Insights October 2013

The Known, the Unknown And the Unknowable

Hugh MacLeod

Welcome back. I hope you have had a great summer and with it an opportunity to re-charge the batteries and re-energize your passion for what you do. I was overwhelmed and humbled by the responses to the first Ghost Busting Essay series and I look forward to being surrounded once again by people like you. People who truly want to make a quality and patient safety difference. People who want to lead change and who want healthy outcomes. What do we have in common, in this moment? We choose healthcare work. We care. We care about the patients, residents, and clients we are here to serve.

I retreated to my usual post-dinner location – a lounge chair that runs parallel to the floor-to-ceiling windows in our apartment. I enjoy spending this part of my evening reflecting upon the conversations, discoveries and opportunities presented to me throughout my day.

It was raining heavily outside, and the city lights had morphed into something non-representational. My eyes and mind set adrift with the cascading rainfall and, before long, after a modest fight, my eyes shut.

As my eyes came to a close, I was swept away from the apartment and transported back to the “balcony of personal reflection.” Although I was now comfortable in this environment, I did feel slightly perplexed over the subtle changes that were presented. Fortunately, the Ghost of Despair was non-existent, but the location of the balcony had shifted from its original position.

I am able to view the map of Canadian healthcare below, but it now offered a much different look. I got to hear about and see quality and patient safety excellence delivered by passionate care providers and excellence provided by formal and informal leaders. Leaders who dare to transform healthcare system failures into learning opportunities and advocate Patient Safety and Quality Improvement change for all patients, residents, and clients. And then a voice …

“What do you see?”

Without skipping a beat, I answer back:

I thought you and I were done!? … I see the map of Canadian healthcare. The same map as before, but this time I am able to view it from a different vantage point.”

The Ghost replies:

“Never assume. You may think you know my voice, but I can assure you, we have never exchanged words.”

I quickly turn to view the voice bellowing over my shoulder.

“Not again! And who might you be?”

“I am the Ghost of Healthcare Consciousness, and although we are strangers, I listened in on your previous conversations. Do you truly comprehend the insights generated and preserved at all levels throughout healthcare? Are you conscious of the multitude of perspectives? After all, healthcare is a formal hierarchical listing of organizations designed to control what is essentially unpredictable properties that will present persistent ramifications at every level … are you surprised when reports and papers do not accurately resemble the true reality of care provider and patient interface?”

After a thoughtful pause, I answer:

I will certainly not stand here and proclaim to understand it all, but I am a firm believer that the perspectives and voices from people at all levels are essential for a healthy and productive organization. People are not just lines and boxes on the official organizational chart. People are the glue in the white spaces and beyond. Organizational charts are static images that imply rigid turf boundaries. High performance comes from dynamic, fluid, highly attuned and harmonious people relationship patterns, not solid lines or boxes on the organizational chart.”

The Ghost continues:

“That all sounds good but, correct me if I am wrong, weren’t all of your previous conversations on the balcony top-heavy? Where is the voice of the patients, caregivers and middle managers? They are not just numbers and job description titles. They are not to be managed or treated as if they are robots, devoid of desire, compassion, creativity and intelligence.”

Surprised and delighted by the comments, I respond:

I couldn’t agree more. I have spent much of my time thinking about this very topic. What if we asked patients, care providers and middle managers what it would take for us to achieve a new dynamic wholeness in healthcare? I envision a conversation aimed at “dynamic wholeness” that values people above all else. 

With a guarded tone, The Ghost responds:

“I really begin to worry when people agree with me. Mark Twain once said: ‘Whenever you find yourself on the side of majority, it’s time to pause and reflect.’ We will see if we truly share a similar vision or if you merely possess a sly tongue.”

With confidence I rise to the challenge and say:

You will see. I will be speaking with patients, care providers and middle managers. In fact, I will place them in the top spot and I will be their guest. Together we will invert the traditional healthcare organizational chart.”

The Ghost asks a simple question:

“And why will you do this?”

I drew strength from a recent keynote ...

Because care is the interaction among our assets both technological and human; care outcomes result from the interaction between patients and care providers. Care delivery is the way providers interact. To propel the quality and usefulness of these interactions, we must accept that culture and value are not static, but a commitment to a condition of being. It is time to fill the “balcony” with new voices, new conversations that will lead to a exploration of the assumptions we make.

And with that the Ghost leaves. 

I reflect on three questions:

  1. Are healthcare leaders ready to move from the sidelines and change the circumstances?
  2. Are leaders at all levels ready to lead by example and inspire others to follow?
  3. Are leaders at all levels committed to creating real and lasting patient safety and quality change that makes a difference?

I am drawn back to a posting by Robert Gordon on the essay 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.”

Nothing like some field work to gain an understanding of manager, care provider, patient, and family interface…join next week’s conversation titled: “Toyota, Air Canada, Best Western Hotels - Are Not ER’s”.

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, CEO of the Canadian Patient Safety Institute, patient, husband, father, brother, grandfather and concerned citizen


Dupre, M. 1989. Leadership Is An Art. Bantam Doubleday Publishing Group Inc. 1989.

MacLeod, H. Davidson, J. 2013. Fragmentation vs CollaborationLongwoods Ghost Busting Essays.

Gordon, R. 2013. Posted Comment on the Essay Fragmentation vs CollaborationLongwoods Ghost Busting Series. 


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