Healthcare and Open Space Technology

These “experiments” with the use of OST around the world, to my knowledge, have not included control-groups. he nature of the evidence in social experiments cannot be as precise as that demanded by medicine. In my own published study of the impact of two open space events in a healthcare related organization there is, however, significant evidence of positive shifts in employee morale and some indication of changed behaviour through the implementation of ideas (Peterson and Peterson, 2006). Certainly there is good anecdotal evidence of the value of the approach from the continuing use in Canada and around the world.

Complex Adaptive Healthcare

Complexity science has been giving us some clues as to why this simple approach to meeting has value. Order or pattern emerges naturally in complex adaptive systems through the interaction of the parts. Stewart Kauffman, a leading complexity scientist, believes that the interaction in each moment of the atoms in molecules, the components of cells or the elements of a global economy lead to the self-organized wholes (Kauffman, 2008). No one atom, cell component or country economy imposes the whole order. so, it is not a stretch to see that the moment by moment interactions of people (and things) in our healthcare organizations actually come together to provide the care. Planning can set the direction and context for that behaviour, but it cannot control the behaviour of individuals, groups or pieces of equipment (radiation isotopes are sometimes not available). The choices that people make within that planned and real context make a substantial difference as to the quality of the care.

To be effective in care or change, formal healthcare leadership must engage the commitment, energy and behaviour of those playing various roles in a healthcare organization. For example, there is US experience that engaging front line workers in hospital services in clarifying the importance of washing hands can reduce MRSA by as much as 85% (Plexus Institute, 2006). Engaging the emergent leadership of physicians was an essential component of developing a successful family health team (Peterson and King, 2007). Sustaining improvements to healthcare requires thoughtful initiative from those playing all roles, especially those at the front lines. Emphasizing compliance to plans may get initial results and measuring behaviour can give good indicators of success over time but care giver choice is still involved particularly when the context or situation changes in ways unanticipated by the plans. Humans and complex systems often behave in unpredictable ways.

Open Space Technology in Healthcare Settings

There are times in healthcare organizations and change processes when getting employees involved in learning and planning contributes to increased understanding, effective implementation, energy for change and success. Encouraging employees or volunteers to take initiative to improve behaviour and plans strengthens the momentum for change that can develop in no other way. Open Space Technology is a meeting approach that can create the conditions for engaged authentic leadership and for focusing the natural tendency of human systems to self-organize. It has been used in healthcare in a variety of ways.

150 Nursing leaders from throughout one province gathered for two days in Open Space to enable the shift from being an association to becoming a self-regulating college. Their new job was to make the established nursing standards “come alive” – to become implemented across the province. 82% of participants stated that in the session they had begun to develop tools to help nurses integrate the standards into their practices. Were these tools applied in their local communities? Were the proposals developed taken seriously by the organization? It appears so.

Fifty hospital and family practice physicians came together with hospital administration in Open Space to develop proposals for improved and innovative clinics in the new facilities. The event took three-quarters of a Saturday, but the physicians came, and over 20 proposals were developed to take forward into the planning process. Priorities for implementation were set. Many of the physicians, who had been working at the hospital for years, commented that they had never met some of their colleagues before the session. Some who had prepared to leave the conversation at noon, stayed for the whole event.

A Ministry transformation initiative used Open Space to launch regional health networks across a Province. Those 350 to 500 person events explored options and priorities for the coordination of healthcare services in the regions. The priorities that emerged informed the regional boards as they began to coordinate healthcare services and continue to be among their priorities.

Other examples include a Ministry initiative to boost the learning curve for using new long-term care software by sharing experience from across a province. A hospital preparing for merger met in open space to explore how best to prepare the various units for the changes that were coming. A major European pharmaceutical has divisional open space sessions at least once a year.

The Open Space Approach

The Open Space Technology meeting approach is simple. A clear theme or question, developed with the sponsor of the event, gives focus to the self-organized conversations. Asking a positive question about the task at hand elicits energy and ideas from those who care enough to take initiative. The details of the agenda emerge from the participants rather than being predetermined and thus fit the current realities. The undergirding “Principles and Law” of OST provide elements of a socially constructed “container” that give surprising permission for participants to self-organize discussions, explore ideas and make connections that can lead to new thinking and action. Authentic leadership emerges in relation to topics for which participants have some passion and for which responsibility is taken.

I will not describe the OST meeting process in any detail here. There are myriads of examples on the internet. Suffice it to say that, when carried out as originally intended, it is a distinctive approach. There are other approaches to such meetings that create some elements of openness, self-organization and participant initiative but these are substantially more guided by the facilitators who are in front of the group much more frequently. In an Open Space event of four hours or more, it is truly the participants who create the agenda topics, generate the synergy and produce the results in relation to the theme question and thus reap the rewards of their initiative. In other participatory approaches the ideas do emerge from the participants. In Open Space, participant ideas and leadership initiative are directly connected and that determines and shapes the content of the discussions rather than a series of leading questions from a facilitator.

There is evidence from an Australian social network analysis research project that patterns of communication within an organization shift after a substantial OST event – new or improved relationships developed and the content of the conversations changed. Such an impact on the informal organization can both provide focus and a “lubricant” that can accelerate important change processes. This conversation can also bring key issues to the surface as the informal organization tries to assert its power, as it always will. The best formal leaders learn from what emerges when a question is posted and self-organization becomes visible.

Complexity theory emphasises the importance of the “container” or “boundaries” within which self-organization happens, within which real “work” gets done. For any OST event, I believe that good planning with the sponsor group is essential to clarify the focus and intent and the “container” for the creative discussions that emerge. This “container” is both a cultural and physical reality. (The word “container” is, for me, too mechanical an image. “Semi-permeable boundaries”, such as those of a cell, is likely a more accurate metaphor but harder to say.)

The planning process should also identify the desired approach to setting priorities or developing action steps when that is appropriate. This can help “converge” the insights and energy that emerges. It is important to realize, however, that some of the outcomes of a successful event will be unpredictable and possibly invisible for a period of time. Some results from engaging self-organized initiative may be anticipated, but there are, overtime, unintended consequences and changes to the environment of the system that are unforeseen.

If what we are learning about complex adaptive systems is accurate, effective leaders in healthcare systems must learn how to both give firm direction and stay intellectually and emotionally open to what emerges. Such leadership is required at all levels of healthcare organizations. (King & Peterson 2007)

Leadership in Healthcare Transformation

I recognize that my expertise is more in the human side of organizational effectiveness than in healthcare per se. I also understand that policy makers state that healthcare improvements need to be driven by what the patient or clients receive and experience. Healthcare leaders are achieving some successes in such transformative change.

My experience also suggests that such a transformation in perspective in large institutions such as Ministries or hospitals is relatively easy for senior leadership to articulate but much harder to realize. Often the front line staff members or their manager have a more grounded perspective on how such transformation can be carried out even if they have a more limited view of the possibilities.

The current strong emphasis on “evidence based” approaches to treatment and care leads some leadership, from my experience, to believe that if the evidence is “clear” people will change their behaviour. Some are frustrated with more open approaches to meeting because even the most professional of doctors or nurses do not understand the evidence as they see it nor do they relate to the evidence in their conversations in the same way they would when presenting a paper. If the event is not structured like a seminar, then some believe that even the professionals will not base their conversations or conclusions on that the evidence. It is often difficult for such professionals to learn from what emerges in a conversation and see the possibilities of incorporating that evidence in new conclusions.

A strong evidence base and clear and useful measurement of indicators both provide important direction and information for improving healthcare. An understanding of the essential character of complex human systems, that they are and will be naturally self-organizing (formally or informally), can also enable effective leadership for change. It appears that the highest learning or performance by employees emerges when they care about what is to be done and have the freedom to both take initiative and responsibility. This perspective on complex human systems can also help clarify the decision as to when to intentionally open a focused space to engage that human energy and performance.

Opening Better Space

I think even better Open Space events, and better application of those insights from the Open Space experiment, are now possible for ongoing higher performance in healthcare systems.

• The ability of formal leadership, sponsors and facilitators to better understand the nature of emergent and self-organizing processes in healthcare systems will lead to better decisions as to when to accelerate or reinforce such processes by using OST. This perspective will also help formal leaders to better deal with the “risks” of being open to and learning from what emerges.
• The choice to open a space for others’ initiative can become part of an executive’s approach to management, as suggested by Harrison Owen in his recent book Wave Rider (2008). Open Space Technology is not just a useful approach to meeting. Elements of the perspective can inform executives or team leaders as they engage their direct reports.
• The choice to hold an Open Space event is best understood within the context of the key events and stories leading up to an event and a strategy for what will be done to reinforce the insights or actions that emerge. Sometimes sufficient time is not given to determining this clarity because of the time frames established for planning. Many healthcare organizations are running at such a fast pace and so content focused that this kind of process thinking is given short shrift and then has to deal with the consequences.
• As stated earlier, complexity science reinforces the importance of identifying the “container” for enhancing self-organization with a group or organization. Developing some initial clarity as to what focuses and bounds the space being intentionally created is especially important in healthcare.
  • A forward looking and positive intent or focus statement leading to a clear question to open a space is essential: for example, identifying new clinics for a hospital, reducing the incidence of MRSA, making the regulations come alive, requirements definition for better patient care through eHealth.
  • Ensuring that those involved have access to the evidence base that informs a particular discussion is important. Some assume that this requires many presentations during a gathering before there is any space for conversation. Internet based data sharing and conversation about the data and encouraging professional adults to do their homework on the evidence can create more space and time for real conversation based on such evidence.
• Hosting such events well is also critical to success, particularly in recognition of the longer hours, differences in specialties, overwhelmed systems, lack of coordination and insufficient resources. The current “scarcity of resources” mentality in much of healthcare can lead to major errors in insufficient strategic work to engage people in change processes.
• This decision not to engage others early also becomes a false economy when issues that are apparent to many surface late in a change process, requiring more “work-arounds”.

I do believe that healthcare, for all of its planning processes in Canada and the emphasis on evidence base, is in essence a self-organizing system. To fully realize its potential for change, integration or performance, Open Space Technology provides an important perspective, meeting approach and leadership experience for the transformations and learning that are part of the journey to better healthcare.

references

1. Owen, Harrison, (2008). Wave Rider: Leadership for High Performance in a Self-Organizing World, San Francisco, Berrett-Kohler, p. 13.
2. Peterson, Larry E. and Peterson, Rebecca, (2006). “Moving to the Next Level at the Canadian Institute for Health Information”, Bunker, B.B., and Alban, B.T. (Eds), The Handbook of Large Group Methods, San Francisco, Jossey-Bass, pp. 343-353.
3. Kauffman, Stewart, (2008). Reinventing the Sacred: A New View of Science, Reason, and Religion, New York, Basic Books.
4. Plexus Institute, (2006). “Plexus vs MRSA”, Emerging: the MRSA Issue, p.16.
5. Peterson, Larry and King, Sharon, (2007). “How Effective Leaders Achieve Success; Critical Change Initiatives Part 4, Emergent Leadership – An Example with Doctors”, Healthcare Quarterly, Vol. 10, No. 4.
6. King, Sharon and Peterson, Larry (2007). “How Effective Leaders Achieve Success; Critical Change Initiatives Part 3, Command and Let-Go of Control”, Healthcare Quarterly, Vol. 10, No. 3.

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What has been your experience with Open Space Technology and how do you think healthcare organizations could better use Open Space Technology? - Larry Peterson