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Surprise Surprise - Surprise Surprise Surprise A Complexity...

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Unformatted text preview: Surprise, Surprise, Surprise! A Complexity Science View of the Unexpected Reuben R. McDaniel ]r., Michelle E. Jordan, and Brigitte F. Fleeman Surprise can emanate from two sources: lack of sufficient information or knowledge and the basic dynamics of complex adaptive systems. The authors expand the traditional view of surprise with a complexity perspective that makes it possible to ask new questions and to consider new ways of understanding the world around us. They discuss creativity and learning as two strategies for capitalizing on the surprises that confront organizations. Health Care Manage Rev, 2003, 28(3), 266—278 © 2003 Lippincott Williams 8: Wilkins, Inc 266 A COMPLEXITY SCIENCE VIEW OF THE UNEXPECTED Traditionally, people in organizations have Viewed surprises as unwelcome and generally dysfunctional occurrences, prompting actions to avoid or manage them. This is particularly true of health care organ- izations with their focus on high reliability and error- free performance. Bounded rationality,1 lack of information, tight coupling, and interdependence of system components2 are seen as major contributors to surprise and it is assumed that surprises can be and should be avoided with more knowledge, better planning, and/ or better systems design.3 The man— agement goal in the face of potential surprise is to create more reliable and predictable organizations through quality control, planning, and standardiza- tion and/ or to manage the unexpected in ways that reduce potential damage.4 Certainly, some organizah'onal surprise is due to lack of information or information processing capacity. When, however, health care organizations are recognized as Complex Adaptive Systems (CAS), surprise is not necessarily the result of bounded rationality, limited information, or system design, but often is the result of the fundamental nature of the system in question. Complexity theory suggests that much surprise is inevitable because it is part of the natural order of things and cannot be avoided, eliminated, or controlled. Paul Plesk, writing in the Key words: complexity, surprise, uncertainty Reuben R. McDaniel, ]r., Ed.D., is the Charles and Elizabeth Prothro Regents Chair in Health Care Management, McCombs School of Business, The University of Texas at Austin. Michelle E. Jordan, MA., is an Elementary School Teacher, Blanton Elementary School, Austin Independent School District, Austin, Texas. Brigitte F. Fleeman, Ph.D., is a Research Associate, Depart— ment of Educational Psychology, The University of Texas at Austin. Many of the ideas in this article were first presented at the Vl-IA “0n the Verge Forum," held October 18—21, 2000 in Ctucago, Illinois. We extend special thanks to Dean Driebe and Karl Weick for their comments on an earlier draft. Thanks to William Miller, Ben Crabtree and John Pierce who each gave feedback on the first presentation of these ideas. Thanks also to many partiCipants in executive education programs who listened to many of these ideas and give very useful feedback. Surprise, Surprise, Surprise! A Complexity Science View of the Unexpected 267 Institute of Medicine report, Crossing the Quality Chasm, put the issue this way: In complex adaptive systems, on the other hand, the “parts” (in the case of the US. health care system, this includes human beings) have the freedom and ability to respond to stimuli in many different and fundamentally unpredictable ways. For this reason emergent, surpris- ing, creative behavior is a real possibility. Such behavior can be for better or for worse: that is, it can manifest itself as either innovation or error 5(P 323) When we understand this, the attitude toward surprises can become one of approach and explora- tion rather than avoidance and defense. When health care managers take a complexity science perspective, they see the possibility that surprises can be promis- ing opportunities for new approaches to meeting organizational goals. Surprise, then, can emanate from two sources: lack of sufficient information or knowledge and the basic dynamics of complex adaptive systems. In this article, we expand the traditional view of surprise with a complexity perspective that enables us to ask new questions and to consider new ways of under- standing the world around us. We identify sources of surprise that become apparent from taking a complexity science perspective and we suggest creativity and learning as two strategies for capital- izing on the inevitable surprises that confront organizations. We also explore some barriers and facilitators to the use of creativity and learning in health care organizations. SURPRISES Definitions of surprise range from “an attack made without warning” to ”a taking unawares." When we are surprised, we are struck with wonder or amaze- ment, or are impressed forcibly through unexpected— ness or unusualness. The list of related words includes awer astonishment, shock, wonder, bewil- derment, overwhelm, perplex, confuse, web, tangle, confusion, and unpredictable events (Merriam- Webster’s Collegiate Dictionary, 8” ed., 1976). “Unex- pectedness, rather than novel , unfamiliarity, or uncertainty, elicits surprise/’5‘“2 0) It might be helpful to give some very specific examples of surprises in health care. While these observations may no longer be "surprises,” they certainly were when they first were made and responses to each were, at one time, quite controversial. 1. A ”steady heart beat" is seen as a dysfunction rather than a desired state and variability in cardiac rhythms is seen as a sign of good health.7 2. Participation of clinicians in hospital strategic decision-making is found to be more helpful in terms of bottom-line performance than the participation of middle managers.8 3. Even after purchasing costly systems designed to assist them in delivering preventive care, physicians ignored the protocols, the systems found their way to shelves in the back room, and the physician delivery of preventive care is found to be much more complex than previ- ously suspected.9 4. Organizations engaged in fast decision making are discovered to use just as much information as slow decision makers but information of a different kind.10 5. Nursing homes that want to improve quality can use RN participation to make improvements without significantly increasing costs.11 Surprises such as those noted above are viewed in a multitude of ways as a function of the framework used.12'16 Often, surprise is appraised as an unfavor- able deviation from past experiences and the organ- ization makes an effort to go back in time to the situation that it “remembers.” People often normalize surprise; they deny its existence, for example, when they deny the information being given to them by the patient about a medical treatment. Observers often attempt to enact surprise away so that they can know what to do and so that they are not confused by new information. Surprise in the health care environment is predominantly appraised negatively, implying a failure or mistake and a threat to organizational reliability. How surprise is appraised has significant consequences for actions taken. The predominately negative appraisal of surprise in the health care environment leads to a defensive stance because ”unpleasant emotional states lead to strategies designed to reduce or eliminate them."17(p'18) How- ever, surprise could be seen in a positive light, as an opportunity rather than a threat, making organiza- tional responses to surprise significantly different.18 It is the potential for a positive surprise that we pursue in this discussion. Although often we assume that our expectations are not met because of limited knowledge or ignorance, 268 HEALTH CARE MANAGEMENT REVIEW/IULY—SEPTEMBER 2003 surprise also can stem from the fundamental nature of the system in question. Surprise originating from either source can be a threat or an opportunity, depending on how the unfolding events are appraised and framed. We can now use a four-cell matrix to organize our thinking about surprise in organiza- tional life (see Figure 1). SURPRISES IN THE TRADITIONAL VIEW Traditional views of management and organiza- tional analysis have concentrated on cell three of this matrix; surprise that is created through lack of knowledge and that is considered a threat. Occasion- ally, cell four of the matrix is considered, primarily when surprise is seen as an opportunity for ”learning from mistakes” as is evident in the recent scrutiny of mistakes in hospitals.19 This negative view of the surprise is also implied when we frame unexpected events in the managerial literature as environmental jolts,20'22 and when we focus on attempting to achieve high reliability.4'23'25 The defensive goal of high-reliability organizations is for everyone to do what he or she is supposed to do so that mistakes will be avoided. Health care organizations are particularly concerned with high reliability because the idea of FIGURE 1 MATRIX OF SURPRISE CHARACTERISTICS Interpretation of Situation Opportunity Threat Systems Dynamics 1 2 (unknowable) Ignorance (unknown) 4 3 surprise as inevitable is highly disconcerting in an environment where the risk seems so great. In our search for preventing surprises or for learning from mistakes, we either look for small wins in the face of large-scale problems26 to motivate consn‘uctive action and avoid possible complacency, or we concen— trate on small losses and failures27 that draw attention and induce learning. The underlying assumption is based on a negative View of the unexpected as threat or error with prevention as remedy.28 With this narrow view, health care managers emphasize predicting the future and concentrate on collecting as much data and as many facts as are possible about the present and the past in the belief that this will enhance their ability to predict the future and through that prediction to control the future. If the future does not meet expectations, data about the present and past are assumed to be flawed and managers engage in even more information collection so the next time around they will not be caught off guard.29 Sometimes the rapid speed of change in health care is blamed for the inability to predict what is going on. We assume that we would not be caught by surprise if we could just keep up with the pace, and we often try to solve the problem with faster computers or other strategies for speeding up responses to events. Or we see the overwhelming amount of information we are asked to consume as the surprise-generating culprit and we fall back on satisficing as a strategy for coping.30 Avoiding the unexpected is the master safeguard in the traditional View, a signpost for being in charge and in control.4 Managers in health care organizations feel a strong need to dominate, control, arran e, program, and organize disarray until it is tamed. Rules and order, guidelines and prescriptions, are constructed and maintained. What we "all know to be the case”— the “ordinary”—is accomplished. What we daily think and believe to be the case is created. Manage- ment—as a belief and managers as believers—plays a big role in producing ”normalcy” and/ or “positive reality.” Laws, rules, and regulations—methods and procedures—are erected around our minds to pre— vent chaos and difference from invading. Indetermi- nacy and uncertainty are thought of as undesirable. They are unavoidable ”problems” that the health care system must deal with. A preoccupation with failure and correction of error causes us to miss the possibility that surprise may be an opportunity. Surprise triggers defensive thoughts of ”How can we fix this? How can we make this not happen?" Surpnse, Surprise, Surprise! A Complexity Science View of the Unexpected 269 instead of creative images of “What can we build out of this?" SURPRISES lN THE CAS VIEW—EQUILIBRIUM PASSE Health care organizations are complex adaptive systems.32 When we recognize this, we are able to see health care organizations in new ways and, thereby, to develop new approaches to managing them. Complex adaptive systems (CAS) are composed of a number of agents interacting over time. These interactions are fairly rich, nonlinear, and usually over a fairly short range although the influence can be over a long range. CAS may operate under conditions far from equilibrium and are able to self-organize and adapt their structure when necessary. The properties of CAS are emergent and, therefore, cannot be determined simply by examining the properties of system’s elements. These circumstances lead to a fundamental unpredictability for the trajectory of the system and, therefore, fundamental unknowability of future systems states?"35 Insights from complexity science show that the natural state of things is not a state of equilibrium. New opportunities are always being created by the system. And that, in turn, means that it's essentially meaningless to talk about a complex adaptive system being in equilibrium: the system can never get there. In fact, if the system ever does reach equilibrium, it isn’t just stable. It’s dead.33 Health care organizations, seen as complex adap- tive systems, are not equilibrium seeking, they are continuously emerging and change is a natural state for them.36 They are always unfolding, always in transition, and this is their strength. Randomness and complexity often lead to robustness and stability, even in biological orocesses such as the random fluctua- Surprise is not a function of ignorance, or at least not only a function of ignorance, and acceptance of this fact leads to a focus on understanding phenomenon rather than being able to precisely predict what will go on. tions in interbeat intervals necessary for healthy hearts.7 The question is no longer one of individuals' intelligence or computer-processing power, but of co-evolution and flexibility in adapting to an ever- changing environment. The problem is not one of speed, but of unknowability. It is no longer critical to know if the system is deterministic or nondetermin- istic because even simple determinant systems can be unpredictable. Surprise is not a function of ignorance, or at least not only a function of ignorance, and acceptance of this fact leads to a focus on under- standing phenomenon rather than being able to precisely predict what will go on. This understanding renders the idea of learning from mistakes much less useful because while unexpected events are often characterized as mis- takes, mistakes are possibly the result of unknow- ability. When we take the unknowability of the world seriously, blame and finger pointing have no target, and mistakes take on a different meaning. Edmond— son,37 in reporting on efforts to learn from mistakes in a hospital setting notes that more error reporting offers more opportunity to learn. Interestingly, better- run hospitals make more mistakes or, better said, report more mistakes. Edmondson suggests that when reporting of mistakes is encouraged, learning opportunities arise. Reframing of the unexpected as a positive event—or at least one that is not entailing punitive consequences—can help prevent negative emotions3 that "are likely to occur when an organ- ized behavioral sequence is interrupted unexpectedly and the interruption is interpreted as harmful or detrimental.”3s(P 47) How managers describe unexpected events impacts system responses and, therefore, how surprise is viewed and appraised have consequences for how it is responded to: “Word choice in usage delimits possibility space and helps to determine the adjacent possible. Thus, it is an active process with real consequences and not just a symbolic toy."39(P'122) When the managers of health care organizations recognize the inevitable unpredictability of the unfolding of CAS over time, ”surprise” takes on a different meaning and thus results in different kinds of responses and possibilities. For example, if the assumption is that the surprise happened because of the lack of sufficient information or speed, our response is likely to be a cry for bigger and better computers and more data collection; if bounded rationality is assumed to be causing the surprise, we 270 HEALTH CARE MANAGEMENT REVIEW/JULY—SEPTEMBER 2003 will ask for more care, more vigilance, while pointing our fingers in search of who is to blame. However, if the assumption is that surprise often arises as the result of the fundamental unknowability of the world, we open the door for creative, innovative approaches without the mark of blame and failure. We change our relationship with the unexpected and resilience becomes a quality that is essential for effective management. Surprise seen negatively (as error) often leads to a search for reliability whereas surprise seen positively (as opportunity) can lead to a search for new approaches to situations. “You have a system exploring its way into an immense space of possibilities, with no realistic hope of ever finding the single 'best’ place to be. All evolution can do is look for improvements, not perfection."33(P'167) SOURCES OF SURPRISES Sources of surprise are twofold. We tend to under- stand surprises that come from ignorance and bounded rationality (cells one and two in Figure 1) but the forces of fundamental uncertainty that are sources of surprise are much less often understood (cells three and four in Figure 1). In this article, we explore five characteristics of organizations as com- plex adaptive systems that lead to the fundamental unpredictability in the unfolding of CAS over h'me. Unfolding trajectories, bifurcations, self-organization, emergence, and co-evolution are sources of the unexpected because of the unpredictability created by nonlinearity in the system. This fundamental unpredictability changes our focus and leads to different conclusions on what to do with surprises. It should be noted here that a sixth source of fundamental uncertainty is the quantum nature of the world where measurement problems and relationship issues lead to unknowability. We recognize the validity of quantum uncertainty at different scales— even cosmologists take into account the Heisenberg principle‘m—but we are going to focus on CAS as an idea that is accessible to managers of health care organizations, who are themselves part of the non- linear nature of the system. Trajectories We most often hear about unfolding trajectories in terms of Chaos Theory through which it has become well understood that systems with even an infinites- imal amount of uncertainty in their initial conditions are likely to exhibit unpredictable behavior. ”Sensi- tivity to initial conditions means that the trajectories corresponding to two close initial conditions separate exponentially in time.""‘1(p 7) Sensitivity to initial conditions is not the only source for unpredictability in the unfolding trajectories of systems. CAS behave the way they do because of nonlinear interactions, including positive and negative feedback. The results of these interactions cannot be predicted, therefore, neither can the unfolding of the system.42 CAS also are time dependent; the direction they take at any given point is a function of the system’s previous behavior, however it is not possible to predict the direction a system will proceed by observing its history.4‘°""'4 An example of an unpredictable trajectory is in the path that is taken in a merger of two hospitals. This is hardly ever smooth riding. A surprise that often results is unexpected turnover in the executive team, as a product of realignments created by the merger. This may mean that the talent that you expected to have to carry out the merger is not available. Bifurcations A bifurcation is a “symmetry breaking transi- tion/45mm usually occurring as a result of changes in the value of parameters. At the bifurcation point, the point of ...
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