Insights from complexity science for health care leaders

Brenda Zimmerman, Curt Lindberg and Paul Plsek (VHA, 1998)

As a manager in the healthcare sector, I have long harbored intuitions about the difficulties of universally implementing “command-and-control” leadership, but I had neither the language for, nor systematic principles underlying, the alternative strategies that I had been applying all along. Seeing similar patterns in systems as diverse as termite colonies, stock markets and hospitals was eye opening. For that reason alone, reading Edgeware was worthwhile.

The goal of the authors to create a clear and useful introductory guide for healthcare professionals is largely achieved: the book is both instructive (if sometimes pedantic) and enthusiastic. It is a resource and a crusader’s manual. They begin by inviting the reader to navigate the book from “multiple points of entry”, for which the text is metaphorically organized along the lines of Internet hyperlinks, complete with cute graphical icons placed at various points in the margins. These images represent the book’s major chapters: Principles (a compass), Tales (pages of writing), Aides (helping hands) and a Bibliography (books). The overall presentation is vaguely reminiscent of the Cub Scout handbook. I skeptically tested the robustness of this “pick a page at random” idea, but ultimately I found the conservative approach somewhat more reassuring as a way of probing the (self-proclaimed) unsettling and challenging concepts presented.

Following a Welcome chapter describing what Edgeware is, how it is organized and how to use it is an excellent complexity science Primer. Briefly discussed are the two primary reasons that healthcare professionals should be curious about the topic: (1) frustration with traditional methods of managing change, which often produce little or no lasting effects; and (2) the resonance of complexity science with what many of us already do, articulating our intuitive knowledge through theory and mod-els. Complex adaptive systems are then generally described, and the related concepts of sustainability, diversity, distributed control, selforganization, emergence, coevolution, nonlinearity, innovation and attractors are introduced. Their relevance to organizational management is established, but specific references to the healthcare field are lacking.

Nine principles derived from the study of complex adaptive systems are outlined by the authors, and contrasted with traditional, physics- b a s e d principles of leadership and organizational management. At first (and, perhaps, second or third) glance, many of these seem obvious (multiple actions, paradox, clockware/swarmware, competition/cooperation, etc.) Indeed, the ensuing tales, while incorporating many of these principles, are largely anecdotal and lack much of the specific data that one expects from case studies. They recount scenarios probably familiar to most healthcare professionals, and although they validate the “theory”, they provided few new insights for this reader in terms of practical applications.

Similarly, only a fraction of the concepts in the section on Aides were new to me, and the distinction between these “living, coevolving assistants)” and the “principles” described earlier seemed somewhat arbitrary. Ralph Stacey’s two-dimensional agreement and certainty matrix, for example, offers fewer analytical levers than does the leadership decision-making paradigm created by Victor Vroom (Professor at the Yale School of Management). I found Gareth Morgan’s generic metaphors entertaining but not particularly helpful, and I’m certain that my colleagues would find the chapter’s learning exercises to be simplistic and of little practical value. They would likely be impatient, as I was, to find greater depth and meaning for their investment of time and energy. I did feel that the book’s bibliography, with its recommendations (including relevant Web sites) and synopses of suggested readings was very good, as was the final glossary of complexity science terms.

In general, the analogies drawn here between natural and social sciences are illuminating, and the concepts, frameworks and models of the former are translated reasonably well to the latter. The book is weak, however, in its superficial treatment of theory and its specific applications. The authors admit that the terms “complexity science” and “chaos theory” are inherently paradoxical (maybe oxymoronic). Traditional scientific inquiry implies a diligent, objective process of empirical study, hypothesis and verification, precisely the kind of linear thinking to which the ideas behind Edgeware are antithetical. In this context, I wonder whether complexity science can contribute more to leadership, planning and managing change in organizations than a loose collection of terms and parallel truths that name what has already evolved from managerial necessity. I have a gnawing suspicion that this entire approach to organizational management may go the way of TQM and reengineering, initially valid and useful but applied improperly and eventually corrupted. To sus-tain and reinforce the utility of the insights presented in this book, a scholarly, rigorous and coherent toolkit is needed, along with a clear set of instructions that go beyond clever graphics and convenient metaphors. As a companion to this toolkit, a more dispassionate, deeper set of case studies would make a much stronger argument for healthcare managers who wish to step closer to the edge of chaos.

The authors of Edgeware have begun to knit together a conceptual fabric to cover many of the more problematic issues confronting healthcare professionals and other managers of complex organizations. Thus far the cloth is thin and loosely woven, but there is reason to believe that a more substantial garment can be crafted. I hope that we can look forward to an in-depth sequel designed with the same care and enthusiasm that the authors devoted to guiding us along the first few steps in the right direction.