Anthony Suchman Regenstrief Conference Slides

©2007 Anthony L. Suchman, MD

Organizations as Machines,Organizations as Conversations:

Two Core Metaphors and their Consequences

Anthony L. Suchman, MD, MARelationship Centered Health Care

Rochester, NY


My hope is that as a result of this talk, you will:

• recognize that an organization is ongoing emergent pattern-making (patterns of meaning and patterns of relating)

• pay more attention to process: how patterns form, what constraints are present and what effect they have

• be more aware of your own participation in the process (how you form it and it forms you) and recognize that organizational change begins with your own mindful changes in how you participate

• recognize the parallels between administrative, research, clinical and educational processes, and

• be more excited and hopeful about relationship-centered methods for both organizational change and organizational research


Core metaphors

• Organization as machine (Taylor)

• Organization as conversation (Broekstra, Stacey)


Curious properties of patterns

• Patterns are perpetually under construction here in the “living present”

• The construction of patterns is a self-organizing process


Helpful concepts from complexity

• Non-linear dynamics: reciprocal influence• Amplification of small difference (Butterfly

Effect) • Inverse power law (Sand Pile Effect)• Self-organization: requires both freedom and

constraint• The emergence of new patterns is favored by

diversity and responsiveness• Similarity across scale


How does change happen?

• Grand design (blueprint) – emergent design• Details come from leader – details come from

everyone


Case History

• IUSM is a 102 year old medical school…

• 2nd largest in US (>1100 students)

• Only AHC in Indiana

• 9 campuses; 5 major hospitals

• 70 postgraduate programs

• Leading-edge competency-based curriculum

• Concerning GQ questionnaire results


Undergraduate Competencies

1. Effective communication2. Basic clinical skills3. Using science to guide diagnosis, management,

therapeutics and prevention4. Lifelong learning5. Self-awareness, self-care and personal growth6. The social and community contexts of health care7. Moral reasoning and ethical judgment8. Problem solving9. Professionalism and role recognition


Problem List

• Informal curriculum (organizational culture, social environment) doesn’t match or support formal curriculum

• Frustrated idealists; reaching point of burnout

The challenge• Transform the informal curriculum such that

it consistently embodies the values and principles of Relationship-Centered Care.


The RCCI

• 3 year project to initiate culture change/ informal curriculum change

• 1 PI, 2 co-PI’s, 1 project manager

• 2 external consultants; monthly visits for 3 years


RCCI Strategy

• Recognize emergent nature of change

• Let go of control

• Initial project followed by spontaneous rippling and dissemination

• Begin with an Appreciative Inquiry – Discovery Team interviews and first Open Forum


Paired interview questions:

Fostering humanism in medicine – creating more room for both patients and clinicians to be fully present to each other – may be the most important work in medicine today. To learn about humanistic environments, we need look no farther than SHIM. Whether you’ve been involved for a day or for decades, you may have experienced a moment when SHIM fostered some degree of congruence, community or renewal. Think of such moment; tell me the story of that time.

• What was it that made that moment successful?

• What did you do or bring to that moment that contributed to its success?

• What did others do?

•What was it about the context or situation that made a difference?

•What lessons do you take from this experience?


STUDENTS

RAD

FM

AD

M

COMMITTES

6 mo12 mo18 mo

DISCOVERY TEAM

RESIDENTS

EDUCATIONADMIN

DEANSRETREATS

TALKS


Lessons learned

• New patterns of thinking and relating are spreading

• Individuals and committees are making more mindful choices

• Emergent approach to organizational change is working; “master plan would likely have failed

• Storytelling has been engaging and community-building

• Ongoing use of success stories is leading to more favorable self-image, higher self-expectations and greater confidence and hope

• Change happens and spreads one person at a time


How do we go about the work of organizational change?

• Focus on the plan – focus on the process• Change agent as director – change agent as reflector

and disturber • Change agent acting from outside – change agent

participating from within


What are the underlying attitudes and expectations of change work?

• Seeking control – seeking relation

• Expecting predictability – expecting surprise


Parallels with…

• Relationship-centered Care

• Health services research


Research questions inspired by CRPR

• What are the existing patterns of meaning? Of relating? • How are they maintained/re-enacted in each moment?• What are the constraints that help them stay in place?• What new patterns are forming? Or what new patterns are

intended?• What are the initial disturbances? How do they spread? • What constraints support that?• How is the change agent participating?• What are the sources of diversity? What favors and inhibits

their availability to the organizational conversation?• What are the crucial relationships? • What factors favor and inhibit responsiveness in the

organizational conversation?


STUDENT RCCI LEADERSHIP

BOOK of STORIES

CENTER VISITS

STUDENT ENGAGEMENT

TEAM

HONOR CODE MEETING

STUDENT LINE


ADMISSION COMMITTEE

INTERVIEWER OSCE

SIMULATED APPLICANTS

NEW SELECTION PROCESS

PROFESSIONAL STANDARDS

TLAC

FACULTY COMMITTEE

LINE

ACADEMIC STANDARDS

CURRICULUM COMMITTEE


SENIORLEADERSHIP

LINE

3D RELATIONAL AWARENESS

CHAIR EVALUATIONS

EAD’S


DISCOVERY TEAM LINE

OPEN FORUM

OPEN FORUM

OPEN FORUM

DT RETREATS

RCCI NEWSLETTER

CTL

CTL

CTL

CTL


HOUSESTAFF FORUM

RADIOLOGY RESIDENTS

RESIDENTS LINE

Discovery Tm

HOUSESTAFF FORUM

Resident Engagement

Team

COGME

Resident Coordinators

Believing in the capacity of all people to learn and grow:

giving them freedom and support to pursue their professional growth

and career development.

The importance of connectedness:

student-teacher, patient-clinician, cross-disciplinary healthcare team;

research collaborators, basic scientist-clinician, across

departments and institutions

The importance of passion:

for patient care, learning, teaching, trying new things, creating new

knowledge.

The wonderment of medicine:

the discovery and continuing appreciation of the profound nature

of our work.


Subsequent steps…

• Tell more people about the stories and themes• Conduct additional interviews• DT becomes cadre of internal change agents

– meets monthly to share ideas, learn organizational change methods, give and get peer coaching and support

– practice and disseminate relationship-centered meeting practices (e.g.: check-in, noticing success, appreciative debriefing)

Technology

Anthony Suchman Regenstrief Conference Slides