The University of Louisville Hospital Story:
The Difference between Day and Night
by Birute Regine and Roger Lewin

The University of Louisville Hospital (ULH) has deep roots in the town’s community, both in terms of its history and in its current passion and purpose. The hospital can trace its lineage back more than a century and a half, to 1823, when the Louisville Hospital Company, as it was then known, opened, with 150 beds, a vital public health resource for the community, and particularly for "the sick poor of the city." And today, in addition to being the teaching and research cornerstone of Louisville Medical Center, ULH still cares deeply about its community, particularly in its care of the less fortunate, those who depend on Medicaid or on charity care.

Just as care has been a constant motif for the hospital, so too has change been its constant companion, as its identity, stewardship, and activities shifted repeatedly through the years, responding to new demands and new opportunities, and a changing market place. And at no time has change been more pronounced than it is today, as ULH navigates the turbulent waters of the health care crisis, experiencing, as all hospitals are, diminishing federal and state income, pressure from HMO’s and insurance companies, and the vagaries of seeking alliances with neighboring hospitals as a way of surviving in the face of intensifying competition. It is a time of profound uncertainty–and of opportunity–and it demands new ways of working, new ways of managing. The fall of 1999 marks the third year of ULH’s experiment with such new ways, which were introduced by CEO and president Jim Taylor, who joined the hospital in August 1996 (see Jim Taylor: Trojan Horse with a Bow Tie).

On February 6, 1996, management of ULH passed from Columbia/HCA to University Medical Center, Inc. UMC is a not-for-profit corporation formed through an affiliation between two downtown, not-for-profit hospitals, Jewish and Norton, and the University of Louisville. In 1997, ULH borrowed more than $40 million, which was used for much needed improvement of physical plant and equipment, and resulted in a restoration of a sense of respect and confidence in the hospital. Most conspicuous of the improvements was expansion and renovation of the Emergency Department/Level 1 Trauma Center, making it the largest and best in the region. The hospital is also the region’s only bone marrow transplant center. ULH now employs more than 2000 health care workers who work with 500 physicians, and has 404 beds. In 1998, ULH staff provided more than 50,000 days of inpatient treatment and $170 million in inpatient and outpatient care, of which half was for indigent patients. In May 1999, the university permitted ULH to use its logo, the first such recognition in 20 years, thus demonstrating the growing regard with which the hospital is now held in the community, the result in large part of the management philosophy introduced by Taylor; and of ULH people’s embracing and honoring that philosophy.

In the folk lore of the University of Louisville Hospital, February 6, 1996 is known as "Miracle Wednesday." The tenure of Columbia/HCA was due to end, with the University Medical Center Inc. set to take over. Columbia’s impending departure was riven with tension, in part because its contract with the hospital had been ended against their hopes and wishes. Columbia had developed a computer system that was a key part of the infrastructure of the hospital, providing operational support day to day and records of patient and financial transactions. Because it was a for-profit operation, Columbia felt it had the right to protect its proprietary information developed in the computer system, and so were reluctant to share information. But the bad feeling that Columbia managers harbored about the lost contract also contributed to their motivation not to do anything that might have eased the transition with respect to the hospital’s information-processing needs.

At midnight on Tuesday, big trucks pulled up outside the hospital, and Columbia’s technicians ripped the computer system out, and carted it all off, destination Nashville. The hospital’s new administration, having been stripped of the hospital’s information system and with a replacement only incompletely ready and ill prepared because of the lack of cooperation from Columbia, stared chaos in the face, with the very real prospect of disaster for the patients. Chaos there was, but it quickly evolved into organized chaos, and not a single patient suffered.

As so often happens in crisis, a "can do" spirit erupted at all levels of the staff. "The administrative people had their challenges," remembers Christy Murphy, an auditor in Financial Services. "Even though they had put an outline together of how things should run during the transition, they turned the day-to-day functions of the hospital over to the front line people, because we were more familiar with these functions. Everyone just knew what to do, and if they didn’t, they figured it out, fast." For Bill Fell, a manager in Cardio-Pulmonary Services, the miracle was "the way people worked together, and did what had to be done, no matter what, even if it wasn’t something you would normally have done." Because the new computer system wasn’t fully operational, a lot of things had to be done manually. "We had runners running from nurse’s station to nurse’s station, picking up requisitions, dropping off results," says Fell. "We were a team," says Murphy. "We declared our independence!"

Mark Pfeifer, ULH’s current chief of staff, describes the atmosphere as having "the excitement of a MASH unit." People were tremendously motivated, he says. "The harder it became, and the more the crisis seemed to threaten the hospital, the more determined people became to make it work, to succeed." Kay Lloyd, the current VP for Operations, remembers that "everyone was so focused on being successful that night, and making sure that the patients wouldn’t see the difference. We were very successful at that." Those first few adrenaline-pumping weeks generated a collective purpose, a collective mission that previously was absent. It was, says Pfeifer, "a honeymoon period." But, like all honeymoons, it eventually came to an end, as the new computer system became established and the new administration began to impose a more formal management structure. It was, says Murphy, as if the administration said, "Okay, you got us where we need to be. Now we’re back in charge." Order replaced chaos, and something vital was lost, as the command and control management structure that had been established during the previous decade reasserted itself.

What ULH people experienced during those first few weeks of the transition is the same thing that many organizations go through when faced with crisis: formal structures and assigned roles vanish, and people collectively organize around problems that need to be solved. And the level of commitment and fulfillment soars. Management guided by the principles of complexity science seeks to achieve the flexibility and willingness to collectively organize that people experience during crises, to liberate people to do miracles, but without the need for crisis, but embracing a sense of urgency, to initiate this way of working in a sustainable manner.

For those people who had been with ULH since the time of Louisville General Hospital, ULH’s name until 1981 and called Old General by the people who worked there, the transition crisis rekindled something that had been lost. "It was like something of the heart of the old place," explains Fell. "We all felt part of the same facility, the same family back then. We worked together and we played together." Even though ULH these days is somewhat unusual in that its staff includes many members of the same families, it was even more so at the Old General. A community within the community. Not that it was paradise. In some areas it was poorly equipped, with nurses having few monitors available to them, and, on occasion, having to prop a bucket on top of a monitor to catch drips from a leaky roof. "The facility was just horrible," remembers Fell. "There was no air conditioning. The windows were wide open. People were lined up in long wards. I mean, it was a horrible place to work. And, yet, you had something special." Echoing the description of the way people were in the 1996 crisis, Murphy says the following about an important quality of life at the Old General: "It didn’t matter if you were a doctor, a nurse, or a cleaning lady, if something needed to be done, they did it. If someone was needed to stay on a ward, they stayed." Although Nancy Overall, an auditor in Financial Services, was not at the Old General, she says that "what I’ve heard from people is that it was like an ‘in the trenches mentality,’ like in war, where you face crises all the time, but you get through to the other side, because you are there for each other." "That’s right," concurs Fell; "every day."

When, in 1983, the hospital moved into its current buildings under newly-appointed Humana as management, the facilities improved dramatically. But, says Murphy, "when we moved here we left something of our spirit in the old building. We became less of a family than we had been." Nevertheless, the spirit of family persisted, and was even nurtured in Humana’s early years of managing the hospital. "The first Humana CEO we had was wonderful," says Lee Tyson, the current Administrative director for psychiatry. "He helped create a sense of common purpose, that we were all in this together." As time went on, however, the pressures that too often are present in for-profit hospitals began to take a toll. Not only did Humana, and then Columbia, impose a tight command and control management regime–"all soldiers carrying out orders, and silos keeping people apart," as Steve Short, the current Chief Financial Officer, puts it–but also the financial bottom line loomed large. "There was intense focus on the financial part," says Short, "with everything being designed around being able to monitor the expense and usage of resources, whether it was labor, whether it was supplies." Finances are important, Short acknowledges, but for different reasons these days. "Before, it was for the shareholders and the stock price, and that didn’t seem to be what we felt our purpose was. Now the money goes into the hospital and to the university, and we support that."

The Humana/Columbia decade took a toll on ULH, on the facility itself and on its people. First, after the initial improvement in the building facilities, subsequent meager investment in the physical plant undermined university physicians’ desire to bring in patients, because equipment and programs received little support. And the deteriorating physical environment eroded morale for everyone. Second, as Tyson describes it, "CEOs became more and more ruthless in pursuing power, money, and publicity." As a result, morale suffered even more. Third, the repeated turnover of administrations had a corrosive effect on the level of trust people could feel. "We were under so many different managers," says Murphy. "Changes are made, and as soon as you get settled with that, whop, new people come in and we have to start all over again. So it is hard for us, as employees, to establish trust in management. And it must have been hard for managers, too, because they knew they might be gone tomorrow."

The command and control style of management pursued by Humana and Columbia/HCA was not unusual: until recently, much of the business world operated in this way. And the culture this management style engendered was typical, too. "If you did what you were told," says Tyson, "everything would be fine. They didn’t welcome initiative or encourage it. But over time it got worse and worse, as management pitted people against each other, and sometimes people would fight like cats and dogs. Morale was very low." Evelyn Duncan, the current Assistant Vice President for Planning who was rising rapidly through management hierarchy, describes it this way: "It was very top heavy, very hierarchical. You were given a set of marching orders toward some corporate goals, and you were expected to follow them. Basically, there was not a whole lot of involvement. It was always very friendly, don’t get me wrong. But it was very structured, and it generated a routine atmosphere." To many people, structure and routine are welcome, because they offer order and safety. But it also generates fear and divisiveness, as people often operate along the lines of "Ok, I’ll look out for myself, and make sure I make my budget." This embracing of order and safety, and "just tell me what to do," very much represents the culture of ULH when Columbia/HCA left, and in the first months of the transition.

Also strong in the culture, and a persistent theme of ULH throughout its history, is care of the less fortunate in the community. This sentiment is exemplified by a comment at an open meeting in May, 1999: "I came here and I stayed here because the hospital takes care of patients that no other hospital does." A second person said, "This is like a second home to me. I’m proud to be able to work here." This, despite the fact that ULH is a very tough place to work, because it is located in one of the city’s more depressed neighborhoods, and because of the high volume of indigent patients for whom this care is intended. Not that this altruistic attitude is universal. For some ULH staff, there was the feeling that indigent patients ought to feel grateful for receiving the care they do, a somewhat paternalistic stance, with distinct tones of condescension.

In August 1996, Jim Taylor took over the post of president and CEO, bringing with him a quiet determination to find a path to working in a different way from that of the entrenched culture, while nurturing further the collective purpose of care for the community.

One of the most powerful concepts in complexity science and most relevant for human systems, that is organizations, is the principle of emergence. Simply stated, when agents in a system interact and have a mutual affect on one another and are rich in diversity, something novel and often unpredictable emerges. When translated into human terms, agents are people and their interactions foster relationships. Relationships based on a sense of mutuality, that is, mutual respect and a mutual capacity to influence and be influenced by others, create the potential for strong connections. In turn, a richly connected system has a greater propensity for being more adaptable and robust. In other words, how we interact with each other, has everything to do with whether the culture that emerges will cultivate innovation, productivity, and commitment, or not.

Jim Taylor, who was and continues to be involved with the VHA leadership initiative, which explores the implications of leadership from a complexity perspective, recognized that in order to engage nonlinear processes within the organization so that a new order could emerge, he needed to focus on relationships and the values that guided them. That meant addressing the prevailing disconnections and forging new connections at ULH. Creating more connections and strong relationships enhances information flow in an organization, which expedites learning. And a learning organization is better able to respond to the kind of fast-changing environment that hospitals find themselves in today. Thus, Taylor’s approach to the organization is an organic one, that is, viewing it as a living organism rather than a machine..

Taylor refocused the values that would guide this world of relationships, behaviors to be practiced individually and organizationally–trust, honesty, respect, collaboration and teamwork, learning, and constancy of purpose, with the hope that these ethics would provide a foundation for people as they embarked on this uncertain journey. These values cultivate a context in which people have the freedom to think for themselves, speak up, and to contribute ideas. Taylor opened a door to a new opportunity so that, as Evelyn Duncan puts it, "Every employee here has the opportunity to affect how well or not well we do today and tomorrow."

An important part of the effort to break down the silos of disconnected departments and forging new relationships between them was the formation early in 1998 of Affinity Groups and the Coordinating Group. Affinity Groups, five in all, are formed from managers from different departments, but with a common area of activity, such as Business Services and Clinical Services. Their function is to meet weekly, so as to "ensure communications among and between departmental managers and the policy and strategy function of the organization." The Coordinating Group is made up of the executive staff plus one representative of each Affinity Group. "The hope in these groups is," says Taylor, "that if you change the way people interact with each other, these people will then go back to their group and try out new behaviors at that level." Forging these new connections holds the promise of developing positive feedback loops. "My role as a representative," says Jim Graham, Director of Materials Management, "is to carry back the information from the Coordinating Group to my Affinity Group, solicit feedback from them and take that information back to the Coordinating Group. A real positive give and take." To follow a biological metaphor, this cross departmental interchange is a cross pollination of ideas and behaviors.

In a for-profit organization, the focus often is money. With the shift to a not-for-profit organization, Taylor refocused this bottom line and instead placed value on the relationship to the customer, seeking ultimately to serve the community as best as can be. As Steve Short states, "Everyone that comes to work here has customers; whether you’re a nurse or doctor and your customer is a patient; whether you’re in the accounting department and your customers are department managers and all the employees. The expectation is that we treat our customers properly and we serve them the best we can." In a highly competitive environment, strong relationships with the customer, whoever that may be, can be the edge that makes a difference for organizational success.

Not only does creating new connections and relationships make for a more robust system and enables "a learn as you go" approach to work, but it also forms the nexus for developing a new way of working--team work, that is people working and learning together for the greater good. Rather than competing, which creates disconnections, a team player is truly interested in the success of one’s peers as well as one’s own success. Taylor’s vision of a team player also extends beyond the work unit--to cultivating a holistic team. A holistic team player recognizes they are part of, not apart from, the whole organization–a part of a larger team doing what is best not only for the individual and their units but also for the organization as a whole. As Martha Dawson, CNO and VP for Clinical Operations, states, "You can make independent decisions, but you have to think globally. I have to think when I make a decision, how does it impact the whole? So if I make a decision with a nurse, how does it impact food services or materials management?"

Taylor personally takes on the responsibility for creating new connections and relationships; he makes efforts to come in contact with people in different ways. But he recognizes that even though he makes efforts to be visible, that doesn’t automatically make him more accessible. "I work very hard at being visible. But my question is, if a guy who is fifty-two years old and wears a suit and bow tie, and comes through someone’s unit from time to time, and if there’s a twenty-six year old staff nurse, I am visible to her, but am I accessible to her? Or if a fifty-year-old African American housekeeper sees me and I may say hello to her and smile and ask how she’s doing, am I really accessible to her? It’s a two-way street. My side of the street is open. I enjoy talking to people, but I’m also who I am, the President. They may think I’m important because my name is on their paycheck, but they probably don’t have a clue about me. So is that being accessible?"

But Taylor’s visibility does have a certain power–the power of his example. Norma Racine, Taylor’s assistant, who might be described as the eyes and ears of administration, observes the following: "This example sounds trivial, but it’s actually a big deal. And these are the kinds of things the support staff like the cleaning people talk about. Jim will be walking down the hall talking to somebody and he’ll notice a piece of litter on the floor. He’ll stop and pick up the piece of paper or whatever it is, and dispose of it. People will just look at him. You would not believe the buzzing after the first time he did that. I heard about it from the housekeeper herself. ‘Do you know Mr. Taylor picked up a tissue off the floor today?’ It was a powerful gesture because other CEOs would scream at some manager to call the head of housekeeping to call someone to go pick up that tissue on the floor. It’s a demonstration of respect for the place and the people in it. And I think that makes people feel pretty good about being here."

Taylor’s effort to positively connect with people sets an example for other executives, such as Short, who started a "work-a-day." He picked fourteen departments and works all day in those areas, one at a time. He believes this gives him a greater understanding for how things are working and how they can be improved. "A lot of times people tell me things about their problems and I have no frame of reference. I’m not acting like I’m going to solve their problems, but it would be very beneficial for me to get another point of reference. And I get that point of view when I’m there working in the department."

For most administrators, visibility is an issue. "We feel that some of the reason there are barriers between us and the rest of the hospital staff is because when we go visit an area, they don’t know who we are," says Evelyn Duncan. "We need to be more visible and really out there talking to people. But part of the problem is that no one drops in to see us. Why don’t the managers drop in?"

Norma Racine sees it this way. "Departmental managers and non-management people were totally intimidated by these [executive] offices and the people in them. Most people haven’t even been here. If they were called to the executive offices, it was like being put on death row. People were terrified. I’ve seen that change tremendously. Even the environmental services people are comfortable just coming up here. They actually talk to us. And are amazed that we talk back. So, it’s really fun now."

It needs to be said here that the changes Taylor initiated were presented as suggestions, not dictates. By his nature, Taylor is a calm, thoughtful person who wants people to come to this way of being on their own and not be coerced or imposed upon, which would put the organization right back to a command and control dynamic. But that’s often difficult. "People want me to be more directive, but I resist that," he says. "My sense is that they want me to be a traditional leader and I’m just not going to do it. It’s difficult because even though they may want it, it’s not what I’m trying to do here. Sometimes it’s a legitimate request like, ‘what should we be doing?’ As long as it’s from a collaborative perspective rather than getting solutions from the boss, I’m fine with that. But I struggle with it all the time. You try to follow-up with people, and show that you’re interested, and if they need help from the organization, try to provide it. But also you have to give back to them the responsibility for dealing with their own problems."

All of this is done with an underlying intent–to make the work environment a happier, better place for people, a place that challenges them, where they can grow and learn and are better able to serve and care for the people in need who come through the ULH doors. With this in place, frequently the bottom line follows. And yet, in spite of these altruistic intentions, engaging people in these changes is a daunting task. In a culture that over the years has eroded into mistrust and has ossified into old ways of doing things, (that may not be effective but are nevertheless familiar) Taylor is asking nothing less than a different way of thinking about the workplace, a new mind set.

Between a Rock and a Hard Place

Change within organizations is always complex and rarely easy. For some at ULH, the changes Taylor brought about are liberating; they make sense, they make work exciting; for others, it is frustrating at best, impossible at worst. Steve Short is in the first group. "It’s like the difference between day and night," he says. "My job is very different now. Before you were dictated to and just carried out orders. Now it’s, ‘We want you to think on your own. You have no general above you. We’re all in this together.’ I was nervous at first because I didn’t really feel like I’d been trained to be a thinker before, to actually think. Now I have to think about what the decisions I make mean. Even though I feel an enormous amount of pressure to do the things that are going to be best for the institution, because a lot of people are relying on my decisions, this way of working is just so refreshing. It’s so much more invigorating coming to work and charting out your own course versus getting orders."

For Jim Graham the change in perspective validated a way of thinking that he valued and was not previously encouraged. "Before, the reality in maintaining a job was always trying to justify the numbers. I’m still a numbers person but the relationship to my work is different. Now I spend my time focusing on processes and the evolutions that my department helps support. Instead of trying to do everything in a box, you kind of see what you have and then find a box with rubber sides to fit it so it can expand and contract as you need it to."

For others at ULH, who think in terms of what they have done for years and are set in their ways, the change is overwhelming; some think it absurd; or just plain wrong. Many of them joined the ranks of culture casualties and left. And there are those who remain, but are not on board with the new ideas. They go along passively, some with skepticism and suspicion, others cautiously. Still others remain passive in embracing the new ideas, but actively try to sabotage the process.

But regardless of where people are on the spectrum of change, everyone enters a period of transition that feels something like being caught between a rock and a hard place–a place of tension between the rock of old behaviors and views, and the hard place of entering a new way of thinking, being, and doing. This transitional place is riddled with emotion–frustration, fear, mistrust, anxiety. But in the context of complexity science, these emotions are hallmarks that the culture is at the edge of chaos, a precarious place, ripe with potential for something new to emerge, a place where things can go for better or for worse.

The container that can hold this collective anxiety through times of change and flux is trust and faith. And these attributes do not come easily for people at ULH, with good reason. As Bill Fell puts it, "People have been through so many changes and have been directed most of their lives. Because of that, they’re really not sure now. It had become a given that a total administration change will happen every two years. So we learned that whatever was implemented, you just waited out. For years we’ve been bossed around, and now we hear ‘You’re the bosses.’ And we say, ‘We don’t trust that.’"

Questions such as, "Is this real?" "Are we really autonomous and do we really have the power to influence and make our own decisions?" hang like a dark cloud of disbelief. These questions, however, may speak to Kay Lloyd’s question, "What is holding us back?" and might explain Fell’s observation that "A lot of our performance is just hanging; it’s all just hanging." The hesitancy to suspend the cloud of disbelief and to trust again ultimately suspends the process of change.

For senior executives and managers attempting to engage a different way of working, the cloud is a source of endless frustration, as Dawson testifies. "I think that some of the things going on at senior level is that we’re not sure who’s leading what initiative, who’s providing what influence, and whether or not we’re doing the same thing. I will be totally honest; last week, I had it up to here. My frustration level was very high."

Mistrust and frustration aren’t the only clouds to cast a shadow on a new way of working. Fear, a conundrum of dynamics, sits like a boulder on the highway of change. The fact of the matter is that changing a way of thinking, being, and doing does not happen overnight: learning to be personally accountable, to take risks and start initiatives, to recognize being part of and contribute to a greater whole; learning to be part of a team effort, to encourage success in others, to cooperate and collaborate; and learning to be straightforward and open to feedback as well as constructive; all this takes time. In this unsettling terrain between a rock and a hard place, new and old ways collide with each other. And with this collision, contradictions and inconsistencies erupt, creating a distance between thought and action. What people may know and understand in this new mind set does not necessarily translate into how they behave.

Many senior executives and managers recognize their own inconsistencies as they engage in this process of change. As Kay Lloyd acknowledges, "I truly see it as a learning thing. I think we all revert to old ways when it gets hard and difficult. What we are practicing is so different, it’s easy to slip back into the old and familiar ways." The key word is "practice" because it is a daily practice of another way of being and doing. And being human we slip back into the familiar which often means taking control. As Martha Dawson admits, "I try to refrain from taking on the problems. Although I will confess, sometimes I just go ahead and resolve it myself, because it’s easier." True enough, it is easier to just take charge and solve the problem. It generates a short time benefit–it’s done. But ultimately, taking charge circumvents a more important long term outcome–discovering a different way of working.

Like any new perspective, a complexity approach is vulnerable to being mechanized and objectified; that is, it can become a fixed picture of what it is suppose to be rather than allowing things to emerge; and is susceptible to falling prey to a command and control framework; that is, ideas being imposed upon people rather than jointly explored. Taylor goes to great lengths not to impose complexity ideas, and as is characteristic of leaders who are guided by complexity principles, he instead gives voice to the collective values, expectations, and principles and then allows people to interpret them for themselves.

Learning to let go of control is perhaps the greatest challenge managers face in embracing this new style of management. Letting go is laced with fear because it flies in the face of the very meaning of traditional management and leadership--to be in control. For instance, one departmental director, who is enthusiastic about having staff at all levels make decisions, was faced by the following concern in his three top managers. The three managers came to him and said they were worried that their authority was being eroded, because their staff were able to make decisions on their own, so what did it mean to be a manager? The director responded as follows: "I said to them, that’s what it’s all about. I want them to make their own decisions. They’re the experts." The managers were concerned that if the staff makes all the decisions, then they won’t be needed anymore. "That’s not what it’s all about," the director explained to the managers. "It’s about helping people be where they need to be, providing them with whatever they need to do their job. You’re at their disposal; that’s what you are here for. You’re not here to tell them what to do." Cast in this light the manager’s role refocuses–they are the harbingers and facilitators of change.

Senior managers can also feel threatened by a flat administrative structure in which decision making is distributed. For instance, Gerald Johnson, Administrative Director of Radiology, says that his initial response was dismay. "I thought, ‘if he’s taking out the hierarchy, the ladder up the organization, how am I going to advance to where I want to be?" he recalls. "But then I realized that it would change the way I work, that I didn’t have to ask permission to do things in my department. When I understood that I had that power, I felt liberated. It took about three weeks to get to that point."

One of the difficulties in this passage between a rock and a hard place, where executives and managers are learning a new way of leading "as they go," is that those under their jurisdiction often hear a double message and recognize an implicit inconsistency between thought and action: "It’s okay to make any decision you want, just so it’s congruent or the same decision I would make." Lip service. People have been down this path before and have been burnt on the way. Consequently, people are often afraid to take initiative because they are afraid of making the wrong decision. As Lee Tyson puts it, "There’s a tremendous fear of screwing up. That if you fail, if you make a mistake, that you are going to lose your job." Not feeling safe, whether imagined or real, people hesitate and hold back. Norma Racine recognizes this dilemma: "There are some who don’t trust that when they make a decision, Jim and the system will stand behind them. We have a ways to go with that."

And yet others, such as Jim Graham, see it differently: "With Jim, I really think we don’t have to fear for our jobs if we make a bad decision. It’s taking a long time to convince people of that; I don’t think he could do any more than he’s already done." From this vantage point, fear reflects personal insecurity–people unsure of their abilities, afraid to ask for help, and rather than address this insecurity, they hold back. Others resort to blame as a way of deflecting from their insecurity. And still others maintain an adult/child relationship with management as a way of feeling secure. Still others’ insecurity manifests as complaining–wanting things to change but feeling powerless to do it, which becomes another source of frustration. "Complainers," as Pharmacy Director Don Kupper states, "don’t challenge you to do better. They don’t challenge you to do worse. It’s like their complaining challenges you to not interact with them." As Graham put it, "I want to shake complainers and say don’t you realize what it was like here four years ago. Don’t complain. We could turn the clock back and everybody could be in that hell again."

The conundrum of fear is a negative feedback loop–inconsistent messages stir insecurities which create frustrations that generate inconsistent messages. With all these complexities, it nevertheless comes down to some simple truths. As letting go is the challenge for management, so taking responsibility is the challenge for staff. As Taylor succinctly points out, "In the end, each person has a personal responsibility to make their own life and the life of their work unit and of the organization better. It’s your job to act. And you can act and do something good." In this way, the meaning of security is refocused. As Graham states, "The degree of security that I feel isn’t based on performance; it’s based on the respect and trust that’s given to me by my peers and the administrative staff. And that respect and trust is not just given. It’s earned."

In these changing times, when health care is itself in a critical stage, the only way to survive and thrive is through a team effort. Things are too complex for one individual, for lone rangers. And so another assumption gets dispelled when we look at complex systems--competing is not the only, nor even the best way, to survive. Competition at the cost of collaboration has been part of ULH culture, and continues to be present.

Gerald Johnson provides an example of how a competitive attitude at work impedes learning and stunts growth. He was sharing with the Coordinating Group some of the initiatives he had taken that were very successful in his department. (See accompanying article, Four Stories: You Can Make a Difference) "Not one person asked how’s it going," laments Johnson. "Not one person has come down to take a look at what we’re up to. If they don’t support this stuff from the top down, it’s not going to go anywhere. That’s the kind of thing that stops people from doing good things."

Everyone loses in the glare of a negative competitive attitude. People don’t see the opportunity to benefit and learn from others’ experience; instead they resent other people’s success. And those who are succeeding feel unsupported, unacknowledged and ultimately alienated. From a complexity perspective, a negative competitive attitude blocks a flow of information, which is so vital to the health of a system and its capacity to evolve. Instead of generating connectedness, negative competition creates disconnections between people and negative feedback loops of bad feeling.

Negative competition is corrosive. In a recent survey at ULH done by Karen Wunderlin, it became apparent that most nurses did not have an expectation that they should support each other. If energy is being spent on trying to outdo colleagues, such as getting patients on your unit versus another so that yours won’t close; or if you take care of your unit and ignore the health of the rest of the system; how will this give ULH a competitive edge against other hospitals, which ultimately affects the individual? As Dawson says, "You’re competing against the wrong individual. You don’t want to draw a patient from her unit to your unit. You want to draw a patient from other hospitals." The larger team vision, the holistic team, sees the whole and not just the parts.

It’s not to say that there isn’t a place for competition, as long as it is coupled with support. Supportive competition encourages others to be the best they can be and people are spurned to do better when they see others excelling and finding better ways of doing things. This kind of competition recognizes that people learn more when they can co-evolve together and that everyone benefits from the joint effort.

A holistic team hinges on creating units of genuine teams. There are two key elements to genuine teams–authenticity and care. Being authentic, that is being more yourself, saying what you think; and caring–caring about your team mates, the project, the organization--creates strong relationships and rich connections, which in turn make the unit and ultimately the organization more adaptable. In other words, until people take the risk and say what they really think and feel and what they really care about, and find ways to care about other team members and shared projects and a common purpose, it’s not a genuine team.

In spite of what might seem to be unsurmountable obstacles in this transitional time at ULH, the way of working that Taylor introduced has penetrated and permeated the workplace. People and departments at ULH are generating positive feedback loops by creating genuine teams. They are the trailblazers, the "champions" that Taylor is looking for, those that are bushwacking their way to a new way of being and working at ULH. As Taylor observed, "People in this organization are resilient and they’re resourceful. To make it through twenty years of taking care of the population we take care of, under the conditions that were created both societally and managerially, those who are still here are the resourceful and resilient ones and those are really wonderful characteristics to have in your people in an organization." Four stories that illustrate this spirit can be found in an accompanying article, Four Stories: You can make a difference

WHO WE ARE

The Spirit Lives

Some have said that the old ULH culture of command and control continues, that it’s just diffused. Whether that is certain or not has yet to be seen. But one thing is certain: despite the roiling crisis in health care, the community spirit of care has been and continues to be a constant. This is no minor feat; for many organizations, the care in health care has been lost. The essence of the spirit comes from a shared mission: "Give me your tired, your poor, your huddled masses," says Nancy Overall, an internal auditor in Financial Services, "and we’ll take care of them. We’ll care for them. We are their safe place."

The mission is certainly more visible for those in immediate contact with the patient. For people like Steve Short in Finance, it takes leaving his office. "When I go into the hospital, and talk to a nurse about a patient, I’ll see a family, maybe I’ll talk to a family who didn’t have enough money, and we worked something out for their payments or whatever. And I come to the realization that the reason we’re here is we take care of people, patients, and try to get them better. It’s so easy for me to forget that. If I don’t go out in the hospital, this is just another business and we could be making cars over there, because I just see the numbers. And I think my responsibility is beyond that."

It’s true that, in the first three years under Taylor’s stewardship, ULH’s financial performance has improved markedly, physicians’ commitment to and respect of the organization has burgeoned, and patient satisfaction figures (though not yet impressive) have improved. All three are traditional measures of a hospital’s success. Nevertheless, at ULH, the real bottom line, the real mission is care. But it takes an exceptional organization to fully engage in that mission, given its patient population and its role in the community of tending to the less fortunate people, as Taylor points out: "I like the reason we’re here–to take care of so many needy people, both medically and spiritually and psychologically, and that we are able to do that day after day. It takes a certain kind of person to work in this hospital. It’s really true. You come to work here, for instance, as a nurse, and you sign on for harder work than you do in most places, just because of the kinds of people you’re taking care of--how sick they are and all the other non health-related issues that so much influence what’s going on–their behaviors, their families behaviors. It’s a wonderful challenge as long as you’re looking for a challenge."

It is a special person indeed who engages in this challenge, as Brenda Kasdin, an art therapist on the psychiatric ward, describes: "You don’t get extraordinary monetary benefits for the work here, so you really have to enjoy the work that you do in order to stay. Everybody essentially likes the patients. And these are patients no one else wants. You have to like the patient population, because by and large they can be very unlikeable people. You have to be a certain kind of person who finds a way to think that these people are unique, interesting, and special and not just the drain on society that many people think they are. You look at the indigent population and some think these are poor people just milking the system. And it is very much the poor of the poor coming here, but, on the other hand, there’s some very interesting people with some very interesting stories here. It’s always different; it’s always challenging. If you can find joy in that, then you’re going to like what you do. I do. That’s why I’m here."

Although the spirit of ULH may seem at times buried beneath stresses and shortages of the health care crisis, the spirit of care and collaboration that was so evident on Miracle Wednesday is, in fact, not dead, but rather buried alive. Of course, not everyone feels it, but enough do so that a collective identity, paradoxically both new and old, is beginning to emerge. An organization that brings hope to the often lost and overlooked, is recovering its own sense of hope and reclaiming its passion. As Bill Fell says, "Give us a cape and we’ll fly."

Or better still, as Evelyn Duncan puts it, "Watch out. Here we come!"