Partnership in care: Organic systems framework strategies for patients and care providers

Abstract

The organic systems framework is a conceptual social sciences theoretical framework developed by renowned author Barry Oshry. Oshry outlines how we are often blind to the context we are in and our reactions to those conditions, which leads to certain experiences. This article emanates from the author’s reflections on bringing organic systems insights to groups and organizations worldwide and how such strategies in relational systems may apply to patients and care providers working together in partnership. As patients and care providers engage in such partnerships, they enter distinctly different contexts, each with unique challenges and opportunities. Written from a first-person perspective, the author moves beyond seeing the patient as a client in the healthcare system and into the possibilities of how patients and providers can work together across contexts to create and sustain meaningful care-based partnerships.

Introduction

This article represents an effort to mobilize knowledge through a structured process of integrated reflective practice. The substance of this article is personal, professional, and academic. In keeping with reflective practice, first-person active voice is used as an authentic means of expression. This article was written after I had facilitated a recent conference workshop for an extensive international organization network in the health and wellness space. During discussions related to a key strategy inherent in Oshry’s ¹ organic systems framework, I was given pause to consider how Oshry’s strategies had affected me personally when a member of my immediate family was diagnosed with an incurable, life-threatening illness. In hindsight, we had unknowingly applied Oshry’s systems strategies at first and, after that, intentionally. The outcome was, at least for now, highly successful, and it is with this awareness practical strategies for health leaders and patients alike are shared.

Gibbs’ reflective cycle ² is an organizing structure for reflecting on events/situations to deepen our knowledge. In Gibbs’ own words, “It is not enough just to do, and neither is it enough just to think. Nor is it enough simply to do and think. Learning from experience must involve links between the doing and the thinking.” This article is organized using Gibbs’ reflective practice framework. Gibbs’ structure is that we first describe the event in detail, identify what our thoughts and feelings were in the moment, evaluate and analyze what happened, draw our conclusions, and integrate our emerging awareness into a plan for future action.

Step 1: Description of the event or situation

I was invited to facilitate a half-day social systems leadership workshop called the “Organization Workshop” based on Oshry’s 30 years of research in developing the Organic Systems Framework (OSF). The workshop was facilitated in Canada at a national health and wellness industry-based conference with 176 chief executive officers and their executive teams from a geographically dispersed organization.

The workshop explored partnership in organization life and the context-based patterns that emerge with great regularity. ³ I modified an element of program design to create space for discussing system processes inherent in OSF. The discussion centred on four system processes: differentiation, homogenization, individuation, and integration. ⁴ Participants engaged in practice-based discussions of Oshry’s three basic patterns of relationship that fall from the system processes. ⁴ One pattern in particular, that of “customer-provider,” generated a brief but lively discussion of whether or not the pattern held up in the healthcare context and, more to the point, whether the patient could be viewed as a customer in that context.

When discussing “customer empowerment strategies” in systems,^3,5 I became aware that I was having a physiological reaction to the discussion. I was reminded of my family’s experience in the health system and the dire consequences that could have ensued had we not employed Oshry’s customer strategies. Some workshop participants expressed that the partnership strategies applied, and others did not. During this moment, I became aware of my lack of self-regulation since I had a deep and personal awareness of Oshry’s framework, both academically and experientially.

Stage 2: Feelings and thoughts (self-awareness)

Leading up to the workshop, I felt excited, full of energy and eager to facilitate discussions of system processes, the contexts within which they occur, and the various leadership strategies that would apply. I was well-rested, although weary from travel. I was energized since this workshop was one of several elements in my Doctor of Social Science portfolio. I was also aware that I was missing my family and might feel vulnerable when considering the patient as a healthcare system customer. My family did not have a pleasant experience in our healthcare journey; the diagnosis was painful, and the care plan was convoluted and fragmented. More dissatisfaction would likely have ensued if we remained aloof from the delivery system. I was not aware of how this discussion might have impacted me at the moment, but I felt capable of working with whatever emerged.

Workshop participants seemed open-minded and willing to engage in experiential learning. Participants were assigned various roles in a learning activity designed to highlight the organic nature of whole systems. Some were very happy with their role, some were concerned others might judge them, and most were feeling the similarity to daily life.

Three years later, I am still shaken by how the “patient as customer” discussion caused an emotional reaction in me. In retrospect, this was due to a feeling of anger my family held at a time of significant vulnerability, that the care system was not working as it should. The consequences to my family could have been devastating. The system itself was overly differentiated while simultaneously lacking in integration. To this day, my sense of anger and indignation is unresolved. However, I have taken steps to help the local care system align itself with the notion of patient and family-centred care that it espouses to practice. In the moment, however, I felt a visceral reaction to the discussion; I thought that if I spoke, I would become physically ill. This was my cue to move on.

Stage 3: Evaluation

In this phase, Gibbs ² asks us to reflect on what was positive about the situation—what went well and what did not. While in the role of facilitator of such workshops, my feelings and personal thought processes are generally not expressed. Evaluations showed that participants greatly appreciated the experiential learning design, the relevant discussions, and the applicability of the leadership strategies inherent in the framework. Only I, as a facilitator, was aware of the design changes as we collectively explored robust strategies for staying focused on partnership in care.

I did not blindly enter into the discussion of patient-as-customer strategies. I was placing the notion of “patient” into what Oshry refers to as “bottom” condition, which is characterized by vulnerability to the direction that “they” provide.^1,6,7 In this instance, the “they” were essentially any element of the system of care that made decisions that impacted my family. What I did not know, however, was the level of emotionality associated with admitting vulnerability as a patient or family member. I thought I could talk about the real-life issue without experiencing it emotionally. I was wrong; my emotions determined what I could or could not say and discuss.

Stage 4: Analysis—What sense can I make of this situation?

I was aware that the view of patient as customer is not shared among all professions in the healthcare system, nor is it shared internally to the various disciplines themselves. Numerous clinical blog sites, for example, ⁸ rail against the notion of “patient as customer,” citing seemingly positive rationale. However, the unit of analysis remains at the level of the patient. While not entirely commonplace, many studies describe positive outcomes associated with patient involvement in decision-making, “very few publications refer to costs or negative impact of engagement, compared with positive findings.” ⁹

In terms of the unit of analysis, authors such as Edmonstone ¹⁰ speak of more extensive, different models of care that involve addressing the whole health and social care system and not the relational social system. The literature focuses predominantly on one-on-one interactions between patients and care providers. It focuses on the interpersonal elements of contact with patients: content, style and care coordination as determinants of productive partnerships. ¹¹ Some research offers hope, finding emerging alternate models of care that “foster less asymmetrical power relationships between caregivers and patients and a greater consideration of patients’ lived experiences.” ¹² Marchand et al. found that patients yielded positive outcomes when “opening [oneself] up, being a part of care, meeting me where I am,” ¹³ which further reinforces a focus on the micro, dyadic relationship but not on the larger social system. Other comprehensive reviews also focus on the individual as the unit of analysis and seek to identify quality indicators at the level of care outcomes but do not offer comment on social system strategies where the patient resides and receives care. ¹⁴ Conversely, authors such as Pomey et al. seem to focus on the legitimacy of involvement when they state, “Patient participation legitimacy is based on the recognition of patients’ experiential knowledge.” ¹⁵ While this statement is on point, it also implies an asymmetrical power relationship. The unit of analysis can be expanded to include team-based care. However, patient comments often pertain to “the perceived purpose of teams, perceptions about the structure of a team, team-based communication, the role of patients, delivery of care.” ¹⁶

Asymmetrical power seems to be at odds with Oshry’s notion of partnership. In Oshry’s view, “each part of the system has its unique potential contribution to Total System Power. These potentials are often not realized […].” ⁷ This view suggests a balanced power dynamic, not asymmetrical, is valuable and wise. It opens up a new means to empower patients and providers within virtually all aspects of Canada’s health system(s). Rider et al. also concurred that to make collaboration in larger systems work effectively; interveners should adopt a “whole systems view.” ¹⁷ Researchers have also found three central challenges to system-level collaboration: defining responsibilities and expectations, negotiating priorities and establishing and strengthening trust and respect. ¹⁸

Three basic relationship patterns emerge in organic social systems: customer-provider, end-middle-end, and top-bottom. ⁶ When considered hierarchically, the elements of these patterns are top, middle, bottom, and customer. Tops exist in a context of accountability and complexity as they shape the organization in its environment and enact its functions. Middles exist in a context of “tearing” with multiple competing demands as they seek to integrate strategy and operations. Bottoms exist in a condition of vulnerability where “others” make decisions that affect them in major and minor ways as they deliver frontline products and services. Customers exist in a context of neglect—a world of promises made and promises broken in their role as validators of the organization’s existence. What is unique about OSF is that none of the contexts identified in the hierarchical relationships is personal; they are systemic patterns that emerge as a function of our interactions with others.

Oshry’s notion of tops, middles, bottoms and customers can also be taken out of a hierarchical context and viewed as sets of “conditions.” For example, a physician can be “top” in the care relationship. Yet, they can also concurrently be in “bottom” condition as they are vulnerable to the direction provided by others, whether professionally or organizationally. Senior healthcare leaders can also be “middle” when caught between other people’s issues and concerns. Any person can also be in a condition of “customer” whenever the service or product we receive doesn’t quite meet our expectations. Oshry^6,18 also says that we are often “blind” to our reflex responses in systems, which can lead us to familiar, disempowering scenarios. Experiences, then, feel like the way things really are, and we do not see our role in contributing to them. This is at the heart of Oshry’s “dance of the blind reflex.” ⁶

Oshry suggests we must take a stand about who we are and how we will lead in these conditions. If we take, for example, Oshry’s view of customers, the stand customers can take to stay focused on partnership and not reflexively remain aloof from the system and hold it responsible for delivery is to be a customer who gets involved in the system and “help the system be more responsive to us.” ⁶ To do so requires a different set of strategies than outlined above: strategies that are systemic and not at all personal.

Seeing patients as customers through the lens of Oshry’s framework suggests they should:

• Contract with their provider to build a relationship/partnership.

• Find out how the delivery system works.

• Be clear about standards and expectations.

• Stay close to the provider/producer.

• Get into the process early as a partner and not late as a judge.^1,6

For patients, these strategies are often tricky in asymmetrical power dynamics in which the patient is at the receiving end of treatment, a mental model that still permeates much of our health system, and societal views on the physician-patient dynamic. Patients as active partners in care are at the heart of relationship-centred care, ¹³ making these strategies particularly salient.

Stage 5: Conclusion (synthesis and recommendations)

So, what happened in the workshop, and what can I do about it? Participants were discussing customer/patient empowerment strategies when my moment of insight occurred. I was reminded of the possible downstream consequences of not enacting Oshry’s strategies as my family engaged the medical system. The emotional impact resulted from the inferences and connections I was making as the lead facilitator and not something that the participants said or did. I was blind to my indignation and anger, yet alive to the feeling of being helpless and “done to” by the healthcare system. However, it was because we applied Oshry’s strategies that we are where we are today. Patients and their families can use these social system strategies to remain focused on partnership.

There are things senior leaders can do to help facilitate partnerships, too. As bona fide “tops” in the system, I recommend they accomplish the following:

• Develop a vision for care that includes patients as partners.

• Invest in their internal relationships with staff.

• Involve care providers and patients in decisions that impact them.

• Invest in the development of staff to learn and stay focused on partnership.

• Develop structures that reinforce partnership.

• Challenge mental models that relegate the patient to a hierarchical relationship.

Mental models refer to models or abstractions we create in our brain that help us understand and approximate what should happen in the real world. Consider for a moment how a patient or family seeking treatment believes our healthcare system should work. There are a variety of lenses through which we conceptualize the healthcare system. ¹⁹ If we seek clarity and share our mental models, we can avoid falling out of partnership and becoming frustrated or confused. Mental models help us navigate the world, make sense of it, and take certain actions. ²⁰ In my family's case, if our shared mental model were to “listen to the care providers and follow their direction,” we would remain helpless to whatever the system did next. We would have remained in “bottom” condition where “others” decided for us. Asserting our expectations was a strategy to help the social system stay focused on partnership.

Stage 6: Action plan

When I find myself in a similar conversation when delivering such workshops, my strategy will be twofold. First, I will consciously prepare for the workshop and consider examples that are less personal to me and less likely to resonate emotionally. However, this is not to say that I will abandon my personal connection to the workshop. Second, I need to process my frustration with what could have happened had we not enacted the strategies. Being more aware of the multiplicity of roles I occupy in social systems, sometimes as top, other times as middle, bottom, and customer, will forever be a work in progress. To operationalize Oshry’s strategies, I should heed his words, “Stuff happens; you can take it personally or treat it systemically.” ⁶

Conclusion

Oshry’s organic system framework is explanatory and offers strategies and insights about what care providers and patients may do to remain focused on partnership. Although the examples presented in this article were from personal experiences in the healthcare system at a clinical coordination level, Oshry’s insights may also be applied to any scenario where the parties are jointly committed to the success of whatever project, process, or endeavour they are in. ⁷