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Complexity Science and Leadership in Healthcare

Burns, Jamie P. RD, MBA

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Author affiliation: Scripps Mercy Hospital, San Diego, Calif.

Corresponding author: Jamie P. Burns, RD, MBA, Senior Employee Relations Specialist, Scripps Mercy, 4077 Fifth Avenue, San Diego, CA 92103-2180 (

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The emerging field of complexity science offers an alternative leadership strategy for the chaotic, complex healthcare environment. A survey revealed that healthcare leaders intuitively support principles of complexity science. Leadership that uses complexity principles offers opportunities in the chaotic healthcare environment to focus less on prediction and control and more on fostering relationships and creating conditions in which complex adaptive systems can evolve to produce creative outcomes.

Current business organizations operate in economic, legal, and technical environments that have radically shifted structure, funding, and operation. Drucker notes that the biggest problem facing managers is that the world in which they learned how to manage no longer exists. 1 Regulatory and statutory initiatives, employer mandates, customer expectations, and financial pressures all drive change, which has become “part of the leader’s daily agenda.”2(p10)

Healthcare leaders are frustrated in this chaotic and complex environment. A study 3 of senior healthcare executives found that they no longer trusted many of the management methods they had been taught and practiced. They did not believe in the long-term strategic plans they developed because the future was not as predictable as was depicted in the plans. They had seen intensive information gathering and consensus building in their organizations, yet did not see any substantive changes. They worked harder, yet thought that much of their hard work had little or no effect.

The emerging science of complexity offers healthcare leaders a new strategy for leading in these chaotic, complex times. It offers the opportunity to adapt new perspectives and competencies on organizations and leadership, that of viewing the world through the lens of complexity. 4 The use of complexity science may fundamentally change the leadership of organizations and other human social systems. 5

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What Is Complexity Science?

Complexity science is the study of living systems, including such diverse systems as hospitals, medicine, manufacturing, and ecosystems. Complexity theorists recognize that each of these systems share patterns of behavior. Complexity science examines the unpredictable, disorderly, nonlinear, and uncontrollable ways that living systems actually behave. 3

The Santa Fe Institute, a New Mexico think tank, is the nerve center for complexity scientists in the United States. Created in the mid-1980s, this group of researchers and scientists is working to establish a common theoretical framework for complexity. The Institute is renowned for its innovative thinking about economies, social interactions, organizations, ecosystems [and] any kind of system that seems complex, adaptive, and self-organizing. 6

The application of complexity science to healthcare management has been led nationally by the Voluntary Hospitals of America (VHA). Beginning in 1995, VHA organized complexity and leadership learning networks of senior healthcare executives, physicians, and nursing leaders. Complexity experts and theorists, including scientists from the Santa Fe Institute, worked with these learning networks to build complexity knowledge and to explore the practical application of complexity principles to healthcare systems. In 1998, VHA introduced more than 900 healthcare leaders to the science of complexity and its implications for management, healthcare delivery, and the understanding of human organizations. 7 In 2000, the VHA initiative evolved into the international Plexus Institute. The Institute focuses on using ongoing scientific findings of complexity and other natural systems to advance the health of individuals, organizations, and communities. 8

Initial results reported by healthcare leaders using complexity-oriented principles are promising. 3 Keyes, at the Muhlenberg Regional Medical Center in New Jersey, used complexity principles to significantly improve patient satisfaction in the emergency department, merge patient care units, and implement a staff dress code. Dwyer, Vice President of Medical Affairs at Burlington County Hospital in New Jersey, used complexity-based leadership to develop new partnerships with physician groups. Hutchens, from HealthEast in Greenville, North Carolina, used complexity principles in developing medical practice management groups. These leaders and others who have experimented with complexity science principles, have found them to be effective leadership strategy in the chaotic healthcare environment.

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The Language of Complexity

Complexity science is the study of complex adaptive systems: the patterns of relationships within them, how they are sustained, how they self-organize, and how outcomes emerge. A complex adaptive system is an individual agent or a group of agents whose behavior changes and evolves in complex ways that are not predictable. Complex adaptive systems can include anything from the stock market to a colony of ants; they also can be a collection of people, such as employees of a healthcare organization, who have the ability to self-organize and produce outcomes. The outcomes that emerge from a complex adaptive system in a chaotic environment are fundamentally unpredictable and unknowable; they emerge from the connections and relationships among the individual agents. In organizations, the relationships among the individual agents in the complex adaptive system are often more critical than the individuals themselves. 3

The study of complex adaptive systems also includes the concepts of chaos theory and linearity. Chaos theory examines system behavior that is contained within boundaries but is largely unpredictable. Chaos is not random, even though it is largely unpredictable. Complex adaptive systems thrive at the “edge of chaos,” the area in a chaotic system in which there is not enough stability to have repetition or predictability, but not enough instability to create anarchy. Linearity refers to the scientific concept that the size of a change is correlated to the size of the input. Complex adaptive systems are nonlinear systems; in other words, the result can and often will be greater than the sum of the inputs. 9

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Edgeware’s Nine Organizational and Leadership Principles

A framework that is useful for understanding complexity science and its relationship to healthcare leadership is Edgeware’s Nine Emerging and Connected Organizational and Leadership Principles From the Study of Complex Adaptive Systems (Figure 1). 3 Additional information about Edgeware, complexity science, and complex adaptive systems can be found online at http//:

Figure 1
Figure 1
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Principle 1: The Lens of Complexity

Viewing an organization through the lens of complexity offers an alternative for successful leadership in the complex and chaotic healthcare world. Zimmerman et al. 3 describe current management axioms of planning, directing, and controlling as similar to managing a machine, in which correctly managing the parts achieves the desired outcome. In many healthcare situations this mechanistic, machine-like management process can be effective; for example, when completing emergency medical procedures or a highly technical task. However, attempting to predict, direct, and control the chaotic healthcare environment is futile. Viewing the world through the lens of complexity means alternating mechanistic, machine-like management activities with leadership behaviors that create environments for complex adaptive systems to evolve and to produce highly creative, albeit unpredictable, outcomes.

Morgan 10 believes that the mechanical way of thinking is so ingrained in leaders that it is difficult for them to manage in other ways. He notes that mechanistic approaches work well under the same conditions under which machines work well: when the tasks to be performed are straightforward, when the same product is desired repeatedly, and when the human machine parts are compliant and do what they are designed to do. Reliance on mechanistic management will result in organizations that have difficulty adapting to changing circumstances.

McDaniel 11 notes that current organizational leadership paradigms were developed based on Newtonian physics and that healthcare managers in the Newtonian world are decision makers. They are required to predict possible outcomes and if the expected does not happen, it must be because the planning and predictions are incorrect. McDaniel believes that healthcare is a chaotic system, which is fundamentally unpredictable and unknowable. Thus, management that is focused primarily on planning, controlling, and decision making (which works in stable environments), is ineffective in the unstable, chaotic environment of healthcare.

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Principle 2: Minimum Specifications and a Good Enough Vision

Zimmerman et al 3 suggest that it makes little sense for organizations (of complex adaptive systems) to spend time in detailed planning, because the behavior of the complex adaptive system emerges from the interaction among the agents and is inherently unpredictable. Often, organizations find that the assumptions and details of their plans are outdated before the plan is implemented. Complexity science suggests that organizations would be better served by providing minimum specifications and a general sense of direction which then allows the complex adaptive system to self-organize and adapt.

Lindberg et al. 12 suggest that companies use mission statements, visions, guiding principles, and boundaries to provide general guidelines instead of specific rules. Leaders who focus on minimum critical specifications, rather than on grand design and excess control, will create environments that allow complex adaptive systems to explore, self-organize, and create successfully.

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Principle 3: Clockware and Swarmware

“Clockware” describes the management of organizational processes in a rational, planned, standardized, repeatable, controlled, and measured way. “Swarmware” is the management of processes that explore new possibilities through trial and error, freedom, intuition, and working at the edge of knowledge and experience. 13

Zimmerman et al. 3 suggest that both clockware and swarmware have uses in complexity and leadership. The challenge is to identify the best method for the situation. When the environment is certain and when there is strong agreement between agents of a complex adaptive system, clockware is appropriate. In this situation the complex adaptive systems will display less emergent, creative behavior and will act much like a machine. However, when the environment is uncertain and there is not agreement in the complex adaptive system, swarmware can provide more adaptability and openness to learning and flexibility. Swarmware also is useful in situations in which clockware is not effective or in situations in which maximum creativity is desired.

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Principle 4: Tune to the Edge

Success in the chaotic healthcare world requires that groups have the right balance of information flow, diversity and difference, connections inside and outside the organization, organizational power differential, and anxiety. When groups of individual agents have the right mix, they will produce creative outcomes. 14 However, the right mix cannot be predicted, because it evolves from the relationships among the individuals in each group. Thus, achieving the right balance requires a process of taking action, reflecting on the results, and then tuning to the edge, an area of the chaotic system [in which] the complex adaptive system thrives and reaches its creative potential. 15

Plsek 15 suggests three types of reflection: hindsight, foresight, and insight (reflecting while participating, often from a detached perspective). He believes that honest reflection by leaders requires that they avoid looking for and feeling the need to provide the right answer.

McDaniel 11 believes that no leader, regardless of how visionary, smart, proactive, or aggressive, can resolve issues in the healthcare environment without developing and managing complex relationships among people who are significantly different from one another. Some leaders and group members trained in command-and-control environments may be uncomfortable with strong organizational diversity; however diverse organizations have a strategic advantage because they can learn, adapt, and evolve more effectively in an unpredictable and unknowable world.

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Principle 5: Paradox and Tension

McDaniel 11 views creative tension as a prerequisite for organizational learning. The learning occurs when managers create creative tension by exposing differences between organizational visions and current reality.

Zimmerman et al. 3 believe that innovative outcomes have the greatest chance to emerge from a complex adaptive system at the point of greatest tension and apparent irreconcilable differences. This emergence only occurs, however, when leaders expose the tension and encourage the system to find new ways forward. Leaders who believe they must control the interactions among agents may attempt to assuage tensions or even deny them, which prevents the complex adaptive system from reaching its full creative potential. Leaders who ask wicked questions (questions that have no obvious answers but expose assumptions and challenge sacred cows), can help bring tension and paradox to the forefront.

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Principle 6: Multiple Actions That Let Direction Arise

Zimmerman et al. 3 advise managers to focus on action instead of plans and design. They recommend trying several small experiments, reflecting carefully on what worked and what did not work, and gradually shifting time and attention to those things that seem to work the best. These multiple actions will generate the best direction and result in organizational learning.

According to Ashmos et al. 16 hospitals that are the most responsive to the external environment are internally complex. These hospitals are quick to experiment, adapt, and change. They suggest that healthcare managers must develop ways of becoming more comfortable with disruption, conflict, and disorderly processes for resolving issues, instead of seeking simplicity and order.

Petzinger 17 writes about a new “biology” model for organizations, in which multiple actions achieve results as the system self-organizes and adapts. He notes that companies have moved toward self-organization for years, as shown by the development of quality circles, teams, and reengineering. The problem is that these reforms were still within command and control structures. In a global society, the best way to organize people is to free them to organize themselves. Why, he asks, should business be any different?

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Principle 7: The Shadow System

Organizations have two networks. First, there is the legitimate official system. It is managed by leaders who are trained in mechanistic styles of management and it focuses on maintaining stability and control. Second, there is the shadow system, which is the network of informal relationships that exist among members of an organization. Because it operates independent of the rules and policies of the legitimate system, it is often where most organizational creativity and innovation occurs. 12

Zimmerman et al. 3 note that everyone in an organization, at different times, is part of both the legitimate system and the shadow system. The coexistence of both systems can create diversity and tension, which can yield great innovation. When the shadow system is viewed simply as another set of interconnections between complex adaptive agents, instead of a system that must be discredited and controlled, leaders create opportunities to explore and validate diverse views.

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Principle 8: Chunking

Kelly, 13 who draws many of his beliefs about systems from nature, believes that organizations should let action emerge from the bottom up and build complex systems incrementally from simple systems that work. He notes that in nature, complex adaptive agents are connected to each other instead of to a central hub. Because there is no center of control, complex adaptive systems, exerting bottom-up control, form simple networks of interconnected links. When the simple network can operate independently, it chunks (ie, it links with other simple systems to create complexity).

Zimmerman et al. 3 note that the Internet evolved in chunks; components were added to the global network only after they had been accepted as able to work individually. They view the Internet as an example of emergent behavior (a complex and diverse system that is self-organized and evolved). They recommend that learning organizations grow complex systems by starting with simple systems, experimenting to find what works, and linking successful simple systems together to create more complex ones.

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Principle 9: Balance Cooperation and Competition

Axelrod 18 suggests that the most successful cooperation/competition balance is a simple strategy expressed as tit for tat. This strategy starts with an individual agent that cooperates, then responds to another agent’s action. Waldrop describes this cooperate-compete strategy as “nice guys—or more precisely, nice, forgiving, tough and clear guys—can indeed finish first.”6(p264) Zimmerman et al. 3 further clarify this phrase nice: they cooperate first; they cooperate when the competitor does; they punish uncooperative behavior by competing; and the pattern of compete-cooperate is easy to identify and use.

Waldrop 19 and Zimmerman et al. 3 describe how the Visa credit card organization, led by complexity supporter Dee Hock, has achieved global success with this cooperate-compete strategy. Every institution that issues Visa cards competes with each other fiercely. They also cooperate fiercely so that merchants can accept any Visa card anywhere in the world, despite significant differences in language, culture, currency, politics, and legal systems.

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Do Complexity Principles Make Sense to Front-line Healthcare Leaders?

Edgeware’s nine principles describe how leaders can use complexity science to lead in complex environments. In the chaotic healthcare environment, leadership is required at all levels. Because front-line leaders operate directly in this environment, they may understand the environment’s complexity even more than executive leaders.

Zimmerman et al. 3 noted that executive healthcare leaders believed that the principles of complexity made sense intuitively. A study was conducted by the author to determine if complexity principles intuitively made sense to front-line healthcare leaders. If so, then the leaders could form networks to explore how complexity principles could be applied to existing organizational challenges.

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The study population was a random sample from 103 supervisors, managers, directors, and administrators at three hospitals of a healthcare system in San Diego, Calif. The study participants were leadership team members that attended each hospital’s monthly management meeting on the day the study was conducted.

The research tool was a 34-statement survey, developed by the author, that described key principles of complexity science and leadership (Figure 2). The research process and survey tool were reviewed and deemed appropriate and credible by a research consultant with more than 20 years of experience in developing, performing, and analyzing surveys. Demographic information (age and years of management experience) was collected. Individual job titles of study participants were not requested; given the organizational climate at the time the research was conducted the author believed that requesting this type of identifying information would have a negative impact on the participants’ responses.

Figure 2
Figure 2
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Study participants were asked to read each survey statement and indicate their “intuitive agreement or disagreement” by circling a rating. The Likert rating scale responses ranged from 1 (strongly disagree) to 5 (strongly agree). “Intuitive agreement or disagreement” was defined as “an immediate apprehension of truth/untruth, or supposed truth/untruth, in the absence of conscious rational processes.” Participants were given a maximum of 10 minutes to complete the 34-question survey.

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Fifty-nine leaders completed the survey, for a total response rate of 57%. Sixty-one percent of participants were between the ages of 36–50 years, and 90% were between the ages of 36–65 years. Most of the respondents (59%) had 11 or more years of healthcare leadership/management experience. Chi square analyses on demographic results showed no significance differences among the three facilities at the .01 percent level, so the survey results were treated as a single sample.

A mean rating of overall “intuitive support” at each hospital was calculated by determining the mean scores for each survey statement. Because chi square analyses on the demographics showed no significant differences between the respondents at each of the three facilities, a grand mean was calculated and used as the measure of intuitive support. Results showed a mean result of 3.5, supporting intuitive support. The grand means for each of the three separate hospitals were similar.

Results also were analyzed to determine whether differences existed among the three facilities in the intuitive support of key survey statements. Nine survey statements were identified as most likely to be different at each facility, based on the author’s knowledge of the facility’s organizational culture. Chi square analyses computed on the statement results showed no significant differences, at the 0.10 level, between the three hospitals.

Because there were no statistically significant differences among the facilities or among responses to selected survey statements, results were reviewed to determine the extent of intuitive agreement for individual principles. Figure 3 shows the results for each principle. The overall agree-neutral-disagree results for each principle were calculated from individual statements results.

Figure 3
Figure 3
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Principles With the Most Intuitive Support

The three principles with the most intuitive support, ranked in order of significance, were Principles 4, 8, and 1. Principle 4, regarding tuning by fostering information and relationships, was supported by 72% of the leaders. They agreed that when groups have the right mix of information, diversity, and connectivity among the members, they will self-organize and produce creative outcomes. They also agreed that organizations have an advantage when there is diversity of thought among the members and that strong leaders are most successful when they develop relationships among people.

Principle 8 recommends that organizations grow complex systems by chunking, or by allowing them to emerge from simple systems that work. Sixty-three percent of the leaders supported this principle, believing that the way to achieve success in complex organizations is to let action emerge, from the bottom up, and grow from simple networks that work well. They believed that learning organizations should start small, experiment to find the small things that work, and link the successful pieces into more complex systems.

Principle 1 addresses the need to view systems through the lens of complexity, in addition to the traditional machine or military organization. Although 60% of the leaders supported the overall principle, there was a range in the support of individual survey statements. The leaders agreed that healthcare organizations are complex and that the healthcare world is chaotic. Most thought that being a leader in the healthcare environment today is frustrating. However, the strong intuitive support of these statements was tempered by less intuitive support, discussed below, for statements that challenged predictability and control.

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Principles With the Least Intuitive Support

The two principles with the least intuitive support, ranked in order of significance, were Principles 2 and 6. Principle 2 recommends building a good enough vision and providing minimum specifications, rather than trying to plan out every detail. Only 29% of the leaders supported this view. Most favored detailed planning, even if the future is unpredictable. The leaders did not agree that leaders are most effective when they provide minimum direction and allow a group to self-organize; instead, most believed that successful companies give specific rules rather than general guidelines.

Principle 6 recommends that leaders try multiple actions and let direction arise, rather than being sure before action is taken. Only 36% of the leaders supported this principle. They did not believe that organizations were more successful when they focused on action instead of design. In addition, they did not agree that they needed to become comfortable with disruption, conflict, and disorderly processes instead of seeking simplicity and control.

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Principles With Intuitive Support in the Middle

The extent of intuitive agreement, ranked in order of significance, for Principles 5, 7, 9 and 3, ranged between 48% and 55%. This suggests that there was neither intuitive agreement nor disagreement with these principles. However, several observations emerge from the responses to individual statements within these principles.

Principle 5 recommends that leaders uncover and work with paradox and tension, rather than shy away from them. Only 48% of the leaders supported this principle; 29% were neutral and 23% disagreed. Most of the leaders did not agree that organizational tension is good because it causes the organization to evolve in a new direction. Most disagreed or were neutral that creativity and innovation are more likely when differences appear unresolvable.

Principle 7 suggests that leaders listen to the shadow system and realize that the informal relationships in organizations contribute significantly to organizational outcomes. Only 49% of the leaders supported this principle; 35% were neutral and 16% disagreed. Most agreed that informal networks are a source of great innovation. However, more were neutral or agreed that organizations are the most successful when they encourage the legitimate network and control the shadow network.

Principle 9 recommends a balance of cooperation and competition, rather than exclusive reliance on one or the other. Overall, 53% of the leaders supported this principle; 23% were neutral and 24% disagreed. Most agreed that cooperation achieves a better long-term outcome, even if competition achieves a better short-term result. In addition, most agreed that collaboration is a better strategy for ensuring long-term survival. However, most of the leaders did not agree that successful leaders use a “tit for tat” strategy: first cooperating, then matching the other’s action (cooperate or compete.)

Principle 3 advises leaders to lead by using both “clockware” (mechanistic processes) and “swarmware” (processes that capitalize on chaos). Overall, 55% of the leaders supported this view; 25% were neutral and 20% disagreed. Most of the leaders agreed that managing in a rational, planned manner made sense when the world is certain and when there is strong agreement in a group. However, more leaders disagreed that managing with experimentation, freedom, and intuition makes sense when the world is not certain and when there is not agreement in a group.

Finally, Principle 1 suggests that leaders view organizations through a complexity lens, in addition to the traditional machine metaphor. Overall, 60% of the leaders supported this principle. However, half of the leaders agreed that successful leadership in organizations is similar to a machine-managing the parts will achieve the desired outcomes. Although most of the leaders agreed that the future is unpredictable and unknowable, one third of them agreed that successful leadership required strong direction and control. Finally, most agreed that leaders could control organizations and move them toward a predictable future.

In summary, these leaders strongly agreed that healthcare is chaotic and complex, and that being a leader in the current healthcare environment is frustrating. They did not agree with principles and statements that encourage minimal specifications, multiple actions without certainty, becoming comfortable with tension and paradox, and managing with freedom and intuition.

What emerges from these results is that the principles of complexity that were not intuitively supported by these leaders requires them to give up control. The same leader who is frustrated when trying to control the chaotic, complex healthcare environment is also uncomfortable giving up control and allowing the complex adaptive system to adapt and evolve toward an unpredictable outcome. Demographically, 90% of these leaders range in age from 36-—65 years and 59% have 11 or more years of healthcare management experience. Most of these leaders have been taught management and leadership skills that focus on maintaining predictability and control. Complexity science can help leaders understand why relying on control and predictability strategies cannot be successful in the chaotic healthcare environment.

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The Opportunities

More research is needed to further clarify the skills and competencies leaders need to effectively apply complexity principles in the chaotic healthcare environment. Consistent with complexity science, this study started small and focused simply on broad principles. Qualitative analysis methods, such as interviews, may provide better insights into leadership attitudes and behaviors related to complexity science. Complexity principles also may be better studied in terms of application as opposed to intuitive support. Finally, future investigators may want to study leadership attitudes before and after front-line leaders use complexity principles to address specific organizational issues.

Lindberg shares a metaphor about the farmer to describe the impact that studying and understanding complexity can have on leaders:

The farmer understands that he cannot control most of the variables that will determine how successful the growing season will be. Along the way he must act, learn, and adapt to what comes before him. Inability to act in the face of changing conditions will result in failure. Inability to learn from his actions will certainly yield failure in the future. 4(p30)

The emerging field of complexity science offers healthcare leaders an opportunity to view leadership in a new way. Just like the farmer, leaders can acknowledge that they cannot control many of the variables needed to achieve success. They must instead learn to promote organizational strategies that focus less on control and more on relationships, action, learning, and adapting. True to complexity principles, the key is to start. Start small, but start. Keep it simple. Learn. Adapt. Evolve. Succeed.

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1. Sherman C, Lando M. Raising management standards in American healthcare. Healthcare Executive. 1999; 14 (2): 12–17.

2. Warden GL. Leadership—an introduction. Journal of Healthcare Management. 1999; 44 (1): 9–10.

3. Zimmerman B, Lindberg C, Plsek P. Edgeware: Insights From Complexity Science for Health Care Leaders. Irving, Tex: VHA, Inc.; 1998:3–44.

4. Lindberg C, Taylor J. From the science of complexity to leading in uncertain times. Journal of Innovative Management. 1997;22–34.

5. Voluntary Hospitals of America (VHA). A View Through the Lens of Complexity. VHA Alliance. Irving, Tex: VHA, Inc.; 1998;10–14.

6. Waldrop M. Complexity: The Emerging Science at the Edge of Order and Chaos. New York, NY: Simon & Shuster; 1992.

7. Voluntary Hospitals of America (VHA). A Complex Science to Better Manage Complex Health Care Delivery. Available at: Accessed February 13, 1999.

8. About Plexus. Available at:http//: Accessed March 4, 2001.

9. Goldstein J. The Unshackled Organization: Facing the Challenge of Unpredictability Through Spontaneous Reorganization. Available at: Accessed March 30, 2001.

10. Morgan G. Images of Organization. Available at: Accessed March 30, 2001.

11. McDaniel RR. Strategic leadership: a view from quantum and chaos theories. Healthcare Manage Rev. 1997; 22 (1): 21–37.

12. Lindberg C, Herzog A, Merry M, Goldstein J. Life at the edge of chaos-health care applications of complexity science. Physician Executive. 1998;6–20.

13. Kelly K. Out of Control: The New Biology of Machines, Social Systems and the Economic World. Available at: Accessed March 30, 2001.

14. Stacey R. Emerging strategies for a chaotic environment. Long Range Plan. 1996; 29 (2), 182–189.

15. Plsek PE. Edgeware—aides for complexity. Available at: Accessed March 28, 1999.

16. Ashmos DP, Duchon D, Hauge FE, McDaniel RR. Internal complexity and environmental sensitivity in hospitals. Hospital Health Service Administration. 1996; 41 (4): 535–553.

17. Petzinger T. The front lines: self organization will free employees to act like bosses. Wall Street Journal. January 3, 1997: B1.

18. Axelrod R. The Evolution of Cooperation. Available at: Accessed March 30, 2001.

19. Waldrop M. The trillion dollar vision of Dee Hock. Available at: Accessed March 4, 1999.

© 2001 Lippincott Williams & Wilkins, Inc.