Essays January 2015

Getting a Grip on Complexity

Dr. Ron Lindstrom and Hugh MacLeod

The challenge

This quote from Crossing the Quality Chasm highlights a patient-centred care challenge…“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.” The 2001 warning is even more applicable today given the complexity of healthcare delivery and the complexity of the patient.

Dr. Ron Lindstrom joins me on the “balcony of personal reflection.” We begin talking about complicated systems and navigating the complexity of the healthcare system. Complexity asks, how do things assemble themselves? Complexity looks at interacting elements and asks how do they form patterns and how do the patterns unfold given patterns may never be finished because they are open-ended. In healthcare this kind of inquiry can create reaction: traditional science does not like perpetual novelty. Newtonian laws are supposed to be unchanging. The question is whether we, as leaders, contribute to the complexity. Far too often we apply simple solutions to complex challenges. And then we are surprised that we have only scratched the surface and pulled the wrong levers.

We hold up the Commonwealth Fund 2014 update Mirror, mirror on the wall: How the Performance of the U.S. Health Care System Compares Internationally. The report (Davis, Stremikis, Squires and Schoen, 2014) contains some insightful and surprising data in terms of how Canada ranks on the international stage of health system performance. In overall ranking, the U.S. stands at last place out of the 11 nations studied. But, Canada is second to last in overall ranking. Canada ranks poorly in many areas. For example, in overall quality of care we stand at 9th place; safe care 10th place; patient-centred care 8th place; efficiency 10th place; and, in timeliness of care we are worst at 11th place. In fact, for many years, Canada has typically been second last in overall ranking of performance and sometimes last in specific areas of quality!

This, despite the ostensible high regard and reputation for our health system by ourselves and other countries. So we ask, “Why the apparent disconnect?” Is it largely because of the 2001 warning noted above, with so much more complexity forced our way that it really is beyond our ability to cope? Perhaps it’s not really about our ability to deliver; rather, it is about our ability to lead. Or, is it about our ability to lead wisely?

Suddenly the Ghost of Healthcare Hope appears…

This is going to require a new kind of leader, one who is a philosopher, master craftsman, idealist, politician, novelist and teacher all in one.

The importance of the link between leadership and health system performance has been undervalued, particularly in the area of health system redesign. Scholars and practitioners are now focusing more on this link from empirical and theoretical perspectives, but the news is not all that good. Importantly, this is not just about leadership at the top of organizations; rather, it’s about leadership at all levels of organizations literally from the bedside to the boardroom.”

As Hall (2010) put it: “One of the hallmarks of wisdom, what distinguishes it so sharply from ‘mere’ intelligence, is the ability to exercise good judgment in the face of imperfect knowledge” (p. 4). And, from the perspective of leaders, imperfect knowledge abounds in complex health systems, yet good judgment and decision-making are necessarily expected of them, if not taken for granted. Health systems are more than complex; they are complex adaptive systems (CASs). The latter is distinguished by characteristics including: elements that can adapt or change; a few simple rules of behaviour; nonlinear relationships; emergent behaviour; unpredictability; self-organization; contextual dependency; and healthy tensions (Plsek, 2001, pp. 313-314). Enter a new kind of leadership — complexity leadership. This emerging perspective is one of several shifts in health leadership starting to take hold to meet the increasing complexities we are experiencing in the health system (Lindstrom, 2013). Marion and Uhl-Bien (2001) put it this way: “Complex leaders understand that the best innovations, structures, and solutions to problems are not necessarily those that they, with their limited wisdom, ordain, but those that emerge when interacting aggregates [linkages in a system that evolve from individual interactions] work through issues” (p. 394). As Avolio, Walumba and Weber (2009) suggest, however, there is a dearth of research in this area likely because it is very difficult to conduct given its emergent construct in a highly dynamic context. This is where we need to go — now — in spite of the difficulty and complexity. Otherwise, we cannot move the scholarship and practice of health leadership forward in any meaningful and sustainable way.

In spite of the tremendous insights that the theory and work of natural systems can teach us about social constructs such as health organizations, we often fail to heed nature’s lessons and learn from them. In terms of complexity and change, Capra (2002) has written persuasively about this seeming paradox:  “…continuous change, adaptation, and creativity; and yet, our business organizations seem to be incapable of dealing with change” (p. 99).  This applies as much, if not more, to health organizations as businesses. Importantly, he suggests that “understanding human organizations as living systems is one of the critical challenges of our time” (p. 100).

So what does all this mean in the context of the challenge outlined at the very beginning of this essay? We offer the following:

First, we have to realize that there is a link between leadership and performance even though there is a palpable sensitivity to creating ill-will among leaders by implying that current leadership is somehow failing (Moat & Lavis, 2014). That is not to say there isn’t excellent leadership occurring in many, many places across the country. But, given performance based on multiple years of international health system comparisons and Canada’s consistent low standings we must pay more critical attention to impact, or lack of, at the system level. This also raises the issue of our Canadian health system or, more accurately, non-system, unlike some of our comparator nations. As the 10-year anniversary forum of the Romanow Commission (November, 2012) emphatically underscored, there remains a gaping disconnect of leadership between the federal and provincial/territorial levels. Getting back to Capra’s key insight, the health system needs to be first understood and respected as a living system with all its characteristics at play, not merely seen as a nice metaphor. Then, we may be able to speak the same language and move forward on some common ground.

Second, we need to respect complexity and figure out, humbly, what we can and cannot do. Flood (1999) talks about “getting to grips with complexity” (p. 90). This is where the practice of wise leadership is critical. As Flood suggests, “[t]he further away in space and time we venture from our locality, the more mythical is our interpretation of things” (p. 92). So, we have to exercise what is described as “boundary judgments.” While needing to think in CAS terms, we can only reasonably deal with what we know from our local perspective, which then creates important questions of where the boundary is ethically drawn. Churchman (1979), as cited by Flood (1999, p. 92), raises the notion of boundaries as mental models, that is, what we include in, or exclude from, our consideration in the moment. This constitutes a boundary judgement – a choice – and is highly value-laden.

Third, we need to deliberately seek out and apply the available evidence on leadership and change management. While this seems trite to suggest, it is clear empirically that this does not regularly happen. Where is the accountability for not practicing evidence-informed policy and decision-making in governance, leadership and management at all levels of the health system? Integrating research evidence into health policy and decision-making practice remains stubbornly sporadic and limited despite the rhetoric. That these are still viewed as “separate” activities is foolish, if not hypocritical, given the expectations placed on clinicians, for example, to practice and be held professionally and individually accountable for evidence-based medicine. Part of the issue stems from prevailing mindsets and confusion about what research is, or is not, particularly when entering the world of qualitative inquiry and collaborative, action-oriented research.

Finally, we need to get past the compulsion to make the complex be simple in the mistaken belief that things can be more readily understood and lead to solutions. In my earlier graduate work, one of my favourite courses involved systems, more precisely systems modeling. The professor affirmed something of which I am constantly reminded in scholarship and practice: “The complex cannot be made simple.” Systems scholars have been making this point for a long time. Systems can only be understood as whole systems – a reductionist approach, while tempting, does not work. As human beings, many of us try to make the complex simple as a sense-making exercise. Most so-called problems in the health system are not problems at all, but paradoxes created in the context of what should be anticipated characteristics and behaviours of CASs. Bohm (1996) trenchantly distinguished between problems and paradoxes. We need to learn from this distinction. He suggested that when our mind sees something as a problem, then we work to find a solution – a perfectly rational thing to do? Not really. If the problem is actually a paradox, it essentially has no solution and our mind gets endlessly ‘caught’ trying to solve the insoluble with increasing inadequacies of responses.

The Ghost of Healthcare Hope returns…

I agree, you need to get a grip on complexity. My hope for the future lies in your understanding the health system as a complex, living, and adaptive system and learning from what works and what doesn’t work in nature. This will at times be counter to human reasoning. But, your natural tendency to simplify things that are, in fact, complex can be mitigated by being mindful of how you approach, or frame, the reality you are facing. To understand both complexity and leadership, particularly wise leadership, is doubly hard. It is wise leadership that is needed to close the gaps that prevent health systems from consistently performing well.

Healthcare transformation cannot be reproduced from its description by using a recipe-book approach any more than listing the hues and tones in Botticelli’s Birth of Venus can reproduce the masterpiece. There is no single book that can provide the road map; understanding the complexity of the healthcare system and with its local plurality, history, culture, commitment, leadership and readiness for transformation will be crucial… Disconnects lead to passive-aggressive behaviour that consumes negative energy, creates a sense of hopelessness, squanders public funds through inefficiencies and above all defeats a vision of creating a patient-centered system.”

We close with a quote from Carl Jung… “The greatest and most important problems in life are fundamentally insoluble. They must be so, for they express the necessary polarity in every self-regulating system. They can never be solved but only outgrown.

Join next week’s conversation with Diane Finegood on blurring the lines between research, evaluation and quality improvement.

See essays in this series.

See essays from series 2

See essays from series 1

About the Author

Ron Lindstrom, Professor, School of Leadership Studies, Henri M. Toupin Research Fellow in Health Systems Leadership, Faculty of Social and Applied Sciences, Royal Roads University.
Hugh MacLeod, Concerned Citizen.


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