I have argued healthcare organizations need to organize around their clinical microsystems if they are to be both resilient and successful. Certainly, the pandemic is testing this notion and seems likely to separate the rigid from the resilient. Steve Denning is a management consultant who argues for a similar approach that he calls “agile management.” In a recent article he listed three principles underlying this philosophy. First, the goal is improving value to customers/users with profits depending on successful execution. Second, work is organized in small, self-organizing teams operating on a short cycle. Third, the firm is organized horizontally with distributed competence rather than vertically.
“…the top-down bureaucracy used to be a better fit with the human world of the 20th century than any previous synthesis. It led to vast material benefits [for] the human race in the 20th century even though those benefits were unevenly shared.
But as the century wore on…organizations that had been successful with economies of scope and scale encountered increasing difficulty in adjusting to these changes…Firms tightened management control. They downsized. The reorganized. They de-layered. They empowered their staff. They re-engineered processes. They expanded sales and marketing campaigns…These fixes sometimes led to short-term gains, but they didn’t solve the underlying problem.”
Quoting Roger Martin, Denning notes:
“The complexity aspect of a complex adaptive system means that the system in question is largely inscrutable, with causal relationships among elements in the system that are ambiguous and non-linear. Even more challenging, those relationships aren’t stable. The actors in the system are continuously driving adaptation of the system. By the time we decide what to do, it is quite possible, if not likely, that the system has changed in ways that renders our decision obsolete by the time it is acted upon…Because of that adaptability, our design principle must be to balance the desire for perfection with the drive for improvement.”
That sounds like the perfect description of a hospital to me; it is even worse if you are talking multiple hospitals. With all of the pressures, including the pandemic, you might wonder why health care systems have remained wedded to hierarchical, vertical organizational structures characteristic of the 1950’s?
It is this question where Denning presents what I find the most novel insight. He used as his parallel the notion of scientific revolutions as articulated by Steven Kuhn in 1962.
“In thinking about the basis and process for deciding between different paradigms…there really wasn’t any objective basis for choosing between two competing scientific theories. There was usually no way to conduct a simple experiment to show that one theory was right and the other was wrong, at which point scientists would drop the old theory and espouse the new. Instead there was generally evidence both for supporting and questioning competing theories. Scientists had to weigh up different kinds of evidence and then decide to put their careers behind one theory or the other. This didn’t happen overnight.”
Kuhn pointed out the change for most individuals was more like a conversion than a choice between competing options, since they involve different world views. I wonder if the pandemic will be a Paul on the road to Damascus conversion event for hospital management and their clinicians?
History suggests some, like Paul, will become mute for a while. Others will try frantically to restore the established order and some will become fanatics for the new way of thinking. Depending upon where the individual was in January 2020 the options may vary. Personally, I favor a pragmatic, hybrid thought process. We need both centralized planning and flexible forward execution to deliver health care successfully. Consider the Army. It must plan to have everything from bullets to toothpaste available with a way of getting those supplies to the front, but the details are determined by the fluid nature of combat, which cannot be predicted in advance. If you prefer a scientific example, consider the immune system, which consists of relatively few moving parts which can flexibly respond to previously unknown threats. The “central planning” determines the capacity, but the actual response is distributed. In a hospital, the planning involves building and maintaining infrastructure and making decisions about what sorts of capacity can/should be provided, while building a highly flexible decision-making process capable of responding to unforeseen contingencies.
This should be the “lesson” of the pandemic. No one saw it coming except in general terms. Our failure to plan and prepare for an inevitable event has made it even more difficult to adapt flexibly to deal with the facts as they present themselves daily to hospitals and their clinicians. I don’t mean to suggest it is possible to plan for every eventuality, but there are certain things, like PPE, that could have been foreseen and planned for.
I am reminded of a story by a preacher who realized at the last minute he had not filled his gas tank before a planned trip. When he got to the gas station, he found a line. The attendant commented: “It seems like everyone waits until the last minute to get ready for a trip they know they are going to take.” The preacher responded: “Don’t worry. It’s the same in my business.”
18 August 2020
 Denning S. Deepening Understanding of Good Agile: General Issues. 16 August 2020. Accessed 17 August 2020 at https://www.forbes.com/sites/stevedenning/2020/08/16/deepening-understanding-good-agile-general-issues/#5c745338771b.
 Kuhn S. The Structure of Scientific Revolutions. (University of Chicago Press, 1962.)
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