On Resilience

    Do you tend to see events as a photograph or a movie? Let me try to explain the question by considering the recent vote by the citizens of Great Britain to leave the European Union. Is this a one time event that can be understood by sifting the tea leaves, the statements of politicians and citizens both for and against the proposition, or is that part of some longer term trend? I don’t know the answer to the question, and don’t mean to suggest that either perspective is correct, but merely to illustrate the difference between a perspective that views things as events or processes.
    So what does this have to do with clinical leadership and medical organizations? I suggest that being able to focus on processes, and by doing so deal with the need for organizational resilience, is the key to long-term effectiveness. I have written previously about some of the items needed to build a resilient medical organization, including an awareness of financial, clinical, and human boundaries of failure and designing processes to keep the organization away from all three boundaries by constant adjustments. Given that “stuff happens” that is inherently unpredictable, what we need are flexible processes embedded in flexible structures that can be adjusted to produce reasonably stable desirable outcomes. In other words, we need systems and processes that possess inherent resilience—the ability to cope and adjust to the vicissitudes of life and fortune.
    I have recently become aware of the ideas of Andrew Zolli, who had addressed this issue in some depth. In a 2012 op-ed piece in The New York Times, he wrote:

“For decades, people who concern themselves with the world’s wicked problems…have marched together under the banner of “sustainability”: the
idea that with the right mix of incentives, technology substitutions and social
change, humanity might finally achieve a lasting equilibrium with our planet, and with one another…Among a growing number of scientists, social innovators, community leaders, nongovernmental organizations, philanthropies, governments and corporations, a new dialogue is emerging around a new idea, resilience: how to help vulnerable people, organizations and systems persist, perhaps even thrive, amid unforeseeable disruptions. Where sustainability aims to put the world back into balance, resilience looks for ways to manage in an imbalanced world…The resilience frame speaks not just to how buildings weather storms but to how people weather them, too. Here, psychologists, sociologists and neuroscientists are uncovering a wide array of factors that make you more or less resilient than the person next to you: the reach of your social networks, the quality of your close relationships, your access to resources, your genes and health, your beliefs and habits of mind.”

As he examines this notion in various contexts, he concludes by saying:

“Unfortunately, the sustainability movement’s politics, not to mention its marketing, have led to a popular misunderstanding: that a perfect, stasis under-glass equilibrium is achievable. But the world doesn’t work that way: it exists in a constant disequilibrium — trying, failing, adapting, learning and evolving in endless cycles. Indeed, it’s the failures, when properly understood, that create the context for learning and growth. That’s why some of the most resilient places are, paradoxically, also the places that regularly experience modest disruptions: they carry the shared memory that things can go wrong.
Resilience takes this as a given and is commensurately humble. It doesn’t propose a single, fixed future. It assumes we don’t know exactly how things will unfold, that we’ll be surprised, that we’ll make mistakes along the way. It’s also open to learning from the extraordinary and widespread resilience of the natural world, including its human inhabitants, something that…many proponents of sustainability have ignored.”

    All of this reflection was triggered by the fact that the trustees of our local health care system are trying to educate themselves about what is needed for the future. I have not talked with them and do not know where they are, but I am sure some started with the question of where does this put us in the future state if we make changes? Or, conversely, where does this put us in the future state if we don’t make changes? Having failed at this conversation at least four times in the past twenty years, usually because others wanted to concentrate on these two questions, I want to suggest a different way to frame thinking about what to do, as summarized by Krista Tippett.

    “I’m glad for the language of resilience that has entered the twenty-first-century lexicon, from urban planning to mental health. Resilience is a successor to mere progress, a companion to sustainability. It acknowledges from the outset that things will go wrong. All of our solutions will eventually outlive their usefulness. We will make messes, and disruption we do not cause or predict will land on us. This is the drama of being alive. To nurture a resiient human being, or a resilient city, is to build in an expectation of adversity, a capacity for inevitable vulnerability. As a word and as a strategy, resilience honors the unromantic reality of who we are and how we are, and so becomes a refreshingly practical compass for the systems and societies we can craft. It’s a shift from wish-based optimism to reality-based hope.”

    Personally, I am convinced the solutions we crafted to accommodate the biomedical revolution of the post World War II era have reached the end of useful life, and we need new solutions. We need new processes for making decisions to deal with the fruits, both good and poisoned, of our previous successes, as well as to address the short-comings of our current approaches.
I am reminded of a story I heard about a conversation President Kennedy had with President Eisenhower shortly after the failure of the Bay of Pigs invasion. Rather than talk about the outcome, Eisenhower only asked one question—how did you make the decision? In other words, what processes did you use to arrive at a decision. Kennedy decided he had been a victim of “group think” and set out to devise a new method. When the Cuban Missile Crisis developed the next year, he had a process in place that forced the advisers to confront all of the options in detail, so when he made his decision to risk nuclear holocaust, he was confident he had the best advice possible.
    I do not think our decisions are of that cosmic scale and risk, but they do matter in the lives of ourselves, our employees, our patients, and our communities. I hope we spend as much time focusing on how we make decisions as we do on how much it will cost or save. That also means we need to spend time developing a process for making decisions about how to proceed as we do on the outcomes. Relying on hired guns won’t really work—we need an organic solution that deals with the practical realities of who we are, how we are, and how we got to where we are—our shared history.

26 June 2016

Further Reading

Clinical Microsystems
Clinical microsystems are composed of front-line clinicians engaged in direct patient care.  Despite a lack of formal authority, they are the key to successful healthcare reform.

Leadership Lessons From the Military
Lessons from leading the military in Afghanistan have implications for which medical organizations will thrive in the current turmoil.

Measuring Teamwork
Measuring Teamwork is difficult, but important if healthcare systems are to invest in their development.  This article reviews the literature and provides suggestions for action now.

Organizing for Success - Lessons from Keystone
 The Keystone Cooperative ICU Project obtained major improvements in safety. The "soft science" lessons need to be applied more widely.

Putting Patients At The Center Of Healthcare
 Putting patients at the center is crucial for healthcare organizations, but how can it be done?

The Center Effect
Some dialysis units have consistently better performance than others, even after adjusting for individual patient variables, which is termed the center effect.  This has important implications for hospitals and health care organizations as they respond to public reporting of data.