Insights (Essays)

Insights (Essays) April 2013

Can an Organization Grow if Its People Are Not Connected?

Hugh MacLeod and Vickie Kaminski


Today on the balcony I’m joined by Vickie Kaminski, a leader who does not back down from challenges. Healthcare in every jurisdiction, province, state and country is under scrutiny. We face massive growth in demand as the population ages. The system is rife with vested interests. Human resources are captive to a labour relations model developed in a bygone industrial era. The public demands input. It questions traditional authority. Meanwhile, finances have deserted us. Unprecedented growth coupled with significant demographic shifts puts healthcare under enormous pressure and will continue to stretch resources for the foreseeable future. There is an urgent need to identify and implement specific actions to meet our increased demands for service.

Ministries gave us a clear design direction — no more silos in management. In other words, the system cannot be managed as isolated, hierarchical services led by care providers. Healthcare is not alone in this. Other social institutions, such as education and social services, are also being assailed by broad societal forces created by the explosion of information, technological innovation and client expectations. These forces are shifting the organizational context in which we work. They are creating an environment rife with paradox. At the same time, the ministries giving the integration direction remain siloed, complicating healthcare further still.

We need to nurture and develop employees; yet we face significant role changes and even downsizing. We need to provide more services to our health customers, with fewer resources. We must be consummate medical professionals, but also be accountable to the public. Today’s healthcare leaders must be able to thrive in an environment that demands vision, change and flexibility — the ability to live in paradox. We want the country’s best health system to become the best in the world. The potential is here. The question is: “How do we do it?” Clearly, we do not have all the answers.

On cue, our familiar critic, the ghost, arrives to offer an unvarnished opinion:

“How does an organization grow if its employees are not? What if their learning potential is crippled by the leadership that employs them? Whose job is it to fix it? The solution requires leadership from all stakeholders in the matrix model. All must create the matrix as a source of wellness in organizational life. What code of conduct must the executive create — and model — that will show everyone the rewards for making it work? The learning organization metaphor is a powerful tool, but how do you develop it practically? The real learning organization is a matrix of strategically valuable interconnection. You are playing with new matrix structures and are not paying attention to the signs.”

A new vision of healthcare is emerging. It is quite different from the familiar old world management, characterized by silo-centred organizations and command and control hierarchies. It is the beginning of a new world. It is being created by a vertically integrated and functionally supported matrix across a geographic region. We envision a system that is community owned. A system in which healthcare providers, regardless of organizational affiliation or interest, deliver integrated, efficient services. A system where members of the public exercise greater preventive responsibility in the pursuit of wellness. A system of high quality, that is affordable and accessible to all. Familiar to most of us is Albert Einstein’s quote: “The significant problems we face today cannot be solved at the same level of thinking we were at when we created them.” That means we must step away from traditional leadership models and make way for new, integrated practices. Inter-professional care in partnership with active, attuned client participation isn’t a new age theory, it’s a fact of life as we embrace the next generation of leaders.

When one thinks about who is going to be the next generation of leaders, we need to remember from where they come. From the time they were children, they were being involved in decisions from things as small as “what do you want to eat for dinner?” to things like “where do you want to go on our vacation this year?” So it is impossible to now put them in a work environment that doesn’t include them in the decision-making framework at all levels. They simply won’t tolerate being excluded from that facet of care, whether they are the provider or the consumer of healthcare.

One of the most powerful of all paradoxes is that an unattainable goal may well be the only one worth working toward. Indeed, is this not the purpose of leadership? To quote Carl Jung: “All the greatest and most important problems of life are fundamentally insoluble. They must be so, for they express the necessary polarity in every self- regulating system. They can never be solved but only outgrown.” 

The new organizational matrix models must be understood and experienced as vehicles, not unlike the automobile. The essential value of an automobile is that it can take you from one place to another. No single part of the automobile — a wheel, an axle, a carburetor — can do that. An automobile is not the sum of its parts, it is the product of their interaction. Interaction brings change. Values and guiding principles for matrix organizations often exist in a polarity between their positive and negative expression.

We publicly proclaim the ideal matrix organization as an expression of new integration and organizing rules, but this does not eliminate their negative expression. Trust is a magnificent value, but when the talk is not walked there is risk. The opposite, or negative, can never be eliminated, only contained. At a certain point in the process of implementing a matrix organization, the model begins to crack under the pressure of the two extended poles on the continuum of values. Unless, that is, people develop a way to transmute the lead of organizational culture into the gold of the organizational vision.

Balancing the polarity is a remarkable engineering and architectural achievement in organizational re-design. The balance is totally dependent on the collective result of individual interpretation of the potential to achieve the vision and reality of what is happening at the community level. Each individual across the matrix organization has the potential to undermine or create positive matrix dynamics at any point in time. They can regard any issue as an uncoordinated, disconnected process, or as a challenge — an opportunity to manifest the vision right now. It is a great test of organizational maturity: To recognize and take responsibility for the reality we create; that our world will be as we see it; and that the effectiveness of the matrix organizational model will arise from millions of moments of interpretation. And while it tests organizational maturity, it also taxes the very supports that the organization must lean on if it is to remain stable and sustainable.

This requires people who can observe the organization as they experience it. Therefore, the challenge is to implement the organizational matrix model in a way that achieves healthy, creative, optimal tension between these two poles. This tension can reveal the difference between rhetoric about shared values and the reality of conflicting core beliefs. There are two risks: If one strand is suppressed, and the matrix identity is unbalanced, the long-term cost of superficial consensus can include underlying mistrust, energy depletion and inconsistent decision-making. This may be expressed by the demand that the group accept decisions based upon either narrow analysis or grandiose creativity. Or worse yet, reverting back to a “command and control” atmosphere to help the organization regain some balance.

There is the risk of prematurely “locking-up” the matrix by making the learning initiatives rigid through premature application of performance measures, constraints and incentives. This creates gridlock in the matrix. Symptoms of organizational matrix gridlock include:

  1. People are torn between multiple objectives;
  2. People are dazed by the introduction of one “priority” after another and intimidated by the resurgence of the hierarchical system from the organizational shadow to straighten out the chaos;
  3. People tend to dig in and pay lip service to initiatives, developing many ways to beat the system;
  4. People become masters of giving the appearance of change without actually changing.

When organizational matrix relations are balanced the following happens:

  1. Individuals are self-directed and multi-skilled;
  2. The relationships between pairs of individuals and pairs of teams is one of mutual interdependence – leaders and followers can easily switch roles;
  3. Groups are open and unrestrictive – people can enter and leave with minimum hassle;
  4. Silos are open and undefended;
  5. Values influence the dynamics at every level, and there is clear respect for the responsibility and duty for personal self-management and formal organizational management;
  6. Actions take place within the context of “immediate return” economies with short feedback loops between action and result which maximizes learning and performance improvement.


Next Week’s Guest on the Balcony of Personal Reflection: M. Vogel in a conversation titled, “Trapped in the Future.” 

Click here to see the First Series of Ghost Busting essays.


Click here to see essays from the Second Series: The Ghost of Healthcare Consciousness.

About the Author(s)

Hugh MacLeod is CEO of Canadian Patient Safety Institute. Vickie Kaminski is President and CEO of Eastern Health (Newfoundland & Labrador)


Putnam, R.D. Malkin Professor of Public Policy at Harvard University, speech 2001. 


David Cochrane wrote:

Posted 2013/04/22 at 08:10 PM EDT

As we describe different (not novel) organizational structures, in this essay, matrices, and try to make the case that these structures will better serve the health care needs of Canadians, I can not help but reflect on the fact that organizational structures are the first things health care administrations focus on. Changing politics, funding, labour relations call for reorganization. We are very good at reorganizing either at the macro or meso levels. With rate exceptions, and perhaps only in those services "streams” that can be made “routine”, we fail at the micro level. Overall of the years, and through out all of the “organizations”, the issues of quality in health care persist. It seems that the outcomes are independent of the organizational structure, what ever it is.

So what is missing? It is not “a” structure; it is a clear definition of the goals that any structure is to deliver. It is the “relentless" pursuit of those goals and transparent accountability to the public. We, inside health care have spend so much time on structures that we have failed to define, understand, design and deliver upon the goals our system is to achieve. In fact in building the artifacts of our health care system (organizational presence, structures, buildings and such) we are protected from having to address quality, sustainable delivery and transformation. It is a safe place to be if you are an administrator or indeed a provider.

Teams are important, matrices may be needed, but more so is the delivery on the responsibilities we all share in health care delivery. We should be guided by the goals society sets for us and not bow to the structures we have created.


Robert Pental wrote:

Posted 2013/04/24 at 10:45 AM EDT

I am not someone you would normally see on this balcony of personal reflection. No, the place for me as a floor nurse would be closer to the lighting booth in the theater of healthcare. A place where you not only watch the performance but have the added feature of being intimately part of the production. A place where you learn that some lights, or in my case, call lights, take priority over others. A place where you know the production is so massive, more complex, interdependent and co-related than any one person should reasonably believe they are able to explain, let alone fully comprehend.

As a result, time on this balcony of reflection seems a welcome reprieve, but of course the ghost of healthcare despair knows no bounds. A ghost that for me is not a disembodied theatrical prop in the wings off stage; no, the ghost of healthcare despair is very real to me, a ghost that at times it could be said that I feed. Not by personal preference, mind you, but nonetheless nourish. I will never been proud of this fact, and attempt with each and every performance to eliminate it, but sometimes, some areas take priority. So when it calls, I go. When it speaks, I listen. And when I listen. I take as my accountable share the view from its sullen and lugubrious eyes and make no attempt to shield its cold wizened hand from my own.

“This system, if you want to call it that, is in tatters. No one comes when I call. I waited hours in that emergency room for what, this.. this.. you call this a room?

“I can't even hook up the T.V. How am I suppose to watch my hockey? This place stinks.

“You're not even a real nurse. You're a man. Why aren't you a doctor? And where is the doctor? I need to see him. NOW.

“This “system” cares nothing about me, only about cutting corners and making money for big wigs and forcing me to look after myself when it should be you looking after me. I pay your wages, I'll have you know.”

So on and on the ghost goes, but what it may not realize is that in its despair is a message of what is also needed for those able to see. What is that silent message weaved into its phantasmal shroud? Well, it is not about how we are going to fix things and when it will be done. No, because like the Dickens' ghost of despair these essays are indebted to, the ghost of what is yet to be, any and all of our futures are unclear. So that maybe what the ghost is requesting is we let compassion be our guide and decency for everyone take the lead.

Why? Because sometimes certain lights need to take priority over others...


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