Plenary Session I:
Understanding and Living With Organizational Uncertainty
Thank you. I want to tell you a little story about this presentation, because I think it’s useful for you to have some idea of how I got here. I’ve been teaching for quite some time now. I taught my first class in 1965. About five or six years ago I became convinced that most of what I was teaching was wrong. Now, not wrong because I’m stupid, but because most of what people are teaching in business schools and in health management programs is just wrong. How do I know? Because the world doesn’t conform to what we teach. Bill Gates gets to be the richest man in the world by giving away his product. That just isn’t consistent with what we teach in business schools. He’s a really interesting guy, because there is something about him that is not very well known, but is easy to observe. He doesn’t mind helping other people get rich as long as he gets rich. Most of us in business teach as though there is some limited supply of money and anything you get I can’t have. And Gates says, "Well, maybe that’s not true. Maybe if I let other people get rich, I’ll get rich too. And really, my goal in life is not to keep them from being rich, but to be rich myself." And that seemed to me to be wildly different than what we normally taught.
A second thing. If we look at Southwest Airlines and management theory, it’s clear that airline does not exist. You just can’t run an airline like that. I’ve had the chance to travel in Europe a fair amount, and if you ask someone who is not familiar with Southwest Airlines, such as European executives, "How long does it take to turn around an airplane at an airport?" They will say "About an hour. But, you really can’t do it in less than 45 minutes." But there’s one small problem. Southwest Airlines does it in 15 minutes. Nobody else does it, but they do it in 15 minutes. The most amazing thing about it is they give you a bag of peanuts and you think it’s a meal.
The Mayo Clinic offers what many of you think of as the best health care in the world. It’s also the cheapest. It’s almost impossible to find anywhere in the country that you can get health care as cheaply as you can at the Mayo clinic. What’s the average turnaround time for the general practitioner examining a patient? Twelve minutes is the answer, but their average turnaround time is about 45 minutes at the Mayo Clinic. How do they do that? The Geisinger Medical Clinic in Pennsylvania started an HMO, and they decided that they liked each other, so they decided not to have any utilization review. They just said, "If you’re not sure about what you’re doing, just ask somebody." And they said, "Okay." Then, of course, the Medicaid people came in and said, "How can you possibly run an HMO without utilization review?" And they said, "One patient at a time." It just isn’t that complicated, it’s just a question of saying, "We have decided all utilization review is people who hate each other." There’s nothing else to it. It doesn’t save any money. It doesn’t improve health care. It just enables people who hate each other to deny each other treatment. So they die. I think that’s really what it is. I know I’m supposed to say some good stuff about utilization review, like it saves money, but it doesn’t. What saves money is the denial to access to care. All of these things contradict the basic belief systems we have about management. You can pick up a good health care management book, I think the best one is the one by John Griffith, and I know John Griffith is a brilliant guy, but he’s just wrong. Now, I have said this to John, so this is not something I’m saying out of school. Of course, if I were you, I wouldn’t believe Reuben yet.
I didn’t know what to do about the fact that what I was teaching was wrong. But through a set of fortunate circumstances I came into contact with and began to understand complex adaptive systems theory. Through the understanding of this theory I’ve developed an appreciation of the way organizations really are, as well as some insights into what it means to understand them. The title of my talk today is pure arrogance. I can imagine you all read that and thought that this guy is either crazy or stupid. How can you understand organizational uncertainty? How can you live with it? What is organizing about? It’s about trying to control that uncertainty, getting rid of it, making things right. However, trying to get "everybody on the same page" requires a very small book. We want everybody in the organization on the same page, so we guarantee to list all the interesting things that will work. All the things that could make a difference in the lives of the people we’re trying to serve. Another one: Keep it simple, stupid. How many of you have heard that? Let me ask you something. Who is the person who is stupid in the room? Not me. Not you. So whom are we keeping it simple for? What a piece of advice. "Keep it simple, stupid."
What I want to do is to talk about this question from a complex theory perspective, and share with you some insights I’ve had. I’m not by myself on this. There are a lot of pretty smart people who have caught on to the fact that ordinary ways of looking at things don’t work out. In fact, all kinds of businesses will be glad to tell you that the traditional ways of looking at the world are pretty inconsistent.
Let’s go back a step. The first thing I want to say to you is all the things you’ve heard about the turmoil and uncertainty in health care are true in the following sense: health care and health care organizations are in great turmoil, and there is a tremendous amount of uncertainty. But it is not for the reason people tell you. People like you to believe that there are economic and political pressures in the world that are making everything kind of unsettled. And, if Congress would ever make up its mind, all of you would be happy in your jobs and have easy lives. Now, everybody in this room knows that’s a lie, but you don’t say anything about it. But, maybe when you’re in the bathroom you say to somebody, "You know, this stuff does not get better just because the legislature passes a law." You see, I’ve been through a lot of turmoil and change in health care, and let’s just think about some recent bad stuff. I set up a whole program to deal with AIDS patients, and people dying of AIDS, based on some wonderful hospice models, trying to think about how not to spend so much money on people who are dying anyway. And then, I woke up in the morning and read in the paper that now AIDS is about keeping people alive rather than helping them die. That’s turmoil. If you’re a manager, you want to go shoot yourself. You look at all the people you’ve convinced, all you’ve invested, all the doctors putting on the rubber gloves, and all of a sudden, it’s gone.
MBA’s are wonderful people. I teach MBA’s. If you’d like to find some MBA’s put a dollar on the floor and wait a minute. The people who all gather around have master’s degrees in business. What MBA’s do well is take credit for things. MBA’s take credit for the fact that so much surgery is done on an outpatient basis. They say the HMO’s have wrung the cost right out of the system. I see the surgeon now, standing there doing surgery, saying to the MBA, "Is this okay? Cut twice here? Should I slip it in the side here? Maybe I shouldn’t sew it up at all, just let him die." You know if you know anything at all about health care that it wasn’t MBA’s at all who were responsible for the growth in outpatient surgical procedures, it was the advancements in modern anesthesiology. The reason we stayed in the hospital after surgery was that we were asleep! It wasn’t that the surgeon was there watching over us. We were there because we were sleeping. But, MBA’s are taking full credit for those cost savings. I think if everybody in the room gets beyond what is popular to say today, they would have to say the issue in health care isn’t political, or economic, or technical, or anything. It is just the way it is. That’s what I’m going to talk about. Just the way it is. And how you change what you do as a manager if you accept the world the way it is.
Traditional views of management are based on Newtonian science. This might be surprising to those of you who haven’t studied management. But, those of you who have studied management recognize management was started mostly by engineers attempting to improve production processes. The focus of Newtonian science is on equilibrium states and determinism. So, we’re always looking for how we get things in balance, how we get things together, how we find cause and effect relationships. What you do as a manager is set goals, influence other people who commit effort toward obtaining those goals, and you get in charge of the situation. This sounds just like a 28-year old. Twenty-eight year olds go to work and set out to do this quite sincerely. They set goals and write them down, and workers laugh. They try to get people to commit effort toward reaching these goals, and workers keep doing what they were doing before, often doing the job that needs doing. And these 28-year olds are getting in charge of things, and they have no idea what happens. If they’re lucky, somebody who is wise will tell them, "be calm, relax. Forget what Reuben taught you in your MBA class."
You see, I was teaching this stuff to people, really live people. And these were dangerous people, because they were going out there and getting jobs. Here are the kinds of assumptions that guided my work with them. Large effects have large causes. If a given tactic works once, it can be counted on the work again, also called benchmarking. I love the chapter in all the books on how managers need hierarchy. The manager must discover the needs of workers, and then meet those needs with organizational goals. Well, the first thing is I don’t know what I need, much less somebody else, and the organization looks to me like it’s about making money, not making me happy. The one I really love is that every one should have a job description. I’m not going to try to embarrass anyone, so I don’t want anyone to really raise his or her hand, but if you do what’s in your job description, raise your hand. Your organization wouldn’t work. We know the best way to destroy an organization is to do what people tell you. We know that, there’s lots of data, and every one of us has experienced it. If I could make a contribution to humankind, it would be to destroy all job descriptions. Two things would happen. One thing is that people would be relieved that somebody else has already figured it out. The other things is that people would come to work and would say, "What can we do to make good stuff happen today?" They wouldn’t have to worry about following what’s on their job description.
Let’s get the organization right. Let’s get it organized. I’m tired of all these reorganizations. What we see today in modern companies is that they’re saying, "If you’re not reorganizing, you’re not keeping up with the changing world." I did work for Mobil Corporation, and they look at their organizational pattern and expect total reorganization every two years. The world is changing that fast. Politically, economically, technologically. They say, "If we’re not changing the way we do business every two years, we’re going to go out of business." If you want to know who to talk to on how to get your work done, I can give you one piece of advice. It’s probably not your boss. The odds are pretty good that your boss has little or no idea what’s happening. Many of you in this room are bosses, and you don’t know what’s going on either. To whom do you speak to get your work done? You either speak to the people who work for you, or your peers. The lines of information in organizations have little or nothing to do with authority. It doesn’t mean that lines of authority aren’t important, it just means lines of authority don’t have any information useful to getting work done.
Modern views of organizations are different. They give you a different perspective. When you look at the organization through these modern lenses, instead of giving orders, setting goals, and being in charge, what you find your job is a manager is sense-making, learning, and designing. Always designing, always recreating the organization. Always seeing to it that the organization is an emerging system. The most important thing the new sciences teach us is that the world is a fundamentally uncertain place. There is no "managing" uncertainty. It just is. And if you believe, as many people do, that there is some solution to all problems, and the only issue is how smart you are and how hard you’re willing to work, you’re making a fundamental mistake in your approach to the world. In some piece of your life you’re probably not doing that, and you probably feel guilty about it. For example, in raising kids, you figure out some of the problems you have are simply beyond you. My mother, a lovely woman, visited me at Christmastime, and said, "Reuben, it’s been 63 years now, and it’s all been downhill. I had been hopeful that somewhere along the line you would improve. But the grandchildren are perfect." There is no solution to the problems of having kids. You worry about them, you fret over them, you say you don’t care, but you lose sleep at night. That’s really what it is. But, if you start out by acknowledging the world is unknowable. That you can’t know. Not that you’re not smart enough, or don’t have enough information, not just that you don’t have enough time, not just that you haven’t read the right book. You just don’t have any way to know. This is a fundamental understanding for modern business. This is not something I’m making up out of some philosophical junk. This is what is means to be a quantum physicist. It’s to acknowledge that you just can’t know. This is what it means to modern geneticist. This is what it means to be a modern chemist. And then say, "What do I do now?"
Just so we exchange some information, there are lots of reasons why the world is unknowable, but here are some things that are critical to people who are managing health care or health-related organizations. 1: The development of the world is terrifically dependent on the initial conditions. Very small differences in initial conditions make for big difference in what happens later. 2: The relationships are non-linear and time-dependent. By any definition of determinism that includes ability to predict is just false. What we have to realize as managers is what you’re doing isn’t like what anybody else has ever done. So stop asking around to see if you can find somebody who has done it before or already solved your problem, because they’re not there. That group of employees you have, that group of clients you have, the circumstances you face, are just different. That means, ladies and gentlemen, you have to create the answers to the problems.
How many of you have heard how hard it is to find a needle in a haystack? A needle in a haystack is a resource question. If you’ve got lots of hay, burn down the haystack, and there’s your needle. If you don’t have lots of hay, but you have lots of money, get a big magnet. What comes up is the needle. The thing that is hard is figuring out how to sew up your pants when you discover there is no needle. That’s when you’re in trouble. That’s what hard.
It’s not a question of buying a book. It’s not a question of finding the right consultant. It’s not a question of getting together all the smart people in the organization, because they’ll "find" an answer. You need to get together the people who will create the answer. Every time you get the people together, they’re going to interact, and you’re not going to be able to predict what they’re going to do. The way in which the people, be they clients, or co-workers, the way in which they come together to make life is completely unpredictable.
I used to teach listening. I made a lot of money teaching listening. I am very good at it, except for one small problem. I was literally in a class just like this, and every one was very excited about it, but it dawned on me that the talker was not in the room. In the absence of a talker there was no way for me to teach. This is because listening is a relationship activity. I could teach you everything I want to about listening, but it’s useless if the person who is talking is not there. My wife said, "Reuben you have to go to the doctor because you need to get your hearing checked." So, I went to the doctor and told him my wife sent me here, and he just laughed. He said, "Every one comes in here and tells me their wife told them to get their hearing checked." So, he checked my hearing and found nothing wrong with it. My children, I have a son who is 35 and a daughter who is 37, haven’t heard anything I’ve said in 40 years. It’s a relationship activity. There is no such thing as a good husband. There are married couples in which somebody is playing the role of husband, and he’s doing it pretty well. There’s somebody playing the role of wife, and she’s doing it pretty well. But, in the absence of that couple, in the absence of the way they relate to each other, in the absence of the way they take care of each other, in absence of that relationship, there is nothing. That’s bad news, folks. That means all those job descriptions you have, all those performance evaluations you have, all those role definitions you have, are useless. There is nothing to it outside of the way folks get along and relate to each other, and the way they relate to problems. It’s time for us to stop acting as if we know what’s going on here.
Incidentally, I can tell you what a good husband is. A good husband is a guy with a rich wife. I happened to be married to a woman who is managing partner of a pretty large law firm. When she comes home at night I don’t say things like, "How was your day? Did you have a good day today?" My questions are very direct. "How many hours did you bill?" If it’s not enough, I send her back. Each and every day I’m out spending money, and I keep track of what I’m spending. Then, I make sure she’s earning enough.
Let’s look at what the leadership tasks are here: sense-making, learning, and designing. Sense-making systems create events that stabilize the environment and make it more predictable. The goal is not to find predictability, but to create events and make predictability. That’s a different task. It is, "We are going to make sense of this." Not "We’re going to find sense." But, we are collectively going to get together and make sense out of this. And, here’s what we’re going to have to do. We are going to have to pay attention. Most organizations are designed to keep people from paying attention to anything important. We’re going to have to complicate ourselves and develop a collective mind. Here are the ways that modern management research shows that effective organizations are complicating themselves. They engage in parallel information processing. They do not find the right source of information. They have four or five sources going all the time. They use a lot of real time information. Sometimes we call that managing by walking around. I used to work for Jerry Chapman. Some of you may know who Jerry Chapman was. He passed away four years ago. He was the welfare commissioner of Texas. You could come up with this brilliant idea with all the cost-benefit analyses you wanted, and Jerry would get on the phone and would call a social worker somewhere in the state of Texas. He’d say, "What do you think of this? How do you think this would affect your job in the morning?" If the answer was negative, he would turn you down. He didn’t care how many economic analyses you had done, because he knew that somewhere along the line, where workers met clients, that good stuff happened. He wasn’t mistrusting your judgement, he believed every number you gave him. He just knew that is was wrong.
You increase the number of goals. This was startling information brought up by Kathy Eisenhart of Stanford University. An effective organization has lots of goals. Not just a short list of things we’re focused on, but lots of goals. Effective organizations pursue multiple strategies, and are always increasing the number of strategic activities. They are not looking for the right way to do things. They are just looking for ways to do things. A lot of my own research shows that effective organizations increase the involvement of workers. They use multiple advisors. I do a lot of consulting. I won’t consult with any one anymore who says, "I want you to come and tell us how to do this." I’ll come and help you figure it out, and I want to be one of many advisors. We can talk through what we should do. Then you get a lot of people saying, "All you’re doing is borrowing my watch and telling me what time it is." Then I say, "Yes, but I’m the only one who really knows how to tell time." You may have watches, but I can help you learn how to tell time.
Increase decentralization. Effective organizations do not put decision-making at the top. Decrease formalization. The fewer the rules, the better. Increase the number of standing activities. Increase the number of conferences you attend. Increase the number of other businesses. You’re not trying to find the right answer. You’re trying to stimulate your own creativity. This means you might go to conferences other people might find foolish. Make sure all the people in your organization are talking to people outside the organization.
Learning. Now, if the future is unknowable, which is what we learn from modern science, then success comes from learning. That can be really discouraging because most of what we know about management organizations today says that to be successful you should know something. What I’m saying is to be successful you should be able to learn something. I have a real problem because I try to place my students in jobs with health care organizations. They say, "We want people with five years experience in health care." I ask them what happened five years ago in health care that is relevant today, and they say, "Nothing." I say what do you want with people with five years experience? They say, "Well, they’ll know the answers." I say, "Yes, they will know the answer to a problem that doesn’t exist anymore." What you want in your organization is people who can learn. The one thing I’m sure about in my organization is whatever I’m doing today is not what I’ll be doing tomorrow. What I need around me are people who can learn so they can help me tomorrow. There are all kinds of way to do this. You can focus on learning in real time. Focus on exploration. Develop skills in learning from samples of one. We think about learning as learning to play piano, or learning to play golf. You’ve got to practice a lot. How many of you have fired 10,000 people? Are there no governors in the room? Maybe you get to fire two or three people in a whole career. But the way you do those is really critical. You better learn from each one. Don’t let it go by.
What the manager has to do is present people with ambiguous challenges. Imagine a big rubber band between my hands. The manager’s job is to keep enough tension in that rubber band so that people will keep learning. See, if you’ve accomplished your goals, then it’s pretty boring. People start drinking on the job. Ambiguous challenges ensure people are always pushed to discover new stuff. It’s not the leader’s responsibility to find answers and teach the others. For you youngsters in the room, this is really bad news. I know that every night you all go home and read books to try to find the answers. You are going to go tell people what those answers are, and nobody cares. Your responsibility is to create environments that excite people, where they want to learn, where they listen to each other. They develop the whole content of what they learn as they respond to challenges. They don’t start with a curriculum. You don’t even have to be a university professor for this to be really bad news for you, because you can’t go to class with a set of notes about what kids are going to learn today. You don’t know why they are there in the first place. For example, I took a wonderful class in folklore at the University of Pennsylvania, taught by a brilliant professor. But, the reason I took that class was a girlfriend I had at the time was also in the class. I’ve now been married to that girlfriend for 43 years. So, you don’t know why kids are coming into your classroom. You just have to get them excited about learning.
As some of you are aware, the first personal computers Michael Dell put out were failures. He didn’t do what people in business are supposed to do. When you have a failure in business what you are supposed to do is discount your product and sell it to people who are too dumb to know. Ford did that with the Pinto. Michael Dell went back to the people who designed his personal computer, and said, "You are the people who made me rich. You are the only workers I have, and I don’t have any idea how to fix this. We just pulled them all off the market, because I’m not going to sell any computers that don’t work. And I trust you all are going to be able to fix it." And, they said, "What do you want us to do?" And he said, "I don’t know." That is literally what he did. He said he didn’t know, and if he knew how to fix it he’d tell them. But he also said, "I know you all are good workers, and have created a great company. You’re not perfect, you’re just people. And I know you want to fix this too. So, go at it folks." Now, his personal computers are rated number one on the market.
Carl Weick and Karleen Roberts said something in an article they wrote, "No matter how visionary or smart or forward-looking or aggressive one brain may be, it is no match for the conditions of interactive complexity." I teach a health care management class, and the first rule is there is only one dumb person in this class, and that’s me. So, if you are all coming in here to find the answers from me, you’re coming to the wrong person. You might find this answer from each other. But there is no one brain smart enough to grab hold of this.
Here are some things that now get to be on your agenda. Reality is defined in terms of relationships. The quality of the connections between people is more important than the quartile of the people. That’s a tough goal. It doesn’t make any difference how good your workers are. The difference is how well they work together. Those of you who live in Chicago should really enjoy this, because no one but a real fool would say anything but Michael Jordan is the greatest basketball player who ever lived. But I know he doesn’t really do all that stuff. It’s all computer-generated. I used to play basketball, and nobody does that. The real thing to understand is how they win. Michael averages about 29,000 points a game. But during the last three championships, he did not take the winning shots. Partnerships are the most important elements of an organization. As managers, you have to help cultivate partnerships. I mean real partners. People I shake hands with. People who I see when I walk down the hall, and to whom I can say, "I’m in a ditch. Can you help me out?" You have to create a well-developed collective mind. You really have to have a lot of participation to get good sense-making and decision-making. Amazingly, visionary leaders have lots of meetings. But you don’t have meetings so you can tell people what the answer is. The agenda for meetings is set by people who are attending. You don’t have to have a well-established agenda in order to have a successful meeting. I don’t know how many of you are married, but if you are married I want you to tell me if the good way to have a conversation with your spouse is to have an agenda. You need to have lots of meetings, though. Lots of ways to talk. The order that comes about in these meetings does not come because you’re smart, it comes about because the system is self-organized. Isn’t that amazing? Nobody is depending on you to bring order to the world. They can do that on their own if you let them talk together.
One thing you’d better not do if you’re the conductor of a symphony orchestra is tell the players that you can play their instruments better than they can. They will be glad to let you know that you can’t. If you really watch a symphony orchestra, within every section they are working together to create a sectional sound. Then, the sections marry each other to create a larger sectional sound. The director of the chorus I sing for always says, "Start by singing with the person next to you. Then, three people together." We have a chorus of 135 people. But what he wants is a sectional sound, and then for the choir to sing in unison, even when every one is not singing the same pitch. You have to do that. You start two at a time. Be self-organizing. Be in charge of creating the symphony sound. If you allow interactions and dialogue between group members, you get coherent behavior. Rich patterns of interaction create more coherent behavior. As a manager, you have to help people find ways to achieve rich patterns of behavior.
Let’s talk a little bit about this living with uncertainty. Here is the bad news. You cannot be in command. You cannot be in control. You cannot predict the future. You cannot plan for success. We in health care know this but we ignore it all the time. I have speakers come into my class, and I remember one year they all came in and said, "The big thing is we are going to have national health care reform, and we now need to prepare for it." Then it was, "We are going to have integrated delivery systems." The next thing you know people are developing heart specialty hospitals. You can’t predict the future. You can’t plan for success. So, what do you have to do? You have to give up planning and control. I didn’t say give up thinking about the future. Give up planning and control. Move to the edge of chaos. Don’t be afraid of it. Push your organization to more ambiguous worlds. Let them know you have confidence. Create brand new organizations with brand new forms. Develop self-referent organizations. A self-referent organization is an organization that determines how well it is doing by how good it feels about itself. Not by whether they sold more stuff than Sears, or whether they built a building. Enhance the quality of connections. Do everything in your power in your organization that connects people better.
One of the hardest lessons I have learned is that I don’t care whether the people who work for me are doing their job or not. What I care about is whether they are helping me do my job. The only way people can help you do your job is if they know what your job is. I spend all my time now teaching the people who work for me what I’m doing. You know what they do? They go out and find ways to help me. And they make me look really good. Teach people what other people are doing so they can help each other do it better. Create learning organizations. Have that as a principle. We are not about what we know, we are about what we learn. We know the world is going to be different, so we are going to be really good at solving tomorrow’s problems. Think about organizational design as an ongoing process. Just go into work tomorrow and tell people, "We are never going to get it right, because there is no right." We just need to keep working to get things done.
Here is the next one. My mother was a business professor, and she told me this one. "Don’t be responsible for setting goals for workers and/or for organizations." You don’t know why people are coming to work. They may be coming to work to get away from their kids. They may be coming to work to be next to the person they are sleeping with. You don’t know why they are coming to work, so stop pretending you can tell them why they ought to be there. That’s pretty rough. It flies in the face of all the stuff you’ve been taught by me. That’s why I feel guilty about it. That’s why I’m here. I taught some of you some bad stuff. I taught you to go out and set goals for your workers so they know what to do. People know what to do. They do all kinds of things without any help from you.
Decrease the emphasis on competition and increase the emphasis on cooperation. I know it’s really tempting to have a parking space for the employee of the week, but there’s nothing dumber. Because once you get it one week, you can be sure you’re not going to get it next week. So, you only have to work one week a year. Why compete? Cooperate. You want a good parking space? Come to work early.
Provide for the emergence of visions and values. I didn’t say give people visions and values, but allow a vision of who we are and what we want to do to grow from the organization.
And last, here’s a brilliant notion from Peter Vail. Peter Vail has developed a notion of "working smart" in a way that I think is really important. Work collectively smarter. Stay in touch with the people around you. Work reflectively smarter. Keep reconsidering what the world is presenting you. Examine the grounds on which an idea rests. Examine the assumptions that must be true. Work spiritually smarter. Pay attention to your own spiritual qualities. Pay attention to your own spiritual qualities, your own feelings, insights, and yearnings. Reach deep within yourself for what is unquestionable authentic. It’s hard to do, but this is the kind of "work smart" that goes beyond "type faster!"
Now, I am going to say a little about change in health care organizations. Health care organizations are stubborn. There are lots of reasons why these organizations dig in their heels and resist change. One of the things is that they are complicated by special problems of expertise and values. A health care organization is faced with a paradox. It needs to learn and change. At the same time it needs to stay the same, because health care organizations hold within them a set of values that do not belong to the organization, nor to the individual health care provider, but belong to the larger society. Society expects those values to stay in place. Columbia discovered that. People from Columbia Medical have always been smart. But, they are a lot smarter today because they now recognize the values of the health care system. You need to learn all the technical stuff, but you have to hold on to what society believes is important in health care. When health care organizations attempt to change, they frequently fail to separate issues of expertise from issues of values. Sometimes they change and give up values that society holds dear, and sometimes they refuse to change when things could be done better. What you end up with here is that you can’t get at the cause and effect relationships just by being technically smart. What you need is a set of professional values that allow for professional judgement to resolve some of the uncertainty. This means we have to get the professional values people involved in sense-making early. We cannot say, "Let the doctors doctor while we manage." What has to be managed is what doctors believe. I’m not saying they’re right, but what they believe isn’t a personal belief system. It’s a belief system held by lots of people. That’s how you get any willing provider laws. You get any willing provider laws because people believe doctors should be allowed to practice their medicine on them. When you deny that they get mad. What you end up with then are patterns of stuff going on, and one of the interesting things about health care is that the patterns you observe don’t belong to your organization. They belong to your profession on a whole. This puts you as a manager in a much weaker position than you might think in other organizations. It’s what the whole community thinks. I don’t want you to think I’m crazy. Small area variations in hysterectomies are evidence of this. You see those patterns existing in geographical areas, not in single organizations or practices. It turns out that the choice about whether or not to give someone a hysterectomy is not just a technical choice. If it was, life would be easier. The patterns we have come about when professionals talk with one another across organizations. You, as managers, must promote that kind of conversation. You need to look at small causes. Little stuff makes a big difference in these kinds of organizations. Stop looking for big stuff all the time. You teach an alcoholic to stay sober one day at a time. Small wins are the way to better health. They are the way to better organizations. Interactions are very important. Interactions among professionals are key to understanding what is going on in health care organizations. You have to figure out ways to get doctors, nurses, and pharmacists, and all those people working with you to serve the clients talking to each other.
Now, you know you need change in health care organizations. There are three things you need to know here. Society is mad at all of you. If you try to dismantle social welfare organizations, you see that society is mad at social welfare programs. Society loves prisons and hates universities. They are gradually dismantling universities and gradually building more prisons. Sometimes there is a specific set of organizations and a key set of values. Run a hospital as a business. If you’ve ever run either one, you know you can’t do that. I do a lot of training of hospital people, and I tell them the thing they have to learn first is the hospital is the building in town where more people go in alive and come out dead. When you get that, there is nothing I can teach you about running a hospital. Deny people the right to choose a physician. I’m a pretty smart guy, I know a lot of physicians, I have tremendous respect for them, but I have no idea how to choose one. I don’t want anyone to deny my right to choose one, though. The gay community has taught us a lot about the use of drugs. They say, "You mean to tell me that I can’t use this drug because you haven’t approved it?" Sometimes, of course, specific types of health care organizations lose legitimacy for no longer being included in the network. Insurance companies no longer include you, you lose legitimacy.
The basic understanding to gain from complexity theory is that the world is unknowable. That’s why the title of this talk was so paradoxical. "Managing and Living with Organizational Uncertainty." Managing and living with uncertainty is the ability to acknowledge that’s the way it is and you’re not going to change it. And then, saying, "What am I going to do now?" One thing you’re going to do is to stop trying to predict and plan what goes on. You are going to talk about managing values and visions, and not be centered on rational expectations and expert belief systems. You are going to manage connections and pay a lot of attention to them. You are going to manage your professionals.
You’ve got some threats and opportunities from these sets of insights. The threats come from when you try to control the world, because you will fail. The opportunity comes from sharing responsibility with those around you, for creating a world that extends beyond the boundaries of your local organization, for creating a world that is exciting, emerging, growing, developing, and a whole lot of fun.
Thank you very much.