Insights (Essays)

Insights (Essays) December 2014

Understanding Organizational and Health System Spaces: Listening to HEAR

Hugh MacLeod

On the “balcony of personal reflection” I think about one of my favourite leadership books, The Little Engine That Could, by Watty Piper, about the brave little engine who repeated the power of intention through these simple words…“I think I can, I think I can” as it climbs the mountain with self-confidence and resolve.

I recognize the power of intention, the alignment of one’s will to achieve results within what is trying to emerge as a larger whole. This key principle was identified by Santa Fe Institute economist W. Brian Arthur who said, “to change the quality of an organizational field, intention, is not the most powerful force, it is the only force”.

The Ghost of Healthcare Hope appears…

“I travel hallways, cafeterias, meeting rooms and hierarchical power-based ladders. When I listen to the stories and experiences from citizens who have lost loved ones due to preventable system failure, I hear a common theme, "They did not listen to us." When I listen to a coroner, I hear a common theme, "The family was not listened to."

When I listen to front-line care providers, I hear things like constantly being over census, short-staffing, casual and constant churn of staff, new processes, reporting and recording for the sake of compliance. I hear a common theme,"Why is no one above listening to us?”

When I listen to middle managers, I hear things like when we raise issues we are perceived as troublemakers, our bosses say we are beginning to sound a lot like the union. They too ask, “Is anyone listening?”

When I listen to senior executives, I hear frustration about the shift from sound public policy development to politically-motivated policy implementation. They wonder, "Is anyone listening?”

When I listen to the policy and funding people, I hear things like, why is the delivery system putting their own interpretation and spin on policy? They ask, "Is anyone listening to us?”

Every week across Canada there are hundreds of thousands of private citizen conversations with physicians. What is the level of listening and understanding?

I hope you will have an honest conversation about intentions. What’s your intention in the space you now occupy? Why should you be a leader? Indeed, if you really think about it, why should anyone pay attention to any of you who are holding formal “leadership” positions? Who are you? Are you just another special interest group who are out to protect the status quo, or are you in genuine stewardship to the greater customer-citizen interest? Do you work for the people you serve? Or are you focused on your own silo, and your own self-interest?

On intentions… I hope all formal and informal leaders become aware of the connection between and experiences of others and their systemic conditions. In other words, instead of fixing one another, work together to master the conditions which are influencing all of you.”

Perhaps the current state of “not listening” is explained in the book Seeing Systems by B. Oshry. The book outlines the dynamics that take place between and among three “spaces” in organizations: the top space, the middle space and the bottom space.

Healthcare organizations are often big and bureaucratic. Let’s begin at the top. How often have we seen the top level, formally responsible for the whole, dissolving the whole into disintegrated domains of responsibility? Often, boundary and turf issues begin to dominate: peers begin to protect their domains and resist joint problem-solving. By rebuilding connections and emphasizing common goals, we can stop polarization and isolation from becoming the standard operating style.

When this dividing pattern becomes the organizational norm, it signals to those in the organization to focus narrowly on their individual areas, losing sight of the system as a whole. The mid level of the organization senses and adopts top level culture. Horizontal connections begin to erode. The managers mirror the isolationist behaviour of their superiors. For the patient and the system, this unhealthy competition is harmful.

Surely the goals that everyone in the system can rally around are (1) high-quality, cost-effective safe patient care, and (2) overall improvements in the health status of Canadians. These are the big imperatives that should trump smaller agendas, which are at the root of silos.

As the top and middle levels become absorbed in their own aspirations, the front lines feel like cogs in the bureaucratic machine chafing under the remoteness and perceived dysfunction of their superiors. They at times are caught between competing organizational imperatives that bring them into conflict with their peers. They feel unified as victims and divided by the absence of common direction and purpose. The healthcare system is already suffering from providers’ lost capacity and this loss can’t continue.

Dissatisfaction with the current state of organizational space conditions is the first step towards progress. Imagine the healthcare system to be a multi-storey building. We have stairs, halls, ladders and balconies. We call them networks, institutes, agencies, foundations, et cetera. In addition, we have independent stairs and ladders called the delivery system. Too often, leaders are more concerned with the drama in the upper floors than the relationship flaws on the stairs and ladders.

Healthcare is a human-service business, delivered by people, to people. Healthy relationships and an active and engaged workforce are prerequisites for excellence in quality, safety and patient satisfaction. As the healthcare system grapples with rising demands and limited resources, the need for creativity has also come into sharp focus. Our challenges are significant but not insurmountable. The key lies in engaging the hearts and minds of the legions of people who work within our healthcare system, as well as the millions more who intersect with it.

Fundamentally, healthcare organizations and spaces are patterns of energy, webs of human relationships, conversations and decisions. The spaces are not just the lines and boxes on the official organization chart, but the white space between and beyond them. Organizational charts are static images that imply rigid turf boundaries, whereas high-performing spaces are dynamic and fluid – highly attuned and harmonious with their internal and external environment. Yes, the multiplicity of professions and the complex hierarchies in healthcare can present challenges, but the same can be said of other systems and structures. 

Rather than laying out a map of the future and giving staff a big push from the top of the organization, work alongside them to define new roles, power relationships and behaviours.

Imagine the benefits everyone can gain by building bridges between people. Imagine friction and negative energy replaced with enthusiasm, hope and confidence.

So what needs to be done to align the organizational spaces and create healthy relationship patterns?

  1. Shared vision that is honoured each day. This places partners at the same table with a common goal. A shared vision might seem critical for those at senior levels. But by its very nature, senior management is one with too much to do and not enough time to do it. Non-pressing items, the organization’s vision, for example, are often neglected. The organization’s vision must therefore be fostered and followed at all levels, so it becomes entrenched in culture.
  2. Respect for the experience and relevance of an organization’s middle management. This is critical for success. Middle managers handle complaints from the top and from the front lines. Middle managers can act as the bridge-builders.
  3. Diversity embraced. By marshalling our diverse resources, we can create powerful coalitions. The challenge is to invite patients and providers to come forward with their ideas — to encourage them to take a risk and share their knowledge.

What is being advocated is captured in one word: culture. Strong people-focused values, a compelling vision of the organization as a great place for both patients and staff, and a spirit of sharing ideas for doing things better – these are the hallmarks of a leading healthcare organization.

The Ghost of Healthcare Hope returns…

Simply put, it’s soft things like organizational culture, teachable moments, effective collaboration, ability to experience change and learning at the rate needed to create breakthroughs that create all the problems with the hard things like healthcare consumer satisfaction, crisis frequency, retention of staff, cost of performance and cost of service. My hope is that leaders take responsibility for the soft and hard reality they create.”

We must continually ask how can we as leaders meaningfully create a culture that encourages expression of the intellect, passion, commitment and experience needed to make real changes that satisfy healthcare consumer needs and expectations?

To quote Peter Senge…By coming together in open and honest dialogue, we can integrate our fragmented, individual perceptions of reality into a more complete and accurate representation of our current circumstances, our true shared reality”.

Next week my guest is Dr. Brendan Carr in a conversation about moving from doing stuff to providing true value.

See essays in this series

See essays from series #2

See essays from series #1

About the Author(s)

Hugh MacLeod, Concerned Citizen


Oshry, B. 2007. Seeing Systems. Berret-Keohler Publishers, Inc.
MacLeod, H. and G. Lowe. 2012. “Organizational Connectivity”. Longwoods Healthcare Ghost Busting Essays.
Senge, P. 2006. The Fifth Discipline. Doubleday, New York.
Macleod, H. and S. Sharkey. 2012. “Self-Organizing Change”. Longwoods Healthcare Ghost Busting Essays.
Piper, W. 2008.The Little Engine That Could. Summary by Hugh Macleod IPAC 19(2).

Arthur, W. B. 1999. Sense Making in the New Economy. Xerox PARC, Palo Alto.  


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