As large numbers of severely injured patients were delivered to Boston hospitals, an interesting phenomenon occurred as was reported by Atul Gawande, MD.
The number of severely injured that arrived so rapidly at all the Boston hospitals did not allow time to mobilize the “incident command” system hospitals have for disaster response. Incident command is a hierarchical system of governance, delegation, and communication to allow a military style command center to mobilize and organize resources in a mass disaster. As Dr. Gawande reported in a New Yorker blog shortly after the disaster, “Everything happened too fast for any ritualized plan to accommodate.”
What happened was not delegated from a command center. As one colleague put it, “they did on a large scale what they knew how to do on a small scale. They divided into teams of six or so people, one trauma team for each patient.” Nurses, without direction, set up eight operating rooms for vascular and orthopedic cases, a decision they made based on what they knew about the bombing and the kinds of injuries they felt were most likely. People self-organized and orchestrated.
This phenomenon occurred at the Boston hospitals that received the traumatized patients. As Dr. Gawande noted, not one patient who reached a hospital alive was lost. Given the severity of the injuries, this is remarkable! Dr. Gawande attributes some of the self-organization to lessons learned after September 11, 2001 and from the battlefield over the last decade.
I believe there is another phenomenon going on here that’s worth noting: the fact that people self-organzied in such an amazingly effective manner suggests that some of the principles of complex adaptive systems are at work. In the process improvement world, we are taught to ask “why" and then to repeat the same question up to five times.
Complex adaptive systems operate according to simple rules, minimum specifications, a “good enough” vision, and a wide space for natural creativity to emerge. Leaders of complicated organizations are realizing that construction of complex hierarchical reporting relationships depending upon cause and effect rules and policies, does not always lead to efficient and effective functioning. Fewer and simpler rules, with corridors of resources available, and encouraging the self-organization of teams such as what happened in the Boston hospitals, may provide “emergence” of outstanding results without the commander figuring it out. One of my favorite organizational ‘simple rules’ is the Netflix policy on corporate travel, entertainment, and education. It is five simple words: “act in Netflix’s best interest.”
So I asked Dr. Gawande the ‘why’ question. Why did he think this kind of self-organization and orchestration occurred, and are there lessons to be learned from complex adaptive systems theory to explain this. Dr. Gawande’s response:
“[I] completely agree with your characterization — what we saw were the ingredients coming together for the formation of a complex, city-wide adaptive system for disaster response. Very impressive. But what the simple rules and minimum specifications are, I'm much less clear on. Physician leadership that understands structures that allow delegation, empowerment, and results-oriented focus seem critical. We're needing to move from values of autonomy to ones of humility, discipline, and teamwork in a lot more than disaster response. [This is] not easy to do.”
As leaders of complex organizations we need to ask our outstanding colleagues “why,” and learn to allow a leadership practice of delegation, empowerment, and results orientation in a value system of humility, discipline, and teamwork. We have much to learn. The medical response to the Boston bombings suggest this new leadership paradigm works.