The explosive growth in the homecare industry helped this particular company go from $0 to $10 million in revenue between 1989 and 1991. From ’91 to ’92, however, revenue plateaued and the company lost a major hospital account. When I came on, I needed to learn what was happening in the company and reestablish the growth pattern set in the previous years.

Challenging Mental Models

As a starting point, I began to explore the different viewpoints held by the company’s key players. Corporate management and the board of directors had opposing visions and ideas that required reconciliation in order to make progress. The board of directors saw only one problem — an inability to sell new hospital contracts. Consequently, they believed that if the company could solve the problem of selling, everything else would “work itself out.”

Management, however, saw the problem in terms of fundamental weaknesses in the company’s underlying operation and infrastructure. They believed that these weaknesses, such as internal capacity constraints, were being masked by flat volume and would become much more evident once the company began to grow again. Ironically, the growth that the board prayed for every day was management’s biggest nightmare.

To prepare the board and management for the systems work, I needed to convey several ideas. First, that the nature of progress isn’t necessarily linear but discontinuous, and, as with learning, you can hit plateaus or take giant steps. Many organizations do not grasp this concept of learning and instead follow a behavior pattern that assumes a linear, constant developmental path. I also needed to convey that there can be multiple “right” paths for strategy, and different combinations of strategies and tactics can conceivably get you to your goal. Finally, to set the framework, I had to illustrate that individual strategies can reinforce each other, cancel each other, or balance each other. Therefore, the strategies need to be viewed as interdependent, and the analysis must take into account how any two or more strategies interact.

Service Volume

By increasing service volume, service demand will also rise. If demand grows and capacity doesn’t, service quality will drop, resulting in a smaller client base (B2). In order to keep customer satisfaction and sales high, service capacity must grow at the same pace as service volume. Higher service quality will ten lead to higher customer satisfaction, which will maintain or expand service volume, revenue, and profits.

Designing the Process

We wanted to incorporate a strategic planning process with certain primary specifications. First, the process needed to help us gain a basic systems-level understanding of how our clients are generated and how they interact with us. It also needed to enable us to explicitly play through alternative scenarios, while letting us treat strategies as dynamic and interdependent, thus allowing us to model the strategies in various ways over time.

Keeping with this criteria, we felt that an approach using systems principles and computer simulation using ithink software would work best. We chose this strategy because it would require a strong understanding of basic business dynamics and would allow little room for ambiguity. It also allowed for explicit definition and debate of underlying assumptions. We wanted to go through a process that included early dialogue to lay out every assumption we were making about both the way the industry was moving and the way our company functioned. Finally, this approach allowed us to generate “real-time” learning and hypothesis-testing, which we achieved by manipulating our assumptions in real time in an interactive computer-based ithink model.

Modeling the Macro View

We started by modeling a macro view of the company and its strategy using causal-loop diagramming. This macro view included assumptions regarding how clients are generated and how the financial and operating systems of the company function. Our primary goal was to frame and illustrate the major issues in a simple one-page strategy for the company. We also wanted to high-light interdependence among the different strategics that had been proposed within the company. The team that worked on the causal loops was a subset of seven senior managers in the company who had the best embedded knowledge of the company.

The causal looping took place in a two-step process. The team knew that the board’s fundamental issue was marketing, so it started by modeling the marketing function and then looking for all of the second-stage implications that might emerge. Suppose, for example, that we are successful in marketing. Would marketing alone be sufficient to successfully move the company forward? The board’s logic was that the marketing program would generate more clients, more clients would generate more service volume, and more service volume would generate more revenue. With reasonable expense control, the result would be higher profits. The board liked that plan and wanted to keep it that way.

As we drew the causal loop diagrams, however, I posed a question — “What would happen to our service volume if we boosted marketing efforts?” (see “Service Volume”). Marketing efforts will drive more service volume. If demand grows and capacity doesn’t, service quality will drop, which will ultimately reduce our client base (B2). The key is to turn this balancing loop into a reinforcing process. If service demand grows and service capacity keeps pace, service quality will be maintained or actually increase over time. If that happens, higher service quality will lead to higher customer satisfaction, which will maintain or expand service volume, revenue, and ultimately profits (R1).

Measuring Performance Standards

A gap between performance standards and perceived performance drives investment in service capacity, which will improve quality and lead to higher customer satisfaction (R3).

This way of thinking produced new insight for the board: a marketing program is important, but building service capacity is equally critical. We needed to invest in capacity immediately to anticipate and meet service needs. The next step, therefore, was to determine what drives service capacity. Our theory was that we operate based on something we call “perceived performance,” in which we are driven by our measures of service quality against some realistic standard. The company doesn’t have well-developed standards beyond the usual measurements of cost per case, cost per visit, and other basic economic standards. Therefore, without well-defined operating standards, we had no realistic understanding of our perceived performance.

Consequently, we were brought to the question of how to drive realistic performance standards. We concluded that we needed a formal learning program under the rubric of Total Quality Management. The belief was that our perceived performance should drive a steady investment chain in process improvement, while also inciting a greater need to study business processes (see “Measuring Performance Standards”). A gap between performance standards and perceived performance would then spur further investments in service capacity, which would raise the overall service quality (R3), leading to higher customer satisfaction and an increase in service volume. With this systemic understanding, we felt comfortable endorsing the creation of a structured program in order to create knowledge that would reinforce and refine the performance standards.

We went to the board with a plan to operationalize their vision by investing in four areas: marketing, service capacity, a rigid set of performance standards, and an organizational learning approach that would drive the kind of knowledge that sets the standards. The result was that the board and our management group began to understand that there was far more than one barrier to success in the company.

The board then challenged management with an acid test: based on the systems logic, they decided to allocate some money up front to start work on building capacity. They would not approve the full program, however, unless we demonstrated that we could deliver on selling new accounts.

We found that the easy part was adding accounts. The much harder part was the other three objectives: building capacity, creating credible performance standards with that reorganization, and instituting a TQM program throughout the company. These other aspects absorbed the vast majority of our time.

For the first three to four months, my time was spent mostly on marketing and partially on systems thinking. We were able to get over the initial threshold, proving that marketing was the apparent and not the real problem. When the board saw two signed contracts within four months, they were more willing to invest in the next stage of development. The next stage of work involved building an operational model of the company, which we used to develop and test our mix and timing of strategies. The model reinforced our understanding of the need for multiple, integrated initiatives to reach our goals.

Company Learning

Through the planning process, we realized that as a company we were not nearly as good as we thought we were. This was partly because there was little history of planning in the company. Previous strategy had been developed by the board, was very top-down, and had no involvement of the operating staff. Because strategy started and ended at the level of the board and executive management, it never found its way to the operating managers who represented 95 percent of our staff and 100 percent of our revenue. It also involved little understanding of the hospital client.

Another major reason for our performance shortfall was that the board had little exposure to the operational reality of the company. The radically different perceptions held by the board and management about future prospects and risks came about because the managers were much more grounded in the reality of the company, but they had no way to communicate that reality to the board. Although the managers could easily point out the systems that weren’t working, the measurements we weren’t doing, and the level of understanding about our core business we didn’t have, that knowledge was not being transferred to the policymakers. Our systems thinking work provided a forum and a language to stimulate that communication.

Until we started asking these questions and modeling our assumptions, many people in the company did not understand certain aspects of the business — such as how a new client was acquired (see “From Causal Loops to Simulation”). For all practical purposes, our clients “materialized out of a cloud.” So what we tried to do was work back from that cloud and really educate everyone in the company about the operational realities. Through that process, we learned a great deal about our company and our client institutions. As a result of the planning process and our work with systems thinking, we have reached a better understanding of our business and a new way of communicating and testing the complex strategies necessary for future success.

Steven DeMello was president and chief operating officer of Alliance Home Care Management, Inc. I le is presently the director of healthcare practice for High Performance Systems, Inc.

Editorial support for this oracle was provided by Anne Cycle.

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In short, I’m one of the millions of Americans who are praying that Hillary comes up with something good. The rumors say she’s going to come up with — something political.

If you’ve been watching the trial balloons float by, you know that the choice is between two systems called single-payer and managed competition. In a single-payer system the government becomes the health insurer for everyone. You don’t pay premiums, you just pay taxes. You go to whatever doctor or hospital you like; the government pays the bill and negotiates with doctors, hospitals, and drug companies to keep rates reasonable. You pay only for services not covered, such as elective plastic surgery.

Canada and many European countries have had single-payer systems for years. They also have longer life expectancies than ours, lower infant mortality, and 25 percent lower costs. If our healthcare costs were like theirs, we would save $160 billion a year — $640 per capita-10 times the job stimulation package the Republican senators just insisted we couldn’t afford.

The other choice, managed competition, doesn’t yet exist anywhere in the world. The rumors say that you or your employer will join a “health allegiance,” an organized group of people who share an insurance plan — like today’s health maintenance organizations. If you are working, you pay premiums into the plan. If you are elderly or unemployed, the government pays, and you get basic coverage. You can join an alliance with more expensive doctors and hospitals and broader coverage if you can afford it. You can choose alliances, but once you’re in one, it dictates which doctors and hospitals you use and which services are covered.

The big political difference between these plans is that in managed competition, insurance companies are still in on the deal. There will be a double layer of bureaucracy, first the insurance companies, then the government regulating costs and operating Medicare.

The rumors say that Hillary and Bill are going for managed competition because managed competition will unleash the power of the market to keep costs down. Canny consumers will shop among alliances and find the one that offers the best service at the lowest price. If you believe that, you’ll believe anything.

If the market worked that way, it would have done so with our present competitive system. What the market has produced, and what managed competition will perpetuate, is a cruel, bloated system that caters to the rich, neglects the poor, and accumulates layers of administrators whose outrageous compensation comes right out of our pockets.

The highest-paid executive in America is Thomas Frist of the Hospital Corporation of America, who earned $127 million last year. Albert A. Cardone, the CEO of New York’s Blue Cross and Blue Shield, is paid a mere $600,000, but his customers’ premiums pay for his chauffeur-driven Lincoln Town Car and the cellular phone in the boat at his vacation home in Florida.

That’s why my insurance premium rises 30 percent a year and why 37 million people can’t afford health insurance. And that’s why Hillary and Bill are going for managed competition — because these big players have millions of dollars with which to lie to us (they like to make up stories about long lines in doctors’ offices in Canada), to bribe politicians, and to kick up an unholy fuss against any change that threatens their lifestyle.

The reasons to favor managed competition are: 1) You love your insurance company; 2) you think the government might be up to enforcing some rules, but not up to actually managing anything; 3) you believe that rich people should have better health care than poor people; 4) you think health care is something you can and should shop for like cars or soap.

You should favor a single-payer system if: 1) You care more about the health of people than the wealth of insurance companies; 2) you think the government of the United States ought to be able to administer something as well as the governments of Canada or Germany; 3) you believe that health-care ought not to be distributed according to income; 4) you think healthcare, like schools, soldiers, fire trucks, and roads, is something to be publicly provided, not marketed.

Whatever you think, now’s the time to sound off. The compromising Clintons and the spineless Congress will not go against the vested health care interests unless the public kicks up an unholier fuss than the insurance companies do. Write to Hillary Rodham Clinton (Presidential Task Force on National Health, The White House, Washington, D.C. 20500), or write to your Congressional Representatives and insist on an affordable system.

Donella Meadows is a system dynamicist and an adjunct professor of environmental and policy studies at Dartmouth College. She writes a weekly column for the Plainfield, NH Valley News.

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Once a system that provided quality medicine in an equitable fee-for-service exchange, the current healthcare system in the U.S. has slowly fallen victim to its own structure. Various players are struggling with one another on an expensive battleground — and patients aren’t the only ones getting stung. Corporate America’s involvement and portion of the bill is at the forefront of discussion.

As cries for a major overhaul of the healthcare system have increased, policymakers have responded with a flood of proposals — over 30 new bills so far this year. An integrated approach to healthcare reform, however, must start with an understanding of the system as a whole.

Multiple Players

The healthcare system is made up of a complex, interconnected network of players. Without a common mission, each group pursues policies that are often at odds with the long-term interests of everyone involved. To understand how the system works (or doesn’t work) we need to see how the various players’ actions play out in the broader system.

Healthcare Providers. Healthcare professionals’ primary concern is that patients receive the best care available. This sets up the system for cost escalation by encouraging doctors and hospitals to provide more tests and procedures in the belief that more is better. Providers’ fear of malpractice suits further exacerbates the problem. In addition, practices such as unbundling (charging separate fees for each part of a treatment) and self-referrals (where doctors send patients to labs or facilities in which they have a personal investment) also contribute to escalating costs.

A surge in hospital construction over the last decade has also contributed to escalating costs, as hospitals scrambled to win healthcare dollars by adding state-of-the-art technology and facilities (see “The Medical Arms Race,” Systems Sleuth, November 1991 for description of escalation dynamics in healthcare). The result is an “Escalation” structure, where one hospital’s expansion efforts are seen by others as a threat to their attractiveness, prompting them in turn to add more services (see “Healthcare Providers: Escalation Dynamics”). The cost of expansion is then passed along to patients and insurers in the form of higher bills — thereby raising the total cost of healthcare.

Consumers. Consumers play into the escalation dynamic through their determination to receive the best treatment, regardless of price. As hospitals add more machines and services, the success rate and public awareness of those services increases (see “Consumer Demand”). Consequently, consumers’ demand for high-tech treatment increases, which gives hospitals further incentive to add more technology. The result a system where supply actually creates demand, rather than balancing it.

Currently, there are few incentives for patients to go to the most efficient, cost-effective providers. As James C. Robinson, a healthcare economist at U.C. Berkeley puts it, “Imagine if we sold auto-purchase insurance and said, ‘Go and buy whatever car you want and we’ll pay 80 percent of it.’ Most people would probably buy a Mercedes” (“Wasted Healthcare Dollars”).

Government. The government is a major player in the healthcare system through Medicare and Medicaid programs. Their goal: to provide the highest-quality health coverage to the poor and elderly at the lowest rate to taxpayers. Efforts to curb Medicare spending, however, have inadvertently increased costs throughout the system (see “Government The Medicare Fix that Failed”). By limiting Medicare coverage, the government reduced its own spending (B4), but increased the share of the cost borne by providers. Providers, in turn, passed those costs on to patients for non-Medicare services. When those to whom the costs are shifted can’t afford to pay, they are left without coverage. This puts pressure on the government to expand its Medicaid program to absorb the additional uninsured people, which increases its healthcare expenditures (R5).

Business. Like the government, businesses have also responded to rising healthcare costs by looking for money-saving opportunities. Many large businesses are cutting costs by enrolling their employees in preferred provider organizations (PPO’s) or health maintenance organizations (HMO’s), which offer low premiums. Such managed-care organizations are designed to reduce costs through methods such as decreasing hospital usage and narrowing provider choices.

But HMO’s, although they are increasing both in membership and revenues from premiums, are hurting financially because of their very attraction — low prices. Despite a 14% increase in premiums, income from HMO’s is expected to drop to $350 million this year, from $850 million in 1991 (“An Operation Fraught With Risks,” Business Week, Jan. 13, 1992). Given this trend, premiums are likely to continue rising until there will no longer be a significant cost differential.

In the meantime, the short-term savings for businesses is increasing long-term costs for everyone in the system. As HMO and PPO membership has increased, enrollment in traditional plans is decreasing (loop B7 in “Businesses: Cost-Cutting Efforts”).

To attract healthcare dollars, hospitals will bid against each other to win managed care contracts, while doctors band together to cut deals with HMO’s, and medical supply companies offer cost-saving products to hospitals. Lost revenues from discounting will put pressure on providers to shift additional costs to individuals and small businesses who are not covered by HMO’s or PPO’s. Similar to the Medicare cuts, these higher costs will force more people out, further reducing enrollment in traditional plans (R8).

Insurers. Although healthcare insurance was originally intended to protect against catastrophic illness or accidents, over time coverage has continually expanded to attract more people (see “Insurance: Expanding Coverage”). The ever-expanding coverage gives consumers more financial incentives to seek treatments. In fact, people with health insurance consume up to 60% more physician services and three times as many hospital services than those without coverage (“Business and the Future of American Healthcare,” Business Week, June 22, 1992). As usage increases, costs rise, leading to higher premiums and demand for even more coverage and choices (R9).

PPO’s and HMO’s were designed to stop escalation by providing limited options at lower costs. As discussed above, however, the rise of PPO’s and HMO’s has come at the expense of traditional insurers and creates a “Fixes that Fail” situation.

The Big Picture

The actions taken by each of the players in the healthcare system are all contributing to a “Tragedy of the Commons” scenario, where the attainment of individual goals are at odds with the long-term health of the system. The “commons” in this case is access to healthcare, and the limiting factor is financial resources. If the present situation continues, the healthcare system may collapse because of the financial burden it places on the whole economy. Currently, more than 12 cents out of every dollar is spent on healthcare, and costs are rising at double the rate of inflation. If current trends continue, in 70 years our entire GNP will be spent on healthcare (“The Brave New World of Healthcare,” Richard D. Lamm, University of Denver, 1990).

Insurance: Expanding Coverage

Ever-expanding insurance coverage gives consumers more financial incentives to seek treatments. Higher usage increases costs, leading to higher premiums and more demand for expanded coverage.

Consumer demand for high-tech treatment and government expansion of Medicare and Medicaid play into the “Tragedy of the Commons” structure by contributing to total healthcare expenditures. This raises the cost per treatment and also limits access (loops B10 and B11 in “Healthcare’s Tragedy of the Commons: One Example”). Likewise, consumer demand for high-tech treatment also affects the “Escalation” structure between competing hospitals. As hospitals invest in new equipment and services, the cost per treatment rises, again limiting access.

The shift toward HMO’s and PPO’s plays into the “Tragedy of the Commons” structure as well. As hospitals respond to discounting by shifting costs to small businesses and individuals, the number of people who cannot afford coverage increases. Those individuals must then be covered by government programs (which increases total healthcare expenditures), or simply forego coverage and pay only that portion of their healthcare bills they can afford. The cost of those unpaid bills shows up once again in higher costs per treatment, as providers raise their rates to cover delinquent accounts.

Looking for Leverage

Current proposals for reform center around three critical problems afflicting healthcare: uncontrollable, rising costs; a lack of a long-term healthcare program, and an increasing number of uninsured and under-insured. Although the plans vary widely on details such as eligibility, acute care, preventative care, long-term care, and the role of Medicare and Medicaid, they can be grouped into three broad categories: government-sponsored (single-payer), employer-based (play or pay), and private plans (market-based reform). (See “Healthcare Reform: Evaluating the Proposals” for a discussion of how these proposals affect the dynamics described above).

Perhaps the most important element of any reform is that the recipient and payer of services be more closely linked. One lesson of the “Tragedy of the Commons” archetype is that the problem cannot be addressed at the individual level. Adequate information, however, will help consumers see the “big picture” and judge the value of alternative care. No matter who pays for coverage, some link needs to be made so consumers feel the financial impact of their decisions.

From Disease Treatment to Health Building

One crucial aspect of reform that is absent from most of the current proposals is a deep change in attitudes surrounding the purpose and direction of healthcare. Most Americans believe that access to healthcare is a “right,” no matter what the cost. Not surprisingly, there seems to be more support for universal access programs than for national health insurance. Many people are afraid of non-market-based plans because of they fear a nationalized system would take away the freedom of choice and the ability to receive whatever care one can afford. But as the “Tragedy of the Commons” structure illustrates, consumers will have to learn that there are limits to everything in a finite world. One reality we all may have to face is that we can no longer expect unlimited choice and care.

How we view responsibility for an individual’s health must also change. Over time, the burden of responsibility for one’s health has shifted from the individual to the healthcare system; the implicit message has been, “live your life any way you want and we will take care of you when your body breaks down.” This gradual shift might not have been too damaging if the healthcare system were focused on helping people stay healthy. Instead, it concentrated its efforts on making treatments more effective and convenient. In a way, it is analogous to finding faster, more painless ways to repair wrecked automobiles, rather than teach people how to be safer drivers and designing better highway systems to reduce the likelihood of accidents. The result? Escalating automobile premiums, runaway costs, and a growing pool of uninsured motorists — the same problems currently facing the healthcare system.

of cure” translates into “a dollar spent on health building may be worth thousands in hospitalization and treatment costs.” The challenge is to design a system that gets away from treating symptoms—where there is the least leverage and the highest costs—and focuses instead on efforts to build health.

The healthcare system in America is not deteriorating in a vacuum. “Health care, for all its technical genius, has become an economic cancer that is eating into other necessary public functions…Our health care industry is draining resources desperately needed elsewhere to keep America a competitive nation” (“The Brave New World of Health Care”). Not only is the healthcare system destroying itself and the economic position of its players, but it is also affecting quality and efficiency in many other arenas. To be truly effective, reform must take into account not just the roles of the players and the structure of the system, but also how the system affects the economy health of the country as a whole.

References: ‘The Brave New World of Health Care.” Richard D. Gamin, University of Denver, May 1990; “Healthcare Reform: A Closer Look.” Management Accounting, Dec. 1991; “Healthcare Reform Stews in Congressional Pressure Cooker.” Healthcare Financial Management, Jan. 1992; “Wasted Healthcare Dollars.” Consumer Reports, July 1992; “Business and the Future of American Healthcare.” Business Week, June 22, 1992. For other re-sources, call our offices at (617) 576-1231.

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The decision-making styles that evolve in the fast-paced setting in which potentially life-threatening clinical outcomes are at stake have significant value. They let team members assess large amounts of data in a rigorous manner while acting quickly. But when transferred to other settings, such as hospital boards and committees, this particular approach to conversation and decision-making can be problematic.

Given their backgrounds, healthcare professionals generally expect that their roles in meetings of teams, boards, or committees will involve advocating for their constituencies and mandating solutions to problems. While more directive approaches play an important role when decisions must be made or actions taken, in other contexts, they can undermine team learning. In addressing issues of organizational strategy, long-term planning, and creative problem solving, generative dialogue has proven more effective than one-way communication. Failure to shift to dialogue-based forms of communication will ultimately have a negative impact on an organization’s ability to rapidly adapt to changing market trends and to truly explore the questions involved in reducing medical errors and improving outcomes.

One Organization’s Challenges

In addressing issues of organizational strategy, long-term planning, and creative problem solving, generative dialogue has proven more effective than one-way communication.

The governing board of one healthcare organization was typical of many in the industry. Physicians attended meetings with the expectation of advocating for their constituencies. Managers learned to fear these meetings, as interactions often focused on criticism of the existing situation or proposed solution. The group rarely explored the challenges through healthy dialogue.

To help determine the board’s future role, board members and other stakeholders participated in a retreat. The following perceptions surfaced:

• Physicians and managers believed that there was value in meeting together regularly.
• Both groups felt that the organization needed to address certain strategic themes.
• Managers understood that they needed to collaborate with physicians to elicit the full range of possible approaches to these issues.
• Physicians wanted to help create ways to approach these themes, but wondered if they would have the power and control to make policies and decisions.
• Both groups had difficulty seeing beyond the current board structure, envisioning that the same struggles and limitations would continue to arise.
• Others in the organization were passionate about participating in the process, although they had not previously been invited to do so.

The Compass Group

The consensus from the retreat was that merely tweaking the existing board structure would be inadequate; nothing short of a complete destruction of the structure, norms, and paradigms would provide the organization with the freedom to explore new paths to achieve its stated goals. With this understanding in mind, the board dissolved its existing structure in favor of a dialogue-based forum that was organized around the stated organizational imperatives of customer service, employee satisfaction, strong physician relationships, and financial stewardship.

This forum came to be called the “Compass Group,” because the group felt that these strategic themes were analogous to the directions on a compass. The Compass Group was seen as a risky endeavor. Much of this fear was based on the uncertainty of where dialogue around these concepts might lead. The organization, however, was able to understand that any learning involves some degree of risk.

“Uncoupling” Old Norms

Cultural and conversational norms had been a major barrier to true learning within the organization. Many feared that the old ways would carry forward into the current efforts. A number of important steps were needed to ultimately “uncouple” the organization from existing ways of interacting, thus allowing for new ways to emerge and thrive.

Associating Pain with the Status Quo. A critical event during the retreat involved discussing aspects of the meetings that board members disliked. Surfacing these feelings markedly raised the group’s level of discomfort with the status quo. This discomfort created a compelling need to move the initiative forward.

Incorporating New Perspectives. The group felt strongly that the constancy of the board’s membership over the past several years had contributed to some degree of stagnation. Understanding that many others in the medical group had expressed an interest in participating, members agreed to open the group up to others who possessed fresh perspectives.

Eliciting Desired Norms and Expectations. During the retreat, board members mentioned rewarding and fulfilling experiences that they had enjoyed in other meetings and committees. Common among these experiences were being heard, contributing proactively, understanding one another, practicing mutual respect, and building upon collective contributions to generate creative approaches. By listing these desired norms and expectations, the group was eventually able to develop momentum for change.

Generating “Buzz.” Through reports from the retreat, others in the organization became aware that the Compass Group was no ordinary board or committee. The communications were lively, genuine, and informal; they carried with them a feeling of realism, openness, and innovation that was not typical of standard emails and memoranda. This “buzz” was instrumental in generating interest among others who might not have been comfortable in the traditional board setting, and in creating expectations that helped to overturn the norms of the past.

Setting the Stage for Dialogue

Because of the risk inherent in any team process, a great deal of planning went into the initial dialogue session. The goal was for people to relax, engage in collaborative dialogue, and explore creative possibilities for action. The Compass Group followed some of the principles used in developing a World Café (see “Framing Questions and Guidelines”).

Establish a Clear Purpose. Unless the group had a clearly defined purpose and objectives, along with concrete outcomes, participants wouldn’t perceive significant value. For the first of the Compass Group sessions, the management team chose to focus on the strategic theme of customer service. With this theme in mind, participants addressed a series of questions that ultimately led to greater insight and collective shared knowledge on the topic (see “First Compass Group Session” on p. 9).

Invite Great Guests. The management team decided to invite all interested physicians, nurse practitioners, and physician assistants. In doing so, they conveyed the sense that the Compass Group was “no ordinary board meeting”; this innovative forum would truly make a difference.

Plan for a Safe and Welcoming Environment. In planning the session, organizers paid close attention to creating a physical space that would be perceived as inviting, hospitable, and intimate. The goal was for participants to feel a high degree of psychological safety. The creation of a welcoming environment began with the invitations themselves. Rather than relying on email, organizers selected stationary and fonts with earth tones to convey the message that this experience would be different.

Form Powerful Questions. Well-structured, open-ended questions hold tremendous value. These questions are the most important determinant of a successful dialogue session. Because the theme of the first Compass Group session centered on customer service, questions related to service and to recent internal efforts in measuring service perceptions were developed in a logical progression of discovery.

Facilitate for Success. The facilitator’s role was (1) to model the process for internal facilitators in the future, (2) to provide a structure for the evening by facilitating between rounds of dialogue, and (3) to provide some training around the skills involved in dialogue, with a heavy emphasis on inquiry. Members of the management team had already received some training in hosting a dialogue session and in facilitating smaller conversations, mainly by encouraging a balance of inquiry and advocacy. To leverage these skills, one management team member served as a facilitator at each table. The other members at each table were carefully distributed to ensure sufficient diversity of conversations.

The session opened with a time for attendees to arrive, get oriented, and enjoy food and beverages while conversing with colleagues. Participants wrote the answer to the question, “What is the location of your most memorable service experience?” on their name tags. They were encouraged to use this memory as a starting point for conversation with others.

The session began with an overview of the evening and a brief session on dialogue. Each round of dialogue was structured around a series of questions. In this particular case, a review of the organization’s patient satisfaction data and video reenactments of actual patient experiences were used as the starting point for forming questions. During the rounds of dialogue, the facilitators at each table helped to encourage effective inquiry and to surface hidden or underlying assumptions. In addition, they recorded the predominant themes that emerged.

Between each round, the tables shared their discoveries and insights with the larger group. In addition, they commented on their success with using dialogue skills. As one of the goals of the Compass Group was to provide an opportunity to share best practices, the group used a separate flip chart to capture these ideas. In addition, items that warranted action, follow-up, or future dialogue were documented on another flip chart.

After the Session

The feedback from post-session surveys was overwhelmingly positive. Participants reported that they had achieved a high level of shared understanding and accomplished a great deal. They also felt passionate about continuing the conversations.

The themes and best practices that emerged from the table dialogues were distributed to all members of the organization, along with a clear plan for future dialogue sessions on the other strategic directions defined by the compass. In addition, efforts to continue the discussion around service were implemented by providing weekly questions for each manager, physician, and department to use with their staff.

As in other industries, healthcare organizations tend to depend heavily on one-way communication, debate, and criticism. Unfortunately, these dynamics present a barrier to learning and to developing organizations that are able to innovate and adapt effectively to tumultuous market conditions, a necessity in today’s marketplace. Dialogue, specifically the skills of understanding mental models and balancing advocacy with inquiry, is essential for building organizations that learn effectively. By challenging the assumption that committees and boards must always be structured in the traditional manner, organizations may be more likely to explore formats that are more conducive to dialogue. Shifting to dialogue-based forums focused on strategic imperatives can be one approach that fosters learning in all kinds of organizations.

Manoj Pawar, MD, MMM, is a managing partner with Nivek Consulting and is the chief medical officer for the Exempla Physician Network. He is committed to developing high-performing teams and organizations in healthcare. He can be reached at pawarm@exempla.org.

Special thanks to Gene Beyt, MD, Richard Hays, DBA, Charles Jacobson, MD, and Bob Myrtle, DBA, for their wisdom, and for their gracious and insightful contributions in the development of this article.

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As founder and CEO Carol McCarthy tells it, “For the first 12 years, we worked very successfully with healthcare clients to grow their businesses. Both agency staff and client retention was high, and we made a record profit. But when the leadership team met to plan the next 12 months, we could think of few projects that had truly excited us the previous year. I thought, this is depressing – especially because, as the leader of the organization, I felt the same way. That was the defining moment when we said, ‘We’ve got to do something differently.’”

Financially, there was little incentive to change. For the previous 10 years, everyone in the company had received significant year-end bonuses. Creatively, however, the leadership team wanted to feel energized, to use their best ideas and engage with the best clients — and to have a greater impact on public health.

The leader’s role is to tap into the collective wisdom of the organization and provide the boundaries within which creativity can happen.

Intrigued by this challenge, McCarthy decided to hire Carolyn Hendrickson, founder of Tandem Group Consulting, to help the agency become a learning organization.

McCarthy wanted learning to become a constant part of what people were expected to do in their work every day. Despite her initial apprehension about the costs involved, she believed that, if her staff could habitually share ideas and learnings, they could maximize their creativity, increase profitability, and attract clients more aligned with their work.

Key Tensions

When Hendrickson began to interview the agency’s staff, she discovered two key tensions typical of small companies: (1) How to apply some big company approaches without losing the benefits of a small-company culture and (2) How to grow revenues over the next 5 to 10 years without growing the size of the company.

In terms of the culture, Hendrickson was struck by the staff’s tremendous commitment to health and creating a better world. Particularly important to people was the company’s intimate culture, nurtured by its two well-loved top leaders. Because the small size allowed them to think creatively and behave nimbly, some staff even felt ambiguous about the need for a leadership team.

In terms of work processes, the agency had an incredibly fluid structure. Everybody was involved on every project. If you worked on seven client campaigns, you were on seven different client teams. This organizational design meant numerous meetings, constant communication, and enormous accountability. Although things often fell through the cracks, people were attached to that way of doing things.

Like many small companies, McCarroll Marketing had become lulled into planning on a year-to-year basis and lacked a clear understanding of the role of leadership in building a company for the longer term. Furthermore, people didn’t have a strong sense of ownership. They believed it was Carol’s company and, although they could provide input into decisions, she had the prerogative to do whatever she wanted.

Learning for What?

What Hendrickson realized was that she had to help the leadership team, and the rest of the company, shift their mental models around shared vision, leadership, and work processes. The approach she used was based on a core belief that organizations are complex adaptive systems — living, interconnected, dynamic systems in which change emerges if the right set of conditions exists. At times, an organization needs to be brought to the “edge of chaos” for new order and innovation to emerge. This approach differs greatly from traditional, mechanical ways of managing or driving change. The leader’s role is to tap into the collective wisdom of the organization and provide the boundaries within which creativity and change can happen relatively easily and naturally.

According to Hendrickson, McCarroll Marketing already had a number of these “conditions for emergence” in place: People had a great deal of discretion to decide what action to take and when to take it. They also felt comfortable saying what was on their minds, and only a few topics were “undiscussable.” Work was also delivered through a flexible structure that allowed information and people to flow across organizational boundaries. What was missing was a shared vision for the future and an understanding of how all their work fit together to deliver value to their customers.

Shared Vision. To get a sense of the larger whole, Hendrickson asked the leadership team to consider what they were learning for. This question helped the group link learning to business results and became the ongoing topic of their strategic planning meetings, as well as several company-wide, full-day offsite sessions. It soon became clear that McCarroll Marketing wanted to “learn for growth” — to establish a thriving learning culture that creates an invigorating place to work, develops extraordinary people, and fuels long-term growth.

This idea was linked to the staff’s vision to achieve a dramatic positive cultural shift in people’s attitudes and behaviors about health. In this vision, the future might look like:

• We help a life-saving technology gain global acceptance.
• Veggies become as popular as McDonald’s.
• For the first time in 50 years, childhood obesity is on the decline.
• We are a national mecca for outstanding talent.

Recognizing that the agency’s strength lay in the services it offered — advertising and communicating effectively – the leadership team came to terms with the fact that, in order to make a difference, they had to find clients, be it hospitals and health systems, medical technology manufacturers, public health initiatives, or healthy foods advocates, who had big ideas similar to theirs.

Leadership. The decision to pursue the shared vision raised the bar of expectation for the entire leadership team. If they were to achieve this ambitious goal, they needed to strengthen their ability to work together. To that end, they spent time exploring what leadership meant and how to model it. Underpinning their current thinking was the CEO’s own philosophy of leadership. As the owner of a service business, she placed high importance on sincerely attending to her employees’ needs every day. For example, when her receptionist lost significant weight on a diet, Carol gave her money to buy a new suit for the staff’s holiday party.

Senior managers are rediscovering excitement and a deeper sense of purpose.

That level of attention created an environment in which people felt personally taken care of. Yet it also made it hard for McCarthy to address difficult personnel issues, including the fact that a key leader who had been at the company for 10 years had not been performing effectively for a while. With the new initiative, she finally addressed the issue and moved her valued friend and colleague out of the organization.

Even more important, McCarthy had to address what she wanted her legacy to be. Did she see her company eventually being sold off or enduring for a long time? To pursue the shared vision, she would have to empower the organization with a sense of shared ownership and leadership. It took her a year to make the inner shift from “it’s my company” to “it’s our company.” With tremendous courage, she has begun the slow process of shifting her role from principal leader to mentor-teacher. This means continuing to loosen the reins on some critical decisions and expand the leadership team’s roles in the company.

Work Process. The question that remained was: How were they going to achieve the desired impact, increase revenues, and keep the company small? To do so, they had to find different, more effective ways to do their work and build capacity.

First, they had to address “undiscussable” organizational culture issues. For example, people believed it was industry standard to work late and felt guilty if they didn’t. They were also uncomfortable with the company’s open-door policy, in which they were expected to be responsive to others, even if they were very busy. The group addressed these challenges by simply airing them and by creating fun signs for people’s doors to indicate their level of busyness.

In terms of building capacity, Hendrickson put together a team to analyze the company’s workflow process from beginning to end, a task that had never been done before. They discovered that marketing took up 70 percent of the process, crunching the creative team’s time on the back end. They also found that 45 percent of the problems happened during that back end. So the team redesigned the flow to give more time to the creative conceptualization of the work.

The redesign had significant implications. A longer creative process meant it took longer to close the job, which affected finances. It also meant reeducating clients, who were accustomed to getting ideas in two weeks but now had to wait four. The group is still refining the process by exploring the question, How do we get back to a course of profitability and moving jobs along while still allowing enough time in the work process for the best ideas to emerge?

Rough Spots

An awkward transition followed the dramatic shift in work processes. For McCarthy, the biggest challenge lay in where to delegate decision-making. As she empowered her staff to do more creative work, take more risks, and push the clients’ boundaries, she struggled with the concept of shared leadership.

For example, one of the leadership team’s goals was to have the “ideal client roster” in five years. “Ideal” meant companies that were involved in the best technologies or public health initiatives and that approached their work with an entrepreneurial spirit. The creative staff wanted to work on campaigns that would allow the most creative risks – a significant modification of the company’s business growth formula. Almost 80 percent of the existing clients did not meet the ideal profile, and McCarthy made the gutsy decision to stop working with a few old clients and pass up some offers to work with new ones.

The company’s revenue and bottom line temporarily took a hit, a deeply unsettling situation for the CEO. But when no one got bonuses last year, and Carol asked her staff, “What do you think of the ideal client now?” they all seemed okay. They expressed strong conviction that McCarroll Marketing can take its expertise and work with the best clients to achieve its vision. Their response has made McCarthy confident that letting go of some difficult clients freed up an opportunity to focus on getting the ones that share their vision of making a positive impact on health.

Another way McCarthy struggled was in empowering the creative team with more freedom and flexibility. In one instance, she found an idea her creative staff was going to pitch to a client to be inappropriate and said as much. At that moment, she asked herself whether she was really going to follow through with her commitment to shared leadership. Reluctantly, she allowed the staff member to present the concept. When the client visibly cringed during the presentation, McCarthy thought, “This is where the learning begins. If I impose my ideas, not only will my own credibility be diminished, but, more importantly, so will my staff’s learning.” So she put the responsibility for the result on that employee’s shoulders.

High Points

What’s different and better at the company today? Their bold vision has inspired and attracted like-minded clients. The life science division of a major telecommunications company has engaged McCarroll Marketing to help them introduce a genetic chip that promises to accelerate drug discovery. The agency is also helping a company that produces a device that facilitates the treatment of brain tumors. And they’re looking at fitness and how to help people commit to exercising.

The agency is also aligned with strategic partners, locally and nationally, who will expand their pipeline of “ideal” clients. For instance, the staff decided to engage with the Brady Campaign to Prevent Gun Violence – Million Mom March partnership on a pro bono basis in support of legislation to prevent weapons from being sold on the streets. Although the bill did not pass, working on the project excited the staff and appealed to prospective clients who have since hired the agency.

Another difference is the tremendous sense of pride in the firm. Senior managers are rediscovering excitement and a deeper sense of purpose, and everyone feels they’re doing important work. The company is currently repositioning itself with a new name and identity (soon to be announced) that reflects their bold vision. Additionally, the agency has begun recruiting exceptional talent who want to be part of a progressive organization. And the staff feels they have laid the foundation to take their company from $5M to $10M in four years — with a client roster that shares their values. McCarthy believes that the organization is now in the perfect position to achieve the desired levels of profit and growth while making a difference in the world.

Kali Saposnick is publications editor at Pegasus Communications.

The post Small Company Big Impact! Powerfully Engaging Your Employees to Change the World appeared first on The Systems Thinker.

A New Threat

SARS emerged this year as a previously unknown virus that is particularly virulent—it is easily spread and can be deadly. Because it kills approximately 15 percent of those infected—the rate is even higher among the elderly—health officials around the world have taken strong steps to mitigate the epidemic and to prevent the public from panicking. In Canada, the great majority of cases were concentrated in Toronto, the country’s largest city and capital of the province of Ontario. From its first news release on March 14 to the latest daily updates on the situation, the Province of Ontario’s Ministry of Health and Long-term Care (MoH, the main governmental department responsible for dealing with the outbreak) sought to inform the public about the progress of the disease and the measures taken to deal with it. Now that the outbreak in Toronto has been suppressed, we can appreciate the impact of this information on public perceptions of and reactions to this health crisis.

A clear and rigorous way to report and interpret data about the spread of infection would help people accurately assess the level of risk.

One element of the daily updates was the summary of relevant statistics on the number of cases of the disease. In keeping with the WHO’s style of reporting on epidemics, the MoH bulletins reported cumulative numbers, in this case the total numbers of probable and suspected cases and deaths to date. Each day, the media reported this cumulative total; some later reports also mentioned cumulative recoveries (referred to as discharges).

I can attest that it was difficult to know how bad the situation was becoming from the raw information being offered. Reporters did little to interpret the data, instead publishing stories about the public’s and their own reactions to the outbreak, to the problems of living under quarantine, and to the few cases of people breaking quarantine. The use of cumulative numbers of cases, discharges, and deaths—numbers that can only increase until the epidemic has run its course—was often confusing and misunderstood. Such information gave no sense of the progress of the disease for example, whether the numbers of cases or deaths per day were increasing, staying the same, or decreasing.

The MoH did eventually include the category of “active” cases in its reports, which gave the public a sense of how many people were currently infected. But confusion was heightened by occasional instances in which the MoH reported tens or even hundreds of potential cases with no clear indication of whether these numbers fell into the active or cumulative category. For the public, this confusion led to the panicked buying of high-quality respiratory masks, cancellation of several large conventions, reduced participation in social activities like sports and cultural events, and a slump in restaurant dining and tourism, with economic side-effects that are still being felt.

A Simple Model

In such public health crises, a simple stock and flow model could clarify the situation (see “Stocks and Flows of the SARS Epidemic”). The stocks would be the “Active” cases— “Probable” and “Suspect.” Their principal inflows would be “New Cases” of each sort discovered each day. The outflows would be the number of “Deaths” (a small figure; the total number in Toronto is 24 as of this writing) and the number of people who recovered from the disease each day, reported as “Discharges.” A final flow from “Suspect” to “Probable” cases would take care of the clinical difference between the two classes.

This model would define the primary data needed to represent different aspects of the outbreak:

• Its onset and its gathering speed with the number of new cases per day.
• Its control and eventual suppression when the number of new cases stays at zero for 20 days (twice the incubation period) and the number of active cases dwindles to zero.
• The requirements for treatment resources based on the number of active cases.
• The treatment success rate as shown by the number of discharges compared to the number of deaths.

All of this information is much more difficult, if not impossible, to assess directly from the current data stream provided by the standard reporting practices. It is not clear what part these difficulties in assessment played in the WHO’s unexpected and unprecedented decision to issue a travel advisory for Toronto (since rescinded). Nevertheless, confusion about the success that public health authorities were having in controlling SARS was certainly part of the issue and continues to inspire efforts to remove the stain on the city’s reputation as a safe place to visit and conduct business.

STOCKS AND FLOWS OF THE SARS EPIDEMIC

In a public health crisis, a simple stock and flow model could clarify the situation by distinguishing between the stock variables (“Suspect” and “Probable”), which give a snapshot of the situation at any given moment, and the flow (or rate) variables, which explain the day-to-day variations in the picture. For more information about stock and flow diagrams, go to www.pegasuscom.com/stockflow.html.

The discovery of a few suspect cases of SARS in Toronto on May 22 and the extension of the voluntary quarantine to a few hundred people demonstrate another element of the dynamic structure—potential but undetected cases. This category exists because of the lack of a precise test for the disease. Without an objective measure of who does or doesn’t have SARS, healthcare workers must make judgments, for example, that an elderly patient suffering from postoperative pneumonia does not have SARS, followed by a realization several days later that this patient does indeed have the disease. Unfortunately, this kind of significant delay in the discovery of problematic cases can perpetuate the epidemic and lead to large social and economic costs.

Using a simple stock and flow model to depict the course of future epidemics could better inform the public so they could make wise individual choices about how best to respond to the health threat.

Wise Choices

This model or a slightly more elaborate version could have reduced some of the confusion surrounding the raw, cumulative data reported during the outbreak. It would have clarified the important distinction between the stock variables, which give a snapshot of the situation at any given moment, and the flow variables, which explain the day-to-day variations in the picture. The usefulness of the stock and flow model is validated by the most recent news reports on the final success of the campaign. These reports include a graphical representation of the number of active cases. The diagram shows a downward trend at a varying rate since the peak of SARS cases on April 18 to May 15, the date of this writing. Such a graphic goes far in highlighting the pattern over time of the outbreak.

Finally, the stock and flow model would identify the important variables—the flows (“New Cases,” “Discharges,” and “Deaths”)—that have to be managed in order to control the outbreak and deal with its economic and social side-effects. For example, an increase in “New Cases” that is not soon matched by an increase in “Discharges” could be a signal to increase resources for treatment (“Discharges”) and quarantine (“New Cases”). Reports of decreasing numbers of active cases should be accompanied by estimates of the probable numbers of deaths or, more positively, by estimates of the probable number of recoveries so as not to give the false impression that success in suppressing the outbreak means no more casualties.

Toronto, like Vietnam before it and more recently Singapore, has shown that SARS can be contained by vigorous efforts to identify and isolate patients (in hospital or in quarantine). Using a simple stock and flow model to depict the course of future epidemics—such as the summertime threat of West Nile virus in North America—could better inform the public so they could make wise individual choices about how best to respond to the health threat.

R. Joel Rahn is recently retired as a professor in the Department of Operations and Decision Systems at Laval University. He has been active in teaching and research in system dynamics for over a quarter century.

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As vice president of Patient Care Services, I was one of those attending the initial session. After three days of intense learning, introspection, and experience with the five disciplines of organizational learning, we understood that we needed to become a learning organization in order to thrive as a rural healthcare system. Peter Senge’s book The Fifth Discipline was perfectly aligned with this goal and the values and culture of GMHS. It would become the foundation of our work. We knew we “weren’t in Kansas anymore.” Our lives had been changed forever.

Our story is much like the plot of The Wizard of Oz, as written by L. Frank Baum and immortalized in the classic 1939 movie. Dorothy lands in the strange world of Oz after her house is carried away from Kansas by a cyclone. She seeks to find the way home by following the Yellow Brick Road. Her intent is to find the Wizard who would bestow on her the knowledge to achieve her goal, only to find that she had the answer within her all along. Here is a summary of our journey.

Dorothy

Similar to the way Dorothy felt when she stepped out of her house to find she was in Oz, our team knew we could not go back to where we had been. We were aware of our destination —to become a learning organization —but didn’t know how we would get there. At first, we felt as though we were “off to see the Wizard,” whose magic would turn us into a learning organization. To get there, we had to “follow the Yellow Brick Road.” In our case, that meant to begin down the path of knowledge and exploration to find out how to become a learning organization.One sunny summer day in July of 1994, the executive team of Gerber Memorial Health Services (GMHS) set off to attend a three-day seminar entitled “Systems Thinking,” sponsored by the Butterworth Management Institute. GMHS is a 73-bed not-for-profit hospital and health system, located in Fremont, Michigan. The organization was one of the first members of the emerging Butterworth Regional Health Network, a group of hospitals interested in sharing resources to meet the needs of west Michigan.

As vice president of Patient Care Services, I was one of those attending the initial session. After three days of intense learning, introspection, and experience with the five disciplines of organizational learning, we understood that we needed to become a learning organization in order to thrive as a rural healthcare system. Peter Senge’s book The Fifth Discipline was perfectly aligned with this goal and the values and culture of GMHS. It would become the foundation of our work. We knew we “weren’t in Kansas anymore.” Our lives had been changed forever.

Our story is much like the plot of The Wizard of Oz, as written by L. Frank Baum and immortalized in the classic 1939 movie. Dorothy lands in the strange world of Oz after her house is carried away from Kansas by a cyclone. She seeks to find the way home by following the Yellow Brick Road. Her intent is to find the Wizard who would bestow on her the knowledge to achieve her goal, only to find that she had the answer within her all along. Here is a summary of our journey.

Dorothy

Similar to the way Dorothy felt when she stepped out of her house to find she was in Oz, our team knew we could not go back to where we had been. We were aware of our destination —to become a learning organization —but didn’t know how we would get there. At first, we felt as though we were “off to see the Wizard,” whose magic would turn us into a learning organization. To get there, we had to “follow the Yellow Brick Road.” In our case, that meant to begin down the path of knowledge and exploration to find out how to become a learning organization.

Scarecrow

We did not know the challenges ahead as we started down our Yellow Brick Road. At first, the learning curve seemed monumental. We attended conferences and studied the work of Peter Senge and others to learn the theory behind organizational learning (OL). After the first year, we came to a fork in the road. We needed a person who would be dedicated to leading and teaching learning organization theory. GMHS management made the decision to hire our first organization development (OD) facilitator. We came to think of this role as being that of the “Scarecrow.” In The Wizard of Oz, the Scarecrow represented the intellect. We needed to find someone to become the “brains” of our organizational learning journey, who would lead us to our destination.

After a few months of searching, we hired our first OD facilitator. At that point, the work intensified. We held visioning sessions and created a “Dream Team” that was responsible for bringing about cultural change. We conducted surveys of the organization to establish a baseline against which to measure progress. In 1997, we conducted Health Quest 97, an event designed to learn what our community wanted from us.

Tin Man

Then we came to the next fork in the road. We had collected much knowledge of what we wanted to create and had a clear vision of where we wanted to go. Additionally, we had learned the language of organizational learning. Now it was time to begin living what we had learned. This would not be the work of the Scarecrow, but of the “Tin Man.” In The Wizard of Oz, the Tin Man longs for a heart. Our first OD facilitator left to pursue other work, and we began the search for someone who could instill what we had learned into the heart and soul of the organization.

Wicked Witch

It wasn’t long after we hired the second OD facilitator and started back down the Yellow Brick Road that the “Wicked Witch of the West” chose to interrupt our journey. In 1998, the federal government enacted the Balanced Budget Act. Provisions of the Act decreased revenues to the healthcare system as a whole. GMHS found itself with a shrinking bottom line. If we didn’t do something quickly, we ran the risk of losing all we had built. The projected loss for the year was $1.2 million.

Lion

Would we have the courage to make the hard choices we needed to make? Could we cut programs that we could not support or for which the government no longer provided reimbursements? Could we reduce expenses to stabilize the bottom line? Could we afford to continue to invest in the tools and concepts of organizational learning? And, finally, in the face of our biggest challenge, did we have the courage to stand up and battle the “Winged Monkeys” of fear and despair? It was time to find our Lion, which in the book and movie represented courage. Our Lion came in the form of the executive team. We decided that if we abandoned the organizational learning initiative, the staff would never again follow us through a cultural change. Why should they?

Using OL tools and processes, we pulled together and created a battle plan. We divided the leadership group into three teams and sent them off to create a new leadership structure. We put safety nets in place, such as generous severance packages that would allow people to safely say “I can leave.” Our president made the hard decision to trim the executive team from five vice presidents to two. Those who left remain friends of the organization. We grieved the loss of our teammates and then moved on.

We have come to realize that we will always be evolving as a learning culture, searching for new answers, and creating our future.

With only two vice presidents and the president left on the executive team, we were afraid that we would not have enough time or exposure to continue the effort. To overcome this obstacle, we formed the Strategic Council. This team of 16 people became the implementers of the strategic plan set forth by the strategic planning body, the Organizational Improvement Council. We regrouped and started back down the Yellow Brick Road. We used OL theory to create our customer service program, improve processes, and design a leadership curriculum. In addition, we put in place a balanced scorecard to measure our progress.

One year later, we were back on track with a positive bottom line. We had reached the Emerald City. Everyone was rewarded with bonuses and celebrations. But where was the Wizard, who would bestow on us the status of “learning organization”? As we reflected one morning in Strategic Council, someone said, “We are a learning organization; the answer has always been within us. Look what we have become.” At that moment, we recognized that we didn’t need an outsider to lead us to our goal; we had reached it on our own.

The Ongoing Journey

Now, six years later, the organization is profitable and healthy, with strong cultural values of trust, integrity, service, and efficiency. Our mission and vision are clear and articulated to all. Our market share has increased by 11 percent. We are adding new services with a patient-centered emphasis and creating healing environments for those we serve.

We have come to realize that we will always be evolving as a learning culture, searching for new answers, and creating our future. When others see our success, they ask, how can we become a learning organization? Our answer is to “follow the Yellow Brick Road.” Their journey will be different than ours, but one day they will know that the answer lies within the people of their organization. Then they will be a true learning organization.

Sue Nieboer, R. N., is the vice president of Clinical Operations at Gerber Memorial Health Services, Fremont, Michigan. Within her responsibilities, she serves as the corporate compliance officer and oversees the Nursing Division, Quality Management Program, and other clinical departments. She is an advocate of organizational learning theory at GMHS and instrumental in sharing the GMHS story with other healthcare organizations in Michigan.

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THE URGE FOR EFFICACY

This diagram describes two sets of actions we might take to satisfy our desire for efficacy. Loop B1 represents the mechanistic or “impactful” fix to a problem, in which we push through a solution that involves a radical action. Loop R2 depicts the unintended consequences of this approach, fragmentation, which further exacerbates the original problem, or even leads to new ones. Loop B3 shows how taking actions that are intended to join people together, allowing their ideas and talents to emerge, can help to develop the interconnections necessary for organizational success.

How often, though, have we found ourselves in situations where our best efforts have fallen short of producing the benefits we intended and so deeply desired? Perhaps we have experienced success once, but for some unexplained reason we have been unable to reproduce or sustain the results. More confounding still are those times when, rather than improving performance, creating new knowledge, or adding value, we have found that our actions have had an opposite effect. In these cases, the harder we have tried to push ahead, the more resistance we have encountered.

Why do negative consequences often occur when we attempt to have an impact? For one thing, when we successfully execute actions that are specifically designed to radically alter current work processes and outputs, we generally break apart existing structures (see “The Urge for Efficacy”). Sometimes doing so is necessary, as breaking up and clearing away the old is truly the most effective way to create space for the new. But other times, the result can be fragmentation of a sort that isn’t immediately apparent. The sudden shift to a new “order” can shatter many things people previously counted on to be solid, including relationships, the value systems upon which decisions are based, and the motivations of others. Trust, quite literally, is shaken. People retreat into themselves or in small, tightly knit groups to try to sort out what has just happened and to reestablish their own center. This process can lead to a compartmentalization of ideas and energy within the system, often at a time when the health of the system is most dependent on maintaining and growing its interconnections.

In this article, we will explore the nature of these unexpected consequences and how they might occur, despite our good intentions. We will examine how the work cultures we have created, and even the language we use to describe the act of making a difference, may be partly responsible for unhappy or unsustainable results. We will explore a model that suggests different language choices, as well as a less mechanistic and more organic approach to satisfying our urge for efficacy in our organizations, our communities, and the world. And, we will examine a recent case study in which many of the ideas presented here continue to be tested.

Clues in the Language

“Language exerts hidden power, like a moon on the tides.”

—Rita Mae Brown, Starting From Scratch, 1988

Over the years, I have been fortunate to work with leaders and teams in extraordinary organizations. My own passion for issues related to health, education, and overall quality of life has meant that most of my colleagues and clients have been affiliated with hospitals, educational institutions, the public sector, or government service. As I often find myself working as a strategic learning partner and coach with organizations that are experiencing significant change, the initial conversations quickly and urgently turn to the subject of “what are we going to do?” I have noticed similarities in the language people in organizations use to describe their concerns, questions, and quest to “do something.” Here are some examples of commonly used expressions:

“We’re going to have to wrestle that one to the ground.”

“They’d better be prepared to go to the mat.”

“We can’t afford another idea that bombs.”

“This should break down the barriers to our success.”

“We’ll just keep grinding away at it.”

“Our approach must hit the target.”

“Whatever we do, it’s got to have an impact.”

These phrases all have one thing in common: They employ physical or mechanical metaphors that involve something hitting against or breaking up something else.

My growing curiosity has caused me to listen more closely to the nature of the language people use in organizations to describe their problems and challenges. As I have grown more aware, I have noticed that some individuals and teams, particularly those who strive to carefully consider the nature of any crisis prior to reacting, tend to use a different type of metaphor. Here are some examples of these phrases:

“How can we nurture an environment that supports excellence?”

“Is it possible to go with the flow without being swept away?” “What pathways will take us there?” “Is this part of a larger cycle?” “What can we do to grow these ideas?” “Can we take actions that will create a ripple effect?” “Are we really understanding the nature of the system that created this dilemma?” “What are the healthiest and most sustainable solutions?”

Does the language we use to describe our activity say something about the culture of our workplaces and the methodologies we employ to make meaning?

There are two interesting characteristics of these expressions. First, they are all in the form of questions. Second, they all use natural or ecological images to describe an action or state of being. As I have continued to listen for these language differences, however, I have noticed that the more organic, questioning metaphors are not the norm.

I began to seriously wonder: Does the language we use to describe our activity say something about the culture of our workplaces and the methodologies we employ to make meaning? And, as I heard story after story about change initiatives and performance improvement programs failing, I further wondered if a mechanistic mindset, and, subsequently, approaches to our work, might somehow be connected to producing results that are either unsatisfying or unsustainable (see “Mechanistic vs. Organic Fixes”).

Take the word “impact,” for example. Whether used traditionally as a noun (, “We need to make an impact on our customers”) or perhaps more questionably as a verb (, “How will this impact our bottom line?”), this word describes something hitting against something else. Some of the synonyms for “impact,” found in the Synonym Finder (J. I. Rodale, 1978), include “collision,” “crash,” “clash,” “striking,” “bump,” “slam,” “bang,” “knock,” “thump,” “whack,” “thwack,” “punch,” “smack,” and “smash.”

It then occurred to me that an interesting exercise would be to substitute some of these synonyms for the word “impact” in the common and popular phrases I have heard in organizations. Here are some of the more darkly humorous results:

“We need a growth plan that will slam our customer base.”

“This new policy will surely whack the morale of our employees.”

“Our new process improvement program is designed specifically to smash against the quality of our services.”

“Whatever we decide must collide with our community.”

Interestingly, this is also the language that is often used to describe military or war efforts. One example is an article titled “From the Front,” featured in the Albuquerque Journal on March 9, 2003. Writing from a military camp in Kuwait, journalist Miguel Navrot describes the attributes of the redesigned Patriot missile:

“This time, the Patriot is intended to slam directly into targets, destroying it in the supersonic collision.”

While most people do not consciously think about their well-intended solutions as actions that are either based on a military model or designed to smash, crash, and dash something to pieces, one must wonder if there are unintended consequences to this way of talking and thinking about problems and opportunities. Is there not, for example, a natural fragmentation that occurs when we implement actions that constantly hit against ideas, values, work processes, and people? And does this fragmentation support our efforts in the long run, when it causes people to feel disconnected, relationships to shatter, and innovation to become compartmentalized or even disintegrate?

Undeniably there are times when the most effective and necessary actions are those that do, indeed, break something apart, but have we overused these tactics in our quest for efficacy? And, if so, what might constitute the characteristics of a balanced approach?

Looking for an Oasis

Because metaphors paint a verbal picture of ideas, I wondered what would happen if people were asked to draw pictures to symbolize characteristics of different kinds of organizations. Would mechanistic or organic themes appear in their images? To begin exploring this question, I took advantage of three opportunities. The first was an invitation I had received to deliver the closing keynote address to the Public Service Commission of Canada’s annual Emerging Issues Forum for Leaders. The second was the chance to work with members of the Research Association of Medical and Biological Organizations (RAMBO), a diverse group of scientists in New Mexico that gathers regularly to explore scientific questions of mutual interest. The third was an invitation to speak at the 2001 Gossamer Ridge Institute, a think tank of teachers and administrators, mostly from public schools.

At the Canadian conference, I distributed drawing paper, along with markers and crayons in many colors, to all of the participants. I then asked them to create two images: one symbolic of the characteristics and attributes of a typical organization, and the second of the traits of an ideal organization. With the RAMBO group, I asked them to draw a traditional organization of which they had once been a part, and then to draw the RAMBO organization. I asked the educators to draw representations of the typical school and the ideal school.

With each of the three groups, the results were astoundingly similar. Drawings of the “typical” organizations included boxes, squares, and lots of right angles, mostly in black and white or monotone colors. Many drawings depicted rows of people who all looked the same, often captured in contained and compartmentalized cubes. Several incorporated mazes. In almost all cases, the blocky, unifying principles of these pictures were immediately apparent. When asked to describe the meaning of their drawings, people used words such as “constrained,” “programmed,” “stifling,” “demanding,” “demoralizing,” and “dead.”

Drawings of the “ideal” organization showed equally amazing similarities. Brightly colored images of overlapping circles, spirals, prisms, and other free-form designs emerged, with the unifying forces more felt than immediately seen. Depictions of natural landscapes were by far the most common themes: Trees, complete with root systems, were laden with fruit hanging on their branches and birds roosting in their nests. Creatures that looked like amoebas floated in a bright blue sea. Flowers bloomed in the midst of a desert oasis. Purple mountains soared above lush, green valleys and flowing rivers. When asked to describe the symbolism of these drawings, the creators used words such as “flowing,” “creative,” “diverse,” “renewing,” “energizing,” and “alive.” The visual metaphors of the desired organizations, along with the verbal interpretations, indicated a desire for a more organic model than currently existed.

A “Live” Issue

As I mentioned earlier, there are some individuals, teams, and organizations that have consciously chosen to slow down and attempt to understand the nature of the problems or opportunities they are facing, rather than charging full ahead with solutions. The language they tend to articulate reflects a way of thinking that is based on an organic model or world view, rather than a mechanistic one. The use of words such as “nurture,” “create,” and “grow” suggests that the problems and issues are alive and must be treated as such. In fact, this language suggests that the very solutions we employ must themselves be alive. Furthermore, we must understand that the processes we use to choose and implement solutions will ultimately influence the results.

If we choose to think of our opportunities and problems as being alive, how might we change the ways in which we go about planning and taking action? I recently took the opportunity to explore this and other questions about the “urge for efficacy” with Tres Schnell, who serves as the chief of the Injury Prevention and Emergency Medical Services Bureau for the New Mexico Department of Health.

In the aftermath of 9-11 and in defense against possible bioterrorism threats, state health departments throughout the U. S. have been charged with creating and implementing a plan to vaccinate physicians and others who would potentially serve as first responders against smallpox. Over the past few months, New Mexico Public Health Division personnel have devoted much time to developing a thoughtful plan to comply with this request. Based on the principle of “first, do no harm,” the division created a phased approach that would begin with identifying healthcare workers who would likely be the first ones to deal with a patient with smallpox, and then carefully screening to identify and remove from the vaccination pool anyone with risk factors that could lead to adverse effects. The inoculation program would then move forward with its first phase of vaccinating a small group of these primary responders, all of whom understood the potential risks and had volunteered for the program. Over time, the approach would be to carefully and methodically extend the vaccination initiative to other first responders in communities throughout the state, with constant monitoring of any adverse effects or signs that adjustments to the strategy should be made. The plan was implemented during the first week of March, with a handful of key personnel receiving the vaccine.

However, as fears of pending war with Iraq began to escalate, the call came to step up the program and to take actions that would have greater “impact” on the goal of vaccinating more people in a shorter period of time. The Department of Health was suddenly faced with a new sense of urgency to get the job done. I asked Tres about her views on the request to move faster, the possible unintended consequences of doing so, and an approach that could serve to mitigate or avoid those consequences.

When people feel that they are not being heard, they tend to compartmentalize themselves according to their alliances. Blaming often occurs, and then conscientious objection becomes passive, and then active, resistance.

Tres began by relaying the story of the planning process. “As we planned our approach in New Mexico, we did so knowing that opinions about the whole process were diverse,” she explained. “There are many health professionals in this country who do not feel that vaccinating people against smallpox is the right thing to do, given the potential risks of the vaccine itself, and the fact that doing so will divert resources away from other critical public health initiatives. Knowing this, we listened to all views, carefully weighed the risks, and developed a plan that held sacred the charge to ‘first, do no harm.’We were well on our way, through building a strong public health infrastructure and trust in a thoughtful process, to implementing a smallpox vaccination strategy in New Mexico. What we must do now is to respond to this new sense of urgency without creating a situation that divides us internally and diminishes the organic approach we believe is critical to the safety and effectiveness of this initiative.”

Throughout it all, Tres said, “We have the goal of remaining whole, because it is through wholeness that we can be most effective. The danger is that when people feel that they are not being heard, they tend to compartmentalize themselves according to their alliances. Blaming often occurs, and then conscientious objection becomes passive, and then active, resistance. We begin to rationalize that the people who don’t think like we do must be ‘bad.’ So, we cannot allow ourselves to be seduced into a defensive posture that builds those barriers to open, honest information sharing and dialogue. We cannot afford to fragment our relationships as we address the smallpox issue.”

In her role as leader of Emergency Medical Services, Tres insists that decisions on how to proceed cannot be made until the health professionals and their concerns have been heard, no matter how diverse or controversial the ideas. “Our diversity is our true strength,” she says. “This will help people to remain united, not harming each other in ways that will hurt our ability to be effective in the long run. Maintaining and nurturing relationships with one another is more critical now than ever.”

Asked about the messages she is sending to her colleagues, Tres responded, “We need to consciously choose our language — our mantras, if you will — selecting those that maintain and communicate our core principles and values. We must prioritize around our commonalities, not our differences. The threat we are currently facing is the added sense of urgency. If we can respond well to this one, we will learn and respond even better the next time.”

The messages are clear: that the language used and the methods employed must serve to join ideas, perspectives, and people if this very serious issue is to have a positive outcome. In the case of smallpox vaccination plans in New Mexico, the health professionals are finding strength and connectivity in their shared passion for protecting the public’s health. It is a critical time for leaders to model the willingness to listen deeply to differing viewpoints and honor one another’s professionalism. This willingness, coupled with strong relationships that have grown from working together in the past to address public health issues, is enabling the team to move forward more quickly with the plan while at the same time continually monitoring concerns and issues as they arise.

Improving Our Awareness

“If language is not correct, then what is said is not what is meant; if what is said is not what is meant, then what must be done remains undone; if this remains undone, morals and art will deteriorate; if justice goes astray, the people will stand about in helpless confusion. Hence there must be no arbitrariness in what is said. This matters above everything.”

—Confucius

Do we consciously choose our metaphors and our methodologies for taking action, or have our responses and approaches somehow become automatic? And if the latter is true, how can we make a conscious attempt to become more aware of our own language and the influence that our words may have on the nature of the actions that we and those around us take?

The “Language/Action Assessment” on p. 5 is intended to help us to explore our own favored metaphors and the kinds of actions they describe. Take a moment to consider the questions it includes. As you think about your responses, reflect on how experimenting with other language choices might possibly lead to solutions and actions that are more organic and alive than other possibilities. Engaging in this exercise can also be helpful when done as a team activity, especially as part of a strategic or operational planning process.

In answering these questions, we become more aware of our past tendencies. As we more clearly understand our past, we are better able to make thoughtful choices about our future language usage and subsequent actions. In this way, the exercise can help us to achieve true, lasting efficacy.

Choosing the Words We Live By

Whether we are addressing global issues such as the threat of bioterrorism or concerns more specific to our organizations and local communities, thoughtfully and consciously choosing our words and deeds is surely the wisest course of action. The desire to make a difference may well be our birthright. But how we go about attempting to make that difference can affect the quality and sustainability of the outcomes and of our lives. The words of an anonymous philosopher serve to remind us of how what we think can shape who we are:

Watch your thoughts, they become your words.

Watch your words, they become your actions.

Watch your actions, they become your habits.

Watch your habits, they become your character.

Watch your character, it becomes your destiny.

Being human means that we are endowed with the wondrous capacity to consciously choose our words and actions. May we increasingly exercise our ability to do so with clarity, compassion, and an understanding that what we say and do will create our future.

Carolyn J. C. Thompson has devoted more than 20 years to helping organizations create vision driven and values-centered workplaces that are able to ask and address hard questions through engaging the power of the human spirit. She teaches, writes, and consults both in the U. S. and abroad on applying systems thinking and complexity principles to organizational issues. Carolyn resides in Albuquerque, New Mexico.

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Acompanion to the PBS documentary, “Good News . . . How Hospitals Heal Themselves,” The Nun and the Bureaucrat: How They Found an Unlikely Cure for America’s Sick Hospitals by Louis M. Savary and Clare Crawford-Mason (CCM Productions, 2006) is the story of two large healthcare organizations that adopted systems principles as part of an effort to reduce death and suffering, medication errors and hospital-acquired infections, waste, and expense and to improve quality of care and working conditions for healthcare professionals. Forty hospitals cooperating in the Pittsburgh Regional Healthcare Initiative (PRHI) and 20 hospitals of the SSM Health Care system in St. Louis applied the management ideas of W. Edwards Deming —who helped the Japanese automotive industry become a world leader in innovation and quality—as they entered a continuous quality improvement effort. The book provides readers with the opportunity to learn about systems thinking and the processes—and difficulties— involved in developing that frame of mind. By offering detailed examples from the hospitals’ experiences, it brings the theoretical description of systems thinking to life.

The Path to Systems Thinking

The healthcare industry’s problems, the authors maintain, are not external—government regulations, insurance restrictions, competition from other providers—but internal—duplication of work effort, quick fixes to apparent problems, and miscommunications within organizations. To design truly sustainable solutions, the institutions realized that they needed to make the patient the focal point; the development of systems thinking then became much more feasible. As the authors point out, “Anyone familiar with systems thinking or Dr. W. Edwards Deming’s principles of quality management will know that the only thing that can turn a collection of people and machines into a true system, that is, make them a whole greater than the sum of their parts, is a shared purpose.”

The organizations started by recognizing that they are systems and that, as such, employees need to act collaboratively: to understand and behave in ways that reflect the interconnectedness of their institution. With the systems understanding and the focus on patients, the hospitals laid the foundation for their improvements. One of the more critical issues they identified was that of blame. Fault finding is inconsistent with a culture centered on quality; rather, efforts were redirected to problem finding. Organizational learning can occur only when problems are acknowledged, not when fingers are pointed.

The use of a “learning line” at PRHI, in which units experiment with others in the system to create improvements, also exemplifies organizational learning. This process operates on the understanding that adoption of a singular model across different areas may not work but that sharing ideas may lead to brainstorms for new ways of operating. Likewise, both institutions went outside their own organizational—and industry— boundaries to learn best practices. PRHI looked at automaker Toyota to help understand process improvement.

As systems thinking became more common in the organizations, practitioners described the phenomenon of seeing things from various perspectives. There was a transition toward focusing on the core purpose—serving the patient, finding connections rather than differences, looking for problems rather than hiding them, and thinking long term rather than seeking immediate solutions. The use of data and the sharing of that data between units was another change.

The Path of Improvement

The final section of the book discusses “The Path of Improvement” and provides specific steps taken. One of the keys to long-range, big-picture thought processes is root-cause analysis. The use of such tools allowed these organizations to understand issues systematically and to avoid the inefficiencies of “quick fixes.” Other quality improvement approaches are discussed, including the issue of employee empowerment. When the hospitals adopted processes that encouraged workers to raise issues and participate in creating solutions, problems were resolved much quicker.

These organizations are not presented as being perfect. The book describes the tension between the physicians’ perspective and that of the administrators. The physicians, like the patients, had at times been forgotten or lost in the operations (pun intended). Systems thinking, and the use of Baldrige quality criteria, required that the organization seek to understand internal as well as external stakeholders.

Systems thinking is often categorized as either overly simplistic or very complex, with multiple loops on loops. The anecdotes provided in this book bring with them an inspiration and a sense of encouragement for those who believe in systems thinking as critical to organizational success and improvement. The vivid examples make it a more palatable piece than many that deal only with the theory behind systems thinking, though that theory is well presented. Finally, as a boost to your own brainstorming for improvement, this book will provide many ideas that can be adapted to any setting.

Ed Cunliff (ecunliff@cox.net), Ph. D., currently serves as AVP for Academic Affairs at the University of Central Oklahoma. He has more than 30 years of experience in innovative organizational development. Ed has worked in social services, healthcare, and higher education and has served in a consultative role with dozens of organizations.

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Weighing the Risk

In recent years, groups that oppose vaccinations because of their potential health risks have sprung up. For instance, some activists claim that the mumps, measles, rubella vaccine is linked to autism, although medical groups studying the possible connection have concluded that the vaccine is not to blame. Anti-immunization groups also doubt the government’s ability to oversee vaccine safety, pointing to, among other things, its delay in banning mercury from injections, despite the fact that it can impair children’s cognitive development.

In response to such concerns, more and more people are choosing not to vaccinate. When weighing the risk of contracting vaccine-preventable diseases against that of experiencing one of the rare catastrophic reactions to the vaccine itself, they are banking on current low levels of infection and deciding to avoid the injections.

Health officials acknowledge that vaccines can cause side effects, ranging from mild (temporary pain at the injection site) to serious (between 1960 to 1999, 8 to 10 children a year in the U. S. contracted paralytic polio from the oral polio vaccine).

But they also point out that as more people avoid immunization, the incidence of certain serious diseases is bound to rise. As just one example, the Consumer Reports article cites the case of Mary Catherine Walther, who contracted Hib meningitis on her first birthday. Her local hospital in Tennessee hadn’t treated a case of the illness for eight years, since the introduction of a vaccine against it. Fortunately, the toddler recovered.

THE SWING OF RELATIVE RISK

As the incidence of a disease rises, people’s perception of the risk to their own health increases. Under these conditions, they are more likely to overlook the vaccine’s side effects. Use of the vaccine reduces the incidence of the disease. When infection rates fall, people’s concerns about vaccine safety grow. If enough people choose not to use the vaccine, the disease begins to spread again.

One reason that formerly dormant diseases can reappear is that they haven’t yet been eradicated worldwide. Travelers from countries where immunization programs have been limited can carry a disease to other regions. Or such illnesses could reemerge through more diabolical means. In June, a simulation exercise depicted a smallpox attack by terrorists that infected 24 people in Oklahoma. After an imaginary two weeks, 16,000 people in 25 states were infected; 1,000 were dead; and 10 other countries reported cases. Following these trends, within three weeks, there would be 300,000 victims, a third of whom would die. Without continued vigilance, such an epidemic could also happen with other serious illnesses that we have long thought were cured.

Relative Risk

The pendulum swing between concerns about disease to concerns about the vaccines themselves represents a classic balancing process (see “The Swing of Relative Risk”). When the threat of a specific disease is high, the vaccine’s desirability rises, regardless of safety concerns. When incidences of the disease are few and far between, people start raising questions about the vaccine’s side effects.

Rather than writing off such concerns as irrational, by recognizing this dynamic, public-health officials can anticipate and manage them through ongoing investments in vaccine safety, education, and immunization programs around the world. In fact, officials might consider activists’ skepticism to be a positive force, in that it keeps pressure on manufacturers and governmental agencies to continually improve these life-saving products. After all, no one wants the cure to be worse than the sickness.

Janice Molloy is managing editor of The Systems Thinker.

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