Little Hope:
How Common Sense Thinking Can Lead to a Mess
Plenary Address for IHI’s 12th Annual Forum
on Improvement in Healthcare
San Francisco, December 8, 2000
Paul Plsek
Paul E. Plsek & Associates, Inc.
Roswell, GA
paulplsek@DirectedCreativity.com
770-587-2492
Senior Fellow, Institute for Healthcare Improvement
pplsek@IHI.org
The Church of Little Hope, Texas
I was born in Texas. But earlier this year, as I was driving outside Dallas, I came across a spot
that I did not know existed. The road sign clearly declared that I was entering the place of…
Little Hope. No kidding. That’s what the sign says.
What had caught my attention and caused me to come down this road was this sign: “The Church
of Little Hope Welcomes You!?!” Now, wouldn’t you think that one of the deacons might
suggest a name change?
It’s a good thing they don’t have a hospital in town. Imagine waking up after an accident and
finding out that you’re in The Hospital of Little Hope!
Little Hope: Stories from Healthcare
But, seriously, I am becoming increasingly concerned that just maybe there actually is a Hospital
of Little Hope... a Group Practice of Little Hope… an Integrated Delivery System of Little Hope.
Some of you may even work there.
Let me illustrate what I mean…
I have a monthly conference call with a small group of wonderful health care senior leaders.
Recently, one of the members was describing a bad situation where, due to political corruption
and general mismanagement, the local public hospital’s ER was headed for closure. This would
have a disastrous ripple effect; very bad for the under-served.
The focus of our discussion was on what he and his organization might do to soften the blow
through better advanced planning. But everything I or others suggested was met with a reason
why it couldn’t be done. It was the most frustrating conversation we had ever had as a group of
friends.
© 2000 Paul E. Plsek & Associates, Inc.
1
IHI Forum 2000 Plenary
Finally, another member said, with a little laugh in his voice, “Paul, you don’t understand, this
situation really is hopeless.”
It succeeded in breaking the tension. We laughed and moved on.
But that public hospital’s ER will probably close in 2001. It probably will be a disaster for the
under-served in that area. And the leaders in the middle of it all are convinced that there is
nothing anyone can do about it.
They just might be the Hospital of Little Hope.
And this is not an isolated case. On the trip that brought me to Dallas and eventually to discover
the Church of Little Hope, a healthcare consultant friend told me that many of the so-called
integrated health care systems he works with have reverted to simply managing a bunch of
separate assets. They’ve given up any hope at all of realizing the promises of integration.
How Current Common Sense Thinking Can Lead to a Mess
I could tell you dozens of similar stories. It seems to me that in healthcare these days we are more
often finding ourselves in somewhat of a mess.
The hopeful news is I think I’ve identified the culprit that brought us to this point. It’s…
Common sense.
No, really. I am convinced that it is our current “common sense” that is leading us into a mess
and the sooner we come to grips with that the better off we’ll be.
Let me ask you this. Don’t the following statements make sense to you? Aren’t they, in fact,
common sense thinking these days in health care?

Most of the problem lies with the system, rather than the worker. The system is
management’s responsibility. Management needs to fix the system. Common sense!

Leaders need to resolve the “great debates” (for example, centralization versus
decentralization) that are consuming so much of our time and energies. Here, here!

We must overcome resistance to change. Of course!

You need a detailed plan to guide a large change effort. Well, yeah, that’s common sense,
isn’t it?
Don’t these statements represent exactly how we need to think in order to get out of a mess?
As I have traveled, read, and thought over the last several years I have become convinced that the
answer to that question is emphatically “No!” On the contrary, I now believe that these—and
other statements like them—are exactly the sort of common sense that has brought us to where
we are.
What we need is a new common sense.
© 2000 Paul E. Plsek & Associates, Inc.
2
IHI Forum 2000 Plenary
Today, I want to shake your confidence in the current common sense. Specifically, I want to peel
back these four statements and rearrange your thinking. I want to propose some new common
sense.
The Science of Complexity
The basis for my boldness in suggesting a new common sense comes from breakthroughs in our
understanding of complex systems. I won’t go deeply here into the details of this scientific
revolution; the books and articles by Waldrop, Capra, Kauffman, and Goldberger in the
“Complexity Science” bibliography in the handout (attached) will help you on your learning
journey. Suffice it to say that in fields as diverse as physics, biology, economics, cardiology, and
computer science, we are learning more about the nature of complex adaptive systems.
Here is a text book definition of the sort of systems I am talking about…
Complex Adaptive System:
A collection of individual agents, who have the freedom to act in ways
that are not always totally predictable, and whose actions are interconnected
such that one agent’s actions changes the context for other agents.
In a complex adaptive system, the parts are not in isolation. They interact and change in response
to the environment.
Take the human body’s immune system, for example. It’s a complex adaptive system. The
“agents” in this system include white blood cells and various other chemical substances in the
body (the “good guys”), along with germs, viruses, and bacteria (the “bad guys”).
The drug companies are also agents in this particular complex adaptive system. They find new
chemical substances to help the good guys fight the bad guys.
These agents all interact with one another. For example, the drug companies study the bad guys
and develop a new antibiotic. This helps the good guys in the body fight-off the bad guys. The
goal, of course, is an overall change in the performance of the system—to a state of better health.
Isn’t that exactly what we are often trying to do as organizational leaders—study the parts of the
system, isolate the right interventions, and move the system on to better performance? That’ll fix
it. Right? It’s just good common sense; the way the world works. Right?
But, of course, we actually know better. Specifically, in the human-body immune system
scenario, what happens after repeated use of an antibiotic in the population? The bacteria change!
It turns out that the bacteria adapt to the new environment. Strains develop that are not handled by
the once-effective antibiotic. In the end, what we thought was the once-and-for-all solution to the
problem turns out to give rise to an even bigger emerging problem, antibiotic resistant organisms.
Has anything like that ever happened to you in your organization? What you thought was a
wonderful solution—for example, buying up physician practices—turns out to produce a
seemingly worse situation as the elements of the system respond and change through interaction?
Of course it has. Like the human body immune system, a flock of birds, or the stock market, our
organizations are complex adaptive systems.
© 2000 Paul E. Plsek & Associates, Inc.
3
IHI Forum 2000 Plenary
Our Understanding of Complex Systems
The scientists who study such systems are beginning to paint a more coherent picture of how the
world really works. It is not always as simple as our current common sense might tell us it should
be. For example…

We now know that in complex systems the elements of the system can change themselves.
Change does not have to be imposed. In fact, imposing change may lead to further
adaptations that we would not be happy to see.

We now know that in such systems, complex outcomes can emerge from a few simple rules.
Our current complex plans may actually be stifling the creativity and innovation we seek.

We know that complex adaptive systems behave non-linearly. Small changes can have big
effects and large changes may have no effect at all. We may not need a big intervention to
bring about a big shift in performance of a system.

We now know that complex systems actually thrive on tension and paradox. For example the
predator and the prey in an ecosystem actually depend on each other for mutual survival. We
may not need to resolve the seemingly paradoxical or upsetting aspects of our organizational
life.

We know that complex systems exist on the edge of chaos, a region of only moderate
certainty and agreement. That may feel a bit disconcerting, but that is exactly where the
creativity and innovation that we so desperately need will occur in our healthcare
organizations.

And we now know that complex systems are parts of larger complex systems, and are made
up of smaller complex systems. Leaders cannot take up a post outside the system. Imagining
that you can, may lead you to do exactly the wrong things.
I am enthusiastically hopeful for the future precisely because I now see a new common sense
emerging around us, based on this new understanding of how complex systems really work.
So, now let me return to those four statements of current common sense and see how they might
be restructured based on a better understanding of how complex systems really behave. Let’s start
with the first one.
Common Sense About Management’s Role Versus 15%
***********
Current Common Sense: Most of the problem lies with the system, rather than the worker. The
system is management’s responsibility. Management needs to fix the system.
***********
Over the past few years as I have traveled around I have begun rearranging my understanding of
this bit of common sense from W. Edwards Deming. Now, I’m not saying that Deming was all
wrong. I’m bold, but not that bold.
© 2000 Paul E. Plsek & Associates, Inc.
4
IHI Forum 2000 Plenary
Deming’s original notion was, itself, a reframing of the prevailing common sense of his time.
There was a time when quality was thought to be totally attributable to the worker. Got a quality
problem? Then you’ve got a worker problem. Find and fix that worker. It was just common sense.
Deming and others labored mightily to craft a new common sense. We now understand that every
system is perfectly designed to deliver the results it gets. Performance lies largely within the
system, not in the individual workers. That’s a common sense I’d like to encourage you to keep.
The problem with this bit of the current common sense lies in where we seem to have placed
management. Management is seen as bigger than the system; somehow outside the system.
Capable of diagnosing and fixing the system, as a mechanic does a car. I’m now convinced that
that is a misguided notion.
Complex systems science teaches us that we are all “within” or “of” the system. Imagining that
you are bigger than, outside of, or somehow rising above the system is nothing but a delusion of
grandeur. And, really, don’t we know that.
I could tell you dozens of stories of CEOs, medical directors, department heads and others who
are frustrated over their inability to impact the system that they are supposed to be fixing. Current
common sense notwithstanding, our common experience tells us that even we leaders don’t seem
to have much control over the system.
I first came upon this issue when I had the pleasure of learning with Professor Gareth Morgan, an
organizational theorist at York University outside Toronto. Gareth totally reframed for me
Deming’s original teaching that 85% of the issues are in the system and only 15% are under the
control of the workers.
Gareth points out that since we are all embedded within a complex system, every one of us really
has only about a 15% influence over the system; workers and managers alike. Of course,
different individuals have different permissions and skills that influence just where in the system
lies their particular 15%. But no one, according to Morgan, has much more than about a 15%
influence.
If you are the CEO, you have your 15% influence. Hopefully, what you say carries a bit more
weight than what an entry-level employee says. But you know that you are no Jean Luc Picard of
Star Trek who can just say, “Make it so!” and it is so. Oh, of course, there are simple issues that
management should and does take full responsibility for, but I suspect that those are not the issues
that keep you up at night.
The notion that managers must fix the system is better than the older notion that workers are to
blame, but it is still wrong in emphasis. Management alone cannot “fix” many of the complex
systems that we deal with these days.
The only really sensible thing for anyone within the system to do is to work on the 15% that they
can influence. See yourself as within the system. Do your 15%. And importantly, find ways to
enable others so that they can do their 15%.
The Story of Mara Zabari. Mara Zabari is a nurse manager at the Providence St. Vincent’s
Hospital in Portland, Oregon. She is a great example of a leader who intuitively understands this
idea of working on the 15%. Mara heads the “NICU”—the neonatal intensive care unit—that
© 2000 Paul E. Plsek & Associates, Inc.
5
IHI Forum 2000 Plenary
happens to be a part of an improvement collaborative that I facilitate through the Vermont-Oxford
Neonatal Network.
Due to the closure of another hospital, Mara’s NICU has grown in just four short years from an
average daily census of only 1 or 2 relatively low-intensity infants, to about 30 infants daily
across the full spectrum of intensity.
When the other hospital closed, the highly skilled nurses who cared for these tiny infants had to
transfer to Providence St. Vincent’s. And when they did, they came in at the bottom of the union
seniority ladder. That meant working the night shift. Those transferred nurses were
understandably bitter.
Yet, despite all that turmoil and hard feelings, the Providence St. Vincent’s NICU consistently
scores among the top centers in our network on a variety of standardized measures of both
clinical outcomes and organizational culture.
One of the secrets, it turns out, is that the leader, Mara Zabari, understands that she cannot fix the
system herself. She is within the system; a part of it like everyone else. Mara understands that her
15% involves creating the climate and enabling others. And, she fully trusts that the system is
capable of evolving itself. When I asked her what the most important thing was that she had
learned over the past four years, without hesitation she said, “Never underestimate what people
are capable of doing.”
For example, one of Mara’s simple rules is that all meetings are open meetings. If any member of
the NICU sees a problem or wants to raise an issue, he or she can do that.
But then there is her other simple rule. If you raise an issue, you have to actively participate in its
resolution. She tells me…
“I find that the best person to go after an issue is the one who feels most passionate about
it. And because everyone knows that you cannot bring up an issue unless you plan to
actively participate in its resolution, we don’t get a lot of petty gripes or other things that
can waste a lot of organizational energy. Time and again, I have been amazed at how
much of themselves a person will put into something that they believe enough in doing.”
And this is in a unit full of people who could have very easily turned out to be bitter, angry,
clock-punchers. Instead, together, they created a system in the NICU that consistently achieves
great clinical outcomes and high scores on standardized measures of unit culture.
Now, if you think I am just using a different language to talk about “empowerment” you’ve
missed my point completely. I don’t even like that term. Underlying it often is the notion that
power has been rightfully held somewhere outside the work-system—by management—but needs
now to be dispensed in small doses to the workers because organizations have just become too
large for the manager to keep up with. That is simply not true in an evolving, growing complex
adaptive system. The power to change the system—or to hold it at status quo—is inherently
distributed throughout the system. If you have ever tried to dictate a change in a complex system
you know exactly what I am talking about. Our illusion of centralized power and control in a
hierarchy has led us into a mess and is continuing to stifle the innovative thinking we need to
evolve beyond the mess.
So, I propose a new common sense. Management cannot fix the system. But maybe if you use
your 15% influence wisely to create the right conditions, and if you truly trust others to use their
© 2000 Paul E. Plsek & Associates, Inc.
6
IHI Forum 2000 Plenary
15%, the system will evolve and grow in ways you could never have planned. Maybe you’ll have
a system that outperforms others even though you started from a dreadful beginning, just as they
did at Providence St. Vincent’s.
© 2000 Paul E. Plsek & Associates, Inc.
7
IHI Forum 2000 Plenary
Common Sense About Great Debates, Paradox, and Dilemma
***********
Current Common Sense: Leaders need to resolve the great debates (for example, centralization
versus decentralization) that are consuming so much of our time and energies.
***********
Let’s look now at the second item on our list of current common sense statements.
Ah, The Great Debates! You know the sort of things I’m talking about. Should we centralize
services such as Scheduling, Admissions, and Radiology, or should we decentralize? Physicians
as employees versus physicians as independent businesses. There are dozens of such issues.
If ever we had the need for a leader, the current common sense tells us, it is for one who can
finally resolve these debates so we can move on, once and for all. We have gone back and forth
on these dilemmas long enough. We need leaders who can finally bring stability on such issues.
Right?
Sorry, I don’t think so.
In his book The End of Certainty, Nobel Prize winning chemist Ilya Prigogine makes the point
that all complex, living systems depend on instability, paradox, and tension. The only truly stable
state in life… turns out to be death.
On-going, unresolved dilemma is the very nature of a complex adaptive system. The scientists
who study such systems tell us that they exist on the “edge of chaos.” While it may seem to our
common sense of today that our failure to resolve the Great Debates is maybe what got us into a
mess, complexity science tells us that living with unresolved paradox may actually be a path out
of the mess.
Author Barry Johnson illustrates paradox, dilemma, and Great Debates on a 2-by-2 matrix that he
calls a “polarity map.” The two “poles” of a debate are the column headings of the matrix; the
plus points for each side are stated in the cells in the top row, with the minus points in the cells
along the bottom.
Johnson notes that in the typical Great Debate, each side points out the plus points of its favored
pole, and the minus points of the other pole.
“I think we ought to centralize our scheduling clerks. As it is now, we have different
scheduling systems that don’t talk to each other. Centralization would be much more
efficient.”
“But patients don’t want to talk to some scheduling clerk in a phone center. They want
someone who is right there in the office.”
And so on it goes. The typical Great Debate presents us with an either-or choice that creates an
“X” on the polarity map. The point lies in realizing that, instead, what we should want are the
plus points of both poles, without the minus points of either—a circle in the top row.
Now, that gives us a new common sense about the Great Debates and dilemmas we face.
© 2000 Paul E. Plsek & Associates, Inc.
8
IHI Forum 2000 Plenary
Let me give you two quick illustrations, followed by a third in the form of a wicked question.
At a leadership retreat that I facilitated for a health care organization, there arose a chronic
dilemma around patient satisfaction with the hospital’s visiting-hours policy. Patients and
families complained regularly that the visiting hours were too restrictive. But, you see, this was
an inner-city hospital and every time someone proposed more liberal night-time visiting hours,
someone else would raise concerns about security. It was either open-visiting for family
satisfaction or security for the safety of staff and other patients. And so had gone the Great
Debate, literally for months, within this organization.
“How about ‘secure open-visiting’?” I asked. Apparently, no one had ever framed it that way
before; as a both-and question. It had only been discussed as an either-or choice.
It didn’t take them long to come up with several creative approaches under the new heading of
“secure open-visiting.”
Now, I know what you’re thinking. As the kids say, “Well, duh!” Of course, it is now obvious
from the outside looking in that they should have explored “secure open-visiting” long before.
But that is exactly my point. They didn’t even think to explore it.
These were not stupid people. They were good, well-intentioned leaders and managers just like
you or I. They were simply doing what the current common sense tells us we should do: resolve
the dilemma, settle the argument. We all face similar choices in our own organizations. We
literally do not see the both-and choice until someone points it out to us. Our current common
sense does not lead us naturally in that direction of thinking.
Story number two involves a wonderfully caring organization faced with a terrible choice—the
expansion plans for the Radiology Department would eliminate Sister Eileen’s gift shop. You see,
Sister Eileen—that is a fictitious name—was legendary for her tireless devotion to her mission of
service to patients and families. Allowing Radiology to take over Sister Eileen’s space would
send a terrible message.
This debate went all the way up to the Board, who eventually decided in favor of Sister Eileen
and the gift shop. Although they recognized the inefficiencies, Radiology would have to be
broken up over disconnected space.
You have probably faced similar tough choices in your organization. But that’s why leaders get
the big bucks, isn’t it? In this case, the message of service and mission just had to win out over
the ambitions of the director of Radiology. Common sense! It was the right choice, wasn’t it?
It was a wholly unnecessary choice, if you ask me.
I look forward to the day when common sense points even the most junior leader among us
naturally in the direction of both-and, instead of either-or. “How could we both expand Radiology
and make Sister Eileen’s service mission even more visible?” It doesn’t take much more than
simply posing the question. Almost as soon as you say it, creative possibilities spring to mind.
So simple, yet so uncommon.
© 2000 Paul E. Plsek & Associates, Inc.
9
IHI Forum 2000 Plenary
And now, here’s that wicked question for you to ponder. What might have happened in healthcare
if only we had not believed a year or two ago that we had to choose between physicians as
employees, or physicians as independent practices? What if, instead of buying physician
practices, we had sought instead to hold open the paradox and find innovative ways to get the
plus points of both physicians-as-independent-businesses and physicians-as-employees?
We didn’t do that because the current common sense tells us that holding open an unresolved
dilemma is not what a strong leader should do. Buying physician practices was held out as a bold
new strategy; health care’s great hope. It has instead turned out instead for many to be a bit of a
mess.
And so it will be for all of the great debates and dilemmas that we try to resolve. Should we be
visionary or practical? Big and regional, or small and local? Do we seek stability or change…
cooperation or competition?
Healthy, living, complex systems actually thrive on such questions and the dynamic tension that
they create. Seeking to resolve them once and for all actually creates a hopeless mess.
That may be hard to swallow for those steeped in the current common sense. It is just the natural
reality for the pioneers of a new common sense.
Common Sense About Resistance Versus Attraction
**************
Current Common Sense: We must overcome resistance to change. (It’s a battle out there!)
***************
Let’s turn our attention now to the third item on our list of statements of the current common
sense.
One of the most exciting ideas in complexity theory is the concept of attractors. Author Jeffery
Goldstein, says that the notion of attractors turns upside-down the notion of resistance to change.
Of course, the pattern of behavior that we label resistance is real. But what Goldstein is saying is
that the label “resistance” is not helpful. Resistance implies that we need to be in battle with the
system and the people in it.
Instead, we now know that the dynamics of a complex system follow attractor patterns. For
example, in human psychotherapy, it has long been known that clients are more likely to accept
the counselor’s advice when it is framed in ways that enhance the client’s core sense of
autonomy, integrity, and ideals. These are underlying attractor patterns within the complex and
ever-changing system of a person’s detailed behavior.
In complex systems, nothing is resisting anything. The issue is not how to overcome resistance,
but how to work effectively at the level of the natural attractors within the system.
Tossing a Rock versus Tossing a Bird. Let me illustrate this concept with a metaphor proposed
by British biologist, Richard Dawkins, who asks: Do you know the difference between tossing a
rock and tossing a bird?
© 2000 Paul E. Plsek & Associates, Inc.
10
IHI Forum 2000 Plenary
Suppose I am holding a rock and I want it to “change.” I want it not to be in my hand, but, instead
over there on the corner of the stage. I judge the weight of the rock and the distance it needs to
cover, then launch the rock on its way with a toss at some velocity and angle. “Change” in this
rock-system is all in the toss. Once you launch it, the rock can only end up in one place. That
place, and the path to it, can be determined in advance with mathematical precision.
In contrast, “change” in tossing a bird has very little to do with the launch. No matter how much
attention you put into the launch, the bird goes where it wants. I can say that the bird is
“resisting” my attempts to get it to go to the corner of the stage, but that’s not very helpful.
Here is the key question: Is leading change in your organization like tossing a rock? Just launch
the change correctly and with almost mathematical precision the organization will go where you
expect it to go?
Or, is change in an organization more like tossing a bird? For all the effort we put into trying to
launch the change correctly and lay out its detailed path in advance, the complex adaptive system
that is the organization follows its own path.
Clearly, we are in the business of bird tossing.
But I’m the leader and I really do want the bird to change its position and end up on the corner of
the stage. What can I do?
I know what some of you are thinking… I could kill the bird, or knock it senseless, or tie up its
wings so that it becomes like a rock, and then toss it. An organizational leader would never do
anything like that, would she?
If I really do want the bird to end up in a certain place, I need first to understand what might
attract it there—some birdseed, for example.
We know something about the complex adaptive system that is the bird. A lot of seemingly
complex bird-behavior revolves, rather simply, around a pattern of seeking birdseed. If I
understand this about the system, then I can take action that links this natural attractor pattern (the
pursuit of birdseed) to the change I advocate (land in that spot, please).
Likewise, I am now convinced that success in organizational change is not so much about how
we launch a change, and then direct it down a pre-determined path in the face of resistance.
Rather, success lies in the attention paid to understanding the natural attractor patterns that
already exist within the system.
What we have been labeling “resistance” all these years is actually a natural, but potentially
changeable, reaction of a system attracted to something else. The new common sense suggests
that if we understand the attractors, change becomes much more natural.
Some pioneering leaders in healthcare are already practicing this new common sense based on
understanding attractor patterns. Let me give you two quick examples from IHI’s Idealized
Design of Clinical Office Practice project.
The Roger Resar Story. Roger Resar is a wonderful physician leader in the Luther-Middlefort
Mayo Health System. He tells of an office assistant who was resistant to the proposed change to
open access that would offer same-day appointments to patients and dramatically reduce the
© 2000 Paul E. Plsek & Associates, Inc.
11
IHI Forum 2000 Plenary
booking of future appointments. You see, this office assistant had an attractor pattern of comfort
associated with the existing scheduling process, chaotic though it was, because she understood it
so well.
Rather than simply labeling her a “resistor,” Roger engaged her in a friendly conversation about
the most appealing and unappealing aspects of her job. One prominent dislike was the process of
having to call dozens of patients to reschedule appointments when the doctor was called away for
a day. When Roger pointed out that the open access system would virtually eliminate the need for
this activity, the assistant became actively attracted to the new idea—the same idea that she was
seen as resisting just moments before.
The attractor pattern remained the same throughout—comfort. However, where before the
assistant saw the change as in conflict with the comfort attractor, now the proposed change was
linked to that same attractor. She apparently quickly weighed the two options and decided that the
comfort of avoiding the cancellation calls was more valuable than the comfort of the current
scheduling approach.
The Gordon Moore Story. Gordon Moore, at the Strong Health System in Rochester NY, is
another physician leader already practicing a new common sense. Gordon needed to select two
sites to send to IHI’s Improving Clinical Office Practice collaborative. These two sites were to
serve as the pilots for further spread within his organization.
As in most organizations, the usual process for selecting sites to participate in such initiatives was
political in nature—identify representative practices and make sure that everyone has equal
opportunity to share in the perks of participation. But, instead, Gordon sent out invitations to all
1100 physicians within the system, asking those with interest to contact him and schedule an
interview in just a few days. While several sites complained that this was too short notice,
Gordon’s goal was to identify sites with a certain attractor pattern. He was looking specifically
for sites that were ready to embrace change, with urgency. Two sites were selected and went on
to be very successful in getting to the point of offering same day appointments, dramatically
increasing patient volumes and satisfaction.
In planning for internal spread, Gordon further tapped into the potential attractors for the
physicians in other clinics. In addition to reporting the improved performance results (which, of
course, are attractive), his message was…
“We have found a way to make life less miserable; we’re practicing smarter, not harder;
our staff are happier; our patients are happier; we’re providing better care; and our
finances have improved.”
Do you see here how Gordon is also tapping into two common attractor patterns among
physicians: desire for a more-hassle free lifestyle and desire to focus on professional practice
rather than perceived peripheral issues such as financial and human-resource management?
The old common sense tries to roll out change across an organization with a precise, predetermined plan; courageously battling resistance all along the way. But Gordon is demonstrating
a new common sense about spread that relies on understanding and tapping into natural patterns
of attraction.
Common Attractor Patterns. As these examples illustrate, there are a variety of things that we
might identify as attractors in complex social systems. While we should, of course, avoid
© 2000 Paul E. Plsek & Associates, Inc.
12
IHI Forum 2000 Plenary
stereotyping and over simplifying, there are some common attractor patterns that we are likely to
see in our work in health care. For example…









Better performance
Stories of direct impact on patients
Professional autonomy and choice
Appeal to social values
Scientifically generated evidence
Self-image as a scientist
Comfort
Personal status among peers
The views of opinion leaders
Of course, many of these complex social-system attractors have been described by Everett Rogers,
Jonathan Lomas, and others. I am not claiming that complex systems science provides a neverbefore-seen insight. Rather, I am pointing out that complexity science provides a unifying,
scientific base on which to organize these empirical observations of the past and build a new
common sense. Appealing to attractor patterns is not just some “touchy-feelly” new management
style. It is a sound, scientifically-based action in a complex adaptive system.
Failure to tap into attractors like these may explain some of the current health care mess. Take the
second one, for instance; stories of direct impact on patients.
You can see “stories of direct impact” clearly in the recent Firestone tire debacle. Weren’t you
outraged about that? There was an enormous public outcry. We all demanded immediate action
because we could all see the direct impact on people’s lives.
But wait a minute? How many people were killed or seriously injured on those Firestone tires?
150 or so? Compare that to the safety situation in health care. While some have argued about the
estimates that appeared in the IOM report, I don’t hear anyone arguing that the number is less
than the 150. Yet, where is our outrage?
We have successfully spread the dry statistics and technical change concepts about adverse events
and harm. But we have failed miserably to spread the emotional stories of the direct impact on the
lives of patients that is needed to tap into this attractor and actually bring about real change at the
pace that it should be coming. Story telling becomes a scientifically-based action when we
understand our organizations as complex adaptive systems.
Those of you who have participated in some of the recent patient safety initiatives that IHI has
sponsored have seen some of the excellent case-study video tapes that are now available that
really connect with the reality of the impact on both the patient and the health care worker.
Tapping into this attractor pattern creates the resolve we need to get moving.
I have similar feelings around that fourth attractor pattern: appeal to social values. Nearly
everyone I know tells of his or her original decision to go into healthcare as one that reflects this
attractor. That is, they went into healthcare because they cared, because they wanted to make a
real difference.
I can assure you that if you create change that really touches this attractor, you can find people
who are more than willing to change. I’ve seen it happen many times in many places. Let’s stop
© 2000 Paul E. Plsek & Associates, Inc.
13
IHI Forum 2000 Plenary
labeling others as “resistors” and start providing much more real opportunity for everyone to
experience change that reconnects them to why they came to healthcare in the first place.
Finally, you may have noticed I don’t have money on the list. Monetary incentives are often
cynically cited as a strong attractor that motivates others. But after reviewing the results of
hundreds of studies, author Alfie Kohn concluded several years ago—as did Peter Drucker,
Henry Mintzberg, and others—that money is greatly overrated as a motivator. Of course, money
can serve as a surrogate for the attractor of status. But before you think cynically about those
around you, just ask yourself this: If I personally did not believe that a change was right, would I
do it anyway just because they paid me?
Let’s stop thinking about battling resistance to change. Sure, the behavior that we give this label
to is real. But the label is negative and energy-draining. It is not helpful and it does not often lead
to constructive action. I know it is current common sense and common usage. But it is not serving
us well.
We need instead to develop a new common sense built on the concept of attraction. It’s not a
battle out there. It is a dialogue out there. It is not “they don’t understand,” it is “we may not have
really understood who they are.”
Common Sense About Detailed Plans Versus Simple Rules
**********************
Current Common Sense: You need a detailed plan to guide a large change effort.
**********************
Now to our fourth common sense statement.
If you were at the Forum last year in New Orleans, you’ll remember this scene. This is the final
bridge across the deep and wide, Mighty Mississippi River. It was just beyond the conference
hotel.
This is the first bridge across the Mississippi River. It’s literally a 4x4 plank. You can cross it in 5
steps. And if you don’t want to take the bridge, you can always just wade across the river. The
water is so shallow you won’t even get the hem of your shorts wet. This is how the Mighty
Mississippi begins at Lake Itasca near Bemiji, in Northern Minnesota.
There is simple beauty in northern Minnesota where the Mighty Mississippi begins its journey
towards draining most of the eastern United States. And I’d like to take that as a metaphor to help
us explore the final item on our list, and another aspect of what I am calling a new common sense.
Today, it is common sense to understand that complex organizations and changes require equally
complex planning. But I propose a new statement of common sense. Complex organizations and
changes can emerge from simple beginnings and simple plans.
Under what I am suggesting as a new common sense, intricate roll-out plans for change would be
replaced with a good-enough vision, momentum to get something started, and simple rules to
guide the way forward. Let me take you through each of those three items.
© 2000 Paul E. Plsek & Associates, Inc.
14
IHI Forum 2000 Plenary
Good enough vision. I was up in Portland a few months back working with a really great set of
senior leaders in Kaiser Permanente. During the retreat, one of the leaders told me, with a straight
face…
“We have a new three-year plan… every six months.”
Everyone laughed. Why? Because common sense and logic dictate that we should only have a
new three-year plan every three years. The fact that we have a new plan every six months must be
a testimony to our inability to get it right the first time. Right? So, we laugh at ourselves. We’ll
try harder the next time to get it all figured out.
But don’t you see, that is all wrong!
You can never figure out totally, predict totally, a complex adaptive system. Remember these
properties… Small things might have large effect. The elements of the system can change
themselves and that might change everything. The system is embedded within larger systems and
composed of smaller systems; and they all interact.
Phil Knight, the founder of the phenomenally successful Nike shoe company, describes what I am
talking about when I say “good enough vision.” When asked by an interviewer how he
formulated the vision and strategy of Nike, he said simply…
“I can’t say we had a really smart strategy going forward. We had a strategy and when it
didn’t work, we went back and regrouped until we finally hit on something.”
The point is that in a complex system you can’t predict the future with a high degree of certainty.
A good enough vision of where we think we are going right now is good enough. Just pick what
seems to be a good direction and adjust as you go. Muddling through is not bad leadership, it is
actually common-sense leadership in a complex system.
Momentum to get started. We worry so much about how to start innovative things. We fret over
whether we are heading in the right direction. Get over it!
I learned a real lesson about this at the source of the Mississippi River in northern Minnesota. It
turns out that the Mississippi River actually flows north out of Lake Itasca, and continues in this
wrong direction for some 50 miles before finally turning south to its final destiny in New
Orleans!
The mighty Mississippi starts in a nondescript place, and then flows for quite a distance in the
wrong direction!
So why do we worry so much about figuring it all out and getting it all right when it comes to
initiating change in our organizations? We cannot figure it all out. We cannot get it all right from
the beginning. And, most importantly, we don’t need to. Just get started. You can figure it out as
you go.
Simple rules. At the same time, I’m not saying that it is all completely open ended. We do need
some framework and structure to guide us forward. That minimal structure can be provided by the
complex systems concept of simple rules.
We now know that immensely complex patterns can emerge from very simple underlying rules.
For example, this is a portion of a mathematical graph called the Mandelbrot set. This intricate
© 2000 Paul E. Plsek & Associates, Inc.
15
IHI Forum 2000 Plenary
and beautiful mathematical pattern is the result of solving this simple equation over and over
again.
We work with simple rules in complex social systems all the time. For example, an alien viewing
traffic patterns in a town would see an inexplicably complex pattern of movement. But we know
that all this complexity emerges from a relatively few simple rules regarding which side of the
road we drive on, what red and green lights mean, and so on.
Simple rules have also been proposed for complex systems in Nature such as bird flocking, gnat
swarming, fish schooling, and termite mound building.
The point is that it is easy to get discouraged when we face the challenge of change and
transformation in the complex systems of healthcare. Our common sense tells us to get our arms
around it. That leads us to attempt to craft complex descriptions of systems, complex structures,
and complex plans. But, don’t you see, that instinct may be just the thing that will lead us into a
discouraging mess.
If we understood what complexity science is telling us, we might instead seek simple rules as a
guiding framework forward.
Linda Rusch Example. Over the past several years, I have seen numerous examples of the use of
simple rules to guide complex systems of change in healthcare. But my favorite remains the first
one I ever heard. It involves my friend Linda Rusch, the Chief Nursing Officer at Hunterdon
Medical Center in northwest New Jersey. Linda is one of the many heroes of this new common
sense within a network led by another hero of complexity, Curt Lindberg.
Linda was frustrated with the nursing committee that she had formed to plan community outreach
initiatives for the hospital. After months of meetings and valiant attempts to figure out what
would be the best initiatives to launch, all she had was a pile of meeting minutes and frustrated
committee members.
So, Linda held a series of meetings with all the nursing staff in which she outlined a good enough
vision about why community-outreach initiatives were needed. She then gave all the nurses in the
hospital three simple rules:



Any nurse can take up to 1/2 day a week off to work on a community health initiative
outside the hospital.
Don’t do anything illegal.
Take the funds you need out of the limited outreach budget on your own approval, and
we will post it publicly so everyone will know what is happening.
Within weeks, Linda learned of 27 initiatives started by various nurses who wanted to do
something. Now there is a novel idea for you… instead of assembling a committee of nurses who
probably don’t want to be there, why not create conditions under which nurses who want to do
something, can just get on with it!
Of course, not all the initiatives were successful. But Linda reports that 6 of them “took on a life
of their own.” These received more organizational resources to grow even further. (Do you see
the organic language here; compared to the mechanistic image of committees, planning, and
design?) Everyone who stepped out and tried something was celebrated. Every attempt under the
simple rules results in learning.
© 2000 Paul E. Plsek & Associates, Inc.
16
IHI Forum 2000 Plenary
Do you see it all working together here in this classic example?



A good enough vision: We need community outreach initiatives.
Intrinsic motivation—what I called a while ago “attractor patterns”—to get the momentum
started. It doesn’t matter so much the details of the direction, just get started doing something
reasonable.
And some simple rules both to:
 establish a few necessary boundaries—fixed budget, limited time, legal requirements,
 and to provide the encouragement for everyone to contribute their 15% influence in the
system—permission to take a half-day a week, the ability to draw money out of the
budget, and permission to let go with honor and thanks if what you tried doesn’t quite
achieve a life of its own.
But Linda Rush and her colleagues were just the first wave of many pioneers who are now using
simple rules to guide the evolution of complex systems in healthcare. For example, groups
organized by Dr. Chris Foote in the UK have worked out the simple rules for better systems of
care for the elderly. Groups convened by Sarah Fraser, Helen Bevan, and others are beginning to
explore fresh approaches to such problems as the winter pressures on acute care beds. Dr. Lib
Maloney and her colleagues at Dartmouth Hitchcock Medical Center are evolving simple rules
for a better medication administration system and for discharge planning. Louise Liang and her
colleagues at Group Health, with help from the Bard Group, are exploring the unstated simple
rules that lead to out-of-network expenses.
A new Institute of Medicine report, due out in the next few months, will describe the design of a
“new chassis for the 21st century healthcare system.” Don Berwick chaired that committee.
Rather than the complicated, hierarchical model that such reports usually produce, this new IOM
report envisions an innovative transition from one set of simple rules to a new set of simple rules.
You see, innovation, by definition, is a violation of the current simple rules in the system. An
email consult with a primary care physician is an innovative idea precisely because it violates the
current simple rule of the system that care is delivered in “visits” to the doctor’s office. The IOM
report will describe numerous such transitions that revolve around new simple rules for the
complex systems of healthcare.
You are going to be hearing a lot about simple rules in healthcare over the next few years.
Trying to describe a complex system in detail is an inherently hopeless task. Trying to plan it all
out in detail is just a road to the Church of Little Hope.
Understanding a complex system at the level of its simple rules gives us hope. Realizing that
innovation and change comes from modifying the simple rules is a road out of Little Hope.
The biggest obstacle to this “simple-complex” thinking is our own self-image as leaders. The
self-image that says that we can figure it all out, that we can find the right answers, that we can
know the right direction to go, and that big change needs a big beginning with lots of hype and
fanfare. If you haven’t figured it all out before you start, for gosh sakes don’t let anyone know, or
they will think you are a terrible leader.
© 2000 Paul E. Plsek & Associates, Inc.
17
IHI Forum 2000 Plenary
My advice: Get over yourself! When you feel that pull on your self-image, just remember that the
Mighty Mississippi starts very small, and heads initially in the wrong direction, but works things
out as it goes along.
Final Thoughts
I could go on all day. Can you tell I’m excited about the new common sense I see emerging all
around us? I’ve only scratched the surface here with these four examples of current common
sense; which I hope you now will see in the light of a new common sense…
 In complex systems, everyone has “15% influence” and not much more than that.
Influence your 15% within the system and see what happens.
 Embrace paradox openly. Seek both-and approaches, rather than resolving the dilemma
by an either-or choice.
 Instead of constantly battling resistance, work with the natural energy in the system.
Understand natural attraction to change.
 Growth and innovation can occur naturally with good-enough plans and simple rules.
Just as Fredrick Taylor’s book Scientific Management laid the foundation for unprecedented
progress at the beginning of the past century, I believe that what I call “extended scientific
management” will lead us to unprecedented levels of innovation in human organizations in the
new century.
But I can’t leave without telling you the truth about the Church of Little Hope.
You see, I actually found the Church of Little Hope on my drive that day outside Dallas. And
when I did I found a historical marker that tells the story of the congregation. It seems that the
church was founded by Elder Jacob Ziegler. But it was his missionary colleagues who named it
The Church of Little Hope. Because, so the plaque says, “…there was little hope that the church
would survive more than a year.” Nice friends, huh?
That was way back in 1881! The church that I visited that day seems to have more than survived.
You see, the true story of The Church of Little Hope is not a story of hope-less-ness. Rather it is a
story of hope-ful-ness.
And that is my wish for all of you this coming year. That you, armed with some new common
sense, will, like the good folks of The Church of Little Hope, find enduring hope and progress,
even amid the pessimism of all those around you who are drowning in a mess. Have a great year!
© 2000 Paul E. Plsek & Associates, Inc.
18
IHI Forum 2000 Plenary
An audiotape and videotape of this plenary speech is available. Contact Paul Plsek
(770-587-2492, paulplsek@DirectedCreativity.com) or the Institute for Healthcare Improvement
(617-754-4800).
Attached is a copy of the two-page handout that was available to the participants at the
conference.
© 2000 Paul E. Plsek & Associates, Inc.
19
IHI Forum 2000 Plenary
Little Hope:
How Common Sense Thinking Can Lead to a Mess
Paul Plsek
Paul E. Plsek & Associates, Inc.
Senior Fellow, Institute for Healthcare Improvement
paulplsek@DirectedCreativity.com
In health care today, we often find ourselves in a mess; dealing with complex situations that seem
beyond control. The problem may lie in the way we have come to think about things. For
example, don’t the following statements represent current common sense thinking in health care?




Most of the problem lies with the system, rather than the worker. The system is
management’s responsibility. Management needs to fix the system.
Leaders need to resolve the great debates (for example, centralization versus
decentralization) that are consuming so much of our time and energies.
We must overcome resistance to change.
You need a detailed plan to guide a large change effort.
I am convinced that these—and other statements like them—represent the sort of thinking that
has brought us to where we are. What we need in health care today is a new common sense; built
on a better understanding how complex systems actually work. From the research in complexity
science we now know that…

The elements of a system can change themselves. Change need not be imposed, and, in
fact, imposing change may lead to further system adaptations that we would not be happy
to see.

Complex outcomes can emerge from a few simple rules. Complex plans may not be
needed and may, in fact, stifle the creativity and innovation we seek.

Small changes can have big effects and large changes may have no effect at all (nonlinearity). We may not need a big intervention to bring about a big shift in performance
of a system; such an intervention might have exactly the opposite effect.
Tension and paradox are natural. We may not need to resolve the dilemmas of our
organizational life; doing so may actually threaten the organization’s survival.


Complex systems thrive on the edge of chaos, a region of only moderate certainty
and agreement. The “edge” is where the creativity and innovation that we so
desperately need will occur in our healthcare organizations.

Complex systems are parts of larger complex systems, and are made up of smaller
complex systems. Leaders cannot take up a post outside the system, and, in fact,
imagining that you can, may lead you to do exactly the wrong things.
The application of these new understandings from complexity science is leading to the emergence
of a new common sense—a different approach to the leadership of systems. Pioneers in health
care and other industries are exploring new leadership approaches based on such complexityinspired axioms as:


In complex systems, everyone has “15% influence” and not much more than that.
Influence your 15% within the system and see what happens.
Embrace paradox openly. Seek both-and approaches, rather than resolving the dilemma
by an either-or choice.
© 2000 Paul E. Plsek & Associates, Inc.
20
IHI Forum 2000 Plenary


Instead of constantly battling resistance, work with the natural energy in the system.
Understand natural attraction to change.
Growth and innovation can occur naturally with good-enough plans and simple rules.
As a new common sense emerges around us, we will begin to see new ways out of the complex messes
we encounter. We can be enthusiastically hopeful as we face our future.
Suggested Readings
For a more extensive, annotated bibliography visit http://www.EdgePlace.com. While there, be
sure to check out the other resources covering theory, principles, aides, tales, and applications of
complexity science in health care.
Organizational Applications of Complexity
Zimmerman BJ, Lindberg C, and Plsek PE. Edgeware: Complexity Resources for Healthcare
Leaders. Dallas: VHA Publications, 1998.
Lewin R and Regine B. The Soul at Work: Embracing Complexity Science for Business
Success. New York: Simon & Schuster, 2000.
Brown SL and Eisenhardt KM. Competing on the Edge: Strategy as Structured Chaos.
Boston: Harvard Business School Press, 1998.
Goldstein J. The Unshackled Organization: Facing the Challenge of Unpredictibility
Through Spontaneaous Reorganization. Portland, OR: Productivity Press, 1994.
Morgan, G., Images of Organization, 2nd Edition. Thousand Oaks, CA: Sage, 1997. (See also
Gareth Morgan’s website at http://www.imaginiz.com)
Zimmerman BJ. Complexity science: A route through hard times and uncertainty. The Health
Forum Journal. 42(2), March-April 1999, 42-46, 96.
Plsek PE. Innovative thinking for the improvement of medical systems. Annals of Internal
Medicine 131(6), 21 September 1999: 438-444.
Plsek PE and Kilo CM. From resistance to attraction: A different approach to change.
Physician Executive. 25(6), Nov-Dec 1999: 40-46.
Complexity Science
Waldrop MM. Complexity: The Emerging Science at the Edge of Order and Chaos. New
York: Simon & Schuster, 1992.
Capra F. The Web of Life: A New Scientific Understanding of Living Systems. New York:
Doubleday, 1996.
Kauffman S. At Home in the Universe: The Search for the Laws of Self-Organization and
Complexity. New York: Oxford University Press. 1995.
Goldberger AL. Nonlinear dynamics for clinicians: chaos theory, fractals, and complexity at
the bedside. Lancet. 1996;347:1312-1314.
© 2000 Paul E. Plsek & Associates, Inc.
21
IHI Forum 2000 Plenary