My guest on the “balcony of personal reflection” is  Dr. Allan Best. In addition to providing a clear purpose or vision, leaders encourage, model and create opportunities for relationships to form and be maintained. Vision needs to be paired with a thorough understanding of the dynamics that explain the organization’s processes, and a shared strategy for how to get from the present to the preferred future. A clear purpose with agreed-upon goals reduces the emergence of sub-agendas that can lead to siloing and turf wars. Strong relationships help foster communication that leads to the creation of networks and emergence of new ideas, practices and systems. But strong relationships can only thrive in an environment/culture of trust and respect.

Credible leaders value diversity of perspective and opinions and model the values and purpose of the organization. High performing organizations reflect these values and its purpose at all levels. People in such organizations feel free to speak up and identify conflict, disconnects, and inconsistencies. Everyone shares accountability for achieving the organizational purpose and is imbued with the personal authority to take action.

It is up to today’s health system leaders to lead with integrity, to model the values and purpose of the system in every aspect of their work, and to encourage such behaviour at all levels of the organization.

The Ghost of Healthcare Hopes arrives...

“It is often said that a healthcare organization’s people are it’s most valuable asset.  I see the “people as an asset” concept within the frame of value statements that includes words such as respect, trust, diversity, and openness.  Far too often, this is merely wallpaper within a frame with no commitment to alter the organizational mindset. 

To make the “people as an asset” metaphor a reality, I hope you become inclusive and engage people’s facilities of reflection, feedback, and decision-making. 

I understand you must achieve sterling performance under conditions of fiscal restraint and increasing service demand.  These are not mutually exclusive.  You deal with many factors you cannot control, such as political agendas and their impacts on policy and funding. At any moment these factors can surge into an issue that demands an immediate response when high level engagement is impossible.  I urge you to fight the normal tendency to pull inward and maintain open communication links and decision-making processes.

This means going beyond the small inner circle that is typically involved in a change process to widening the circle to create a critical mass for change.  Unfortunately, most organizations attempt to connect people only to the task at hand and rely heavily on inspirational talks, slide presentations and outside consulting and often minimizing the importance of dialogue to create new conversation.”

Healthcare systems hum or sputter in the “white space” between the hierarchical power lines on organizational charts. White space is a process management concept described by Geary A. Rummler and Alan P. Brache as the area between the boxes in an organizational chart  – where, very often, no one is in charge. It is where important handoffs between functions happen and it is where an organization has the greatest potential for improvement as things often "fall between the cracks" or "disappear into black holes," resulting in misunderstandings and delays. Managing white space entails improving an organization's process performance.

Maletz and Nohria describe "white space" as an area within a company where the existing corporate culture does not apply, somewhat like a skunk works... "white space exists in all companies...where rules are vague, authority is fuzzy, budgets are nonexistent, and strategy is unclear". If white space is undefined, then the rest of the corporation operates in what they call "black space". The four key challenges to successful white space management requires establishing legitimacy, mobilizing resources, building momentum, and measuring results.

Adam Hartung describes “white space” in his 2008 book, Create Marketplace Disruption: How to Stay Ahead of the Competition as a place that "provides a location for new thinking, testing and learning." He cites examples of companies that used the white space to evolve new formulae for business success free from the existing "defend and extend" culture.

The leadership path to strengthen the people relationships within the “white space” requires a self-awareness of one’s current mindset, and a readiness to a change of mindset in the following areas: 

Information mindset.  With this mindset, the nature and role of information changes from being restricted and used for power to be openly shared.  Information is available to everyone like the air we breathe.

Openly share information as a tool for relationship building. This is important because: Accurate information must be the air that all breathe, and the more open the flow the more easily people can convert data into meaningful knowledge.

Relationship mindset.  Relationships flourish when barriers are removed.  People are able, even compelled, to bump into each other and create and circulate new information.  As new patterns of interdependence grow, trust begins to increase due to the recognition that listening skills, with a willingness to be influenced are critical. A deep appreciation for the fullness of the system’s diversity begins to grow.  

You don’t have to know everything if you trust the others. This is important because: If I am committed to being trustworthy myself and take responsibility for building relationships that model this behaviour, others will deliver for me.

Identity Mindset.  The quest for identity, the sense of who we are and how we fit into the entire system and its goals is a critical factor. Symptoms of frustration due to a loss of identity include concern with roles and responsibilities. Leaders with an identity mindset want people to learn that such frustration can be healthy, an impetus to defining personal responsibility.

However, traumatic frustration with the loss of historically valued sense of organizational identity may result in an obsessive concern with role direction. This is driven by the need to establish control over others, presented as a desire for “improved trust,” which is actually a defense against a fear of competition and loss of influence.

Understand and be committed to what is in this for all … not just for me. This is important because: people must see themselves in the vision. Without a feeling of personal connection, there will be a need for control based on fear. 

Collective Potential Mindset. People bring many untapped gifts to an organization. They include not only the components of ourselves, staffs, and systems that we deny or have learned to diminish but also all our undiscovered talents and potential and the energy to make them come alive.

As people begin to see themselves in the larger picture and feel good about it, work becomes more meaningful.  Creative energies are released, feeling the transformation process.  People across the system begin to realize that the more they do with others,the more their influence grows.

Cannot do it alone. This is important because: To maximize our effectiveness take advantage of the unused skills, talents and potentialities of everyone in the organization, and overcome the intellectual, emotional and systemic barriers in the way of creating a truly healthy learning organization.

The Ghost of Healthcare Hope returns:

“Powerful dimensions of organizational life are invisible. I hope for a basic shift of attention on what is called “white space” to illuminate critical but typically invisible qualities that shape organizational life, the experience of the workplace, and the capacity to deliver results.

I hope for:

  • Improved relationships, in particular, how trust and leadership that models trust and relationship building responsibility can be enhanced.

  • Much more conversation among leaders at policy, management, and practice levels, to develop shared language and logic, and to sort out who needs to do what in the white space.

  • Identity focus, especially, amplifying focus on what is in this for us, not just me.

  • Optimal management for the optimal flow of accurate information that, like the air that we breathe, strengthens connections among people and assists us to transform data into meaningful knowledge.

  • Structured opportunities and incentives for teams to reflect on the feedback loops provided by this information, in a shared learning network for continuous improvement.

  • Taking advantage of the unused skills, talents and potentialities of everyone in the organization and overcoming the intellectual, emotional and systemic barriers in the way of creating a truly healthy learning organization.”

Join me next week’s in a conversation titled....The Patient Will See You Now. Are You Ready?

See essays in this series.

See essays from series 2

See essays from series 1

About the Author

Hugh Macleod, Founder Global Healthcare Knowledge Exchange. Concerned and engaged citizen.

Allan Best Ph.D. Director, InSource Research Group. Associate Scientist, Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute. Clinical Professor, School of Population & Public Health, University of British Columbia.


Axelrod, R.H., and H. Macleod (2002). Engaging the Staff. Health Forum Journal, May/ June 2002.

MacLeod, H., and R. Alvarez (2013). Four Mindset Shifts. Longwoods Essay.

Rummler, G.A, and A. P. Brache (1995). Improving Performance: How To Manage In The White Space In The Organizational Chart. Jossey-Bass Publisher.

Maletz, M.  and N. Nohria. (2001). Managing In White Space. Harvard Business Review

Hartung, A. (2008). Creating Marketplace Disruption: How To Stay Ahead Of The Competition. FT Press.  

Saul JE, Best A, Noel K. (2013). Ghost Busting Series I – Synthesis - Implementing Leadership in Healthcare: Guiding Principles and a New Mindset. Longwoods Healthcare Ghost Busting Essays.