It was a perfect prairie afternoon — a colleague and I sat on the porch, watching the pollinators on the sedum and reflecting on the winding paths of our careers and the moments our journeys have intersected.
One of those intersections took us back to a small, rural multi-specialty clinic with an inpatient rehab unit. Despite its modest size and rural location (or possibly because of it), it became a surprising hub for creativity and change. From that setting bloomed several innovative projects that ultimately helped shape programs across the VHA (Veterans Health Administration).
What was it about that space that made innovation possible?
The VHA and other large systems thrive on consistency, accountability, and safety — all essential when missions and patient care are at stake. Yet within that structure lies a paradox: those same qualities that sustain the system can also limit it. Without room for creativity, organizations risk hardening around “the way we’ve always done it” instead of exploring new ways to serve patients, staff, and communities.
When we began implementing initiatives like PACT (Patient Aligned Care Teams, the VHA medical home model), integrative pain clinics and Whole Health, the challenge wasn’t in the ideas themselves — it was finding the courage and structure to try something new inside a highly regulated, hierarchical system.
So, we started small: a pilot here, a cross-disciplinary conversation there. Over time, those small experiments widened into lasting pathways of change.
As I look back, three practices stand out:
- Micro-experiments, not massive shifts. In structured systems, small, well-contained pilots create safety to test ideas without destabilizing the whole.
- Leaders who protect the sandbox. Effective leaders give their teams “cover,” providing psychological and organizational safety while still honoring the rules.
- Permission to learn, not just succeed. Hierarchies often reward getting it right the first time. Real innovation happens when “failure” becomes data for the next iteration.
The tension between structure and innovation is real — and it’s not something to eliminate, but to navigate. The invitation is this: find the smallest space where you can give yourself and your team permission to experiment. Protect it. Learn from it. Over time, those small acts of courage can lead to transformation.
