the grist for new conversations. They are very, very insightful…in particular I must admit to admiring the phrase, “First, on the themes Access, Quality, Appropriateness we are tinkering within a silo with a modest system lens.” That statement says succinctly and clearly what a major leadership issue is. This is not to say of course there are not other gems: there are.”

“Very enjoyable. How is it that this knowledge exists, but is seldom implemented.
We all have a part, a role... Be that as a front line worker, or in the broader context of a regional health authority, provincial health care organization, provincial government or federal government. Disconnected approaches to goal attainment, misalignment, variation in vision, and excess ambiguity with regard to roles and responsibility. How can anyone be accountable or feel a sense of ownership for results in that environment? Just my 2 cents, and I guess with the penny gone, that equals no cents...”

“It read a bit loop sided to me ..I agree that the issue of accountability is poorly defined and is applicable to all players but I found the comments on docs and their relationships to the health system as a cause for this lack of accountability to be incorrect. Even the alignment issues need to be reviewed. If it is alignment to organizational goals, many would find this challenging, but if it is alignment for the betterment of patients, most will be in line, with the nurses and dos leading. We (the health system – management, providers and politicians) are forgetting our common and shared responsibilities to patients. As we have corporatized health care we have moved our responsibilities to structures and institutions.”

“I am thoroughly enjoying this series. Have you thought about binding them together into a book that people could savour the first time and then return to time after time. Quick reads are great but this is really well-written, important and powerful stuff.”

“I read your most recent Courage: A Rare Competency Essay with interest. You highlight the issue of access to mental health care for children and youth; I would like to add access for children and youth to addiction services to the list. I think I can best do this by sending you the links to my 4 blogs, which I am writing monthly (2 more to go) ..I really hope you have time to read them, and, if you do, I would love to hear your thoughts.”

“Thank you, Hugh. Wonderful writings. I'm going through them slowly.”

“Thanks for the wonderful Ghost busting series. So useful. Just sending correct spelling for Daniel Goleman who was referenced in the Four Mindsets article.”

“This is a very good and insightful essay. I have posted it to the Canadian Society of Physician Executives Linked In group.”

“The essays bring a balance of truth and hope.”

“I now look forward to my Tuesday morning reading of a new essay, beginning to see how they link.”

“Hi Hugh. I like the way you tell your stories. They are interesting, real and emotional which creates impact. I assume you are getting much interest and reaction.”

“Thanks so much for sending these messages out – I have really enjoyed reading the articles – and from my perspective, they are dead on. We do have some interesting and challenging times ahead – I have taken the liberty of sharing some of the articles – as they are so good for reflection.”

“These essays capture current challenges and opportunities, thank you”

“An interesting balcony and dance floor, great essay series.”

“Pausing and asking tough questions is critical to learning, thanks for the series.”

“You are creating a long overdue conversation about the current state, which hopefully will move us to the future.”

“Just a quick note to say I like the ghost busting series that you are producing.”

“I was intrigued by your piece in Longwoods today on the Danger of Simplification. You distinguish simplicity, complexity, complication. Besides Zimmerman (2002), can you refer me to any more substantial account of this idea, especially in healthcare, whether published or available online? Thank you kindly.”

“The essay was true. It is the right approach, and I will use this going forward. It is a good reminder in the midst of constant change and pressure, and thank you for making this very excellent observation.”

“The essays are thoughtful, challenging and balanced”

“I came across your article Danger of Simplification the other day and enjoyed reading it. The following point especially hit home for me: “You need to walk the frontline to manage the complex. People will give freely if the environment is right — if it is respectful and open to possibilities. You do not make real, transformative changes because it is in your short term interest to drive your staff into the ground on the basis of false productivity, to satisfy both large and small politics of the moment.” Along with your point that we need to build on ‘current structures and relationships to stabilize and enhance healthcare delivery.’

Commentary following each essay:
[The complete series can be found here.]

Ghost of Healthcare Despair

“One of the best essays that I have read on the state of our Healthcare System. The Essay captures both the essence of the challenges to changing the Healthcare and the fear of those changes.”

“This should be turned into a theatrical monologue to be performed at healthcare conference across Canada! :) Excellent article!”

Forging Complete Question To Defeat The Ghost Of Healthcare Despair

“Great article. Says it all. The analogy of the ghost is helpful to get readers to see what ghost they are holding onto.”

Courage A Rare Competency

“Beyond the excellent points made, we also have to set our minds to stopping the introduction of further harm. While governments and others increasingly are becoming engaged in new mental health initiatives, Ontario is dramatically expanding gambling by introducing 29 new casinos. This will cause substantial harm not only to gamblers, but also to their families and communities. Government simultaneously claims to protect health while introducing harm, a classic application of doublethink. As for courage and leadership, no one being funded by government or in its employ is speaking out - the realistic fear of retribution silences all.”

“It is passing strange that the leader of the country's Patient Safety Institute can co-author a useful commentary on leadership without even mentioning the concept of safety - the goal of reducing preventable harm. The question of courage is indeed paramount. Nobody is talking about the deplorable and unacceptable situation in Canada with respect to preventable harm. There is no evidence that the situation described in the Canadian Adverse Event Study, published in 2004, has changed - that 1 out of every 13 patients admitted to an acute care facility in Canada will experience an adverse event associated with significant harm including death. Unless we talk about the situation we will never change it - truly courageous leadership will speak truth to power and promote discussion with the broad public - who often will have innovative suggestions for solutions. The evidence that quality improvement automatically leads to patient safety and reduced harm is very thin indeed.”

Conditions Leaders Influence

Truthfully, top down change will not work unless all believe in treating patients with respect. That is what it boils down to, and those who cannot or will not treat patients this way must be reported, and either disciplined or terminated.”

Fragmentation vs. Collaboration

"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.”

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.”

Accountability for Performance

“As a front-line provider, all of these essays puzzle me a bit. All we need is a leadership structure which is wise, altruistic, and able to balance dynamically the greater public good all the way through the system with what an individual patient needs (or wants)."Find someone without a vested interest," the ghost might say (but there is no such person). But "accountability" is a sticky point here. I know of one place - ask Dr. Kitts (previous article in this series) - where it's bi-directional. "Shared" or "multi-directional" might be better. Anecdotally, that seems to be working much better. Because, frankly, it's also somewhat offensive to hear that there is no system. (That might not be what you said, but that's what I heard.) I work hard for patients every day in a system which - yes - does need better coordination, but where many, many people function in high-performing teams to look after the often distinctly-individual circumstances of a particular patient. As Dr. Ted Boadway of the OMA said years ago, he could come down with appendicitis, go to an ER, be evaluated, be seen by surgery, anesthesia, and internal medicine, have surgery and be resting comfortably (and safely) in his bed recovering all before the day was out - without any "central" system at all. Don't ignore the tremendous system which has been carefully crafted over many years in response to health-care needs. The people on the ground often know very well what they're doing!”Would that benefit from more of an overview? Certainly! Would that overview benefit from a sincere, pervasive, multi-directional engagement with all levels of the system, most definitely including the workers? Most definitely!
Be careful with the concept of "accountability"! As one patient-safety expert I know says, "The standard concept of 'accountability' probably does more harm than good!" (And he's a fervent accountability-promoter!”

“Where does the patient fit into all of this accountability?”

“Offering a pilot model to allow HCWs see "how easy" it can be, will help to move these systems forward. My proposal is to use "Hand Awareness" as a pilot that integrates all 4 of the key success factors mentioned, wrapped into a simple initiative that would greatly benefit patients and reduce costs, by encouraging ALL staff to comment on the lack of compliance reporting to a "centralized data repository” by clinical category. Hand Awareness is hand hygiene, respiratory etiquette and cross contamination awareness(T Zone) which are critical behaviors in infection prevention that would benefit Patient Safety and cost reduction immensely.. “

Shaping Canadian Healthcare Alignment

“A very insightful and honest appraisal of current alignment challenges and opportunities. Agree now is time to begin surfacing wicked questions to challenge outdated assumptions held.”

“A wonderful start with your oppositional metaphor comparing the healthcare system to the automobile. They are both systems but radically different in their nature, with healthcare being complex, open, and adaptive and automobiles being slightly complicated, closed, and mechanical. So it is not surprising that the techniques to influence change must be different for different systems. Excellent observation about there being no single "Game Book". In fact, complex adaptive systems (CAS) can never be fully controlled or planned or even aligned, but we can learn how to influence the way they evolve. And studying other complex systems is a great idea (one that we are quite hesitant to adopt in healthcare) and this study should not be restricted to healthcare systems only. The question of "mal-alignment" that you have identified is an important characteristic of the Canadian healthcare CAS. Unfortunately the solution to this is not to be found in the automobile metaphor where wheels can and are routinely "balanced and aligned. Sigh….If only we could find the right place to take Canadian Healthcare for a tune-up and re-alignment.”


“This is an excellent description of some of the most important elements that allow healthcare (as a fairly typical complex adaptive system) to be influenced in positive (albeit frequently surprising and unpredictable) ways. I applaud your emphasis on involving patients, families, and frontline staff. For an interesting and more detailed discussion on the importance of information flow as a way of promoting transformative exchanges, see Olson and Eoyang's Facilitating Organizational Change.”

Passive Following or Future Focused Leading

“Some very interesting metaphors - the balcony one may possibly accurately describe how some healthcare leaders feel and act. And the dance floor metaphor is an interesting way to introduce the concept of complexity. But then the important points are lost - when you say "healthcare is large and complex" you are bang on in your description. Unfortunately you then add that healthcare is "inherently prone to inertia". In fact the opposite is true. Most complex adaptive systems are constantly adapting and changing as the external environment changes. This is happening whether we acknowledge it or not and complex systems self-organize whether we understand or attempt to understand and influence the processes that lead to the emergence of new patterns and relationships within a complex adaptive system. Our "rules" cannot be imposed on the self-organization processes - it doesn't matter how many dance instructors there are or how well prepared they are if the processes they are "teaching" are imposed from the "balcony". To explore this further visit One final extremely important point - the "music is [definitely not] controlled by the customers". You are probably right that "politicians are playing the music" but when it comes to patients, we have all been spectacularly tone-deaf for decades. For the few courageous patients who try to compose music we definitely cannot hear the tunes or understand the stories they contain.”

Danger of Simplification

“Thank you for a clear and cogent discussion of the simple, complicated and complex paradigm. You are absolutely right that we often ask the right questions and apply the tools, techniques or solutions that are applicable for a different kind of system (usually a simple one!).Brenda Zimmerman's earlier work Edgeware provides many additional insights in this area.”

 “Thank you for referring to our work on complexity for the Romanow Commission. This is an excellent summary of our piece and a good application of our findings.”

“Thanks for this essay, and for highlighting a leadership dilemma in healthcare. However, I do take issue with the suggestion that complexity should be "solved" by moving the problem into the complicated/simple, predictive domains. Complexity per se is not a bad thing - for example, innovation primarily exists in the complex domain. But traditional leadership tools help us mostly in the complicated/simple domains. Leading complexity consists of defining boundaries, seeding the space, paying attention to the patterns that emerge, providing stimulus to the desired patterns and dampening the undesired patterns. Perhaps what is needed are a few more tools in the leadership toolbox.”

“The vexing issues presented by complexity are not broadly amenable to reducible solutions. Resilience is the key. Paul Cilliers wrote in 1998 "Order is not imposed; it emerges from the multitude of relationships and interactions between component parts. Success in a complex system flows not from having it follow one best method but from a diversity of responses that allow it to cope with a changing environment."

The complete series can be found here.]



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