The Power of Information
What Happens When a Vacuum Fills?

Surprising impact of increasing information flow in a project to restructure a medical center's quality efforts

Told by: Paul Plsek

Illustration of:

• mental models
• shadow organization
• unfolding, emergence, and unexpected outcomes in a CAS
• paradox
  
  

Administrative leaders in a large, medical center hospital asked me to help them re-structure their quality management efforts. The told me that the organization had a traditional quality assurance (QA) system, coupled with a more modern continuous quality improvement (CQI) effort.

The leaders felt that the first step in this year long project should involve me doing a series of interviews to assess the current quality efforts. To their credit, they insisted that I interview some 50+ people in the organization and form my own recommendations about what needed to be done, rather than relying on their assessment. They were convinced that the quality efforts were fragmented and not very effective, but they wanted me to decide for myself. They also admitted that communication within this traditional, hierarchically structure organization was not always the best it could be. I might learn something very different, they felt, by talking directly to the people who do the work.

"I did not appreciate how profound the lack of communication was. In fact, I now realize that my mental model caused me to believe the opposite of what they were telling me."

Reflection: At the time, I thought that this disclosure and insight was commendable. I am often told things like this and over the years have developed a mental model that goes something like this: When leaders tell you that communication is bad in their organization, they often overstate the case. The fact that they are telling you means that they are sensitive to the issue, and that usually means they are doing something about it. It’s the leaders who are clue-less that you have to watch out for. As you will see later in this Tale, I did not appreciate how profound the lack of communication was. My mental model caused me to discount what they were telling me; in fact, I now realize that my mental model caused me to believe the opposite of what they were telling me.

In my proposal to them, I structured the work in two parts. I would do the organizational assessment and make my recommendations. They would pay me for this work. After receiving the report, they could then decide whether or not they wanted me to continue working with them to help plan for the implementation of changes based on the recommendations in the report.

Reflection: In essence, I was going to be talking to the shadow system and reporting to the legitimate system. The information in the report would be new input to the organization’s CAS. The information would fundamentally change the context itself. Who could predict what I would hear in the interviews, what I would write in the report, whether these administrative leaders would want to work with me on the next phase, or whether I would want to work with them? Based on some past bad experiences I am careful about not getting caught in a no-man’s land between the shadow and legitimate systems of an organization. Having a clear break-point in the consulting contract allows all agents in this CAS to make up their minds on next steps as the context unfolds.

Without going into detail, let me say that my report confirmed the administrative leaders’ views that quality efforts were fragmented. Physician leaders associated with the organization were also unhappy with the situation. Physician-staff and cross-departmental teamwork within the organization was weak and in need of attention. Among other things, I recommended that the many separate physician-only and staff-only quality committees be disbanded and replaced with physician-staff quality groups who could look at issues in a more holistic fashion. Physician and administrative leaders agreed that working together sounded better, and was potentially more efficient, than working separately.

Reflection: This theme of physician, administration, and nursing collaboration is also reflected in other work I do. It is clearly a strong mental model for me. Am I drawn to a "physicians, nurses, and administrators should work in mutually-collaborative structures" attractor? Am I seeing this everywhere because it is there, or because my particular set of "lenses" puts it there? I don’t know. But I am very much aware of the possibilities.

To wrap up this part of the Tale, let me simply say that we arrived at a mutual agreement that the organization was ready to work on the changes I had recommended, and that I would continue to work with them. The planning for the changes in the quality system is a work in progress at the time of this writing.

Reflection: The contract with its clear phases allows me to now formally transfer from the shadow to the legitimate systems of the organization. My report brings the information input of the shadow system into the legitimate system. Importantly, the senior leaders in the legitimate system have made a conscious decision, in an open dialogue with me present, to accept the information in the report as legitimate. This feels a lot better than the more ambiguous situations I have found myself in in the past, caught in the no-man’s land between the two systems.

As a fascinating side street in this Tale, I want to report on a strange CAS behavior that I observed. I asked the senior administrator who was my contact to distribute a draft version of the report to all the people I had interviewed for their comments before I finalized it. She agreed to do this. I later learned that this was unprecedented. People in the organization had been interviewed on issues by outside consultants before, but never had they seen a copy of the consultants’ report, much less a draft version upon which they could comment.

Reflection: Yikes! My mental model is showing! When the leaders said communication was not a good as it could be, they were telling the truth! They knew it, but they really hadn’t addressed it! Wow!

While it might seem that this "new thing" of open information sharing would be a positive and refreshing development, it had a decidedly dark side to it. Managers began taking pot-shots at their colleagues in the quality departments (there were two quality departments, one supporting the QA efforts and one supporting the CQI efforts). The organization was in the throes of its annual budgeting exercise where cuts were needed. Since the outside consultant’s report indicated that the quality system was ineffective, perhaps the needed budget cuts should come out of the quality system. As I understand it from reports from several people, some downright nasty comments were made, citing the draft report as evidence. I spoke to several members of the quality department who said that they agreed with the information in the report and acknowledged that I had written it in a positive, "let’s improve the system" tone. They told me that they were angry at their colleagues, not at me.

Regardless of who they were mad at, two members of the quality department supporting the CQI efforts resigned to seek jobs elsewhere. My conversations with both of them after they left indicated that they just didn’t see any hope for the organization and they didn’t want to put up with the aggravation. They both felt that there were better opportunities elsewhere. (Both were in their 20s, bright, and energetic.) The department director left a few months later. I have not spoken to her since she left. In conversations before she left, I could never tell whether or not she blamed me for the abuse she was taking. She said she didn’t, but I still have an awkward feeling about it. She clearly didn’t like talking about it, and I suspect that her inability to deal openly with what was happening made things more stressful for her. The stress just built up until she decided to leave. Two members of the department supporting the QA-side, including the director, left a few months after that (although there were other reasons beyond the sniping that had emerged based on the draft report). Only two of the seven people devoted to quality activities at the beginning of my relationship with the organization are still there.

Reflection:/font We know from the studies of CAS that injecting information into a CAS changes its behavior. We also know that the system can be pushed into a chaotic region yielding unpredictable system behavior. This clearly happened here. In the language of Stuart Kaufmann’s fitness landscapes, this was a rugged landscape. Because they were so information-starved in the past, many people made a strong connection to the information in the report; in Kaufmann’s language, K was large in this NK system. Kaufmann has clearly shown that large values of K lead to chaotic and sub-optimal system behavior in a CAS.

I had no idea that my long-standing practice of asking the people I had interviewed to comment on my report before I finalized it was unprecedented in this organization. I did not know that I was so dramatically increasing the information content of the system, relatively speaking. My mental model discounted the input from the management team at the beginning of the engagement. And later inputs raised no visible red flags for me. For example, I did mentioned my intention to send around a draft report in my comments at the end of each interview. But I got either no reaction, or a comment like, "Oh, that will be nice." No one told me that this was absolutely unprecedented. My contact within the organization who distributed the report also gave no indication that this was unusual. Perhaps this is one of Gareth Morgan’s organizational "gulfs," that no one acknowledges openly. You can bet that I will inquire more directly about this in the future.

I stand by the report as written and would not change anything about it. It was a factual reporting of what I was told; it was a good analysis of what is needed based on my professional experience with quality systems; and it was written in a non-judgmental, "let’s fix the system" tone. The people who left made adult, individual decisions to leave. I am comfortable with my role here. I will in the future, however, be much more cautious about the timing and mechanism of release of such information in a CAS that is not accustomed to receiving it.

Brenda Zimmerman adds her reflection: There is a paradox at play in Paul’s intervention and his struggle with the outcomes of it. The paradox is common to intervening in a CAS. IT IS THE END OF THE AGE OF INNOCENCE AND THE END OF THE AGE OF GUILT. The innocence is gone because any intervention-or nudge, or new information-may be the difference that makes a difference (using Bateson’s language). The guilt is also gone because you cannot control the outcomes of an intervention to a CAS. There is not a linear cause and effect between Paul’s intervention and the outcome. In other contexts, sharing that same information would have had little or no effect. This story is another example of context-specific knowledge when working with a CAS.

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