October 10, 2019

The Unordered World of Healthcare – Part 1: Assuming Too Much

Clinician Leadership | Leadership Development

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Does it ever feel like leading in healthcare is difficult? Messy? Perhaps it feels like success is just beyond your reach – no matter how much you move forward?

I’ve heard all the above from my coaching clients. I assure them (and you) that they (and you) are not alone.

Almost every leader in healthcare I know works very hard, oftentimes for decades, to make things better.

Considering how much time, effort, and resources that have been deployed to improve or transform our health systems over the past 30 years to positively impact public health and overall spend on healthcare, things don’t seem to be getting a lot better.

In regard to spending, Don Berwick, former CMS administrator for CMS recently stated in an editorial:

“…health care costs more and more and more, with expenditures relentlessly increasing at a multiple of the general rate of inflation. Incredibly, even health care economists purvey a kind of double-speak; they score a slowing of the rate of rise of costs as a cost reduction. That deceptive language would not last long when it came to cars or computers.”[1]

We have yet to tame the cost curve, our quality and outcomes measures show some modest improvements and some modest deterioration, and in the end there’s not a lot to hang your hat on in regards to ‘transformational’ improvements.

Here’s the thing – my clients are smart. They are highly motivated people with access to plenty of information and resources. Yet they still encounter situations where solutions that seem right won’t scale as expected, aren’t sustained, or don’t work at all. Sometimes these solutions, even simple small changes, result in outsized, unpredictable negative consequences that do more harm than good.

So why is it that even when we apply best practices, harvested from one setting and carefully deployed in another, the results can be unimpressive, or may not stick. The cause-effect predicted outcome doesn’t always fulfill our aspirations. Basically, it doesn’t make sense.

Everything about it feels unordered.

Assumptions of an Ordered World

“The default approach favours reductionism—the assumption that reducing a system to its parts will inform whole system behavior..yet is inadequate where issues have multiple interacting causes..”

 Eric Van Beurden[2]

There’s good reason why it feels unordered to lead in healthcare today. It is.

As healthcare leaders, we tend to understand our leadership through the lens of an ordered world. Doing “x” will or should result in “y.” We see our organizations as essentially complicated machines. We can break them down into their parts, fix the part, and when we put things back together, the whole works better. We think that way because of the assumptions we hold about our teams and our environment.

In my view, we tend to make three fundamental assumptions:[3]

1) The Assumption of Order: Things always or should happen in an ordered, predictable, reducible cause-effect way.

2) The Assumption of Rational Choice: When given a choice, mature, well-adjusted humans will always pick what we dub the “rational” alternative, dismissing other factors that influence choice.

3) The Assumption of Intentional Capability:  We accept that we sometimes do things by accident but hold the belief that others do things deliberately. I like to equate this to thinking that every blink is a wink.

My advice, to start, is to focus on awareness. Just being aware that you may hold the above assumptions is a start towards understanding the unordered world. That understanding is important because, I believe, most leaders today live in a world that is mostly unordered. If we relax the assumptions above, we become open to a view that may help us better understand our unordered reality.

The first responsibility of a leader is to define reality – Max DePree



[1] Elusive Waste: The Fermi Paradox in US Health Care. Don Berwick, JAMA. Published online October 7, 2019.

[2] Making sense in a complex landscape: how the Cynefin Framework from Complex Adaptive Systems Theory can inform health promotion practice. Van Beurden, EK et al. Health Promotion International, Vol. 28 No. 1

[3] The new dynamics of strategy: Sense-making in a complex and complicated world. C. F. Kurtz and D. J. Snowden. IBM SYSTEMS JOURNAL, VOL 42, NO 3, 2003

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About the author

Michael S. Hein, MD, MHCM, ACC

Michael S. Hein, MD, MHCM, ACC has over 20 years of healthcare leadership experience in multi-specialty practice, large integrated health systems, academic medicine, and start-up companies. He has extensive clinical leadership experience and deep knowledge in transformational change.

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