Insights (Essays)

Insights (Essays) November 2013

Not only am I impressed with the conversations taking place on the “balcony of personal reflection,” I am also thinking about my recent ER experience captured in two previous essays. Does the notion of a healthcare system lead to a belief that rational managers stand outside of a pre-given system, while employees work as automatons fulfilling the plans, designs and intentions of managers? Does this raise issues of split thinking – manager and employee? Does it also raise ethical issues in terms of human relationships and the objectification of a talented and informed workforce?

Everyone has the free will to choose, decide and intend for themselves. If one noted the conversations that occur around the water cooler and throughout the system, they would certainly observe the principle of “free will.”

The Ghost of Healthcare Consciousness appears, and offers this view:

“Power relationships, along with the constraints within healthcare organizations, serve to underscore the split between the rational manager and the objectified employee – a structure that breeds and perpetuates a divergence across the system.

“Healthcare organizations must evolve and recognize the significance of the human element within the system. Healthcare is much more extensive than just its science and technology component. The tension created is paradoxical, as each aspect exists simultaneously. The problem is that healthcare managers and leaders attempt to resolve the paradox by splitting their thinking which restricts the organic and emergent movement necessary to generate transformative change.”

When someone splits their thinking, they tend to only focus on one aspect of the problem. This form of selective reasoning naturally produces thoughts and dialogues rich in polarity. The end result: a series of unintended consequences that will remove the wheels on their great healthcare plan.

Paradoxical movement is essential in any process of change. Within every paradox, a dialectical movement prevails which prevents either aspect from taking precedence over the other. The associated elements are inextricable and, therefore, they will perpetually rise and fall together. The difficulty in all of this is the uncertainty regarding when each aspect will present itself.

For example, let us examine the notion of medicine being both a science and an art. If you concentrate, or split-think, on the scientific aspect of medicine, and forget about the art, you end up with an assembly line of medicine. In many cases this is exactly what we have – nine minute visits and a penchant for pharmacological solutions. How would this instance look if we evaded a paradox solution and worked both aspects at the same time?

Here is another example, organizational charts are two-dimensional, but due to the organization being human, people wish to enjoy the view of their individual journey more so than the map provided.

Outcome is only as good as the process that produced it. Moreover, structure is an input to process. Outcome simply shows us that the process is inadequate for the desired outcome. Emphasizing structure and outcome measures permit managers to believe in control and predictability.

Bottom line, unpredictability is an emergent property of healthcare complexity. When you understand the role of and necessity for paradox, you begin to understand how uncontrollable healthcare organizations really are. Deming knew this – the known, the unknown and the unknowable. Yes, we can and should improve process, but process works on probabilities not on absolutes.

Paul Cilliers wrote in 1998 “order is not imposed; it emerges from the multitude of relationships and interactions between component parts. Success flows from a diversity of responses that allow it to cope with a changing environment.” Hence, we need stability and instability at the same time. We also need simultaneous effectiveness and redundancy.

Well-known leadership expert, Peter Senge, was asked a penetrating question: “Are the basic fundamentals for sound leadership the same, and are we just responding to a different world or are we fundamentally shifting?” He responded: “For me, the fundamentals start with a set of deep capacities with which few in leadership positions today could claim to have developed: environmental intelligence, building partnerships across boundaries and openness of mind, heart and will. To develop such capacities requires a lifelong commitment to grow as a human being in ways not well understood in contemporary culture. Yet, in other ways, these are fundamentals for leadership that have been understood for a very long time. Unfortunately, this ancient knowledge has been largely lost in the modern era of quick fix without understanding paradox.”

Three questions for your consideration:

  1. Do you accept that we do not take time to understand the difference between simple, complicated and complex?
  2. Does this create disconnects that contribute to passive-aggressive behaviour?
  3. Does this consume negative energy and ineffectiveness?

A comment posted by Rob Robson on the essay, “Passive Following vs Future Focused Leading” captures an important message:

“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.’ … 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.”

Is our tone-deafness connected to our lack of understanding about what alignment is really all about? Join next week’s conversation titled: “Alignment: A Misunderstood Concept

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)

Ghost of Healthcare Consciousness … voice of the patient, family, care provider and middle manager.
Hugh MacLeod, CEO Canadian Patient Safety Institute … Patient, Husband, Father, Brother, Grandfather and Concerned Citizen.


Demings, W. 1966. Some Theory of Sampling. Dover Publication

Cilliers, P. 2005. Complexity and Post Modernization. London. Rutledge.

Meuser, E. 2013. email exchanges with Hugh MacLeod.

Robson, R. 2013. Web site posting on essay: “Passive Following vs Future Focused Leading.” Longwoods Ghost Busting Essays.

Senge, P. 2009. Webinar interview.

The Canadian Patient Safety Institute (CPSI) exists to raise awareness and facilitate implementation of ideas and best practices to achieve a transformation in patient safety. We envision safe healthcare for all Canadians and are driven to inspire extraordinary improvement in patient safety and quality. To address many of the challenges mentioned in the essay above, the Canadian Patient Safety Institute – with partners – has tools and resources, please contact


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