Insights December 2013

Are We Prepared To See and Leverage the Grey Zone?

Hugh MacLeod

On the balcony of personal reflection, the Ghost of Healthcare Consciousness is waiting for me:

“I pose to you a somewhat rhetorical question: In order to realize safe care and quality improvement, what would be more difficult: the challenge of scientific discovery or the challenge of changing mindsets and human behaviour? That may seem like an odd question. Obviously, scientific progress is essential, but so is change. It is essential to regard patient safety and quality improvement change as seriously as you would healthcare scientific discovery.”

With that the Ghost leaves.

We need to recognize quality as more than just method, technique, discipline or skill, but as a human and organizational accomplishment, a social process. At the personal level, great leadership starts with deep self-reflection. Moments of self-reflection restore personal balance and allow us to take the necessary and succeeding risks. We have to create the conditions for change within ourselves before we are able to foster change in our colleagues. 

It is important to understand how we have evolved as leaders, for we are representations of the culture and milieu that encompasses us. Together, and throughout our collective healthcare work life, we have had our fair share of teachable moments. If I had to choose one specific theme, it would be centred on learning to let go and placing trust in others to deliver. 

I, like many executives, managers, professionals and care providers, developed my career in a silo-centred, bureaucratic model of healthcare delivery, driven by the provider’s control of health services, not the consumer’s perception of need. In command-control hierarchies, behaviour is honed to enable survival of the most political! Like many of you, I too have experienced the political and organizational “urgencies” of leadership and the conflict that occurs between planning and the daily demands of the position.

Imagine that you could step out of your familiar role for a moment. Leave the lab, the bedside, the desk or the board table and come with me.

We are joined by our Ghost of Healthcare Consciousness, a challenging voice who lives on the periphery of our awareness and in the comments of our colleagues. Sometimes we cannot wait to hear from our Ghost, and at other times we are tempted to hide. To truly comprehend the Ghost’s message, it is best, even for only a moment, to distance ourselves from our customary way of perceiving in order to remove the “me” out of the process and replace the focus with “us.” Every conversation with the Ghost is unique, and to illustrate one of the many forms I have provided a sample below. 

Ghost (of Healthcare Consciousness): “You look terrible.”

Me:  “Gee, thanks. I am feeling a bit overwhelmed as new ideas and solutions continue to allude me. I had hoped that by coming here, and looking things over, my creativity and conceptions would be stimulated.”

Ghost: “It is a good thing that you are out of ideas. It appears that your soil could be ready for a new vision to take root.”

Me: “What are you talking about? I already have a vision and wrote it all down. I’ve got it here somewhere. Let me read it to you.”

Ghost: “Oh, please! What you wrote sounds like a badly written obituary. A regurgitation of the familiar, outdated and recurrent claims made before. It doesn’t capture the essence of what drives you.

Me: “You think a slogan will save us?”

Ghost: “No, but it could cement your hopes. It could spur the imaginations of your colleagues. You continue to shy away from trying new approaches because you subject yourself to the naysayers most of the time.”

Ghost: “Explain to me what your accountability is really for? Is it mostly about blame or is it about learning? You may try something new, something you will have to monitor and possibly shut down if necessary, but when accountability chokes out experimentation, you are in big trouble”.

Me: “Well, in truth, we are most concerned with the possibility of losing control. We are the ones that are supposed to be leading this thing.”

Ghost: “When you were in your 30s and you were brimming with answers, I didn’t bug you too much, but now that you are older with a title, you really have to get over yourself.”

Me: “True. It’s an impossibility to come up with all the answers on my own. We must do more to encourage the risk takers, to help them shape their ideas.”

Ghost: “Now we’re talking! Welcome to the grey zone! The place where we continually balance between the light and the dark, the place where it all begins.”

Like so many of you, I too have been engaged in confrontation, clashes of priorities, struggles for status quo and battles over beliefs. The all too common experiences that cause a combination of excitement and anxiousness in our bellies.

I reflect on a basic leadership story read to children and grandchildren: “The Little Engine That Could.” It is about a journey, community involvement, overcoming roadblocks, crisis conquering, competition, ego and self-indulgence, work jurisdiction and turf, old versus new technology, courage and the power within, and getting on with it. But what did we learn from this simple story concerning courage, attitude and risking self? Leadership is the result of saying at a deep level, “I think I can, I think I can” in an organization that sets its tracks uphill and at an angle worthy of a challenge. It is up to the leaders to take that very first step, thus demonstrating a willingness to forge ahead while instilling in others the courage to act and persevere.

Imagine the healthcare system as a multi-storey building. We have stairs, halls, ladders and balconies called networks, institutes, agencies, foundations, etc. In addition, we have independent stairs and ladders called the delivery system (hospitals, long-term care facilities etc.). Often, leaders have been far more concerned with the dramas taking place in the upper rooms of the building than the relationship flaws on the stairs and ladders. Instead of thinking and acting as isolated silos under siege, governance and managerial leaders can choose to see themselves through another lens. A lens in which you can see yourself and your hospital in relationship to a local health service delivery system.

The more open the flow, the more easily we learn to translate the information to meaningful awareness and knowledge. To return to our analogy of a multi-storey building, we need to ensure that all levels are properly aligned, with a foundation that is capable of supporting the structure.

In closing, our reality is made up of interconnecting circles of complex activity; however, we are conditioned to see and think in straight lines. What we see depends on what we are prepared to see.

Three recommendations for your consideration:

  1. Organizational processes are in place to identify and address unjustifiable variations in practice.
  2. Measurement, evaluation and feedback systems focus on team performance and processes.
  3. Organization does not rush to congratulate itself on short-term results made at the expense of long-term stability.

I close with a comment by Wendy Bowles on the essay, “Empathy: A Foundation for New Conversations”:

“ … self motivated, dynamic, active and energetic. Does this sound like our healthcare system? … I am a nurse practitioner but my job is actually as a detective, a mediator, a guide, a police officer, an air traffic controller; essentially I am an advocate … We race to adopt the qualities of the business world in terms of economics; we count beds, count days, count procedures and complications. We do not however, adopt the qualities of business that make a strong, dynamic company; these include listening to our (patients and) employees, engaging with them and the surrounding community …”

To test our willingness to shift, join next week’s conversation tilted: “Why Are We Still Looking the Other Way?

About the Author(s)

Hugh MacLeod, CEO Canadian Patient Safety Institute … Patient, Father, Husband, Brother, Grandfather … Concerned Citizen.


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 such as: Effective Governance for Quality and Patient Safety Program, Global Patient Safety Alerts, Patient Safety Incident Analysis and Canadian Framework for Teamwork and Communications. Please contact


Bowles, W. 2013. Web site posting on essay: “Empathy: A Foundation for New Conversations.” Longwoods Ghost Busting Essays.

MacLeod, H. 2011. “What Are You Prepared To See?” International Hospital Federation Journal. Volume 47, No. 4 


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