Insights (Essays) March 2014

Health System Relationships – A Paradigm Shift for Safety and Quality in Healthcare

Hugh MacLeod and Dr. Mary Ditton

Once more, I find myself standing on the balcony of personal reflection. But I am not alone today: I am joined by Mary Ditton from Australia. Together, we begin to digest the insights and discoveries recently shared by previous guests, along with the feedback provided by readers. I am grateful for the honest dialogue shared and for their optimism within each personal vision. Reflecting back on these conversations, we cannot help but recite once again Tommy Douglas’ quote: “Courage, my friends; ’tis not too late to build a better world.”

Expectedly, the Ghost of Healthcare Consciousness joins us:

“On a daily basis, you experience the gap between the practice and theory of quality care. By reading global newspaper headlines, studies and papers, and through our day-to-day interface, I sense a growing global unease regarding the prospects for major healthcare improvement, both in absolute terms and in comparison between countries.

“Ideological debates dominate the op-ed pages while concrete and proven strategies for improving performance receive little or no play. Clinicians, healthcare leaders and politicians visit renowned centres of excellence around the world and continually return home filled with enthusiasm for change. Yet the domestic terrain resembles a battlefield where every inch is hotly contested. Too often, the prospect of change is morphed into preservation, despite the harm done, lives lost and the sums dispensed.”

One of our biggest challenges, and therefore our biggest opportunity, is that we spend much of our time evaluating the evidence pertaining to the hard side of healthcare. Our attention is constantly focused on outcomes, cost and harm. We do not spend nearly enough time, if any, talking about the soft relationship side of healthcare. These are the relationship patterns, the teachable moments, the integrity between physicians, between physicians and nurses, between care providers and patients. These relationship patterns have a direct and potent outcome on the hard side of the business. Just think about how these relationship patterns relate to crisis frequency, the cost of doing business and harm events.

We believe an organization is defined by the interactions among its people and the synergy these healthy, or unhealthy, relationships generate. But does this definition portray a true representation of a healthcare organization? For instance, healthcare provided in developed countries is delivered in highly complex systems, and inhabited by skilled professionals with an abundance of advanced technology at their fingertips. Health system relationships, and their significance in the delivery of quality and safe healthcare services, are a compelling concern that features the interactions and connectedness between its people. Before we continue down this path and while you continue reading this essay, we ask you to please reflect on this statement: “The science and technologies involved in healthcare – the knowledge, skills, care interventions, devices and drugs – have advanced more rapidly than our ability to deliver them safely, effectively and efficiently.”

Health system relationships present the third element of organizational design. We are certainly aware that structure follows strategy and that function precedes form. We are also old enough now to see that relationships run the show, and without relationships there is no strategy implementation, there is no function to begin with.

Companies such as Starbucks, Virgin and Nike, have clearly and inventively demonstrated the market value of customer relationships in business. However, selling a coffee, records/airline tickets and running shoes based on good customer satisfaction is so simplistic when compared to the complexities of healthcare. Ultimately, the relationships that exist within healthcare need their own analysis and development.

Let us take a moment to define what is intended when we speak of relationships. Relationships are the way in which two or more people regard and behave toward each other, or the way in which two or more people are connected. Patient-centred care, as a movement in healthcare, focuses on only a one-dimensional aspect of interactions and relationships between patients, families and healthcare givers. It is one-dimensional because it is the patient who is being served, whose needs are being met. The health professional is the care provider.

However, healthy relationships are multi-dimensional. People in the health system relate to each other as individuals, role holders, same discipline colleagues, inter-professional colleagues, technical supports and functional supports.

We need to embrace the theory of soft systems thinking and inject it into the operation of healthcare systems. 

1. The Public

Today, the public have access to information like never before. Social media catapults ideas and information into people’s lives. Much of the information we individually possess is obtained through, and provided by, our present technologies. Much of the public who experience the healthcare system are not scientific thinkers, or at least to the level of those who staff the health system. The public often use their intuition to make sense of their dealings. The public looks for health system relationships because through them, they will have the language to deal with what they intuitively felt previously.

2. Trends in Society Impacting on Healthcare

Two major cultural trends of the 21st century are Individualism and Economic Rationalism. Both of these trends have been greatly influenced by technology, and along with technology, they have a direct impact on healthcare. Individualism fosters a climate of “independence.” An ideology founded on the principle of “me” rather than “other.” Individualism impacts the development of organizations and workplaces, and the level of trust between employees has a significant impact on their health, well-being and work performance.

Economic rationalism is a form of ideological reasoning, and is based on the notion that the free market is a much better arbiter of economics, and other matters, than the governments that are in place. It is a science largely devoid of social goals, and the language and logic of economics begins to dominate social policy. A corollary of such reasoning is a reduction in spending by the governments on such things as education, health and social welfare, and a shift in providing these services to the private sector.

The challenge for many is the impact these two cultural trends have on social capital. Technology is now heavily integrated into modern life and shapes many cultural dimensions. It operates as part of the socio-economic, cultural and environmental condition.

Embracing and understanding health system relationships will create new conversations. Mediocrity, and the process of networking for political power can be replaced by acknowledging the value of learning and improving through critical reflection with teams and systems. 

3. Healthcare is an Organic Complex System

In spite of what one may think, healthcare is not about bed numbers, surgery and ER waiting times, home care hours, long term care beds, availability of CT and MRI or health workforce predictions, it is about what staff and patients do with the facts and the limitations that arise. Nevertheless, healthcare is managed like a bureaucratic machine, with a command and control hierarchy. Though contrary to how the system is run, healthcare is a complex adaptive system. As described by Plsek and Greenhalgh, “a complex adaptive system is a collection of individual agents with freedom to act in ways that are not always totally predictable, and whose actions are interconnected so that one agent’s actions changes the context for other agents.”

Unfortunately, health professionals are trained to be a part of a bureaucratic machine and work in separate disciplines. Yet nothing is further from the reality as many of the essays in Series #1 and #2 have pointed out: healthcare delivery is multi-professional teamwork. One of the most important and unanswered questions today is, who integrates and coordinates the aggregate of autonomous organizations that make up real healthcare systems? This is an important question because professional knowledge and organizational culture rest at the care provider level and in middle management in healthcare, and because the individuals who occupy the space have been around long enough to know how the system works. In addition, culture is also tribal; it changes by shift and with the team mix.

4. Healthcare Goes on Forever

Healthcare is a continual exercise for both its staff and the patients. Most health professionals work in healthcare from the time of their training until their retirement. Patients come to healthcare to be born, they come when they are young, when they are old, when they hurt and when they come to die. Relationships at critical life points are so meaningful and so powerful. The patient’s critical life points experienced in healthcare are more obvious than those of the health professional. The health professional’s critical life points are played out backstage while patient care is onstage. Some of these critical life points for the health professional can be the first day on the job, first big mistake, being part of some successful treatment intervention, a patient tells you a secret, a patient says she wants to die, witnessing a huge harm and the time you are severely criticized by your superior.

The emotion that permeates during and after these critical life points have a powerful impact on those involved. These highly charged events are part of the health system, but those involved in these circumstances possess many answers and questions of value. Depending on what is fostered within an organization, the outcome of critical life points can be very dissimilar. For example, one outcome could be a values-based reaction of humility to foster learning and improvement, while another scenario could be one of damage control or compartmentalized experience.

5. Vertical, Horizontal, Longitudinal and Circular Relationships

Those who work in healthcare are subjected to many types of relationships. The chain of command-controlled relationships is vertically directed down from the CEO to front line health workers. These relationships are bound by rules and regulations and maintained by the employment contract and psychological contract between employer and employee. Horizontal relationships are those with peers, fellow workers in the day-to-day routines of health services delivery. Longitudinal relationships deal with the reality of changes in relationships as peers, superiors and subordinates come and go from the workplace over time. The notion of circular relationships refers to those relational interactions that have a feedback loop in them. All these relationships operate within single disciplines in healthcare and across disciplines.

In this rich tapestry of relationship patterns, cycles of connectivity are established between people, and micro-systems can develop where excellence flourishes. So, too, patterns of avoidance and lack of mindfulness can develop, and staff difficulties and patient safety problems can arise. The interdependencies within teams are important in healthcare since most health interventions require more than a single patient–doctor interaction. Team functioning contains a paradox: the group work is better than the sum of individual effort, while at the same time the group is vulnerable to the weakest member of the team.

6. Myths, Disasters and Good Stories in Healthcare

The public face of healthcare is important politically because it is emotive. The ministry of health in any country is usually the one with the biggest budget of any government department. As part of the worship of Medicine, the public has been encouraged to have great expectations of healthcare. The public is fed miracles of modern medicine, and therefore, they expect miracles. Politicians, the media and Medicine are in a constant tussle to provide a golden view of healthcare, and those who work in healthcare know that they must deliver on that golden view. Healthcare is a heated and highly charged environment.

It is hard to make sense of this assorted picture of healthcare. What is clearly demonstrated is the episodes of covering and protecting, followed by blaming and shaming, when the public gets wind of some catastrophe. The health professional is not trained to admit mistakes, and in the rare occurrence where healthcare does admit to its mistakes, it could hamper potential career moves. Also, the legal fraternity seeks the public good by prosecuting individuals, almost always clinicians. Managers of health services are not prosecuted for the poor supportive systems they devise. Patient safety is negotiated in a volatile and highly contested arena.

7. Relationships Do Not Run Smoothly

It is a truism to say relationships do not run smoothly. In healthcare what we want to know is how to prepare those work relationships to anticipate, prevent and manage our collegial, patient and technical problems. By way of risk literature, the answer is simple: we need to walk in the other person’s shoes for a while to see what he sees, to understand work from his perspective. Understanding an experience from the other perspective makes it easier to reduce difficulties. For example, understanding the impact of forced overtime over an extended period of time. The effects of stress and fatigue encountered by the provider, and with it the increased possibility of error, must not only be recognized but also acknowledged and resolved. By understanding other people’s experiences, we are provided with the knowledge necessary to produce alternative working arrangements.

Working in healthcare is complex and health professionals have a tendency to burn out with the unrelenting human work. In many areas there are tragic losses that staff endure with patients: losses of young patients with untimely deaths, losses of human functions, and persistence of grief and suffering. Difficult decisions are the norm. Certainly in patient-centred care, the patient decides, but it is the health professional that guides, explains and walks the journey with the patient. This can be particularly stressful, as patients try to come to grips with internal demons of all sorts.

The call for quality and safety in healthcare is growing stronger and all OECD countries are progressing along this path to some degree. For transformational change in healthcare to occur, and to address patient safety and the existing inefficiencies, there must be a change in the management at the strategic, middle management and operational levels of healthcare. Healthcare does not need a new list of orders from the top; it needs the top being engaged with the middle and the operational level of healthcare and the patients through health system relationships and a paradigm shift for safety and quality in healthcare.

We close with a passage from Series #1 essay, “Lessons from the Stanley Cup Playoffs”:

“A transformative approach is interested in everything that is happening in and around the ice rink – the players, coaches, spectators, ice conditions, temperature and so forth. Our players find themselves in a complex game situation where a map is useless. There are game rules and rules of conduct for fairness and safety, but due to the circumstances within the play, their pre-game map is insufficient. The outcome of the game is unpredictable and uncontrollable. The whole situation on the ice is self-organizing and non-determined. No one in the bleachers or on the ice knows how the game will be played out or what the final score will be.

“The players are self-organizing according to the micro-interactions between, within and among them in the living present. Constraint as power and free will are inherent within their interaction and participation…

“No individual player or team of players is in control of the interaction; no individual player or team can decide or intend for others. In the heat of the action, no coach or manager is standing on the sidelines planning or controlling the event. The future of the game is continually under construction in the living present due to the political, social, physical and psychological freedom players bring to their micro-interactions and participation. The dynamic of the game is emergent within the context of micro-diversity and small fluctuations in play.

“… No one player can decide for another or for his team. But, the interplay of expertise, diversity, power, constraint and interaction has the potential to produce unexpected and often unwelcome outcomes. The centrality of self-organizing interaction causes new, novel variations to emerge within the game action and potentially the game of hockey itself.”

This is the last essay of this series

About the Author

Hugh MacLeod, CEO Canadian Patient Safety Institute. Patient, Husband, Father, Grandfather, Concerned Citizen.
Dr. Mary Ditton is Senior Lecturer in Health Management at the University of New England, Australia. After a career as a psychiatrist, she remade herself gaining an MBA and a Doctorate in Health Services Management. She is Fellow and examiner for the Australasian College of Health Services Management and is on the NSW State Board of the College, and is a Fellow of the Safety Institute of Australia.


Plsek, P. and T. Greenhalgh. 2001. “The challenge of complexity in health care.” BMJ 323: 624-28.

Runciman, B., A. Merry and M. Walton. 2007. Safety and ethics in healthcare: A guide to getting it right. Aldershot: Ashgate.

Holmes, D., K. Hughes and R. Julian. 2003. Australian Sociology: A Changing Society. Pearson Education Australia.

Organisation for Economic Co-operation and Development (OECD). 2010. “Health care systems: Getting more value for money.” OECD Economics Department Policy Notes, No. 2.

Meuser, E. and H. MacLeod. 2013. “Lessons from the Stanley Cup Playoffs.” Longwoods Ghost Busting Essays.

Richardson, W. 2001. Crossing the Quality Chasm: A New Healthcare System for the 21st Century. Washington, DC: National Academy 



Lewis Hooper wrote:

Posted 2014/03/25 at 03:07 PM EDT

This is an interesting article and I like that it highlights the sins of "economic rationalism", i.e. the idea that a business approach will solve the problems we have in healthcare. I think it clear that services that are deemed public goods are not often amenable to a market driven approach. The article also points out other factors that make change difficult, the complexity of healthcare, the impact of politics, the multifaceted role of the public as a consumer of a public good, and funder of the same good.
But at the bottom line I fail to see how this focus on “.. the soft relationship side of healthcare. “ brings us closer to solving the problem of increased demand for services in the face of tightening purse strings. At root it seems to be saying lets pull the curtain around the Budget, Quality and Outcomes issues and focus our attention elsewhere.


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