Physician leaders and healthcare executives sometimes speak of creating oases of efficiency and people-centeredness within organizations or systems they consider dysfunctional. Get enough people together for long enough, they say, and years of good policy intentions turn redundant, excessively complicated, and wasteful.
Dysfunction in healthcare systems (often pejoratively described as “healthcare bureaucracy”) is especially problematic because it can lead to moral hazard, loosely defined as the emotional and psychological distress produced when healthcare workers perceive they are unable to deliver the quality of care they aspire to provide.
This is when some healthcare leaders report taking matters into their own hands. They endeavor to establish functional subcultures within organizations and systems they perceive as flawed. Like Atlas bearing the world on his shoulders, they see themselves as insulating their reports from bureaucratic excess. They seek to create terrariums in the weedy garden.
Obviously, organizational- or system-wide improvement is always the best option. In a perfect world, we would improve the systems, not establish subcultures. But system improvement isn’t always feasible.
I’ve seen and heard examples of terrarium leaders creating and leading productive subcultures. There are, however, some very important concerns relative to this approach. Subcultures within organizations and systems can be destructive when paired with cynicism, rigidity, tribalism, leadership arrogance and immaturity, and so on. If you attempt to create or lead a subculture with an us-vs-them leadership mindset, your attempt to create a pocket of stability may only exacerbate existing disfunction or discord.
If terrarium leaders truly aim to contribute, they must incorporate the following into their philosophies:
- Challenge yourself to think with complexity and hold multiple truths. For example: be independent and participate simultaneously. Stay aware but avoid cynicism. Accept what you can’t change but avoid resignation.
- Perceive wholistically, keeping in mind that you and your team are nested in, and a supportive part of, the larger system. Look for and participate in opportunities to improve the system.
- Honor existing authority structures.
- Understand the concept of reciprocity. Be conscious of the ways you depend on and receive from the larger organization or system while continually looking for ways to give back.
- Think developmentally in every direction, including toward the people, systems, and processes you perceive as counterproductive.
- Assume positive intent.