Once more I find myself standing on the balcony of personal reflection. My guests have all departed and a much welcomed silence has now ensued. But I am not alone. Embracing the present stillness, I begin to digest the insights and discoveries recently shared by my guests and those who provided feedback. I am grateful for their honest dialogue and for their ability to convey their personal visions with such optimism.

Reflecting on the feedback and conversations I found myself again reciting Tommy Douglas’s quote, “Courage, my friends; it is not too late to build a better world”. Leaning over the railing, I glance down at the floor in order to inspect the map of Canadian healthcare. Initially, I thought my eyes were failing to adjust to the distance. The map appeared much different than it did when I surveyed it last (see "Ghost of Healthcare Despair" essay 2012). I realized it wasn’t my eyes, it was my perceptiveness that had shifted. I couldn’t help but smile. Unfortunately, my delight was suddenly interrupted by the appearance of the Ghost of Healthcare Despair. The Ghost leaned into me and, with a scoff, uttered,

“You stand here, filled with hope. That’s what dialogue has always done - it inspires and invigorates the players involved. You may see a new map, a brighter future but remember this: talk is cheap. What I witnessed here was another talk, no different than any other research paper or report never acted on. Before long your optimism will dwindle and everything you have discussed here on the balcony will be added to my wardrobe.”

I paused for a moment and then leaned in:

“I hate to disappoint you old friend but things are different now. Progress continues to be made. What you are unable to realize is that victory can, and will, succeed our failures. Perhaps you have become too habitual; perhaps you only hear what you wish to hear. I believe we leave the balcony of self-reflection with added hope.”

With a snicker the Ghost replied: 

“Tell me what has changed! Healthcare delivery will continue to chug along guided by vested professional interests, political realities, disconnected personal ambitions, economic forces and a host of other factors that make up the real world.”

Accustomed to cynicism, I graciously answered back:

“We may not have provided a specific direction for change but we did raise questions. We attempted to stimulate humour and self-acceptance in order to relieve stress, to enhance creativity, and to evolve our understanding. We aimed to enable individuals, families, communities, regions, and the healthcare organizations that serve them, to come out of despair.” 

I paused momentarily until I could make eye contact with the Ghost and continued:

“You are a product of our past environment and although we proceed to sustain your presence it is imperative for you to understand that we are not permanently confined to our past, nor shall we be impeded by our prevailing obstacles. It is never too late to build a better system.”

And with that the Ghost of Healthcare Despair disappeared and with its departure came these parting words:

“Time will be the testament.” 

The reverberation of the Ghost’s ominous laugh was all that remained. Every object began vanishing around me. Before long I was enclosed by total darkness and free falling. Suddenly I awoke. I was back in my office. I quickly swivelled my chair in order to scan my office., Was this all but a dream?

Sitting motionless, I attempted to make sense of my recent 20-week experience. I find it quite remarkable how much we each daydream - an activity that goes on, usually in the margins of our mental life. I also find it interesting how many of our daydreams involve some form of dialogue with an imagined other. Some moments in daydreams contain something both personal and yet truly reflective of our social world. Aspects of our social life that make it into the cauldron of our fantasy life often harbour deep social insights.  These insights often gestate in the realm of daydreams for countless days before we can begin to articulate them. 

For those who are listening to their own margins, these elements can spark conscious reflection and active moral reasoning, and can lead to the forging of a complete question. I have also come to realize that our ghosts, when we are willing to embrace them, can provide the questions and perspectives needed to attain essential answers, and help push us beyond our current aspirations. If we fail to explore the light and the shadow within healthcare, we will undoubtedly produce a fragmented vision.

Healthcare will always remain a touch business and, therefore, reliant on the knowledge, skills, energy and values of its people. The rest, including its buildings, machines and medicines is actually secondary. A passage from Roy Romanow’s report says it best: “The most important work in providing quality healthcare happens in every interaction that our citizens have with healthcare providers and people working on the front lines of service delivery.”

"That’s right," I thought… "caregiver interaction with the patient and families." Analyzing this interaction, finding out how to build processes of participation and engagement that serves the patient and the caregiver – now that’s a potent topic.

Throughout the next day, I kept thinking about my daydream of finding the balcony, encountering the Ghost of Healthcare Despair, talking with my 20 guests and reflecting on the feedback received from you. I became convinced that the basic metaphor and the idea of a balcony as a place of discovery and dialogue are useful. It was only natural that I began to consider what additional questions could be presented in such an open and honest forum. 

I thought of asking patients, care providers and middle managers: “What will it take for us to achieve a new dynamic wholeness in healthcare?”  I envisioned a conversation aimed at “dynamic wholeness”. I imagined patients, healthcare providers and middle managers challenging me to think of how failure can be reframed to opportunity. I began pondering the term "accountability" in the context of healthcare. We could examine the indispensable learning required for optimal outcomes in our communities in relation to the money invested by system owners – the taxpayer.  The dialogue could then evolve and could perhaps suggest that, in time, accountability may come to mean facilitating a change in consciousness, or how leaders will be accountable for changing how Canadians learn to care for their personal health. Thus, accountability may come to signify a shift where people understand their role in preventing illness and disease. 

The metaphor and the balcony could be a vehicle to start encouraging people to ask questions…what are we doing to press formal and informal leaders at all levels to hammer out truly meaningful questioning? Probing questioning – including questions about existing authority structures – contains the power needed to find real solutions to today’s healthcare challenges.  The freedom to ask questions out of honest personal reflection will enable us to outgrow constraints in the current collective approaches to healthcare.

But something was nagging me, something was missing. And then it hit me; we do not understand system, complexity and, with it, paradox and polarity.

Healthcare may have system-like qualities, but we cannot accept that it is a system. A system takes a formative view wherein every element is present and unfolds like an acorn. The entire oak tree is contained within the shell and, given the correct environment, unfolds into the tree. Yes, humans have system-like properties but we also have free will and the ability to think, intend and decide. So let’s ask, is the notion of system applied to human endeavours problematic? Does the idea of a healthcare system keep us stuck in adaptive change via learning or by unfolding the potential of the people who work daily within healthcare?

Without warning the Ghost of Healthcare Consciousness appears and shouts out:

“Many make such a mistake. Rather, think of human beings as processes of participation and interrelationships – dynamic human communication networks. Herein lays complexity. Moreover, when one begins to think in this way, the possibility of transformation becomes more evident. By the way, if one views human organizations as systems then the whole is simply greater than the sum of its parts; in complexity, the whole is different from the sum of its parts. That’s transformation!”

So we have the technological/people paradox. While we need the lessons that the quality movement has taught so well, we have as much as ignored the paradoxical human side. Deming and Juran were quite cognizant of the needs of workers - pride and joy in work, break down barriers, drive out fear, eliminate slogans, and initiate programs for education and improvement of all. Somehow all this was missed when healthcare leaders jumped on the TQM/CQI bandwagon. It was the rare manager/leader who took the time to really understand what Deming and Juran were saying before leaping on the “I think we can improve the process, improve outcomes save money and reduce workers with this way of doing business.”

Again, we have concentrated on the technological/scientific side of healthcare organizations. So, we have overworked nursing staff, discontented physicians and patients. We're actually asking questions like, “How do we know what our patients want?” Unbelievable in 2013! Just ask them. Provide care with them not for them. Empathy and compassion are often at the bedside but not within the work life of our healthcare providers. Often, healthcare professionals treat each other in ways devoid of compassion — compassion/abuse paradox.

Unpredictability is an emergent property of complexity. When we understand the role of and necessity for paradox, we begin to understand how uncontrollable our healthcare organizations really are. Deming knew this - the known, the unknown and the unknowable. So, we can improve process but process works on probabilities not on absolutes. Could this be another paradox - simultaneous known and unknown?

The point here is that if we want to understand complexity and system then we need to be willing to do the work and really understand what we are saying.

Next Week – Lessons from the Stanley Cup Playoffs. 

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.

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