Emerges from the Fabric: Working Inside and Outside

Establishing the context and conditions to foster new communtiy health improvement intitatives, and creative approaches to inpatient nursing care.

A Story from Linda Rusch, VP Patient Care, Hunterdon Medical Center
Told by: Ken Baskin, Brenda Zimmerman and Curt Lindberg

Illustration of:

• complexity lens
• clockware/swarmware
• wicked questions
• min specs
• conditions for emergence
• good enough vision
• metaphor

Principles
Complexity lens

For Linda Rusch, VP, Patient Care, Hunterdon Medical Center, complexity theory can help health care professionals do more than improve their hospitals operations. By focusing on interconnections, it can help us understand the health care system that is now emerging.

"When President Reagan fired striking air traffic controllers, many of the results arose at the family level," she explains, "in higher suicide rates, broken marriages, and domestic violence." Or think about drug abuse and teenage pregnancy. Are these social issues? Or health care issues? Complexity theory tells us it's foolish to draw a sharp line between the two. They're interconnected; they effect each other.

"So what we need is a model of health care that emerges from the fabric of the community," Rusch adds. "As consumers continue to revolt against the excesses of managed care, that kind of system will emerge. Already, nurses in the maternity unit collaborated with the prosecutor's office to provide an educational program on domestic violence. Complexity theory tells me that will happen, if we allow forces to run their course without trying to control it."

Unlike some of the participants on VHA's complexity task force, such a hands-off approach to management was second nature to Rusch. Her graduate school training in psychiatry emphasized systems theory.

"I learned family therapy," she notes. "You don't direct family therapy. You create conditions, expose paradoxes, and watch the dynamics play out. The healing occurs as you let people work out their problems. All these ideas are at the heart of a complexity approach to management." Even though she was used to thinking this way, Rusch at first found herself confused by complexity theory.

"About two years ago, Curt [Lindberg] was putting together the complexity task force and wanted to include nurse executives," she says. "I volunteered, but was really confused at first. We were bombarded with a barrage of new concepts, like clockware and swarmware. It was like nailing Jell-O to the wall. "

But after a while, Rusch recognized that most of these ideas were "really systems theory." Now she finds many of the concepts from complexity theory indispensable, both for doing her job and teaching others to do their jobs more effectively.

Aides
Wicked questions

"I loved learning to use the Wicked Question," she offers as an example. "You know. The question everyone is thinking, but no one has the guts to actually say. It helps people understand what's actually going on. Until they do, it's hard to resolve any problem."

Principles
Clockware/
swarmware

Rusch has also become fond of the terms "clockware," those routine tasks that require careful adherence to standard procedures, and "swarmware," those where precise outcomes are unlikely, and creativity and innovation are valuable.

"My staff goes around saying, "We're swarming now!"" she laughs. Still another of her favorite techniques is "minimum specs." The idea is to ask people to take on challenges by giving them only one or two absolute requirements, the minimum specs. Rusch has begun working with two nurse managers in one such project.

"I asked both Carol and Pat to pretend they were the CEO of the Marriott Hotel, and write down all the things they saw in their units, but hold off on solutions," Rusch explains. "Carol came back with a three-page list of things she hadn't realized before-from the cluttered appearance of the nurses' stations to the disturbingly high level of noise."

"I'm asking Pat and Carol to work with their nurses to transform their units into "humanistic healing environments," she continues. "That's all. I'm convinced that they will create two units that are both very, very customer-service oriented and good places to heal."

A final technique Rusch discusses is releasing control. She's talks about it in terms of Gareth Morgan's comment: "Farmers don't grow crops. They create the conditions in which crops grow."

Aides
Metaphor
Min specs
Good enough vision

"My training in systems theory ensured that I'd never be a control freak manager," she says. "But with complexity theory, my role is to set the minimum requirements and then get out of the way. I want my people to have the time to be creative, to experiment, and to see what happens. That's not traditional management theory, but I see it working."

Rusch adds that, in teaching others about complexity theory, she's found the desire to drop control more widespread than she'd expected. "Some people really want to stop controlling, but are afraid," she notes. "Everywhere, things are changing, creating high degrees of uncertainty and anxiety. And the more anxious you are, the more in control you need to be."

"Making all this even worse, we've bought into the myth that leaders have all the answers," Rusch continues. "Managers who accept this myth have their levels of anxiety ratcheted up again. So when I tell people about Gareth [Morgan]'s rule that we can control only about 15 percent of what's going on around us, many of these managers are enormously relieved. If complexity theory can begin freeing managers from this myth of control, I think you'll see people a whole lot more comfortable."

Rusch adds that the issue of control has also had an unexpected part in the emergence of the new health care system. "On one hand, President Clinton's attempt to impose a new health care system that emphasized control could never have worked," she explains. "On the other hand, it created an enormous amount of second-order change. Everyone in the system began to change more rapidly in response to the impending change."

Rusch also believes that managed care has become a major source of second-order change forming the new health care system.

"Managed care came into the system like an intruder," she says. "It focused on cutting costs without any understanding of what the consumer wanted. Americans are used to choices. Managed care's "gatekeeper" model is beginning to fail. So managed care helped us get the fat out of the system. Now we're entering a period where the real changes can emerge."

"Complexity theory would suggest that these changes would arise from lots of little interactions, rather than large-scale attempts to control the system," Rusch points out. "That's exactly what's happening. The AMA doesn't need to confront managed care. Instead, grassroots efforts are popping up everywhere, with the consumer saying, I've had enough! Out of this tension between the need for containing health-care costs and the demand for choice among quality alternatives, a new system is emerging, with the consumer in the driver's seat."

Rusch is convinced that new system will emphasize public health by integrating health care professionals with community partners and public policy makers. After all, so many health issues today are also social issues.

"Many of our most costly health problems arise from social issues-violence, drug and alcohol abuse, or sexually transmitted diseases, for example. We can't really address any of these problems by staying in our hospitals and clinics," she adds. "Many communities have taken their streets back from drugs and prostitution. We can help them do the work to address their health problems."

One of the major reasons Rusch wants to spread the word about complexity theory to leaders in health care is to help them become involved with this community model of health care.

"Traditionally, health care has been very bureaucratic," she notes. "Now we have to break down bureaucracy's departmental silos. Complexity theory can help health care leaders see all the interdependencies. When there's an issue, it teaches us to bring everyone to the table. And as we uncover the tensions and contradictions within the system, we can help a new one emerge."

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