David Hutchens
A story from
HealthEast, Greenville, N.C.

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What role does courage play in the application of complexity theory? It's not a question that Tom Irons would have thought to ask in the Spring of 1995 when he was named president of HealthEast. Given the task of purchasing medical practices and developing practice management services to increase the educational and referral base of HealthEast's parent hospital and sister medical school, Tom's challenge was one that required keen business insight, fortitude, even political acumen.

But courage? No one - including Tom - would have guessed that it would become the central job requirement.

"The pressure was getting intense," reflected Irons, a self-professed cowboy-booted Southern boy whose Carolina drawl masks an intellectual intensity. "On the one side of me were rapidly growing IPAs, eager for capital and posturing against each other, often through me. On the other side was my parent hospital, anxious for me to start linking up with physicians as quickly as possible. And all along, I was getting this sneaking suspicion that I didn't need to be in the business of purchasing practices or working with these IPAs. The practices were too expensive, and the IPAs had their own agendas and no infrastructure."

Flanked by organizational forces that were beyond his scope of influence, Tom began to realize that it was fruitless to try to directly control the direction the system was taking. Perhaps it was time to create something in a new way. The question was, what would that be?

It was time to get courageous.

The leap into uncertainty

Time was passing and the hospital was becoming nervous. Irons had been hired to forge new relationships with physicians, but those relationships weren't emerging. Management services organizations were not an immediate answer. And with the available nonowner relationship structures, there was little incentive for clinical integration or innovation.

Increasingly aware that the old owning-and-controlling model was producing very little, Irons couldn't ignore his intuition any longer. "That's when I made the radical decision," he said. "I decided I would cease working with the IPAs. I would keep positive relationships with them, but there would be no more conversations about financial commitments. As for buying practices, I would do this only in the exceptional cases where there was a competing offer or where physician services in a community were imperiled."

Irons was now in unchartered territory, where terrain was uncertain and direction was unknown. It was in this ambiguous place that he would begin to discover a new way to influence the development of the system.

"The first thing I did was get help," Irons recalled. "I began looking for a small group of physicians here in the North Carolina region who I felt were key leaders. Not knowing exactly where I was headed, I selected them based on these four simple criteria:

• "One:They must have high clinical credibility.

• "Two:they must have absolute personal integrity.

• "Three: They must have strong interest in a system of care, in addition to their individual practices.

• "Four: They must have this vital shared belief:that whatever we create will improve the health status of the people we serve.
  
  

"In retrospect," Irons noted, "I realize how radical this final criterion was. Most health programs only pretend to aspire to that goal. That's their fundamental flaw!"

Tom found four physicians who met the criteria. He convened with the group, offering to compensate them for the time they spent away from their practices. A little tentative, but excited at the prospect of creating something new, all four agreed.

"So, just what is it we're going to actually do?"they wanted to know.

Irons confessed:"I don't know. We're going to begin growing this thing before we know what it is." And that's what they did.

An emergence of the new

The plan was almost haphazardly simple: to solicit the support of physicians around the region who were of a like mind with Irons and his team, and find ways to facilitate a mutual coming-together.

But reality soon set in. "At the end of our second session together," said Irons, "we all said we can't do this. What would we offer doctors? What would prevent us from doing just what the IPAs were doing - that is, growing and posturing with no real ability to change systems of care? We agreed that what we could do is start from the bottom and build something new - a grass-roots effort that could become a model that the rest of the system may or may not choose to adopt."

So the team agreed upon two central goals: "We must improve the health status of the people we serve," and "Our efforts cannot hurt the hospital or school of medicine, rather, we will support the educational mission of the school and the service mission of the hospital."

With those two key parameters in place, the small group of physicians divided into four task forces. ("Each was a task force of one!" Irons recalls bemusedly.) They identified the issues of structure and governance, information systems, practice reengineering and medical management, with each task force investigating one issue. The task forces got to work, and by the end of three sessions, they realized these systems in their current state were fragmented, had misaligned incentives and, in short, could not integrate care in such a way as to improve outcomes or increase financial value. So again came confirmation of what they had sensed all along: if they were ever going to get off the ground, they needed to create something new. Irons reflected:"That was the beginning of a year of extremely difficult work. During that time, the outside pressures never let up! But it became obvious to others that the five of us were determined, and threats and pressures from many sides began to diminish. Still, we were constantly on trial. People were thinking 'This work can't be right - you're spending too much time here while Rome is burning!'"

It was a fearful time, too. "We never stopped feeling unsure, afraid and anxious," Irons confessed. "We knew we could fail. It was a real possibility. But our trust in each other was what finally held us together. In fact, the greatest part of our work was in building lasting, trusting relationships among the five of us."

Confirmation from complexity

It was October of 1997 and the team was hard at work. It was during that time Tom Irons attended a VHA learning network meeting on the subject of complexity - a subject to which he had been introduced only recently.

"It was dramatic," he said. "As I sat there, I could hardly contain myself. I went back the next week and told my team, 'I have marvelous news! I just got tremendous reinforcement that what we're doing is right!Now I understand why we have to do it this way!'

"So I brought three of my teammates to the VHA Complexity and Health Care Conference in December of 1997. After just two hours of presentation, they were stunned. They said 'My God, this is us!'"

Irons and his team sat entranced over the course of the two-day seminar as they learned the central tenets of complexity management: that systems in which people are far from certainty and agreement can be breeding grounds for creativity and innovation; that order can spontaneously emerge from complex adaptive systems if you nurture it, and don't try to control it; that complexity principles can guide us in creating a new future, even when we don't have a clear vision of what that future should be.

Indeed, Irons and his team realized they had been practicing complexity theory all along. Now they had a language to give shape and confirmation to what they had been doing intuitively. "We immediately wrote down our min specs," said Irons, referring to the principle of minimum specification, which indicates that a few simple rules are sufficient for producing amazingly diverse and complex self-organizing behaviors in a system.

"Then we began thinking about our 15 percent," said Irons, referring to another complexity principle that suggests we have the ability to influence only 15 percent of what goes on in our system, and the rest is left up to forces beyond our control. Therefore, by finding and leveraging that critical 15 percent, leaders may produce remarkable, systemwide change. "We said to ourselves, we are the 15 percent!" said Irons.

"We also realized we were creating a new strange attractor." (That is, a new model around which activity could organize.) "The old attractors - the existing systems of structure, governance, practice reengineering and so on - weren't capable of achieving the goals of improving the health status of its people.

"As we listened and participated, a burden lifted from us," Irons said. "We realized we had been dealing with a nonlinear phenomenon all along. We were almost jumping up and down!"

Trust and courage

"I look where we are now, and where we began,"Irons said with a laugh. "I thought that by now, we'd have a very clear structure in place and we'd be selling it to our practices. I thought we would create a business, recruit some doctors, the hospital would put up X amount of dollars and people would come. But we just kept putting off bringing in the consultant, because we didn't know yet what we wanted to build. Instead, we discovered we had to let the new system emerge. We couldn't force it. We could only nurture and facilitate it." Where does the effort stand now?

"Some creative ideas are really beginning to emerge," Irons said. "We're looking at some new ways to merge practices. And we are working on some emerging disease management programs in heart failure, diabetes and more. It's slow going. We're finding that change is incremental instead of sudden and massive. But we are continuing the collaboration necessary to redesign the system.

"The trust we built in our team is expanding to the outside," Irons added. "In the beginning, our hospital partners responded to us with skepticism, and even competed with us for resources and control. They perceived our actions as being control-centered. But we just stayed focused on our min specs, and most of the skeptics are coming to realize we're interested in building bridges - not gaining control. We still have some skeptics, but as others have watched our work emerge, they have caught fire!They've said, 'this is important - not just your goal, but the process you're using.'"

Today, those skeptics see an emerging physician equity model network, in which community hospitals and physicians all have a stake in its success. And it's built around managing care rather than costs, with the business structure evolving to accommodate function. "You know, that trust we built was key," Irons said. "It was hard to get here, but today the trust we have is extraordinary. One doctor on our team was having some problems back in his practice that were making it difficult for him to keep the vision. So each of us met with him often to offer our help. That's the kind of relationship we have.

"Now we call each other almost every day, just to share what we've learned or read. It's very infectious. And it's all the result of creating a new attractor." Even though he is equipped with the tools and language of complexity theory, Irons is quick to point out that fear is still a real element. "There were many times at the beginning of this work I was tempted just to go back and start buying practices, because it's easier," he admitted. "But now I wouldn't dream of it. My confidence is growing. At its core, a complexity approach is about letting go of control to let a structure self-organize. It's the letting go that's frightening." "And we could still lose," he added. "But we're building a powerful new attractor, and closing out the influence of other attractors. I don't know quite what's going to happen in the future. But it's going to be good."

So, this is a story still in progress?

"You bet it's still in progress," Irons responded. "And I hope it never gets out of progress. If you build something good, it never stops changing, growing and evolving. This 15 percent is my chance to make a real difference.