Leading in a chaotic health care environment. (Health Care Leadership).

BEING A LEADER HAS never been easy. Being a leader during a time of chaotic, even revolutionary, change is enormously difficult. It is no wonder that health care executives and physician leaders are confused about how to become effective agents of change when it is hard to get our bearings about the environment in which we toil.

The extreme, cautionary example for health care executives may be Sherif Abdelhak, former leader of Pennsylvania's largest health care organization (Allegheny Health, Education, and Research Foundation). In five short years, Abdelhak went from admired and feared health care visionary giving the prestigious John A. D. Cooper lecture at the Association of American Medical Colleges (AAMC) to being indicted for actions that allegedly led to Allegheny's bankruptcy.

What is leadership? James MacGregor Burns in a Pulitzer Prize and National Book Award winning volume defined it as "leaders inducing followers to act for certain goals that represent the values and the motivations-the wants and needs, the aspirations and expectations-of both leaders and followers," (1) Dwight D. Eisenhower defined leadership as "the ability to decide what is to be done, and then to get others to want to do it." (2)

Leadership is not a thing; it is a relationship. It involves leaders and followers. Leaders mobilize, in competition or in conflict with others, institutional, political, psychological, and other resources to arouse, engage, and satisfy the motives of their followers. (1) Leadership is a relationship that deals with power.

Leadership can be measured by the degree of the intended effects produced. (1) Erik Erikson judged Martin Luther and Mahatma Gandhi to be great leaders because they successfully produced the important changes they advocated. They both demonstrated "a grim willingness to do the dirty work of their ages." (3)

If physician executives have to, in Einsenhower's words, "decide what is to be done," how are we to proceed? The arena in which we operate is confusing, to say the least. At one time in my career, I thought that the theory of managed care as articulated by the Jackson Hole Group made some sense in trying to deal with the high cost of American health care.

We've failed miserably

Managed care has brought some benefits to American medicine: cutting the cost of health care, unleashing the search for best practices, championing patient satisfaction, emphasizing prevention and coordination of care, realizing the power of Information Technology, and stressing population-based medicine. (4) But even the most ardent spokesperson for managed care would have to admit that it has not produced happy and satisfied patients and physicians. The often quoted survey that found that 46 percent of American physicians often think about leaving medicine and that 79 percent are against managed care indicates that it has not been a uniform success. (5)

I attended seminars hosted by the AAMC, the University HealthSystem Consortium, The Wall Street Journal, and the National Managed Health Care Congress, and came away with tools to help build statewide integrated delivery systems. And, yet, it is hard to point to many IDSs that have delivered the excellent health care, enormous cost savings, and satisfied providers and patients that the theory espoused in these workshops seemed to promise. The bankruptcy of Allegheny, the merger and subsequent divorce of Stanford and UCSF, and the financial troubles of the University of Pennsylvania system are high profile examples of problems felt by almost all providers in American medicine.

Health care leadership has failed miserably when judged by the production of intended effects. I do not think any of us intended to create a system where providers feel angry and under attack, hospital systems are going bankrupt, many Americans still do not have health insurance, patients feel alienated from physicians, hospitals, and insurance companies, and the Institute of Medicine states that errors cause 44,000 to 98,000 deaths every year in hospitals. (6) And yet we have produced just such a health care system.

Physician executives must provide leadership for an extremely complex system that deals with a very important subject: our health. None of us fully comprehends human health and the many factors that are changing the health care system: the Information Revolution, the Human Genome Project, the Internet, and the globalization of both the old Industrial and the new economy. (7) Medicine and the delivery of medicine is changing at a chaotic and exciting rate, and no expert or futurist at any seminar knows the answers. Nobody actually knows what is going on with medicine in the new millennium. The question is how do we lead effectively in such an environment of our own ignorance and inadequacy?

Admitting that nobody knows what is going on does not mean that we give up or stop trying to improve health care. But we cannot act as though we can control or truly understand our situation. It is not really that different from life.

Nobody knows what is going on in life anymore than in health care.

What is knowledge?

Although some have defined knowledge as a justified, true belief, Edmund Gettier demonstrated that one can have a justified, true belief and still have no idea of what is going on,8 Gettier postulated a man who mistakes a dog for a sheep. The man believes there is a sheep in the yard. There is a sheep in the yard that is hidden from the man who is looking at the dog. The three criteria for knowledge (belief, justification, and truth) have all been met, but the man still does not know what is going on in the yard. (8)

I used to think that science explained the world around me so that I could understand my universe and make wise decisions. Traditional experimental science, with its emphasis on simple systems and linear relationships, tells us relatively little about complex adaptive systems like disease, the health care system, or life. And the emerging study of complex systems does not tell us enough to truly understand our situation enough to make wise decisions.

One example from quantum theory and one from cosmology may satisfy the most diehard rationalist that science does not give us a full understanding of our world. Electrons act as waves and particles at the same time. Which are they? They seem to be both, and the same electron according to quantum physics can be in two places at the same time. The double slit experiment has been said to "contain the only mystery... the basic peculiarities of all quantum mechanics." (8) If one fires monochromatic light through double slits they are detected as waves. If one blocks one slit, they are detected as particles. Photons know when both slits are open, and waves are caused by one photon going through both slits at the same time and interfering with itself. (8)

Quasar QSO 0957 + 56 is detected as a double image because it appears to be split as it goes around another galaxy. We can make the light from the quasar that left its source 10 billion years ago either take both paths around the galaxy or take a single path depending on where we place the measuring device today. We can determine a situation (whether the light went around the galaxy using one or two paths) that common sense says should have been settled 10 billion years ago. The latest scientific theory indicates that what you and I do right here, right now, affects everything that ever was or will be. (8)

Guidelines for leaders

So health care leaders are faced with making decisions about an important subject (health) that is rapidly changing and that nobody truly understands. Are there any guidelines For leaders functioning in such chaos? There are a few, but you have to look outside health care to find them, and there are no hard and fast rules that always work when leaders take on complex problems in complicated health care systems.

Phil Jackson, the coach of the Los Angeles Lakers and the coach of six Chicago Bulls championship teams, exemplifies a leader who knows he cannot control or totally understand NBA players and basketball games. "Jackson's goal is to yield control at a superficial level in order to regain it at a more profound level by creating an environment in which, he says, the players 'become policemen of themselves, and that's really more fun for a coach to watch happen than anything else."' (9)

When Scottie Pippen refused to enter a 1994 playoff game, Jackson said in the locker room, "What happened has hurt us. Now you have to work this Out. You've got two minutes to get together, to talk softly among yourselves."' (9) He let the team come up with its own solution and that brought the team closer together and another championship. This example shows that top down leadership sometimes is less effective with highly skilled workers than letting the team come up with a solution. Wisdom that comes from the entire group and not just the leader may be most effective in shaping the group's actions and attitudes. Jackson's brand of leadership takes into account the relationship between the leader and the followers.

Leaders and followers are being affected because of the changes that the Information Revolution and the global economy are making in how we work. All executive search consultants and many in the start-up culture are acutely aware of the enormous shortage of motivated workers with the critically needed skills (many of which did not even exist ten years ago) that are essential to making a global or Internet company successful. Executives are also acutely aware that retaining employees in an environment where there is not a negative stigma attached to frequent job changes is another enormous challenge. Old-fashioned executive search consultants shake their heads at young knowledge workers who successfully hop from start up to start up looking for the stock options package that will make them millionaires.

Tom Peters' advice is to "Forget loyalty. Or at least loyalty to one's corporation. Try loyalty to your Rolodex--your network--instead."' (10) Gary Hamel describes the situation with the following statement: "In the knowledge economy the only employees that are worth having are those with other choices of employment. ..,Beavis and Butthead are not the only ones with a problem with authority--try winning the fealty of a whip-smart 32-year-old bond trader or brand manager on the basis of raw, positional authority."' (11) The implications for leaders who are used to being followed simply because of a title or position are obvious.

A radical departure

Dee Hock, the architect of Visa International, understood the limitations of planning. He was dealing with a complex adaptive system--a non-stock, for-profit membership corporation, in which the banks that issue the credit cards cooperate in the graphic design of the card and the back office operations and compete with each other in pursuing the same customers. "It was beyond the power of reason to design an organization to deal with such complexity. The organization had to be based on biological concepts to evolve, in effect, to invent and organize itself."' (12)

This approach to leadership emphasizes minimum specifications, rather than trying to plan every little detail of a complex system. It allows the entire organization to utilize flexibility, adaptability, and creativity to come up with solutions as the environment continually changes. It also recognizes the need for midcourse corrections as the organization encounters change. (12) It is a radical departure for leaders who have been trained to engage the entire organization in expensive strategic planning. But it does make sense if one describes planning as Aaron Wildavsky has: "Planning is not a solution to any problem. It is just a way of restating in other language the problems we do not know how to solve."' (13)

The emergence of networks where many parts of a system are connected and share information has played a central role in the new economy. Many do not realize that there are more silicon transistor chips (6 billion) in objects other than computers and that Tim Berner-Lee's vision of the World Wide Web as "about anything being potentially connected with anything" is becoming a reality. (14) The power of such networks is creating opportunities for experimentation, intuition, new solutions, and innovation.

Effective leaders are encouraging workers at all levels of the organization to make mistakes and come up with solutions by trial and error. Since one cannot be sure of anything in a complex system, it makes sense to encourage multiple experiments to solve difficult problems. (12) Where the traditional approaches have not produced the intended results because the system is complex and not well understood, there is little to lose by embracing flexibility, new ideas, and experiments.

Kevin Kelly described a Mexican cement company whose rigid traditional advance reservation system resulted in an on time delivery rate of less than 35 percent. Using extensive networking technology, such as global positioning satellite signals in the trucks, sharing all information with drivers and dispatchers, abandoning the delivery schedule in favor of ad hoc decisions by drivers, and massive telecommunications, the organization now gives a 10 percent discount for deliveries that are more than 10 minutes late. Such an improvement was only possible because the leaders gave up considerable control and shared information at all levels of the organization. (15)

The value of interdisciplinary solutions

Effective leaders of complex organizations recognize the value of interdisciplinary solutions to specialized problems. The history of the development of chaos theory is instructive in that major contributions were made by meteorologists, biologists, mathematicians, and physicists working at the fringes of each field and trying to piece the whole picture together. (16)

Benoit Mandelbrot, who made major contributions to our understanding of boundaries and scale, describes himself as a "nomad by choice." (16) He taught economics at Harvard, engineering at Yale, and physiology at Albert Einstein Medical School, and it was just such an eclectic generalist background that allowed him to take unorthodox approaches to unfashionable corners of mathematics. Mandelbrot, who coined the term fractal, played a significant role in establishing the new theory of complexity with its disturbing conclusions that simple systems give rise to complex behavior; that complex systems give rise to simple behavior; and that the laws of complexity hold universally.

What is important for leaders is the sadly predictable response of specialist experts to each new Mandelbrot revelation of complexity theory: "Who are you and why are you interested in our field?.. .How does it relate to what we have been doing?...Are you sure it is standard mathematics?.... What do people in these branches of mathematics think about your work? (11,16) The truly effective leader who understands that nobody really knows what is going on will not be put off by rejection of new ideas and solutions by narrow-minded experts. He or she will read widely and apply new ideas and solutions that make sense. A leader should pay more attention to what is actually being said than to who is saying it. (18)

The nebulous shadow system

Effective leaders understand the importance of what Ralph Stacey describes as the shadow system of hallway conversations, the rumor mill, and the informal procedures that all organizations have to get things done. (17) In the novel Moo, Jane Smiley describes such a phenomena when she gives the secretary to the Dean more power than her boss in making things happen at the university. Stacey observes that much of the creativity in an organization resides in this shadow system because it tolerates diversity of thought and opinion. (17)

A study of why new employees fail revealed that two of the main reasons centered around failure to build partnerships with employees and a lack of political savvy. New employees often forget that all organizations have a traditional hierarchy with its organizational chart and a shadow system with its not always obvious powerbrokers, like the secretary in Moo. (19)

Health care is a confusing field. But it still needs effective leadership. Even though nobody really knows what is going on, physician leaders can play a beneficial role by encouraging everyone they work with to experiment and innovate with ways to make health care work better for patients. Physician executives can insist on accountability and on implementing what really works in their given context, rather than what the latest theory (reengineering, total quality management, theory Z, management by objective, T groups, demassing, excellence, etc.) states should work.

Physician executives can take a lesson from biology and learn like bacteria do through the constantly occurring process of action, feedback, and synthesis. (20) Peter Drucker advised leaders who are making a key decision to write down what they expect to happen. Nine months later the executive should feedback from results to expectations to learn about his or her strengths and weaknesses. (21)

References

(1.) Burns, James MacGregor. Leadership, New York, New York: Harper & Row, 1978.

(2.) Larson, A. The President Nobody Knew, New York, New York: Popular Library, 1968.

(3.) Erickson, E. Gandhi's Truth. New York, New York: Norton, 1969.

(4.) Bottles, K. The Effect of the Information Revolution on American Medical Schools, Med Gen Med, July 26, 1999.

(5.) "The 1998 Med Stat. Quality Catalyst Physician Study." Ann Arbor, Michigan, Med Stat Group, 1998.

(6.) Kohn, LT., Corrigan, J.M., Donaldson, M.S., eds. To Err is Human: Building a Safer Health System. Washington, D.C.: National Academy Press, 2000.

(7.) Bottles, K. The Information Revolution: Opportunities and Pitfalls for Patients and Providers. The Physician Executive, January/February 2000, volume 26, issue # 1.

(8.) Hagen, S. How the World Can Be the Way it is: An inquiry for the New Millennium into Science, Philosophy, and Perception. Wheaton, Illinois: Quest Books, 1995.

(9.) Shields, D. The Good Father, The Now York Times Magazine, April 23, 2000, pp. 58-61.

(10.) The Toni Peters Seminar (London, 1994).

(11.) Hamel, Gary. The Prize That Lies in Foreseeing the Future, Financial Times, London, June 5, 1995.

(12.) Zimmerman B, Lindberg, C, Pisek, P. Edgeware: Insights front Complexity Science for Health Care Leaders. Irving, Texas: VHA, Inc., 1998.

(13.) Wildavsky, A. If Planning is Everything, Maybe it's Nothing. Pot icy Sciences, volume 4, 1973.

(14.) Berners-Lee, T. Weaving the Web: The Original Design and Ultimate Destiny of the World Wide Web by its Inventor. San Francisco, California: HarperSanFrancisco, 1999.

(15.) Kelly, K. Note Rates for the Now Economy; Ten Radical Strategies for a Connected World. New York, New York: Viking, 1998.

(16.) Gleick, J. Chaos: Making a New Science. New York, New York: Viking, 1987.

(17.) Stacey, R.D. Complexity and Creativity in Organizations San Francisco, California: Berrett-Koehler Publishers, 1996.

(18.) Smiley, J. Moo. New York, New York: Ivy Books, 1998.

(19.) Harrison, R.P. "1997 Manchester Survey," Philadelphia, Pennsylvania, 1997.

(20.) Kaufmann, S. The Origins of Order: Self-Organization and Selection in Evolution. New York, New York: Oxford University Press, 1993.

(21.) Drucker, P.F. Management Challenges for the 21st Century. New York, New York: HarperBusiness, 1999.

RELATED ARTICLE: Recommended

Resources

James Gleick. Chaos: Making a New Science. New York, New York: Penguin USA, 1988.This is the classic book that revealed chaos and complexity theory to those of us who are not mathematicians or physicists. The story of how complexity theory evolved is a perfect example of how innovation and new ideas arise at the interdisciplinary interfaces of mathematics, biology, law, and physics. This book truly changed the way I view the world.

Steve Hagen. How the World Can Be the Way It Is: An Inquiry for the New Millennium into Science, Philosophy, and Perception. Wheaton, Illinois: Quest Books, 1998. This is a truly brilliant look at the interface of philosophy, science, and religion. It clearly shows how science does not explain all of our reality and how important it is to truly see what you are looking at, no matter what your common sense and ideology tell you you should be seeing.

Phil Jackson, Hugh Delehanty, and Bill Bradley. Sacred Hoops: Spiritual Lessons of a Hardwood Warrior New York, New York: Hyperion, 1996. Those who understand complexity theory change the way they lead. The NBA's most unorthodox coach has the championship rings to show that new thinking can result in winning results. Jackson's "mindful basketball." instead of winning through intimidation, can be applied to any organization.

Brenda Zimmerman, Curt Lindberg, and Paul Plsek. Edgeware: Insights from Complexity Science for Health Care Leaders. Irving, Texas: VHA, Inc., 1998. A confused, disorganized, wonderful book from a bunch of in the trenches health care leaders who attempt to use complexity theory in the daily running of hospitals.

Ralph D. Stacey. Managing the Unknowable: Strategic Boundaries between Order and Chaos in Organizations. New York, New York: Jossey-Bass Publishers, 1992. The best scholarly treatment of chaos theory, the unknowability of life, and strategic planning with case studies from Kodak, Sony, and Federal Express. The writing style is a bit dry, but the content is excellent.

--Kent Bottles, MD

Kent Bottles, MD, is President of the genomics repository of Genomics Collaborative in Cambridge, Massachusetts. He can be reached by calling 617/661-2400, ext. 254 or via email at [e-mail].