Multiple challenges face us when we have made this decision. Middle management needs to rely on expertise from diverse sources when it is moving into a new valley. The same old “experts” probably don’t know everything anymore., The ways in which we acquire knowledge and test out the validity of this knowledge is itself contained in the pathway down which we are now traveling–to modify Einstein’s dictum a bit. Second order learning is required when we enter a new valley and find out how to travel down a viable pathway in this valley. There are often new rules to follow in determining what knowledge and perspectives are of greatest importance in this valley. Finances, for instance, might suddenly become of primary concern. We also face new challenges that require slow, deliberate thinking. We might not be aware of all the assumptions that underlying the financial analysis that we are now required to complete. Greater awareness of (and even testing of) these assumptions will be critical.

There is an additional challenge: how do we test out the validity of the new knowledge being offered, and assumptions being made. Which spread sheet do we trust? What accounting procedure do we adopt? New experts are often of greatest value. It is a matter of diversity–as Scott Page (2011) has shown us. The quality of problem-solving and decision-making, as well as the creativity that attends these critical thinking processes will significantly improve with the invitation of new members, new perspectives, and more diverse representation on the middle management team. It seems that something “new” tends to unfreeze people and teams (Lewin, 1947).

In order for middle managers to gain more skill working with even a static, warped plane of care, we must gain more comfort and patience with variability and the ambiguity and discomfort of the oscillations that precede decisions on which valley of care to decide our way into. Patience with oscillation, ambiguity, and uncertainty are required of our middle-managers, yet we tend to train them to limit and reduce each of these wherever they see it in the name of efficiency.

Middle-management efficacy must begin to emerge as a higher priority than middle-manager efficiency.  A quest for efficiency without regard for efficacy will reduce the energy in the system and eventually freeze the domain.  As happens in nature, when a person or system begins to freeze, it can paradoxically feel warm and comfortable just before death.  We must learn ways to help thaw our middle-management by giving them new skills as coaches and guides to work and manage across the many oscillations, ambiguities and uncertainties found on the warped plane of healthcare.

Portrait Two: Navigating in a Turbulent System

As we delve into the dynamics of complex adaptive systems, we might wish to switch from the mechanical metaphors of a ball rolling in the valley or a ball being putted on a green to representations of actual complex systems that are operating in nature.  Shifting from a static, multi-ridge-and-valley warped plan towards a dynamic, ever-changing, turbulent living system further points to the need for dynamic, collaborative leadership and coaching. We find flowing and tumbling rivers the ideal metaphor for the Fluid state of organizations—when we have thawed all the frozen areas of the organization and decisions begin to flow like water across the system of care.