Insights (Essays)

Insights (Essays) April 2013

Self-Organizing Change

Hugh MacLeod and Shirlee Sharkey


Today I am joined on the balcony by Shirlee Sharkey, a leader known for innovation. Observing the healthcare system from a detached distance opens our eyes to the fact that control and change are two different things. We also see that a system can in fact undergo meaningful change without control.

While it is true that control can achieve some degree of compliance or success in an organization, real transformation emerges from healthy relationships and the intrinsic motivation that is rooted in truth and human values. Unfortunately, healthcare is often viewed as more mechanical in its orientation and culture. Health professionals are frequently managed and directed with underlying assumptions more fitting of machines than people; as if we are robots, devoid of desire, compassion, creativity and intelligence.

When we pause to look outside our own windows and walls, we see a society that is changing at a seemingly dizzying speed. At the same time, people’s definitions and expectations of healthcare are evolving and Canadians are increasingly frustrated they are not part of the conversations that are taking place. This necessitates that organizations adapt and shift their thinking in unprecedented ways.

Fortunately, we are beginning to see promising examples of this shift taking place. We have leaders who recognize that change does not always need to come from the top. With the right environment and enablers, effective change can start and spread at any level of an organization. In fact, the best ideas and solutions may come from the very people and places you least expect.

Self-organizing systems have the capacity to create aspects of change and transformation typically ceded to leaders: through dynamic webs of communication, organizational values, and the creation of shared meaning, behaviour and norms. In essence, self-organizing systems do for themselves what was traditionally done for them.

Health system change and transformation can and will arise based on people’s needs and interactions, rather than the structure imposed upon them. Of course, critics will also arise, like our uninvited guest, the Ghost of Healthcare Despair.

“You are spinning your wheels. As complex healthcare systems undergo multiple change dynamics, rarely do they create cultures that inspire change. The first thing cut is education and staff development. In times of restraint, what frontline staff hear is, ‘Don’t mess up; don’t make mistakes; don’t make the boss look bad.’ The healthcare system is asking for a kind of predictability, control and compliance that often has nothing to do with what staff were taught. Promoting self-organization in a highly charged political environment will only add multiple layers of brilliant ideas that will never be adopted.”

Healthcare is a human service business, delivered by people, to people. Healthy relationships and an active and engaged workforce are prerequisites for excellence in quality, safety and patient satisfaction. As the healthcare system grapples with rising demands and limited resources, the need for creativity has also come into sharp focus. Our challenges are significant but not insurmountable. The key lies in engaging the hearts and minds of the legions of people who work within our healthcare system, as well as the millions more who intersect with it.

The Value of Emergence

By observing how self-organizing systems and networks grow and transform into active, working communities of practice, we discover how things change through emergence. When separate, local efforts connect into networks, then strengthen as communities of practice, a new system emerges at a greater scale. This system of influence possesses qualities and capacities that were previously unknown and are often distinct from the local actions that engendered them. It’s not that they were hidden; they simply do not exist until the system emerges. They are properties of the collective that individuals come to possess. Emergent systems wield greater power and influence than what is possible through planned, incremental change. The whole is always greater than the sum of its parts.

It is interesting to note that networks are the natural form of organization on this planet. Networks result from self-organization that fosters emergence, where individuals recognize their interdependence and organize in ways to create solutions that support the diversity, strengths and viability of the whole. Emergence is a subtle aspect of transformation; it is difficult to predict and can appear suddenly and surprisingly. Emergence can be a game-changer.

Today, we are seeing the power of emergence in many different sectors – from business and politics to community development and the arts – as the power of technology and social media enable people to congregate, collaborate and indeed innovate around shared areas of interest. There are countless examples of ordinary people working together to achieve extraordinary things, including solving incredibly complex problems that have stumped even the most skilled and qualified experts. It comes as no surprise then that savvy organizations and businesses are looking to unearth and unleash this knowledge.

Talented amateurs exist both inside and outside our organizations and the healthcare system. One does not need to be an expert on integration to have ideas about how the players in the system can work together to improve our performance and better meet the needs of people.

The Power of Relationships

If you look at quantum physics, chaos theory and the science of living systems, what do you discover? 

  • A world in which the primary material form is that of relationships; in healthcare, we define this in terms of care interactions, episodes and transitions. 
  • A world where nothing exists independent of its relationships.

Fundamentally, healthcare organizations and systems are patterns of energy; webs of human relationships, conversations and decisions. They are not just the lines and boxes on the official organization chart, but the white space between and beyond them. Organizational charts are static images that imply rigid turf boundaries, whereas high performing systems are dynamic and fluid – highly attuned and harmonious with their external environment. Yes, the multiplicity of professions and the complex hierarchies in healthcare can present challenges, but the same can be said of other systems and structures. 

When a system is failing or performing poorly, the components must come together to learn more about itself, from itself. Bringing in new voices and perspectives as part of this process is just as important. Here are just a few critical questions to keep asking:

  1. What is the shared vision we are working toward?
  2. What is our starting point? What beliefs and assumptions do we hold?
  3. Who needs to be part of this work? Is anyone missing?
  4. Is the meaning of this work still clear? Is it changing?
  5. Are we becoming more truthful with each other? If not, why not?
  6. Is information becoming more open and easier to access?
  7. Where are we using control? Collaboration? Innovation?
  8. What are we learning from working and adapting within confusion and chaos?
  9. What do we want to become?

The value of this practice was evident at the beginning of the customer revolution. Interviewing customers and incorporating their perspectives became a potent force for stimulating organizations to new levels of quality, service and innovation. That’s what the evolving plan for transforming healthcare should be all about: developing a deep understanding of the things people want and need both in the whole of their healthcare journey, and within each and every care interaction. This will allow us to take Medicare to its necessary next step – creating a comprehensive and integrated system of care that is shaped and driven with the active involvement of many, including people, families and communities.

It is not about tinkering on the edges, or cutting on the margins anymore. It is about introducing deep changes. Such change must combine the rich wisdom and experience of people in the system with the imagination and passion of “outsiders.” Giving employees, patients, caregivers, community leaders and citizens a greater say in the future direction and workings of our health system necessitates that we as leaders diminish and decentralize our sphere of control in favour of facilitating more local knowledge and open decision-making. Relationships built on mutual trust and respect are implicit for this process to work.

To be truly successful at healthcare transformation, we must believe this: People matter. But we can’t just put our faith in this belief – we must act on it always. Action will build trust between employees and leaders and between organizations and communities. People will begin to realize they have the capacity to have an impact in ways that were never before possible. The motivation, ultimately, is to make a positive difference, rather than to command power and control.

Next Week’s Guest on the Balcony of Personal Reflection: V. Kaminski in a conversation titled: “Can an Organization Grow If Its People Are Not Connected?”. 

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 of Canadian Patient Safety Institute. Shirlee Sharkey is President and CEO of Saint Elizabeth


Robert Pental wrote:

Posted 2013/12/04 at 08:42 AM EST

To think, there may just be life outside the confidence interval. Hedging our bets does not make us a brave team of explorers but leary gamblers seeking lies and secrets instead of mystery and adventure.


Andrea McLellan wrote:

Posted 2013/12/04 at 11:36 AM EST

Thank you Shirlee Sharkey for a wonderful presentation of the ways in which complexity science principles when applied to healthcare will promote self-organization and the emergence of new patterns. I applaud your distinction between trying to control a complex system and trying to influence change. We sorely need to stop trying to control that which is fundamentally unpredictable and full of surprises. But we certainly can influence the way the system develops. Are there any politicians and Ministry rep's listening?

I recently had an interesting epiphany while teaching a SPHERE workshop (systemic nonlinear approach to analyzing critical incidents) to a group of representatives from the LTC sector. They immediately understood the importance of relationships at multiple levels. At first I was surprised since this is often a challenging concept for acute care colleagues to understand. The participants in the workshop explained that of course relationships are central - they will be living with the residents in their facilities, often for the rest of their lives. So perhaps your connection with the non-hospital setting explains your clear thinking on this issue. Thank you again.

Rob Robson


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